Ask the Endo: All Your Diabetes Questions Answered
Have a burning question about diabetes? Dr. Charles Alexander, diaTribe's medical advisor, is here to answer questions and give insight into real issues readers are facing.
Dr. Alexander is an endocrinologist with more than 35 years of experience in diabetes – in both direct care and research. Dr. Alexander spent nearly 25 years working in Outcomes Research and Medical Affairs at Merck before retiring in 2016. Before that, he practiced diabetes, endocrinology, and internal medicine in Los Angeles for 10 years and was a clinical professor of medicine at the Keck School of Medicine of the University of Southern California.
Dr. Alexander is board-certified in Internal Medicine and Endocrinology-Metabolism and is a fellow of both the American College of Physicians and the American College of Endocrinology. He has been an advisor for the diaTribe Foundation since 2016.
Question: My story personally is that my blood sugar drops once I have a seizure. Do you know how or what could cause them to relate? I was diagnosed with frontal lobe epilepsy four years ago. I stay hydrated and eat the way I need to as well. It just affects me that way first. It's tough trying to get things done and having to continue to fight at all cost, but I'm grateful.
Answer: Both diabetes and epilepsy affect each other – there is a complex interaction between them. Diabetes can lower seizure thresholds due to nerve excitability caused by hyperglycemia (high blood sugar). Diabetes can also affect brain function, complicating the therapy of epilepsy. Seizures can affect many different hormones that affect blood glucose levels, especially cortisol and catecholamines. Both conditions have common risk factors like genetics and lifestyle. It can be challenging to manage both diabetes and epilepsy since both hyperglycemia and hypoglycemia can cause seizures. It is also true that seizures can affect glucose levels. Lifestyle changes like stress reduction, physical activity, and weight management are important to help manage both conditions. Continuous glucose monitoring is frequently helpful to help manage diabetes treatment. Treatment should consider each patient's unique characteristics, epilepsy type, as well as their glycemic variability. Neurologists and endocrinologists need to work together to help people with both conditions. Additional research is also needed to answer many questions regarding mechanisms, specific treatments, and prevention measures.
Question: Please help me understand why my boyfriend, a person with type 2 diabetes, should take cholesterol pills when his blood work shows his cholesterol is normal. I know my boyfriend should take these pills as diabetes is a disease of the small veins. How can he be convinced that he should take cholesterol pills to avoid what's eventually going to happen? I love him very much and I don't want him to die.
Answer: We don’t want anyone to die, especially when it could have been prevented. Diabetes can affect both large and small arteries. A normal blood cholesterol is the level or range of levels most common in the population. A normal LDL cholesterol level of 130 mg/dL (3.4 mmol/L) may not be the appropriate target, especially for people with diabetes. For those who do not have either diabetes or cardiovascular disease, an LDL cholesterol less than 130 mg/dL (3.4 mmol/L) may be acceptable. For people with diabetes aged 40–75 years at higher cardiovascular risk, including those with one or more cardiovascular disease risk factors like high blood pressure, the LDL cholesterol target should be less than 70 mg/dL (1.8 mmol/L). For people with diabetes and cardiovascular disease, the LDL cholesterol target should be less than 55 mg/dL (1.4 mmol/L). Otherwise, it is recommended to target an LDL cholesterol goal of less than 100 mg/dL (2.6 mmol/L). Cholesterol medication is often needed to reach an individual's recommended target level. Unfortunately, many are only willing to take medication when they are in pain or have some kind of symptom. Blood pressure, cholesterol, and diabetes often do not cause pain or other symptoms until the disease process is far advanced, which is why managing blood pressure, cholesterol, and blood sugar is so important.
