November is American Diabetes Month. Diabetes is a condition in which the body is unable to produce the correct amounts of the hormone insulin, resulting in high blood sugar levels.
In the United States, 29 million Americans have diabetes and 86 million Americans have pre-diabetes. With type one diabetes, the body does not make insulin at all because the immune system attacks the cells in the pancreas that produce it. In type two diabetes, the body does not make or use insulin well due to age, family history, weight, physical inactivity and certain other health problems.
Recently, we spoke with Linda Tilton, a certified diabetes educator at the UVM Medical Center, about diabetes, the screening processes, and what to do if you are at risk.
You can listen to our interview or read the transcript below.
What is pre-diabetes and how is it different from diabetes?
Linda Tilton: Well, pre-diabetes is a condition that most people are unaware that they have because they really don’t have any symptoms. We used to call type two diabetes either adult-onset diabetes or non-insulin-dependent diabetes. We don’t call it by either name anymore, because we’re seeing a lot of young people with type two diabetes, and we often choose to treat type two diabetes with insulin in addition to oral medications.
Pre-diabetes is the pathway that leads most people, ultimately, to develop type two diabetes. In type two diabetes, there’s a genetic disconnect at the level of your cell. So, when your pancreas makes insulin, when your blood sugar goes up after you’ve eaten, instead of quickly moving the glucose in to fuel the body cells, the body cells push back on it, and your pancreas will respond by making more insulin.
Those beta cells in the pancreas that produce insulin have a capacity to compensate but not indefinitely. In type two diabetes, it’s a clinical diagnosis of diabetes. Pre-diabetes is the space between normal blood sugar control and actually developing diabetes. This is where we want to meet people, because at this point, we can work with lifestyle modifications to help either delay the onset of diabetes or perhaps prevent it.
What are the warning signs of diabetes? How might somebody know?
Linda Tilton: You won’t know. You won’t feel any different. So, what we are encouraging people to do is, if they have a family history of diabetes, if they’re overweight, if they’re over 45 years of age, for a woman if they’ve had gestational diabetes, to really discuss this with their primary care provider, and ask to be screened with a hemoglobin A1c test.
Let’s talk about genetic risk. Can you be at risk for both types?
Linda Tilton: You know, there are families that have both types in them, but usually a person will just have one type. Type two diabetes never becomes type one diabetes, although often type two diabetes, you know, we need to at some point add insulin in addition to all medications.
Who else is at risk of developing diabetes?
Linda Tilton: Sometimes diabetes is caused by something else. We have people who have had injury to their pancreas, people who’ve had pancreatitis. We’re having more and more people who actually survive the diagnosis of pancreatic cancer, where they have to, in order to treat the cancer, remove most or all of the pancreas, and of course, if you don’t have a pancreas or your pancreas is damaged, you’re not going to make insulin.
Some medications can increase your risk. If you’re pre-diabetes, sometimes if you have to go on steroids, that increases insulin resistance, and it may speed up the process.
Some mental health medications, that they really cause people to gain weight and increase insulin resistance. But these are people who would have had a genetic risk anyway.
So, what’s the link between type two diabetes and food?
Linda Tilton: I always tell people when they’re newly diagnosed with type two diabetes that we all could have made better choices as far as our food. We all could have monitored our portions. We all could have been more physically active. However, that didn’t cause them to develop diabetes. People who develop type two diabetes have that genetic disconnect. And as time passes, if they gain weight, it just makes it progress.
You know, we always look at people’s food choices and think, “Oh, it was all the donuts they ate, or the soda they drank.” That certainly didn’t help, but there are people who can eat as many donuts or drink as much soda as they want and they’ll never develop diabetes.
So the recommendations usually are to moderate portions of food high in carbohydrates, all carbs count, even healthy carbs. Carbs are things like bread, cereal, rice, pasta, white or wholegrain. Starchy vegetables, things like corn, peas or potatoes, white potatoes or sweet potatoes. Carbs are in all fruits and fruit juices because of fructose, or natural fruit sugar. They’re in milk and yogurts because of lactose, or natural milk sugar. They’re in all the combination foods we eat every day, things like macaroni and cheese, pasta with sauce, tacos, burritos, shepherd’s pie, pot pies.
