good evening and welcome to doctors on call I'm Dr Ray Christensen faculty member from the Department of Family Medicine and biobehavioral health at the University of Minnesota medical school duth campus and a family physician at the Gateway Family Health Clinic in Moose Lake I'm your host for our program tonight on diabet and other endocrin topics including hyper and hypothyroidism the success of this program is very dependent upon you the viewer so please call in your questions or send them in ahead of time to our email address ask bbsn north.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Kanan Kor a pediatric endocrinologist with essential to health Dr Chris aoti a hospitalist with Aspirus Aspirus St Luke's and Dr Jason wall a family physician with the duth Family Medicine Residency program our medical students answering the phones tonight are Jessica Crossen from Hugo Minnesota McKenzie Peterson from Lever Minnesota and Wyatt Windor from Alexandria Minnesota and now on to tonight's program diabetes and other enderin topics including hyper and hypothyroidism well welcome panel there's a lot there how we're going to cover it all I don't know Canan this is your first time with us do you want to tell us a little bit about yourself sure um I am a pediatric endocrinologist so I deal with children and their metabolic issues metabolic and hormonal issues um on on issues and diseases like type 1 diabetes growth issues puberty concerns and um hypo and hyper hyper thyroid issues as well it's nice to have you here so certainly don't be afraid to call in some pediatric questions we have a family Dock at the other end that can help out too generally we go more for elderly but it's nice to have you here and diabetes takes us there Dr qu what where are you practicing so um I am at St Luke's Aspirus is the way I guess we supposed to say that I know I had it wrong all right it's brand new so I am there about one week to two weeks a month and then I am actually the course thread instructor at the University of Minnesota delut school of medicine for endocrinology and diabetes and enjoy that Jason welcome again thanks hry it's it's great to be here I'm fortunate I get to work at the Family Medicine Residency so when people graduate medical school they come to our program to be a family medicine physician they're with us for 36 months and they learn the whole gamut of you know Pediatrics Adult Medicine obstetrics and everything in between and uh I I have the Good Fortune of working at same Maries in St Luke's so thank you for doing that it's really great for the region and for the state Chrissa we talked a little bit earlier about the history of diabetes and you said that you would tackle that first ah this is one of my favorite stories so if you like history and you like medicine the story of the discovery of insulin is of utmost interest so um in the late 1800s there were two German Physicians who decided to take the pancreas out of a dog and they discovered that that dog then developed the symptoms that were consistent with type 1 diabetes the dog unfortunately perished but that's how research was done back then then um as time progressed and Medicine progressed um there was a physician by the name of um Frederick Banting um who was out of Hudson Bay um in the in Canada and he had a particular interest in studying um what exactly the pancreas made to help treat type 1 diabetes and so he actually hired a medical student to help him with his six dogs um actually he picked the medical student by the flip of a coin um his name was Charles best and the two of them were able to extrapolate what is now insulin from the pancreas of several dogs and were able to keep a dog named Margaret alive for some time by using that substance um a man I I should say a young boy who was 14 named Leonard Thompson was the first human to receive insulin it was sort of a sad story because at that time uniformly type 1 diabetes was Lethal so parents who could identify that their child was sick and a physician at at the time would um diagnose the disease with the the bad message that you know certainly their child would perish so this discovery um was revolutionary it was life-changing and uh Leonard Thompson's father um was anxious to sign up for anything that would save his son and so he was um able to receive the first dose of insulin interestingly Charles Banting and I'm sorry Frederick Banting and Charles best actually tested the insulin on themselves first sure they did and so um they were certain that it was safe and then they they were able to give that to a human they went on to win the Nobel Prize and actually it was awarded to um a man named McLoud and Frederick Banting I'm sorry if this is too long I could go on and on about this story but 30 seconds okay all right the fun part about it is that Frederick Banting decided that actually his student deserved um recognition as well and he split the prize with Charles best and the two of them decided among the other people who discovered insulin that insulin belonged to the world it did not belong to them so they did not take any uh royalties from the discovery they sold the patent for about a dollar to the University of Toronto and um mass production of insulin ensued and so it's a wonderful story of selflessness of Discovery and of medicine thank you if I may add he said specifically I don't I do not want people to profit out of this drug I want it to be free and of course people have never profited out of insulin right they've never made big uh big big big um money from Big Pharma hasn't made any money on insulin it's true to their word so back to you now as the