Whether you have just been told that you have diabetes or you've had it for years, managing diabetes can be a challenge. You are a key player on your health care team when it comes to managing your diabetes. Food, physical activity and stress management are a few of the ways you can help control your diabetes.
Listen as Matt Kresl, PharmD explains that diabetes education at Allina Health clinics offers the knowledge and tools you need to manage diabetes every step of the way.
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Living With Diabetes
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Learn more about Matt Kresl
Matt Kresl, PharmD- pharmacist practitioner
Matt Kresl is a pharmacist practitioner with Allina Health. He started with Allina Health in 2004 and has worked in various patient care and administrative positions. His current practice involves working with primary care providers on improving patient symptoms, better treating chronic diseases, and removing barriers to safety and effectively taking medications.Learn more about Matt Kresl
Transcription:
Melanie Cole (Host): According to the Diabetes Research Institute, in the last decade, the cases of people living with diabetes jumped almost 50% to more than 29 million Americans. My guest today is Dr. Matt Kresl. He's a pharmacist practitioner with Allina Health. Welcome to the show, Dr. Kresl. So, people hear the word diabetes and they think Type I or Type II and they don't know the difference. Please explain that for us.
Dr. Matt Kresl (Guest): Yes. So, Type I is also referred to as Juvenile Diabetes, although that can be a bit misleading because there are certainly other individuals who are diagnosed not in childhood with Type I diabetes. But, you know, the causes are a little different. With Type I, there are suspicions of infectious causes. There are other suspicions that it's an autoimmune-driven disorder, meaning that your body kind of attacks itself, or attacks the pancreas. It's kind of like friendly fire a little bit on the body. The takeaway is that with Type I diabetes, your pancreas is kind of rendered ineffective or not useable as it relates to insulin, so you're basically dependent on insulin to treat your disease. With Type II diabetes, it's a little different. It's usually developed over a lifetime. Most patients, it's developed through lifestyle-related things that go on and not all patients with Type II diabetes need insulin. In fact, many of them don't versus Type I patients which are basically managed exclusively with insulin. So, as far as medicines go, kind of the important distinctions. Again, Type I, very much insulin dependent; Type II's, sometimes insulin necessary, but not always.
Melanie: So, let's concentrate for a minute on Type II as this is becoming more and more common and as we're seeing this obesity epidemic. Type II diabetes, Dr. Kresl, used to be called “Adult Onset”, but now it's called Type II because we're even seeing children and teenagers coming up with this type of diabetes, so what are we doing about it? What kind of medications? What is the treatment that we're seeing now for diabetes?
Dr. Kresl: Well, it kind of depends on you know, where a patient is at and so, really just to kind of set the stage, you know. Diabetes is typically diagnosed with a blood test that you would get at your doctor's office. The way it's been diagnosed has evolved over the years, but the most common test that's done is what's called an “A1C” and that's a shorthand for what's kind of longhand called “hemoglobin A1C”. And if your A1C number is above a threshold, 6.5 is the cutoff, so if it's 6.5 or higher, generally you are labeled or diagnosed with Type II diabetes. Any number, again, above that would tell you worsening degrees of Type II diabetes, and at that point, that's where the intensive discussion with your doctor or provider is going to happen. At that point, there are a couple of decisions. One is if whether you need to go on medications or not or whether you want to approach it with just lifestyle intervention and, frankly, it's going to depend on how high your number is above that threshold of 6.5. Really, to give a little more detail about that test, what that test is picking up is a measure of how much sugar that's been floating around in your bloodstream over about a three-month period of time. So, it's a very useful test for doctors to tell long-term what type of sugar control your body has. And then, from there, decisions about medicine or no medicine can come.
Melanie: There are glucose monitors at the pharmacy. Do you advise people to keep track?
Dr. Kresl: Certainly for diabetics, it's kind of an entry-level expectation and, certainly, for patients that are poorly controlled or have longstanding diabetes, you know, checking 2, 3, 4 times a day is a norm. For those patients that are very well controlled, meaning their A1C is close to 6.5, maybe it's dipped even a little below that, meaning that they've kind of reversed course a little bit, you know, checking a couple of times a week is going to be important, but the level of intensity in monitoring is generally driven by how well or poorly controlled you are. More poorly controlled means more monitoring, less poorly controlled means less monitoring. So, one of the things I always tell my patients is, “The better you do, the less you have to monitor; the less you have to poke yourself.” So, it provides an incentive because most patients don't like to have to check their sugars.
