Show 1173: How Is Diabetes Diagnosed and Treated?
I'm Joe Graydon Terry Graydon welcome to this podcast of the People's pharmacy you can find previous podcasts and more information on a range of health topics at People's pharmacy dot com type. Two Diabetes is one of the fastest growing epidemics around the world. What's the best way to diagnose this condition? This is the people's pharmacy with Terry and Joe Graydon and there are important differences between type of one and type two diabetes. What are they and how do they impact treatment? Traditionally many diabetes experts believe believe that aggressive blood sugar management would reap rewards in better health researchers have tested that strategy. How well did it work? The price of insulin has been skyrocketing as a result. Some people have been rationing earning their doses. How does that impact their health coming up on the People's pharmacy learn how diabetes diagnosis and treatment is changing welcome to the People's People's pharmacy? I'm Terry Graydon. I'm Joe Graydon today. The topic is diabetes according to the C._D._C. More than thirty million Americans have this metabolic disorder. That's roughly one person in ten type. Two Diabetes Diabetes says become an epidemic not just in the United States but around the world to learn more about how diabetes is diagnosed and treated we turn to Dr Kasha Lipscomb. She's an assistant professor of medicine and an endocrinologist endocrinologist at Yale School of Medicine Doctor Lipsky is also a clinical investigator at the Yale Newhaven Hospital Center for outcomes research evaluation abbreviated core welcome to the People's pharmacy Dr Tactic Kasha Lipsky. Thanks for having me Dr Lifts Insulin has been available to treat diabetes since nineteen twenty two and there have been recent investigative reports that note the price of insulin has skyrocketed in recent years. We're going to discuss that in a few minutes because I know you have some opinions about that but I can. You please give us an overview on diabetes basics and the difference between type one mm-hmm and type two diabetes. Absolutely diabetes is a chronic condition that's defined by elevated blood sugars and the bloodstream <hes> so we define diabetes it just based on that that somebody has an elevated blood sugar either at that moment or we also measure something called Hemoglobin a one C which gives us a measure of blood sugars over the last two to three months on average. There are two different types of diabetes than the two major types of diabetes are type one and type two type. One diabetes happened when the Pinkus Stop secreting any insulin and typically typically type one diabetes diagnosed early in life but it can actually occur anytime during somebody's lifetime it is an auto immune disease which means that the body itself is producing immune cells that attack the pancreas pancreases and that results in insulin deficiency or not enough insulin in the body <hes> because there's not enough insulin blood sugars are very high and in order to treat type one diabetes people absolutely need insulin to survive type. Two diabetes is the more common type of diabetes in our country and that is typically diagnosed later in life although if had actually an epidemic of type two diabetes now in in younger patients as well and that type two diabetes is associated with increased body weight and happens because the insulin and the body is so the body's not responding to insulin properly something called insulin resistance there is actually insulin around but the body's not recognizing insulin properly and the end result is that blood sugar levels go hi the treatment for type two diabetes varies so some of it may start with changes in lifestyle such as <hes> diet that's low and carbohydrates and sweets <hes> with with some weight loss that can really help control the blood sugars exercise size and then a variety of medications that may sensitize the body to the insulin. That's already around some people would type two diabetes also require insulin particularly later in the course of their diabetes to control the blood sugars ducker lifts. I've heard this described as sort of a real paradox where you've got all of this fuel this glucose sugar a floating around in the bloodstream but you're sort of starving to death because you can't get that fuel into the cells where it needs to be and so that's what happens when the insulin is not available to do the job of transporting that glucose someone wants described it a little bit as if you were in a lifeboat in the middle of the ocean surrounded by water but not a drop to drink because as you can't drink the saltwater. Is that a fair analogy. I think that's a very good description Joe. That's exactly right <hes> the insulin unlocks this ability of the sugar to get into cells so that we can produce energy so you're exactly right without either insulin around or proper response to insulin the body is unable to use that fuel as energy and that that can produce devastating devastating consequences for people particularly those have no insulin around <hes> people can die without it duck lipsky. How'd you diagnose diabetes? Diabetes is diagnosed <hes> based on a blood test that shows either increased <hes> level of Plasma Blood Glucose or sugar in the blood and that's typically done in the fasting state so we have different criteria for diabetes media. If if you get a fasting blood sugar you're you haven't eaten <hes> at least for at least eight hours before that and you get a blood sugar that hundred twenty six milligrams per deciliter Amore and that's confirmed firm on a subsequent test that is diagnostic for diabetes. You can also diagnose diabetes with something that I mentioned before Haemoglobin Onc- which is the an indicator of average blood sugars over the last two to three three months and hemoglobin when C._F.. Six point five percent or more is is diagnostic of diabetes and then there's one other test that's done that to our oral glucose tolerance test where somebody ingests glucose and we measure to see what their blood sugar is and a blood sugar growth of two hundred or more two hours after glucose or or sugar load as is also diagnostic diabetes Dr Lipsky. There's been a bit of the controversy in the last several weeks about this diagnostic approach to you know determining whether somebody actually has diabetes or not and that's the what you referred to as the hemoglobin a one C versus the oral glucose tolerance tests that we've actually heard from a lot of our readers saying hey you know I I was normal on hemoglobin a one C but then it turned out that I actually had diabetes in the oral glucose tolerance test revealed that so convenience versus accuracy what do you you think while you're right Joe that the hemoglobin and went see test is very easy to do. You don't need to be fasting. You can do it anytime of the day you get your blood test and you're done the oral glucose tolerance test is is used less often because has it requires the glucose load and then you have to have a blood glucose level checked two hours later so it's it's not as convenient but as you noted there are some circumstances under which the hemoglobin ONC- <hes> test may not pick up on diabetes <hes> including their differences in a one sees by race by certain chronic conditions and in people with variety of <hes> red blood cells survival times so there there are some circumstances Francis under which it may not be as accurate Dr Lifts CA patients care about different things than hunters to and that's not to say that there isn't a shared concern but what what people really want from their diabetes management program is I think first of all quality of life and longevity they don't WanNA heart attack. They don't WanNA stroke they want to avoid kidney disease and visual problems and neuropathy nerve pain and we could good down a long list of things that people really are trying to avoid when it comes to whether it's type one type two diabetes but the food and Drug Administration often often approves medications based on their ability to lower blood sugar not necessarily to provide the outcomes that patients are looking for so. Can you help us better understand the difference between what will call all the surrogate endpoint of blood glucose versus really important clinical outcomes like heart attacks strokes neuropathy etc Joe. That's really critical. I think it for us to understand how drugs affect what matters to people I a you. Put it very very nicely what you asked. That's exactly right so the the F._D._A.. Right now approves drugs for diabetes based on how they lowered blood sugar. Although they've changed their guidance over time and now they require that the drugs be at least cardiovascular the safe which seems a little bit backwards if you if you ask me that you know one of the biggest risks risks from diabetes heart disease but the drugs just just need to not increase the risk of heart disease they don't need to actually lower it but they're not required to show that these drugs that we used to lower blood sugars actually reduce the risk risk of blindness. I'm mutations and kidney problems and overtime. I think we've learned that different drugs have different effect on these outcomes even though they may lower blood sugars just the same so for example <hes> there are drugs that have been implicated in increasing the risk of heart disease like Rosie glittered zone Rosie glitters own lowers blood sugars at does a lot of things that you would think would be helpful for the cardiovascular system stem but yet it may actually increase the risk of heart disease but another medication. It's just more new and peg lift Lison also lowers blood sugars and in recent trials was shown known to actually reduce the risk of heart disease so I think what we're learning over time is that it's not just about lowering blood sugars. We have to really know how these drugs affect the things that mattered to patients such as having a heart attack and even though to drugs may lower blood sugars about the same they may have different impact on those and points such as the heart disease <hes> <hes> so. I think I'd I diabetes is actually undergoing a lot of change given these findings that we we realizing that the strategy that we use to lower blood sugar really matters. You're listening to Dr Caccia Phillips GotTa. She's an assistant professor of medicine and an endocrinologist at Yale School of Medicine Doctor Lips