Question: Hi, I have a question for Dr. Alexander that no one has been able to give me an answer to before. I have been living with type 1 diabetes for 31 years (nearly all my life) and my hypos seem to get worse over time. Not all, but several hypos with common symptoms (glimmering before my eyes, numbness, shaking, etc.) leave me completely exhausted for days. After the acute phase, I typically sleep for a while to get away from the headache and impact of my surroundings, but then I never really wake up. For up to two days the headache is still there and it feels like I’m in a shell (the world seems darker, quieter, like I’m in a fog). I feel completely empty inside and I walk around staring, cannot concentrate on anything, and find it hard to tolerate light and sound. Then suddenly after a day or two, it’s like the shell cracks open and from one second to the other I see the world clearly again and feel energized. So my question, what is happening here? I have tried to ask my doctors but they avoid the question.
Answer: The problems you are having seem very likely to be the short-term consequences of hypoglycemia. Hypoglycemia is often associated with brain fog. When the level of glucose in the brain becomes too low, the brain essentially starves for fuel. The brain uses about one-third of all our calories. Unlike the muscles, the brain does not store any fuel. Therefore, it must have a continuous supply. Although many people recover quickly from hypoglycemia, some take longer to get back to normal. A 2015 study of 24 patients with type 1 diabetes showed that there is a substantial impact of hypoglycemia on brain function; furthermore, the study showed that the brain needs time to recuperate after an episode of hypoglycemia. The answer is to reduce or completely eliminate the episodes of hypoglycemia, which admittedly, may not be easy. Have you tried using a continuous glucose monitor to alert you when your blood sugar is falling? Have you tried an automated insulin delivery system to help with the variability in your need for insulin? Have you worked with a diabetes care and education specialist to help you try to reduce the episodes of hypoglycemia?
Question: My doctor took me off metformin because of my gastrointestinal issues. What's out there for me now? I'm insulin-resistant. I've been on metformin for about six years. Over a year ago I started having intense cramping in the middle of the night. Waves of cramps that made me get up and go to the bathroom. It was tiring to have my sleep interrupted and hard to get back to sleep. These nighttime cramps happened 2 or 3 times a week. My doctor had me keep a food journal to help determine if it was caused by what I was eating. That was no help because they happened with different foods even vegetarian meals. A doctor ordered a CT scan and said he saw nothing to cause the cramping. I saw my primary care doctor and the only thing she could think of would be for me to stop the metformin and see how it goes. I stopped it and have not had any nighttime cramping since. My concern now is my glucose readings. On metformin, my A1C has been almost normal – 5.6% sometimes 5.7%. I understand from my own research that there is no other drug that helps with insulin resistance. I guess I should also add that I am 76 years old. Thanks for your help.
Answer: It is likely that metformin is the cause of your gastrointestinal symptoms and not taking metformin would seem to be the best option. Fortunately, there are other options to consider to treat insulin resistance. With A1C levels below 6% on metformin, it is likely that even without metformin, diabetes will not be a concern. It is also important to realize that insulin resistance is more common as we get older and also as we gain excess weight. The best treatment for insulin resistance is changing one’s lifestyle with increased physical activity and caloric restriction. However, besides metformin, there are other medications that can be used for insulin resistance if necessary.
Question: It was recently my 75th birthday, I am an active person and can't complain about how I look and feel. However, my addiction to sugar is getting worse – I just get cravings for sugar. I do my training and try to walk more by leaving my car and traveling by train, bus, or metro. I lost three kilos so I am happy, but I know pure sugar is very bad, if you have some advice on that, please. Thanking in advance.
Answer: By pure sugar and sugar, I assume that you mean sucrose as opposed to other carbohydrates. Some people can handle sucrose better than others and whether pure sugar is very bad depends upon how your body handles the nutrient. Of course, obtaining the carbohydrate portion of your diet from complex carbohydrates and fiber is much better than eating a lot of sucrose. It’s great that you are physically active and have lost weight. You should continue to remain as active as you can. If you haven’t had your A1C tested recently, that also might be useful to determine how your body is handling your current diet and activity.
Question: I’ve been a subscriber to diaTribe for several years. I was diagnosed with type 2 diabetes over 19 years ago and am considered well-managed. Even though I educate myself and adopt healthy habits as I get older, I often wonder how much my life expectancy has been shortened because of my condition. Are you aware of any studies about longevity for people with well-managed (A1C consistently under 7%) type 2 diabetes? Thanks in advance!