Melanie: So, as we made that distinction at the beginning, Type I is insulin-dependent, so that's generally an injection. Now, what kinds of medications are used for Type II? Is it always an injection? Can it be in oral form? What are the medications?
Dr. Kresl: Yes. So, once you're kind of at the point where you're starting medicines, there are luckily a number of medicines in the toolbox. In the last, I'd say 25 years, there's really been a windfall as far as science in the pharmaceutical industry producing medicines. The first one that most patients will be offered is a medicine called Metformin. The trade name is Glucophage, although it's available in the generic form and very affordable for most patients. You can often get it for $4-6 per month out-of-pocket. What that medicine does is a couple of things. One, is it tells your liver to stop producing sugar to the same degree it had before and the other thing it does is it helps your muscles use sugar a little bit better than it would otherwise. It's a nice medicine; it's generally well-tolerated; and it's got a lot of evidence supported kind of life-changing, life-altering, life-prolonging effects. And, because it's cheap, generally well-tolerated, there's a lot of evidence where it's benefit; it's generally kind of the first option providers are going to offer. But there are certainly many others. There's a medication class called the Sulfonylureas. There are medicines called GLP-1 Inhibitors; DPP-4 inhibitors; SGLT-2 inhibitors--these are long acronyms and probably will confuse most, but the takeaway is that there are lots of tools in the toolkit for providers and the right medicine for the patient is going to depend on a discussion with your doctor and then really understanding the effects and the side effects.
Melanie: When people ask you, and we know that with diabetes with Type I it's, as we said it's insulin-dependent, but with Type II, it's insulin-resistance; your body just isn't utilizing, but it still making insulin. What do you tell them when they ask about lifestyle and other things that they can do? Because we have learned that exercise has an insulin-like effect. Do you talk about that with your patients?
Dr. Kresl: Yes, I often do. So, as a pharmacist practitioner, we sit down and sometimes patients are newly diagnosed, depending on the situation, we may be meeting with them in conjunction with a diabetes educator. So, as far as lifestyle goes, we do talk about diet. We oftentimes refer the specifics around diet to the diabetes educators, but, yes, that's certainly the first lifestyle intervention. And, we really spend a lot of time talking about carbohydrates because that's the most kind of prevalent culprit of causing high blood sugar to develop. But, certainly from there, it's lifestyle related to physical activity. You know, once patients become obese, it becomes more difficult to move, so we oftentimes set goals around just modest changes in lifestyle that they can build up to. That might be as simple as going on a walk for 10-15 minutes a day, again something as simple as that. But we do look at other lifestyle things. Smoking certainly is not going to improve exercise tolerance, so we do kind of look at the whole patient, the whole picture, and try to make sure we're addressing whatever it is that ails them. Sleeping is another common challenge. A lot of obese patients have sleep apnea or other medical conditions that makes it harder to feel rested during the day, so we oftentimes think about that or discuss that. Again, holistically thinking about what is going to impact lifestyle in a global sense, not just kind of sending them out with get more exercise and have a nice day.
Melanie: So, wrap it up for us, Dr. Kresl, your best advice, what you tell people every day as a pharmacist practitioner about managing their diabetes and what you really want them to know.
Dr. Kresl: I think, really, the best advice I can give them is where they're at. You know, diabetes can be a very frightening diagnosis. It comes with a whole host of worries from kidney damage to stroke and heart attack increases and many patients you'll deal with have family members who have been diagnosed with Type II diabetes and have seen their family members suffer. So, usually the first piece of advice I give them is, “Help me understand what your concerns are. If you have a cousin who had dialysis or a mother who went blind from diabetes, okay, well, let's talk about that.” And then, once I understand what their worries are, then I can talk about what motivating factors are going to be needed to take your medicines as you should, to check your blood sugars, and to know what the numbers mean. What's a good number, what's a bad number, what risks come with the medicines, meaning low blood sugars or things like that. And then, from there, you know, what type of follow up they're going to see. So, that might mean coming to the doctor's office every three months, it might mean coming to the doctor's office every six months for their A1C re-check, and then just to give them hope that while Type II diabetes isn't necessarily cured, it is oftentimes a disease that I would call reversed, or optimally managed, meaning that you can largely make it disappear and there is hope for medicines to be reduced or stopped if the disease is managed. So, I know that's more than one piece of advice, Melanie, but that is kind of what I try to tell patients when they're dealing with this.