Gut is also a clinical investigator at Yale Newhaven Hospital Center for Outcomes Research and Evaluation Valuation Terry. I'm so glad that she emphasized the importance of outcomes that matter to patients versus those surrogate end points absolutely after the break will learn more about how doctors are rethinking thinking the goals for Hba One C. Can you get blood sugar too low. What happens then find out what hypoglycemia that low blood sugar? You're talking about feels like is there an advantage to continuous continuous glucose monitor a large scientific study aimed for very tight blood sugar control. I I wonder how well it did our older people with diabetes being over treated. We'll find out how to tell whether symptoms. As an older patients are due to low blood sugar or a T._i.. You're listening to the People's pharmacy with Joe and Terry Graydon. The People's pharmacy podcast is sponsored in part by Kaya -Biotics Kyi. A -biotics offers the first probiotics which are both certified organic and Hypo allergenic. All probiotics are produced in Germany under laboratory conditions with high quality ingredients and under strict regulatory oversight the three available formulas are created for very specific purposes such as strengthening the immune system fighting yeast infections and helping with weight loss to learn more about Kaya -biotics probiotics and the important topic of gut health. You can visit their website Kaya -biotics dot com. That's K. A. Y.. A. -BIOTICS DOT COM use the discount. What Code People for ten dollars off your first purchase welcome back to the People's pharmacy? See I'm Joe Grayton and I'm Terry Graydon if you would like to purchase a C._D.. Of this show you can call eight hundred seven three two two three three four. This is shown number one thousand one hundred seventy the three the number again eight hundred seven thirty to twenty three thirty four for you can visit our website people's Pharmacy Dot Com and place your order then you can also download the podcast from our website or wherever you get your podcasts casts. The People's pharmacy is brought to you in part by Verizon A- An analytical laboratory providing home health test for hormones gut health and the microbiome online at V. E. R. I. S. A. N.. A. Dot dot com today. Our topic is diabetes. Can you treat this condition too. Aggressively what are the most appropriate goals for blood sugar control were talking with Dr Cashew Lipscomb. She's an assistant professor sure of medicine and an endocrinologist at Yale School of Medicine Doctor Lips is also a clinical investigator at Yale Newhaven Hospital Center for outcomes research in Evaluation Dr Lips Go. We understand that over the years people who have been dealing with diabetes have been encouraged to try to get their H._p.. A one C number as low as they possibly can and there's some wreath thinking of of that goal that you have been involved in. Can you fill us in please sure thing Terry. You're correct that for many decades I think <hes> this point. We've we've heard that lower is better. Get it as low as you possibly can with H._p.. ONC- and truthfully you know if you're lowering your each one see because you have type two diabetes and you're eating healthy and you're exercising and you've lost weight and you're going down in down in down. There's really no no <hes> no harm to that that that's great. I think that the controversies really in people who require medications to do so and that's because the medications carry a certain risk of harm and the the more medications you require to lower your H._p.. One see the bigger the harm they're still controversy even among doctors about hollow. Oh these blood sugars should on average be or how low the H._p.. Once she should go again for many decades <hes> the guidelines said you know for most people H._p.. ONC- should be below sevenpercent but now even among guideline headline makers there are disagreements. The diabetes guidelines still say most people should go under seven but the American College of Physicians recently put out a guideline which said well for most people that number should be between seven the eight percent so less stringent correct less stringent according to the A._C._p.. Or the American American College of Physicians this reminds me a little bit of the the guidelines in the recommendations nations over the years for cholesterol or even for high blood pressure because there was a time you know fifty sixty years ago in doctors were a little more casual about both lipids as well as hypertension and then the last decade or too. It's like no no no. You can't get cholesterol too low. You know if it's if it's L._D._l.. Of thirty that's way better than seventy which is way better than a hundred with etc and did with high hi hi blood pressure people never get concerned or very rarely get concerned if blood pressure is like one ten over sixty unless of course here a little old lady and you start falling over when you stand up we'll that's where I was going next next. What happens when people are just too aggressive in getting their hemoglobin a one c down because some people think that's like a report card the lower the better and you're suggesting that so fast and that's right not so fast and