Then, they’re also in the things we associate with diabetes: sugar and sweets, cookies, cakes, pies, sweetened beverages like regular soda, sports drinks.
So, we’ve been over all the things that we should eat less of and drink less of. What should we focus on? What should we be eating more of or drinking more of?
Linda Tilton: I usually encourage people to focus on increasing the amount of low-carb vegetables they eat. Usually, filling half their plate with that. Things like broccoli, carrots, green beans, spinach, salads. I usually encourage moderate portions of lean meat, fish, poultry. I encourage fresh fruit in moderation, keeping in mind that the larger the apple, the more carbs that are there.
I encourage people to find a beverage as their beverage of choice that does not have added or large amounts of natural sugar in it. Ideally, that’s water. You know, there’s nothing wrong with a Diet Coke now and then, but sugar-free sodas are just artificially sweetened chemical water. There’s not really any nutritional value in there. Just like a regular soda is sugar-sweetened chemical water. So that’s usually a goal that I work with people on achieving, is finding something they like to drink that doesn’t raise their blood sugar.
I actually encourage people, if they want to have something sweet, to choose a moderate portion of something that is a natural product. There’s no reason you can’t have a cookie or a serving of ice cream or a small piece of cake or pie. You just have to moderate the portions. It’s not going to affect your blood sugar any more than a serving of fruit, usually.
I encourage people, though, to really read nutrition labels and become familiar with how much carbohydrate is in the food.
Can diabetes cause other medical problems?
Linda Tilton: Diabetes can cause a lot of medical problems, and I think when people are first diagnosed with diabetes, since many people have a family history of diabetes, they have memories of parents or grandparents or aunts or uncles who had some unpleasant complications of diabetes. You know, uncontrolled diabetes increases your risk for cardiovascular disease, problems with your kidneys, problems with your eyes, problems with your nerves, problems with your circulation. So, we really encourage people to look at taking action to decrease those risks.
I usually tell people, “The good news is that you were diagnosed with diabetes.” That’s not always what they want to hear.
But, if you weren’t diagnosed, you couldn’t have been treated, and if we can control your diabetes and keep your blood sugars well controlled, we can decrease the risk of these unfortunate complications of diabetes. It’s not diabetes that causes these problems. It’s high blood sugars that damage your body, if we don’t control your diabetes.
I try and get people to see the positive side and see what they can do. I think if people have the opportunity to meet with a certified diabetes educator shortly after diagnosis of the disease, it can really help frame how they proceed. They can come up with some goals to really make some changes that improve their health outcome.
So, if somebody is worried about whether they might have pre-diabetes, or just concerned about their health, where should they start?
Linda Tilton: I would start with your primary care provider. It’s really a good conversation to have. Bring up your family history, bring up your concerns. It’s very easy to do that A1c test. That way, you’ll know early on if you’re at risk, and you can start to make some changes. You can meet with a diabetes educator, you can meet with a registered dietician, you can meet with a health coach, and really sit down and come up with some goals of things you can change. It’s small changes that add up.
If you’re diagnosed with diabetes and you start making a plan, is it curable? Is anybody ever cured of diabetes?
Linda Tilton: I try and use the word “control.” This is a question I hear multiple times a week, and it’s probably the hardest question I have to answer. Let’s see if we can put the process in remission, if your numbers are higher than we want to see, let’s see if we can get back to better control, but we can’t go in and change that genetic piece. Not yet. Hopefully someday, but at the moment, we can treat both types of diabetes and we can control blood sugars. I try and tell people, “That’s a really good goal, because if we can control the blood sugars, your risk of developing any unfortunate complications of diabetes is much lower.”
You mentioned going to your primary care physician, but, when would you want to go to a diabetes educator, and where would I find one?
Linda Tilton: We’re very fortunate here at UVM Medical Center in Chittenden County because we have a number of certified diabetes educators. Certified diabetes educators are healthcare professionals. They come from a variety of disciplines, but most commonly they’re registered nurses, registered dieticians. Now, increasingly, registered pharmacists, who have advanced training in diabetes and have passed a fairly rigorous national certification exam.
Here at the Medical Center, we have certified diabetes educators, so they’re fairly easy to connect with. The cost of seeing a diabetes educator is usually covered by health insurance.