Melanie: Well, it's certainly great advice, Dr. Kresl. Thank you so much for being with us today. You're listening to The WELLCast with Allina Health and for more information, you can go to www.allinahealth.org. That's www.allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): According to the Diabetes Research Institute, in the last decade, the cases of people living with diabetes jumped almost 50% to more than 29 million Americans. My guest today is Dr. Matt Kresl. He's a pharmacist practitioner with Allina Health. Welcome to the show, Dr. Kresl. So, people hear the word diabetes and they think Type I or Type II and they don't know the difference. Please explain that for us.
Dr. Matt Kresl (Guest): Yes. So, Type I is also referred to as Juvenile Diabetes, although that can be a bit misleading because there are certainly other individuals who are diagnosed not in childhood with Type I diabetes. But, you know, the causes are a little different. With Type I, there are suspicions of infectious causes. There are other suspicions that it's an autoimmune-driven disorder, meaning that your body kind of attacks itself, or attacks the pancreas. It's kind of like friendly fire a little bit on the body. The takeaway is that with Type I diabetes, your pancreas is kind of rendered ineffective or not useable as it relates to insulin, so you're basically dependent on insulin to treat your disease. With Type II diabetes, it's a little different. It's usually developed over a lifetime. Most patients, it's developed through lifestyle-related things that go on and not all patients with Type II diabetes need insulin. In fact, many of them don't versus Type I patients which are basically managed exclusively with insulin. So, as far as medicines go, kind of the important distinctions. Again, Type I, very much insulin dependent; Type II's, sometimes insulin necessary, but not always.
Melanie: So, let's concentrate for a minute on Type II as this is becoming more and more common and as we're seeing this obesity epidemic. Type II diabetes, Dr. Kresl, used to be called “Adult Onset”, but now it's called Type II because we're even seeing children and teenagers coming up with this type of diabetes, so what are we doing about it? What kind of medications? What is the treatment that we're seeing now for diabetes?
Dr. Kresl: Well, it kind of depends on you know, where a patient is at and so, really just to kind of set the stage, you know. Diabetes is typically diagnosed with a blood test that you would get at your doctor's office. The way it's been diagnosed has evolved over the years, but the most common test that's done is what's called an “A1C” and that's a shorthand for what's kind of longhand called “hemoglobin A1C”. And if your A1C number is above a threshold, 6.5 is the cutoff, so if it's 6.5 or higher, generally you are labeled or diagnosed with Type II diabetes. Any number, again, above that would tell you worsening degrees of Type II diabetes, and at that point, that's where the intensive discussion with your doctor or provider is going to happen. At that point, there are a couple of decisions. One is if whether you need to go on medications or not or whether you want to approach it with just lifestyle intervention and, frankly, it's going to depend on how high your number is above that threshold of 6.5. Really, to give a little more detail about that test, what that test is picking up is a measure of how much sugar that's been floating around in your bloodstream over about a three-month period of time. So, it's a very useful test for doctors to tell long-term what type of sugar control your body has. And then, from there, decisions about medicine or no medicine can come.
Melanie: There are glucose monitors at the pharmacy. Do you advise people to keep track?
Dr. Kresl: Certainly for diabetics, it's kind of an entry-level expectation and, certainly, for patients that are poorly controlled or have longstanding diabetes, you know, checking 2, 3, 4 times a day is a norm. For those patients that are very well controlled, meaning their A1C is close to 6.5, maybe it's dipped even a little below that, meaning that they've kind of reversed course a little bit, you know, checking a couple of times a week is going to be important, but the level of intensity in monitoring is generally driven by how well or poorly controlled you are. More poorly controlled means more monitoring, less poorly controlled means less monitoring. So, one of the things I always tell my patients is, “The better you do, the less you have to monitor; the less you have to poke yourself.” So, it provides an incentive because most patients don't like to have to check their sugars.
Melanie: So, as we made that distinction at the beginning, Type I is insulin-dependent, so that's generally an injection. Now, what kinds of medications are used for Type II? Is it always an injection? Can it be in oral form? What are the medications?
