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Melanie Cole (Host): A diagnosis of diabetes can be unnerving. If your doctor tells you you are at risk for developing diabetes, you should take it very seriously, but there are ways that you can start living healthier right away. My guest today is Dr. Ronak Desai; he's an internal medicine physician with Greenville Health System. Welcome to the show Dr. Desai. So, give a little lesson for the listeners about the different types of diabetes, type 1 and type 2, and you can even go into pre-diabetes. Just explain what these are and what the difference between them are.

Dr. Ronak N. Desai (Guest): Sure. So, if we were going to start right from prediabetes. Let's not even get to diabetes. Prediabetes means borderline diabetes. You're getting there. It's when the blood test shows that your A1C or hemoglobin A1C which is a 3-month measure of your blood glucose is running between 5.7 and 6.4 and that means your blood sugars are just starting to creep up a little bit; it's starting to smolder above what's normal. It's becoming more important because it's a warning sign -- hey, listen, something is wrong. We're starting to move towards a trend of you becoming diabetic which leads to a lot of other medical problems in and of itself, and so, in the primary care setting, we're looking at prediabetes more and more because it's the time to be aggressive about our dietary modifications, exercise, maybe the addition of certain medicines, but really getting that good healthy lifestyle back into play so that you don't have to go into type-2 diabetes and the complications.
Type 1 diabetes works a little differently in that our body attacks its own insulin-producing cells. We don't make this happen with diet and lifestyle as much as it's an autoimmune condition, and so for those patients who are type 1 diabetics, which we typically see as younger people and children, they are insulin bound. Type 2 diabetes, on the other hand, is in the setting of what's called insulin-resistance: the insulin is there, but the body just doesn't respond to it as well, and things that can affect that are the type of diet we consume, our exercise level, the general distribution of fat in our body. Because of lifestyle those are the issues at hand -- or some of the issues at hand with type 2 diabetes.

Melanie: Dr. Desai, as is we're seeing an obesity epidemic in this country and even in children. Type 2 diabetes used to be called adult-onset, but now it's type 2 because you're even seeing it in children. Are there some symptoms? How would somebody know if they are either prediabetic or on the way to full-blown type 2 diabetes? Is there something parents should look out for with their children, and adults should watch out for in themselves? What would they notice?

Dr. Desai: So, with pre-diabetes, because of all the negative that type 2 diabetes is associated with, pre-diabetes doesn't necessarily have any symptoms apart from the sugar's running high on the blood test and that's what makes it sneaky. There's no way to really tell that unless you follow up with your doctor, go to your routine check-ups and make sure that if you do have history or family history that they check a little bit more aggressively. Type 2 diabetes typically what we're looking for are classic features like increased thirst, the term is called polydipsia, or polyuria, increased urination, which occurs because there's so much sugar that it spills out from the kidneys, and the sugar in the urine becomes very high, but it can be other things. Blurry vision, dizziness, there can be a lot of other vague symptoms: stomachaches -- it can vary so much because of the different places that diabetes has effects. Another place that can happen is in your toes and your fingers. The numbness and tingling -- that can be one of the early signs of diabetes if you haven't had it checked.

Melanie: And you mentioned the A1C hemoglobin test. Explain a little bit about a fasting blood glucose and the tests that the doctor might run or should they run in your annual physical to see if you are somebody at risk.

Dr. Desai: Absolutely. So, the hemoglobin A1C is one of the more convenient tests we have because it checks the amount of hemoglobin that has been bound to sugar and checks it over a three-month period because that's the average life cycle of a red blood cell, and so the diagnostic criteria for diabetes is when the A1C goes at or above 6.5. Now, sometimes hemoglobin A1C can be skewed, say from things like transfusions and what not, and so the other tests that can be done are and to meet diagnostic criteria for diabetes are having a fasting plasma glucose that's greater than or equal to 126 milligrams per deciliter on more than one occasion. So, a fasting, where you haven't eaten or drank anything in 8-12 hours, and your doctor checks that and if that number is say 130 then we want to repeat that. We can't just say, that's diabetes. We repeat that, and if it's on more than one occasion, then that's concerning. The other one is just -- say you come in and say you didn't fast, and that's ok, but if the random glucose is over 200 that's a red flag, and so that should also be checked again. So, those are some of the things to look for.

Melanie: So, then, what would somebody do? What would be the first line of defense if you are told that you are have full-blown diabetes, or even if you're pre-diabetic -- what do you tell them to do right away because people think as in type 1, insulin-dependent, they think right away they have to start giving themselves insulin, but they don't understand that there are other things that can be done -- first line of defense -- and that type 2 is different because as you mentioned -- it's a resistance type of diabetes? So, explain what that first line -- what would you do for them?