that's because these again it's different in in people who don't require medications and so-called Diet Control Diabetes? I think that Diet and exercise are healthy ways if controlling blood sugars but once you require medications there are risks to them particularly with the use of insulin all people type one diabetes require insulin on about a third or thirty percent of people type two diabetes eventually they require an insulin to control their blood sugar in our country and those those medications insulin or insulin like medications can lower blood sugars too much and cause low blood sugar reactions. hypoglycemia and hypoglycemia can be quite dangerous eight first of all. It doesn't feel good to people so we know it's people report their health related quality of life is worse when they experienced hypoglycemia and <HES> can develop yeah go ahead what does it what does it feel like what well it feels like <hes> almost like a panic attack sometimes so you feel your heart is racing. You may feel sweaty. You Feel Hungry Week Doc <hes> like you're you're craving fuel in your body because you're you're the blood sugar and the blood is so low sometimes when the blood sugar goes to low though you may run out of fuel particularly to the brain I and you may pass out completely so you can go into a coma and you can die when when blood sugars run really really low so it's very it can be very dangerous and this can happen with both insulin as well as oral medicine awesome it can happen with insulin and I think I said insulin the like oral medicine so there's a group of medicines called Insulin Secreta dogs which include soften a urea drugs like lip aside glamorized Glib you ride and then <hes> kind of less used medicines called Glee nights so not with all of oral medications but certain ones yes Dr Lipscomb. I think everyone has seen the type of finger prick blood tests that people with diabetes use to determine what their blood sugar is right at that moment and <hes> people who use insulin in May test several times a day people with type. Two diabetes may only test <hes> a few times a week. Perhaps we have encountered a new technology that even people who don't have diabetes diabetes are starting to use that is continuous glucose monitoring system that does so through a patch that you slept on your arm. Is this something that will be helpful for people with Diabetes So yes continuous glucose monitoring can be very helpful to some people with diabetes particularly people who use insulin and require multiple as you said multiple finger sticks today so oh it's particularly helpful in people with type one diabetes or those people with type two diabetes who are more have more advanced disease where they require multiple injections today and particularly those people who are prone to low blood blood sugar reactions or hypoglycemia because we can pick up those with with these C._G._M.'s continuous glucose monitors now there were some trials they they they had an umbrella name called accord and I'm sure that you know what that stood for but we don't even younger and in this trial they basically were thinking aggressive aggressive control of blood sugar aggressive control of blood lipids like cholesterol aggressive aggressive control of high blood pressure and everybody thought well hey people with diabetes or the there the canaries in the coal mind if we can demonstrate that aggressive control of blood sugar for these folks folks is really working well and that will have implications. Perhaps for the wider community it kind of flamed out what happened. Yes I think it was a it was a huge surprise in disappointment because has early on the trials for diabetes did show did demonstrate that lowering blood sugars can reduce the risk of complications of diabetes like problems with vision amputations nerve nerve problems kidney problems and so there was <hes> there was enthusiasm for for lowering blood sugars and demonstrating that you know that that this may have beneficial effects that the try to you mentioned a cord <hes> there were two other trials around that time advance in V._D._T.. Where really designed to answer the question of whether lowering blood sugars even more than in prior trials can reduce the risk of heart disease and heart disease? The major issue for people with with diabetes diabetes really increases the risk of heart disease so <hes> the thought was that you know if you nor you bring the blood sugars close to normal. Maybe be weakened reduced that risk and unfortunately at least in these trials among the people this was among people with type two diabetes most of whom have had diabetes for awhile so there were not newly diagnosed. Neither one of these three trials reduce the risk of heart problems and accord one of the three trials was actually stopped early because of increased risk of death in the group of patients who were randomized to the more intensive blood sugar control and that was big surprise in a disappointment has that had an impact on how doctors think about <hes> treating diabetes over the last ten years so because I think it was about ten years ago that it was published accord was in no I think it was Oh yeah you're right. Two thousand eight correct has it had an impact. I