Dr. Kresl: Yes. So, once you're kind of at the point where you're starting medicines, there are luckily a number of medicines in the toolbox. In the last, I'd say 25 years, there's really been a windfall as far as science in the pharmaceutical industry producing medicines. The first one that most patients will be offered is a medicine called Metformin. The trade name is Glucophage, although it's available in the generic form and very affordable for most patients. You can often get it for $4-6 per month out-of-pocket. What that medicine does is a couple of things. One, is it tells your liver to stop producing sugar to the same degree it had before and the other thing it does is it helps your muscles use sugar a little bit better than it would otherwise. It's a nice medicine; it's generally well-tolerated; and it's got a lot of evidence supported kind of life-changing, life-altering, life-prolonging effects. And, because it's cheap, generally well-tolerated, there's a lot of evidence where it's benefit; it's generally kind of the first option providers are going to offer. But there are certainly many others. There's a medication class called the Sulfonylureas. There are medicines called GLP-1 Inhibitors; DPP-4 inhibitors; SGLT-2 inhibitors--these are long acronyms and probably will confuse most, but the takeaway is that there are lots of tools in the toolkit for providers and the right medicine for the patient is going to depend on a discussion with your doctor and then really understanding the effects and the side effects.
Melanie: When people ask you, and we know that with diabetes with Type I it's, as we said it's insulin-dependent, but with Type II, it's insulin-resistance; your body just isn't utilizing, but it still making insulin. What do you tell them when they ask about lifestyle and other things that they can do? Because we have learned that exercise has an insulin-like effect. Do you talk about that with your patients?
Dr. Kresl: Yes, I often do. So, as a pharmacist practitioner, we sit down and sometimes patients are newly diagnosed, depending on the situation, we may be meeting with them in conjunction with a diabetes educator. So, as far as lifestyle goes, we do talk about diet. We oftentimes refer the specifics around diet to the diabetes educators, but, yes, that's certainly the first lifestyle intervention. And, we really spend a lot of time talking about carbohydrates because that's the most kind of prevalent culprit of causing high blood sugar to develop. But, certainly from there, it's lifestyle related to physical activity. You know, once patients become obese, it becomes more difficult to move, so we oftentimes set goals around just modest changes in lifestyle that they can build up to. That might be as simple as going on a walk for 10-15 minutes a day, again something as simple as that. But we do look at other lifestyle things. Smoking certainly is not going to improve exercise tolerance, so we do kind of look at the whole patient, the whole picture, and try to make sure we're addressing whatever it is that ails them. Sleeping is another common challenge. A lot of obese patients have sleep apnea or other medical conditions that makes it harder to feel rested during the day, so we oftentimes think about that or discuss that. Again, holistically thinking about what is going to impact lifestyle in a global sense, not just kind of sending them out with get more exercise and have a nice day.
Melanie: So, wrap it up for us, Dr. Kresl, your best advice, what you tell people every day as a pharmacist practitioner about managing their diabetes and what you really want them to know.
Dr. Kresl: I think, really, the best advice I can give them is where they're at. You know, diabetes can be a very frightening diagnosis. It comes with a whole host of worries from kidney damage to stroke and heart attack increases and many patients you'll deal with have family members who have been diagnosed with Type II diabetes and have seen their family members suffer. So, usually the first piece of advice I give them is, “Help me understand what your concerns are. If you have a cousin who had dialysis or a mother who went blind from diabetes, okay, well, let's talk about that.” And then, once I understand what their worries are, then I can talk about what motivating factors are going to be needed to take your medicines as you should, to check your blood sugars, and to know what the numbers mean. What's a good number, what's a bad number, what risks come with the medicines, meaning low blood sugars or things like that. And then, from there, you know, what type of follow up they're going to see. So, that might mean coming to the doctor's office every three months, it might mean coming to the doctor's office every six months for their A1C re-check, and then just to give them hope that while Type II diabetes isn't necessarily cured, it is oftentimes a disease that I would call reversed, or optimally managed, meaning that you can largely make it disappear and there is hope for medicines to be reduced or stopped if the disease is managed. So, I know that's more than one piece of advice, Melanie, but that is kind of what I try to tell patients when they're dealing with this.
Melanie: Well, it's certainly great advice, Dr. Kresl. Thank you so much for being with us today. You're listening to The WELLCast with Allina Health and for more information, you can go to www.allinahealth.org. That's www.allinahealth.org. This is Melanie Cole. Thanks so much for listening.