pediatrician here what's the difference between type one and type two diabetes yeah so type one diabetes is an autoimmune autoimmune condition it um it uh the the body's own self destroys this eyelet cells of the of the of the of the like pancreas that that do produce insulin and so there is a deficit of insulin with type 2 diabetes uh there is no deficit of insulin there's enough production of insulin but what happens is the insulin is not able to act properly either because it's not able to sit on the receptor or it's not able to function so in type 1 diabetes there's no insulin insulin and type two diabetes is actually excess insulin but it's not able to function function um effectively Jason pre-diabetes is that reversible and just kind of describe what pre- diab diabetes is and how it relates to diabetes maybe to start certainly there's a Continuum let's say normal blood glucose is let's say less than usually around less than 100 and diabetes would be consistently more than 126 these are all just arbitrary numbers that you know modern medicine has arrived at but there's a range of you know let's say 100 to 125 where we would call that you know elevation in blood sugar over time pre-diabetes and I think just because the sequele the downstream sele of diabetes are you know increased risk of kidney disease kidney failure dialysis um heart disease peripheral vascular disease amput ations you know you're you're immunologically uh suppressed um so you're more at risk for infection all those the sooner we can identify and treat diabetes the better off we're going to be you know we're going to have healthier people healthier communities and so um while the um path to Frank diabetes is um you know is can be gradual it's pre-diabetes is sort of that uh that wakeup call chrisa what's what do you uh you're an internist I believe uh how do you treat diabetes what's what's your what's your sequence and how do you go about that um a great question so of course we look at the whole patient and we do what's called um shared decision- making we assess how bad the situation is um how we usually use a measurement called a hemoglobin A1c which is a measure of how someone's average blood sugar has been over the past 3 months um if it's really really high then we may have to jump to some more aggressive measures but if it's not too bad like if it's just the the marker for actually the diagnosis of diabetes would be a hemoglobin A1c of 6.5 or greater and so if it's close to that 6.5 Mark we might say well let's have our little wakeup call like Dr Wall was suggesting and let's Institute healthier eating more exercise better sleep um maybe we might take a look at whatever is going on in that patient's life and then we'll assess for example whether there is a need to introduce some medications we often will start with um oral medications and then add others as needed and that's a whole another topic of different medications that we use to treat diabetes but um usually we kind of start small if it's well controlled and then we'll go big as as things get worse Jason you're dying to talk about CGM so we've got a lot of questions so I want to get that in thanks R and then and then maybe talk a little bit about treatment what so CGM stands for continuous glucose monitoring and one of the biggest barriers people would come into a clinic and I try to treat them and I have two blood sugar readings over the last you know four to six weeks I don't know if I give them more insulin I put them at risk of overdosing on insulin and getting sick so now with continuous glucose monitoring which I encourage everybody to talk to their healthc Care Source about whether they're eligible and whether they get it it is a patch you've probably seen it on TV and there are numerous models out there but it can read your blood sugar nearly continuously so there's no more poking your finger and it tells you it can even tell eight to 10 of your friends via their smart devices if you're blood sugar is going up or down so if you had an event where you were gardening and you passed out you know your partner would know hey you know it would alarm and let them know so this is revolutionary not only for um us being able to say yep your blood sugar is going down you know at night maybe we'll back off on this dose but after dinner you must have too much cake we need to bump things up a little bit it's just a you know knowledge is power in diabetes and so it's better for the patient it's better for us and uh I think I'll I'll leave it at that what was the well move on to the next question just interestingly now cgms have even entered into the fitness market now you can buy a CGM without a prescription Stell which is made by Dexcom which is the popular CGM company offers it for sale for just anybody to use it's it's got much more uses now that that you say is that through the skin or is that with a needle it's through it's through a small canula Under the Skin yes but it has to go into the subcutaneous space because there's a lot of questions we don't have a lot of time let's talk about thyroid yes uh hypo and hypothyroid hypo and Hyper thyroid those questions are here and this is kind of an area you're very interested in so tell us about it a little bit and then your props yeah so I the like reason why I got these props is uh the props because uh when you talk about thyroid disorders um this is not seen recently it was in the past there was something called endemic goiter and endemic guer um was a condition which was in past because there was no iodine supplementation in the diet it was popularly seen in geographical regions which were mountainous