think that the field has has shifted from you know pushing blood sugars again as as low as they can to now a more cautious approach although some of my work suggests that we still treating a lot of patients with advanced diabetes with many chronic conditions too tightly despite this evidence well in fact Dr Lips got in a recent New York Times article a new are expedite beatty's lighten up you are quoted it about your research saying it's important in shifting the thinking that lower is always better are older people with diabetes being over treated what we found is that treatment mint of diabetes both in terms of the low A. Onc- and also the types of medications used to achieve it really did not differ based on what we called the health status or how healthier stick you were which which is totally against what most of the guidelines recommend. which is you know you should treat based on these factors? If somebody's healthy without many chronic conditions you can treat them more aggressively particularly with these medications that carry less risk of hypoglycemia or low blood sugar reactions but if you have somebody who has end stage comb abilities who was very sick who has functional impairments well. You should be more careful in that person you should you should. You should really try to make sure that the treatment is safe again. We we found no evidence that that treatment differed am in these groups of people which suggests that one you know we have a lot of over treatment into that. We're not really individualizing care meaning that we're not tailoring <hes> the treatment based on on those factors how sick or healthy somebody is. It sounds as though that would be something you'd advocate. Yes absolutely I think it's really important that treatment is on a case is designed on a case by case basis and not just based on age or how many chronic conditions somebody has but also based on who that person is what do they want in terms of goals of care and how difficult it is to get them there right so there may be a person who is really <hes> not burdened by checking finger sticks often or taking multiple injections today <hes> an is happy to do that that doesn't doesn't lower their health related quality of life but there may be another person where that is really bringing them down and their quality of life is really affected by the treatment of diabetes in that person thinking about how to reduce that burden how to make the diabetes eighties as least disruptive in their life as possible isn't important. I think role for the clinician one of the symptoms of hypoglycemia that I worry about a lot especially in older people is dizziness us and the possibility that people may fall because a fall in an older person can lead to a hip fracture which can lead to all kinds of devastating consequences. What are the symptoms that you tell your patients to watch out for when it comes to to low blood sugar? This Simpson's May vary from person to person so I think it's it's really critical when a physician or clinician is starting treatment treatment with drugs that may put that person risk for hypoglycemia to describe this some patients may have the classic symptoms the heart racing sweating feeling weak perhaps dizzy hungry and it's easy to identify but others may have more <hes> subtle symptoms in fact one of the things that's really important. particularly in older person's is that they're they're mental. Status may change so I've had patients where they've had these episodes of sort of what people had called cognitive impairment. They were not really there. They seem to kind of drift off somewhere else. What turned out when we when we tested their blood sugars that their blood sugars were actually low so at those times and once we fix the blood sugars their their mental state really improved so some symptoms may be classic but there may be also more subtle symptoms? It sounds like that could actually be kind of hard to narrow down. Some people might think that this older person is having a T._A.. or a mini stroke correct sometimes it is hard to identify and I think particularly in people who are prone to hypoglycemia and those who use insulin it's important to monitor blood sugars either through finger sticks or you know people where we suspect well May- maybe there is something going on there that could be hypoglycemia to <hes> to potentially put on a continuous glucose monitoring device at least for some time to see whether whether there are low blood sugar reactions happening that we may not be otherwise picking up. It sounds a lot like the goldilocks phenomena you don't want it to be too high not too low not too hot not too cold. You're looking for that sweet spot right there in the middle exactly right the right balance and that right balance may be different for different people which is where you know a lot of guidelines now suggests that you really have to sit down with the patient on talk to set them about what's right for them. Dr Lips Go. We have a very good friend who has type one diabetes and he has a challenge because his blood sugars can go up to two fifty or three hundred and then they can drop down to forty or fifty and so it seems like he's on a roller coaster ride and that