5 Questions To Discuss With Your Physician

  • 5 Questions To Discuss With Your Physician

Currently, over 37 million Americans have diabetes. The forecast is for that amount to go up rapidly by 2050. Reading, learning and asking your health care provider questions about diabetes may help change your future of developing diabetes or how well you can control it OR if you do eventually develop it.

1. Is type 2 diabetes a progressive disease?

Answer- YES.

You may have been able to control your diabetes for years using the same treatment. It originally could have been managed by eating a proper diet and performing consistent exercise. Often, at the beginning a diabetes pill, called metformin, that decreases the amount of sugar produced by the liver is added to improve your blood sugar control.

Diabetes is a complex disease affecting multiple organs. Over time, it may become more difficult to manage. There is “no one size fits all” approach to managing your diabetes, so staying diligent and aware of blood sugar changes is critical. Some people simply fail early on by not using a proper diet and exercise plan or even forget to take their prescribed medications.

Most people just progress with diabetes, doing everything right, as a course of history. Eventually, your eating, exercise and medical management plans will need to be updated and adjusted. The sooner you get back to “diabetes control” the less you will have to be concerned with complications.

Out of control numbers create problems for your heart, blood vessels, eyes, kidneys and nerves. Avoiding diabetes complications is paramount for your overall and continued health. Previously, diabetes control was based on just one marker called an A1C which is a 3-month average blood sugar of 7% or less. Today’s A1C goals have become more “individualized” and specific to your age as well as if you have other chronic health conditions.

Diabetes control may then be considered having an A1C of “7-8%”. Many people may eventually require other oral medications which work on your kidneys, liver or pancreas. Injectables called GLP-1 are usually given weekly to reduce your appetite by slowing gastric emptying and keeping you full longer.

Your physician will choose which one is best for you. It does not mean you have “failed at taking care of your diabetes” or “you have caused this to happen”. It just enforces the fact that diabetes is progressive. Sometimes your thoughts take over and self-blame can occur. You may have negative thoughts that you did this to yourself, but that is not true.

The beta cells of the pancreas progressively deteriorate causing less insulin to be made. And over time the body works harder to make more insulin, but eventually it can’t keep up. Chronic exposure to elevated levels of glucose or sugar causes more beta cell dysfunction. This progression varies from person to person.

It also progresses at a different timeframe for every individual. Even with research and studies, scientists and researchers still have not unraveled the “mystery of diabetes progression.” There are over 70 genes dealing with just type 2 diabetes. There is still much more to learn about the diabetes process.

Your body changes over time, not just concerning diabetes but possibly affecting how your diabetes is controlled. You may become less active over time and exercise increases insulin sensitivity or how well you use insulin as you age. You may develop osteoarthritis, limiting or eliminating your ability to exercise. This could raise your blood sugars.

Exercise also assists with weight maintenance and your weight will eventually creep up. Excess weight causes insulin resistance making it harder to maintain your blood sugars. You may develop tooth and gum problems causing you to have difficulty chewing, eat differently, adding empty calories and ultimately raising your blood sugars.

According to the CDC, “people with diabetes are 2-3 more times likely to suffer from depression.” This happens because you must come to terms with all the changes that diabetes brings. Depression occurs often as we age, leading to reduced diabetes self-care and motivation.

Even if you are doing everything right, daily life stress can make it difficult to maintain blood sugars. When under stress your body secretes adrenalin and cortisol which makes blood sugars go up. Even certain medications such as HIV medications, steroids for inflammation and opioids for pain relief can raise sugars.

Dementia may make diabetes treatment more of a challenge, forgetting to follow your protocol. You may suffer with low back pain, emphysema (a breathing problem) or cardiac failure. Each of these things will affect your diabetes control. Even finances may change limiting your ability to care for your diabetes because you can’t afford supplies or medications.

The reality is diabetes “is a very manageable disease” when given all the tools and using all those tools. According to many physicians “diabetes is always in flux” and needs to be continuously monitored. Doing your best to control diabetes even under duress will limit complications. Find ways for continued diabetes self-care.

Remember that the number of medications to treat diabetes is constantly evolving and increasing. Eventually “getting pancreatic beta-cells from somatic cells will be a great resource for people with diabetes.” We are not quite there and there are still challenges for this option at this point.