and did not have um areas where there was proper iodine in the diet as we know it iodine comes in the sea and so Shores and they were all the places that were next to a sea shore had enough iodine but geographically deficient areas um did not have them um and surprisingly there are two areas in the the US which are geographically iodine deficient and that's the Pacific Northwest and the Great Lakes area and that's because uh when the glaciers retreated they took away the top soil and so we are in an iodine deficient Zone and so it's very important for us to have iodine in the diet because iodine the thyroid is like a irine pump all it does is takes irine from the blood and pushes it onto proteins and sends them out and so it's a very important component and so it's very important for preg women to have a proper iodine in the diet 150 micrograms is the RDA the recommended dietary allowance for uh for for um healthy person and goes up to 250 even for a pregnant women and so from that point what we have noticed now is there's been a increase in not introducing iodine into a diet and that comes with many reasons uh processed foods if you buy food from a restaurant or just buy processed foods they're not going to put iodine in the diet because it's more expensive it changes taste so if a person is on a processed diet food on a on a processed um buys buys a lot of processed foods they're going to be I I and deficient and then is the new fad of using um designer salts and so that's like uh we have some examples here now this is kosher sea salt and here is um Mediterranean Sea salt and then uh Himalayan pink salt and so this is touted as uh the best salt in the world without any polluted oceans uh and there's no sea salt from any any sort of polluted oceans but what you need as in all these three ones they do not have iodine in them and some of them uh especially make it and they have the statement that says this salt does not supply iodide a necessary nutrient but they don't necessarily have to use them now this is 9.99 this is uh $1.99 and this is $ 13.99 but what you really need is the 3.99 iodi salt and that will help your thyroid gland so that was my props so one other thing on the treatment of of thyroid of hypothyroidism uh desiccated thyroid versus generally we're using Le Leo thyroxine or whichever um Jason do you want to take a shot at that one I think I would defer to Dr cerri um in that you know lexin is is the gold standard and um I'm personally a little nervous when anybody is uh you know using any sort of just because how do you uh you want to make sure that it's of sufficient Purity and of sufficient potency and you know it's leave ather axin the gold standard that is exactly right because we don't know because these brands that have it's it's basically from a pig so that's pig that's Pig um thyroid that's desiccated and brought in now the biggest thing about that is in that's very important that we don't know how good it is how pure there's no large scale studies to show that that is as good and effective the and the biggest problem is that has both T3 and T4 now there's a difference between the two T4 is not metabolically active it gets converted to T3 and T3 is the actual one that actually does the job and so the body the the actual thyroid gland secretes a very little amount of T3 what it does is T4 it sends it to the cells and the cells use T4 to make it into T3 as a as need basis so it converts it when it's required and then sends it to the cell but when you have this pork thyroid that has T3 in it now you are infusing the body with all T3 which you may or may not need and we should understand that the thyroid is not just a metabolic hormone it works on the cardiovascular it works on mood it works on growth it works on digestion so now we are activating all these systems for no reason at all so um as you correctly said we always advise them to use regular T4 croid Leo thyroxin rather than the this brand chrisa any comment on that one um I would have to agree the gold standard is Leo thyoxin you do see patients who prefer um it's it's usually branded arm more thyroid it's hard to convince them otherwise and you always have to meet your patient where they're at but I think the most important piece of knowledge that I would add there for the the public is it's really important just to continue to monitor your thyroid and whether you choose to take lexin which is probably what your physician is going to recommend or Armor Thyroid the most important advice I would have is that you need blood work you need to make sure that that medication is being dosed appropriately and your body is not being over or underdose because um many tissues are affected by by thyroid hormone so that Jason why is the prevalence of hypothyroidism and diabetes so high this is from a nurse and anybody else can jump in because I'm not sure I know the answer I cannot think of any immediate connection other than if you had some sort of an autoimmune process um that you know there are multiple you know sort of endocrine um immunologic conditions that could uh but yeah I I can't think of a direct disease that you know captures both of those that's common um I think certainly diabetes is incredibly and I did want to follow up there was the earlier question of type one diabetes and type two and I think we we um didn't really get to the type two and type two is much more of so type one being you know your pancreas doesn't create it you need insulin to survive to stay alive um type two your your pancreas is still making insulin um perhaps not enough and your the tissues in your body um aren't able to properly