can be a very hard thing for the body. Yes your friend is not alone many any patients particularly those with type one diabetes or advanced type two diabetes when there isn't any insulin around have these experiences of a fluctuations in in blood sugars from really high really low or Brittle Diabetes Ace. We know that it first of all doesn't feel good to people right so these these swings in blood sugars can really affect how a person feels and functions and obviously the very low blood sugars can be a can can cause serious harm so that's difficult situation. You're listening to Dr Kasha Lip Ska. She's an assistant professor of medicine and an endocrinologist at the Yale School of Medicine Doctor. Lipsky is also a clinical investigator at Yale newhaven. You Haven Hospital Center for outcomes. Research and evaluation also called Core C. O. R. E.. I love the idea of this continuous glucose monitoring system because it really gives you a much finer her insight as to what's actually going on inside the body chew enough after the break will find out why insulin has gotten so expensive. What's the impact on patient health? Doctor Lips got testified about insulin prices cases before Congress. What did she tell them? Can people with diabetes live there healthiest life and how can people get their numbers in line with flexible guidelines. You're listening to the People's pharmacy with Joe and Terry Graydon. Yeah welcome back to the People's firm AC- Armijo Grayton Terry Graydon if you'd like to purchase a C._D.. Of today's show or any other people's pharmacy episodes you can call eight hundred seven thirty to twenty three thirty four today day. Show is number one thousand one hundred seventy three that number to call eight hundred seven three two two three four or go to people spicy dot com and you can find it online you can also download the free podcast from Apple Stitcher or from our web store. We invite you to consider writing a review. The People's pharmacy is brought to you in part by Kaya -biotics probiotic products made in Germany from certified organic organic ingredients K. A. Y.. A. -BIOTICS DOT COM. We're talking today about diabetes and how it's treated for people who have type one diabetes insulin is not optional. It's their lifeline line. The cost of insulin has been rising dramatically. How does this impact patient? Health or guest is Dr Kasha Lipscomb. She is an assistant professor of medicine and an endocrinologist. They Yale School of Medicine. Dr Lipsky is also a clinical investigator at Yale Newhaven Hospital Center for outcomes research and evaluation that your lips go. We've seen the price on a lot of different medications go up lately but the price of insulin is out of sight. This is an old drug. Main insulin has been around since nineteen twenty two. Why in the world is it becoming so expensive active the price of insulin's absolutely outrageous? I totally agree with you and the reasons for this are now under intense public scrutiny. I think that the people we'll have various opinions of why this happened but if you want to boil it down it can be quite simple in the United States just the re pharmaceutical companies have patent that allow them to manufacture insulin and that's ally Lily Jason Ofi in Nova Nordisk so we have three giants controlling our U._S. market for insulin and making much money as they can perhaps and making as much money as they can exactly this is stuff for profit industry and clearly we've seen the prices for competing products go up and up and up also in tandem together which suggests that this this market is not competitive. It's not the same as with some of the statin drugs or blood pressure medications that have been around whether it's a very strong generic competition that helps to bring prices down. We really haven't seen that with insulin with insulin. We have of these branded products that have just gone up an up and price. What's the impact on patient health? The impact of these high insulin prices is dramatic on people. I I became interested in this issue because patients began to tell me stories about you know the types of things they had to do in order to buy insulin or they were simply saying no Dr Scott Sorry. I can't go up on my insulin. Does I can just barely afford what I'm what I'm buying now so the the impact on a patient is is that patients can't you know many patients cannot afford insulin and many ration insulin. We have done a study in our yield diabetes Diabetes Center asking patients over the last year. How often have you used less insulin than prescribed specifically because of cost and we found that one in four patients reported rationing insulin? That's a huge proportion of people at diabetes. What are the consequences of rationing insulin? When people would type one diabetes use less insulin them prescribed or you don't use Insulin Day Condi- right so we've we've had very very sad and tragic consequences to this and people have died because they could not afford to buy their insulin so again as it was? We talked earlier. People type one diabetes need insulin to survive over the long term. If fusing less you still using enough to stay out of trouble out of diabetic cuter acidosis but not enough to control your blood sugars