Know there are many treatments available to you and take advantage of them. A study from 2020 found that “in people with well-controlled type 2 diabetes there was no reduction in life expectancy compared with people who do not have the condition.” Learn to safely manage your condition.

2. Is there a new insulin pump that is even smaller than the present ones now on the market?

Answer- YES.

In July 2023, the FDA granted clearance for the Tandem Mobi insulin pump for those with diabetes who are 6 or older. This new device is “less than half the size of the Tandem T:slim X 2 insulin pump. It is automated and can be controlled by a phone APP.”

It is small enough to fit into a coin pocket, be attached to your clothing with a clip or worn directly on the body with an adhesive sleeve. “This pump allows patients greater choice with proven benefits.” Besides control from a Smartphone, the pump includes an button for bolusing (surge) insulin.

The pump can receive remote software updates through a Smartphone that is compatible. It can be used in conjunction with a CGM. A limited rollout of the Mobi insulin pump will occur in late 2023 and a full roll out will happen in 2024.

It is water resistant, has wireless charging and holds 200 units of insulin in the cartridge. It can be worn tubeless or with a 4 inch tube. If you currently have a T:slim X2 with at least 12 months remaining on the warranty, you may be able to switch to the Mobi pump. The cost will be comparable to other pumps on the market. Out of pocket costs depend on your current health insurance.

What does an insulin pump do again?

Insulin pumps can offer more convenience to people with diabetes to help manage their disease. Insulin pumps are used by people with diabetes who require several shots of insulin a day. By wearing an insulin pump you can avoid multiple daily needle sticks.

The pumps are small, computerized pre-programmed devices that deliver insulin throughout the day and night in either 2 ways, steady or continuous. You still need to check your blood sugars with a meter/monitor or CGM (continuous glucose monitor) even though you are wearing an insulin pump.They add convenience and less needle sticks for someone who needs insulin several times a day.

Pumps improve diabetes control by doing a lot of calculating of insulin for you. There are both advantage and disadvantages to wearing an insulin pump. You and your health care provider will weigh the risks, costs and the benefits before making a decision as to whether this is a good option for you.

3. Does it matter if I lower my A1C? Can I lower my A1C with diabetes self-care?

Answer- YES and YES.

The A1C is a simple test that measures the glucose in your blood. The more glucose that enters your blood stream the higher your A1C will be. The higher your A1C and the longer it stays elevated the more you run the risk of developing severe diabetes complications.

What should my A1C be?

This needs to be discussed with your physician and it depends on multiple factors. 6.5% indicates you have diabetes. Above 8% means you may incur complications such as vision loss, kidney problems, heart issues and nerve damage.

The best ways to lower your A1C:

  • Moderate excercise. Using both strength/resistance training and aerobic exercise. Exercise makes your body more sensitive to your insulin. Check your blood sugar before and after exercise especially at the beginning of starting a program to look for variations. If you are on insulin you may need to check more frequently. Exercise can also help maintain weight loss, lower blood pressure and improve inflammation levels and immune responses. “Physical activity is strongly associated with better outcomes across a range of factors.”
  • Watch portion sizes. This sounds so easy, but most people think if they eat healthful food, they can eat as much as they want. This is not true. Eating large portions of nuts, beans, whole grains, lean meats and low-fat dairy, which are all healthy choices are going to add weight which will ultimately raise your A1C. When preparing meals use the plate method which is 1/2 plate of cooked or raw vegetables, ¼ plate is a serving of a lean protein such as fatty fish, skinless poultry or lean red meat and ¼ of the plate is a serving of whole grains like quinoa, brown, jasmine or wild rice, red or black beans (legumes) or a small, sweet potato or winter squash. These foods are excellent for supplying brain and body energy. Use measuring tools such as cups or spoons to place food servings on your plate. Do not eat straight out of the container, bag or box. Space out carbohydrate foods throughout the day. Do not save for just one meal.
  • Plan meals ahead of time to prevent becoming famished.
  • Increase fiber in your diet. Foods with fiber take longer to digest and lower spikes in your blood sugar.
  • Drink adequate calorie-free beverages. Water, coffee, tea, sugar-free beverages.
  • Achieve and maintain a healthy weight.
  • Eat on a regular schedule. Eat every 4-6 hours. Do not skip meals.
  • Include small servings of unsalted nuts. They contain healthy fat and protein and keep you satiated for a longer time.
  • Keep all your medical appointments. Remember to include skin care, gum and mouth care and foot care along with your internist/endocrinologist, eye MD, cardiologist and nephrologist. Look for a Diabetes Management course, a dietician and a mental health therapist to complete your team. “It takes a village” for complete diabetes care.
  • Monitor blood sugars with a Meter or CGM. Depending on your situation, discuss with your medical professional when you should be checking blood sugars. Guidelines state “keep your blood sugars in range-70-180mg/dl.” as much as possible.
  • Take diabetes medications as recommended. Do not skip doses even if your blood sugars are in range.
  • Practice stress and anxiety management. Hormones are secreted during emotional upheavals which raise blood sugars and contribute to insulin resistance. Stress and anxiety make you crave more, sugary, salty and fatty foods and it reduces self- control. Use whichever techniques that appeal to you. Do in a group setting or alone.
  • Do not smoke.
  • Reduce alcohol intake / do not start drinking alcohol. Drinking has recently been downgraded and health benefits “are not really being identified” as once noted. Drinking adds calories and may raise or lower your blood sugars to dangerous levels depending on what or how much you drink. Consult your physician for specific advice.
  • Get good, restful sleep for 7-8 hours daily.
  • Be aware, medications for other health conditions may raise your blood sugars. Never stop taking medications without discussing with your health care provider.

4. Was there a recent approval for the first immune therapy for type 1 diabetes?

Answer- YES.

In 2022, there was FDA approval of a “new drug called Tzield for the delay of type 1 diabetes in adults and pediatric patients over 8 years old, for an average of 2 years.”. Tzield is the brand name for teplizumab. It is made by Provention Bio.

Type 1 diabetes is known as an immune disorder that requires routine and regular insulin injections or use of an insulin pump to deliver insulin. Type 1 diabetes is when the beta cells in the pancreas which produce insulin are destroyed. Glucose accumulates in the bloodstream causing symptoms including increased hunger, increased thirst and increased urination.

If not treated, type 1 diabetes can lead to coma or death. Over time undertreated type 1 diabetes can lead to a slew of serious complications. Generally, type 1 diabetes is seen in those who have a sibling or a parent with it, but many people have no family history. It is said to be “a disease of genetics and environmental factors.”

This new FDA approved medication is a first-in-class therapy. Tzield “bonds to specific immune cells putting off the progression of the disease.” At this point Tzield, an injectable medication, is prescribed to be given every day for a 2 week period.

During the clinical trials “some people who were expected to develop diabetes never did.” This is significant in the treatment of diabetes since it opens the way for many more innovations which can prevent/control diabetes.

The potential to delay clinical diagnosis of type 1 diabetes may provide patients with months to years without the “burden of the disease.” It is delivered in an IV infusion and the side effects may include rash, headache and a drop in certain white blood cells. This is not approved for treatment of type 2 diabetes, but it is an impressive milestone in type 1 diabetes research.

Currently it is approved for those who are at high risk of type 1 diabetes based on abnormally high blood sugars determined by an oral glucose tolerance test. Also needed is a screening test that confirms the presence of at least 2 specific autoantibodies that “indicate the body is already attacking the insulin producing beta cells in the pancreas.”

It is used for people in stage 2 of the disease. It is not as effective when given during stage 3 of diabetes. Find a well recommended medical center that is involved with diabetes research and type 1 diabetes for the most up to date care.

5. Are foods that contain nitrates safe to eat or not? I’ve heard conflicting information and I know with diabetes I need to eat healthy.

Answer – No and YES.

Food nitrates contain both nitrogen and oxygen molecules. There are nitrates found in cured, processed deli meats as well as in green leafy vegetables.

Which nitrates should you avoid?

Nitrates are mostly unreactive, but nitrites are more reactive. Nitrates in cured and processed meats are close to proteins which when cooked at high temperatures form nitrosamines. Nitrosamines are a cancer-causing compound. Nitrates are broken down by your “gut biome” into nitrites which may increase your risk of cancer.