utilize the you have an insulin sensitivity so you need more and more insulin and and so that's the vast majority of diabetics are the type two diabetics that they're still producing some insulin but we have to use a combination of more exogenous in insulin that we inject and then other medications that make our body more sensitive to insulin and um so uh but yeah I think I'll defer to my colleagues here because I can't think of a a part from a couple rare autoimmune conditions I can't think of a combination that's gonna a disease that's going to give you hypothyroidism and and diabetes at the same time I think both of them are just very common conditions and so the fact that they' be coincident is you know is certainly possible but uh I I don't personally think that the percentage of either has increased over time it's been kind of constant on the amount that there is uh over over lifetime but I'm not sure that was uh is diabetes related to lymphatics anybody got a shot on that one lymphatics is the immune system broadly so I guess it's related in a way but not not but not directly no no it's a separate I would say yeah it's more of an endocrine so an organ that produces a hormone system certainly related to your metabolism especially I think one of the most common things I see are people their triglycerides are out of control their cholesterol is out of control and when you don't have insulin and your um your liver doesn't quite process um the fats that you consume and your Tri triglycerides can be through the roof you can get pancreatitis from these excess triglycerides and so once you control your diabetes you know with insulin or other medications your your lipids meaning your cholesterol profile triglycerides get much better and so that's an important thing to always keep an eye on can you self-manage your Di diabetes with diet only certainly go ahead you can yeah especially um not type two sorry type one absolutely not that's lethal I think we established that but anyways type two um especially if you're pre-diabetes um or in early stages um with the help of eating correctly healthy um regular exercise and certainly weight loss you can control um your diabetes without medication when do you need immediate intervention for hyperglycemia like what level I leave it you guys I don't think there's a set number it differs because for people who have diabetes they might run into sugars like 250 and they'll be fine they can adjust to it it all depends upon how much your body can cope at what level it starts producing acids and starts breaking down fat in response to not using thyroid so there's no one number the 12 six is the official fasting blood sugar number to diagnose diabetes anything greater than that but um otherwise there's no number to act on it differs on each patient and case yeah you can when your blood sugar is you know 600 700 you can start to get severely dehydrated and if it gets you know much above that you can have some um what we would call like you have some changes in the the um consistency of your blood that can lead to confusion and and along with the metabolic you know an acidosis that can that can be fatal um blister on your shin is it a concern if you're diabetic blister on your shin absolutely any any skin is our probably our most important defense against infection and when diabetics they are prone to a peripheral neuropathy where they lose feeling in their in their feet and they often stub their toes damage their skin and that's a that's a that's a doorway for infection so good foot care for diabetics is imperative this person takes long acting insulin and fast acting insulin what does this do to his pancreas or her pancreas uh and the pancre the to his pancreas is natural ability to produce insulin and will it produce less there's a lot in there we got a minute or so chrisa do you want to D that sure I'll take that um okay so if a doctor is prescribing insulin it is presumed that the pancreas is not making their own your own insulin and so probably it does nothing to your pancreas in in essence it's taking the place of your pancreas I always tell my patients that when we dose insulin we try to mimic how the pancreas does it for us naturally for example the reason for the long- acting insulin is because the pancreas naturally secretes what we call a basil rate of insulin so a continuous amount and then our pancreas is smart because of a bunch of Med um mediators that are given off in our stomach and our liver and and our even you know our brains he there's many different mechanisms that tell our pancreas that we've eaten for example and we need more insulin and so that's what we call a prandial amount of insulin that's we usually use the short acting to supplement for that so long acting is the basil and the short acting is usually the pr crandal which is given when someone eats could a burning sensation be a symptom of diabetes and you pee or just in general any one of those diabetic peripheral neuropathy is it that's you know you see the pictures in the magazines people with foot blow blow torches under their toes um especially at night burning in your lower extremities in your hands is all very very um consistent with the diabetic thank you panel we we didn't get to a lot of things we should have I want to thank our panelists tonight Dr Canan curri Dr chrisa Co and Dr Jason wall and our medical student volunteers Jessica crosson McKenzie Peterson and Wyatt windhorse next week please join Dr Mary Owen for a program entitled indigenous Health when our panelists will be Dr Ryan Dunley Dr Charity Reynolds and Ricky defo thank you for watching good night e