than you run into the complications of diabetes including blindness <hes> problems with your feet amputations promise with your kidneys going on dialysis and neuropathy so these are devastating consequences. What our other countries doing? I mean what is the solution into this problem because I have to assume that if you're in Norway or if you're in France or Canada or Australia that you know they these countries have type one people with type one diabetes. How how are they managing to control their prices? Prices of drugs are much lower elsewhere in the world compared with what the United States in in fact many patients go to Canada to get their insulin for that very reason and you know we have a system in our in our country where we really rely on market competition and our government states out of the way in many of the European countries and in Canada. There's a there's much stronger. Stronger government presence in regulating these prices and that can bring prices down as we see Dr Phillips Guy Understand that you testified before a House subcommittee easy on the topic of insulin not too long ago. Can you give us the essence of your testimony. Please <hes> sure I testified because I felt I couldn't do enough in clinic right so one when I see patients with with diabetes who can't afford their insulin. I get very frustrated because there's only so much that I can really do to help them. In the office and I felt it was important to to raise a voice and really tell our legislators about what's what's happening in our clinics in what impact this has on patients so the essence of my testimony was to say that this is a huge problem Lim again it affects potentially up to you know maybe more than one in four at least in our center one in four patients rationing insulin others make trade offs where they go they buy less of something else in order to afford their insulin and this this has these devastating consequences on people's health and I think it's I was calling on the legislators to interfere at this point point and to <hes> to regulate this market better because in order for us to protect the patients with with type one and type two diabetes who need insulin to survive into control their disease. I think we need a a better solution than what we have now. <hes> I think that the market is not working the way it is. I assume that your colleagues other diabetes experts of dealing with the same issues that you are equally frustrated because it has to be tragic as a physician to write a prescription for insulin for someone with type one diabetes and learned that they've had to ration it because they couldn't afford it. That's right a lot of people have a lot of physicians have expressed frustration Dr Lips go we heard an anecdote which was very disturbing. A young woman twenty eight years old you know as soon as a person turns twenty eight there too old to be covered under their parent's insurance any longer the affordable care act covers people until they're that age but twenty six twenty six so I believe so yeah I think you're right twenty six so so once a person gets into his or her late twenties they are pretty much on their own. They have to find their own insurance or go uninsured some of them do this. Young Woman said she started rationing her insulin once she had to leave her parents insurance plan and she said nobody cared. Nobody understood that without the next vial of insulin I wouldn't live you know to be able to do anything else us. I think it's unconscionable. What's going on with with insulin? I've heard stories this version of the story many times now <hes> I think that's right. I think our system leaves patients out. I think that the insulin prices are ridiculously high and these these <hes> pharmaceutical company assistance programs really do not have the <hes> the impact that the industry says they do because patients like the the patient you're talking about our common and you hear their stories and there is very little help for them in our system I think that's I think that's absolutely wrong and theoretically a twenty-six twenty-seven-year-old person who is able to control her diabetes. Appropriately has a a good long life expectancy but if not controlling her diabetes diabetes. She's in big trouble. She's in big trouble and she could. She could die right so Alex. Smith was in that exact. It's similar story right. He aged out of his mother's insurance couldn't afford the premium for prescription drug coverage was trying to raise money enough money for his insulin and couldn't and was was found dead with with empty cartridges Trajan for his insulin so this can have very tragic circumstances. There are other young people who you know intentionally <hes> have their blood sugars run highs it can be admitted to the hospital in provided with with free insulin upon discharge for two weeks afterwards Yikes. That's it's crazy yeah. It makes no sense it makes no sense and makes no sense. I'd like to switch gears for just a moment. Talk a little bit about type two diabetes if we might there is a diabetes epidemic in the world. You alluded to it the idea that <hes> younger people including children are now being diagnosed with type two diabetes. Do we have any understanding why