Your own body makes nitrites but most of the nitrates come from your diet. Cured and processed meats are high in nitrites which are added chemicals and help with food preservation. It prevents harmful growth of bacteria. Nitrites also give the food a richer flavor and keep the color of the meat red. Without added nitrites, the meat would turn gray or brown.

These foods are unhealthy for everyone, and especially those with diabetes. Cured and processed meats are also high in sodium which increases your blood pressure. Nitrates from cured meats can cause migraines, headaches, fatigue, dizziness, stomach cramps and vomiting. These foods which should be eaten at a minimum or not at all are:

  • Ham
  • Bacon
  • Salami
  • Bologna
  • Hot dogs
  • Sausage
  • Corn beef
  • Pastrami
  • Deli meats such as chicken, turkey, roast beef, liverwurst

If you really enjoy these foods and find it difficult to limit, ask for the uncured, nitrate/nitrite free options.

There are also healthy sources of nitrates. 80% of dietary nitrates are from vegetables. Nitrates are found in the soil are part of natural mineral deposits and our water. Nitrates accumulate in the leaves, stems and roots of the plants.

Dietary nitrates and nitrites change into nitric oxide which helps dilate blood vessels and lower blood pressure. This improves cardiovascular health and lets the blood flow more freely which is a big benefit if you have diabetes. Nitric oxide also helps your GI-gut function and regulates immune and inflammatory cells.

Green vegetables definitely have a “cardio-protective effect.” The bottom line is nitrates from fruits and vegetables are beneficial since they also contain polyphenols, fiber and vitamin C, besides nitric oxide.

“Nitric oxide may also prevent metabolic diseases and protect your stomach lining. The American Journal of Clinical Nutrition recently published a study stating, “Higher dietary nitrate intake from these vegetables was associated with a reduced risk of dementia.” You should try to eat 5 servings of vegetables and fruits daily.

Listed below are vegetables, seeds, nuts and fruits high in nitrates which are healthy for you and include:

  • Cabbage, lettuce, Bok choy, chicory, broccoli, arugula, collard greens, Kohlrabi, Swiss chard
  • Edamame, seaweed, algae, spinach, kale
  • Carrots, celery, beets, beet root, beet juice, radishes, turnips, onions
  • Flax seeds, hemp seeds, walnuts
  • Lower amounts of nitrates are in these vegetables: asparagus, peppers, mushrooms, green beans peas, eggplant and summer squash
  • Fruits. Fruits contain lower amounts of nitrates compared to vegetables. These fruits have higher amounts of nitrates. Included are: oranges, grapes, apples, bananas, kiwis, pears and strawberries

Try to avoid foods that contain sodium nitrates, sodium nitrites, potassium nitrates and potassium nitrites, when possible.

There continues to be new medications, new research, new discoveries and new trends in the field of diabetes. Stay informed, ask questions and do what you can do to improve your daily life with diabetes.


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About the Author: Roberta Kleinman

Roberta Kleinman, RN, M. Ed., CDE, is a registered nurse and certified diabetes educator. She grew up in Long Island, NY. Her nursing training was done at the University of Vermont where she received a B.S. R.N. Robbie obtained her Master of Education degree, with a specialty in exercise physiology, from Georgia State University in Atlanta, Georgia. She is a member of the American Diabetes Association as well as the South Florida Association of Diabetes Educators. She worked with the education department of NBMC to help educate the hospital's in-patient nurses about diabetes. She practices a healthy lifestyle and has worked as a personal fitness trainer in the past. She was one of the initiators of the North Broward Diabetes Center (NBMC) which started in 1990 and was one of the first American Diabetes Association (ADA) certified programs in Broward County, Florida for nearly two decades. Robbie has educated patients to care for themselves and has counseled them on healthy eating, heart disease, high lipids, use of glucometers, insulin and many other aspects of diabetes care. The NBMC Diabetes Center received the Valor Award from the American Diabetes Center for excellent care to their patients. Robbie has volunteered over the years as leader of many diabetes support groups. More about Nurse Robbie

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