Dr. Desai: So, and this is single-handedly the biggest thing that you need to do for type 2 diabetes is you have to look at how you got here, and that usually means looking at what you've been eating, what kind of exercise activity do you have, the type of lifestyle that you've been leading. If the diet is predominately heavy in your breads, your pastas, pizzas, potatoes or very rich in certain fatty foods, and we're not exercising. So, to burn off these calories, then this is single-handedly the biggest thing that needs to change because at the end of the day, we have medicines, and we have more medicines today available for diabetes than we ever have, but medication should not be the answer. The fixing of the lifestyle and the diet can do more to get you out of the pre-diabetes range or even the diabetes range, and at the end of the day, that will help sustain and protect you much longer. If it happens that you've done all this and still are not quite there though, there are some medications that are available to you.

Melanie: So what would you like people to know about diet in these last few minutes? And when you mentioned sugars, people get a little confused Dr. Desai about -- they hear the word carbohydrate. They say it's bad for you, so they don't eat them, but tomatoes and carrots are carbohydrates as well, and so you want that healthy diet combination. What do you tell people every day about leading that healthy lifestyle, getting the exercise, and the diet they should try to follow?

Dr. Desai: So, in terms of exercise, the goal here is if you haven't been exercising at all, if you can give me 10 minutes three times a week, just a start. Just to get you out moving around, even that little bit will start helping. Ultimately, the goal, which has been well-validated and studied is to hit about 150 minutes a week of exercise, and that’s about 30 minutes, 5 days a week, and that exercise will help the body burn the sugar, help burn some of the excess fat, and help reduce that insulin resistance.
Now, the diet is going to involve looking at a couple of things. What are your sources of carbohydrates? And like you mentioned that fruits and vegetables, while we encourage that you eat more fruits and vegetables, certain ones have more carbohydrates than others. So, it's balancing them. You can't be sitting there having, you know, fruit salad or fruit cocktails and say, ”Well, you know this is healthy, right?” No, because there’s still so much sugar. It's about looking at your plate and saying where can we improve on this? A simple idea is if you look at the -- if you divide your plate into quarters, then half of the plate should be, you know, vegetable-based and a low carbohydrate. So, roughage -- spinach, kale, some degree of tomatoes and carrots, but then your true heavy-duty carbohydrates -- potatoes, breads, pastas -- should be only a single quarter, and then meat or protein sources would make up the other quarter and that would constitute a more balanced plate for you. What I like to tell my patients is if you're going to go have a sandwich, just take off one piece of bread. Make it an open-faced sandwich. So, you've reduced your carbohydrate intake for that particular meal at least by half. Or if you're going to have Mexican food -- if you're going to have it, get the burrito bowl as opposed to the burrito. Everyone likes the stuff on the outside -- not the outside. So, if you remove the tortilla wrap, then you get more of the stuff that you want on the inside. So, economically, it's a little lighter, but you always have control in saying, you know, little bit less rice, more meat and vegetables, and that’s how you can make a more protein-rich, vegetable-rich, less carbohydrate meal.
I think that's the thing that scares the patients the most is that – “Oh my gosh, no carbs! What am I going to do?” and it's about smarter carbs, or just seeing how our portions can be a little bit tighter so that we get that feeling of sustenance, but we haven't eaten something that's going to be detrimental.

Melanie: Absolutely great information. If you'd like to wrap it up for us, Dr. Desai, please just give your best advice -- what you tell people every day about hopefully preventing diabetes, and if they do have it, living with and managing.

Dr. Desai: In terms of preventing, we can't stress it enough, look at what you're eating and look at your exercise. If you feel that -- “I be doing a better job” -- you're probably right, and if you can think about the things that I mentioned about the sandwiches and the Mexican food, if you start thinking a little bit more about where something could have been changed, that is singlehandedly the best way for you to start looking at how to improve on the dieting and in following with your lifestyle, and for the people who do have diabetes, this is actually much more exciting time for diabetes in the sense that there are more medications available to us that are not insulins that have very specific goals and how to help manage your diabetes and particularly with weight reduction, we have found that that has such a bigger role to play and so when you get -- if you get told that you are diabetic -- don't panic. It's not automatically going to be insulin. There are some new treatments out there that can really make the diabetes under control and get you to a better health than ever before.

Melanie: Thank you so much for being with us today, Dr. Desai. It's great information. You’re listening to Inside Health with Greenville Health System, and for more information, you can go to ghs.org. That's ghs.org. This is Melanie Cole. Thanks so much for listening.