what went wrong. We have some understanding of what aren't wrong. You know people people always say that there is a genetic contribution Russian to type two diabetes that there is there is often a family history of of type two diabetes people but if you look at the recent history of the increasing incidents of type two diabetes or genes haven't changed our genes have been the same for those few decades so what's really changed is the environment. It's really the environment that driving this this diabetes epidemic and it can track the obesity rates. The obesity rates go very much hand hand-in-hand with increasing diabetes incidents. I'm that's fueled by the way the way we each the way we work the way we spend our time. which is you know we eat more carbs over time <music>? I'm more more sweetened beverages over time and were much more sedentary than we used to be and that is definitely contributed to the diabetes epidemic. What do you recommend to your patients so they can live live as healthier life as possible despite having diabetes that seems like a simple question but it is so difficult to answer questions are hard to answer and even ought to carry through they are and you have? I do not have the same advice for everyone so I have to tell you that I tell patients that in terms of nutrition the advice that we not as doctors have given them over time has changed and still A._M.. Extremely skeptical about going on record saying things like eat eggs. Don't eat eggs eat carbs. Don't eat carbs. Everybody has to find a diet that fits them and because I see mostly you know my specialize in sort of older patients with diabetes. I find that it's difficult at that age to make huge changes in the Diet. I think people should enjoy their food. I think food that if you eat a variety of foods that are you know as these processes possible. That's likely to be good for you. You eat vegetables and fruits you eat lean meats and fish and you avoid a huge cartloads but that's as sort of specific as as I get to be honest what about activity now I recognize that with older adults that there's a huge huge range in terms of what people are able or interested in doing exactly so it depends again it depends on the person's <hes> ability to to be active <hes> for many older adults it may be safer to do water-based sports to aqua aerobics <hes> or swimming <hes> because some people are more prone to to false they may also need some assistance in and physical training in order ready to do this safely. I'm a huge you know I'm a I'm an athlete. I love sports but I recognize not not everyone does not everyone drives joy from being active so I tried to figure out what is it that the person really likes to do for some some people it's participating in you know walking with the group where it's a it's a social event and they really enjoy being with people and that's what really gets them out going in and walking and so I you know I tried to help them figure how how they can do that so that they can really enjoy that and for some people it's it's other things you know biking or joining a gym or tracking their steps but I think it it really depends on what what is it. That's going to make that person do it again. Dan and again consistently an enjoy it and ducker lips go when it comes to blood sugar readings Hemoglobin A. One see what's your recommendation. How do we get people to not obsess us about trying to get their numbers as low as possible and and get a pat on the back from their doctors so that it's actually more flexible what trying to get there? I think as a as clinicians <hes> I think that that this concept of individualizing care meaning that it's not the same report card for everyone and let's not focus so much on that one particular number but let's think about overall the person's quality quality of life how how they are feeling how they're functioning what's their burden of treatment what brings them joy in life and trying to really focus more on the whole person as opposed to just a number. I think that in the end that's going to be more helpful to helping people really live happy. Healthy lives that cash Lipsky. Thank you very much for talking with us on the People's pharmacy today. Thanks for having me. You've I've been listening to Dr Cossio Lipsky. She's an assistant professor of medicine and an endocrinologist at Yale School of Medicine Doctor. Lipsky is also a clinical investigator at Yale Newhaven Hospital Center for outcomes comes research and evaluation also known as core one of the things that we did not have a chance to talk to Dr Lips about was medications that can either raise blood sugar or actually cause diabetes or make it harder to treat that condition and one of the categories is statins. <hes> there was a study in the British Journal of Clinical Pharmacology not that long ago that suggested statins may increase increase the risk <hes> by about thirty eight percent and they said that you author said individuals using satins maybe at higher risk for hyperglycemia that's high blood sugar insulin resistance and eventually type two diabetes. He's Lynn single produced. Today's show Alydar ski engineered Dave Graydon Edits our interviews. 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