Answer: Much has changed in the treatment of diabetes over the last 75 years. We didn’t even know how to estimate average blood sugar (A1C) until the 1980’s. The ability to control blood glucose has improved by leaps and bounds since the 1970s with blood glucose meters and more recently continuous glucose monitors. It is also now known that blood pressure and cholesterol levels have as much impact on lifespan as glucose or A1C.
Studies have attempted to estimate the shortening of lifespan due to diabetes, but such studies are limited because of the dramatic and continuously improving progress in diabetes treatment as noted above. A 2020 study estimated that for people with either type 1 or type 2 diabetes, one year with an A1C of more than 7.5% causes the loss of around 100 days of life (0.27 years). A 2023 study concluded that every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy. To summarize, it’s difficult to provide an exact answer, but maintaining lower blood glucose without hypoglycemia as well as carefully managing blood pressure and cholesterol is key to prolonging the length of life.
Question: I've lived with diabetes for two decades, and now that I'm retired, I'm very interested in participating in clinical trials to further diabetes innovations. I often click on links for new trials, however, only to be disappointed, so I often discover that I'm not eligible. This is not always the case – I recently found I could qualify for one study that allows participants up to the age of 80 – but it seems that just about always, people aged 65 or older are part of the exclusion criteria. What is the reasoning behind this (and how come some studies make exceptions)? Thanks!
Dr. Alexander: While those over 65 years of age make up the majority of patients for many medications being used to treat chronic conditions, clinical trials conducted in the adult population typically only include patients between the ages of 18 and 64 years. This is because many individuals 65 years or older have other conditions besides the one being studied in the clinical trial, and the presence of other diseases can confound the results of the trial. Also, these individuals are more prone to adverse effects due to other diseases and the use of other medications. The adverse effects can be severe, or less tolerated, and have serious consequences.
In spite of those concerns, drugs should be studied in all age groups, and trial participants should be representative of the patient population receiving the medicine in clinical practice. Elderly patients are poorly represented in clinical trials. Subsequently, there is inadequate information regarding the response of elderly patients to medications. Regulatory authorities in most countries are now urging pharmaceutical companies to avoid arbitrary upper age limits and not exclude elderly people from clinical trials without a valid reason.
Question: One thing that does not seem to be covered by any diabetes organization is diabetes and menopause. My insulin needs increased as I went through menopause. I also gained weight without changing my diet or exercise routine. My endo blamed me, saying I wasn't taking good enough care of myself! This led me down the path of diabetes distress, something I'd never experienced before and hope I never do again. So, I ask that you discuss diabetes and menopause. What are the effects of menopause on the body? How does menopause affect insulin needs? We need this! Thank you.
Dr. Alexander: It’s sad when healthcare providers blame the patient, especially when it causes diabetes distress. Levels of the female hormones (most notably estrogen and progesterone) fall dramatically during menopause. Changes to these hormones can affect blood sugar levels and make managing diabetes more difficult. In some women, menopause can lead to other changes like more abdominal obesity as well as higher blood pressure. It’s great that you have continued your diet and exercise routine, but you may need to have your medication adjusted to compensate for the hormone changes. The impact of changing hormones on diabetes management isn’t well understood and there is an urgent need for more research about menopause and diabetes to help provide answers to your questions.
Question: As a person with type 2 diabetes, what is the significant, practical difference between consuming equivalent amounts of glucose from sucrose, and getting it from a starch such as a potato or white rice (or for that matter, a whole grain in the context of its fiber and minerals)? This seems to be somewhat controversial, though I’ve always understood the two to be practically equivalent for a type 2. Thanks.
Dr. Alexander: For both type 1 and type 2 diabetes, the difference between consuming equivalent amounts of glucose from sucrose, and getting it from a starch is how fast the food or drink is absorbed, which is known as the glycemic index – a measure of how quickly it can make your glucose rise. Not all carbohydrates work the same. Some trigger a quick spike, while others work more slowly. Orange juice and other fruit juices cause the quickest spike. It's best to eat a whole orange, which has a lower glycemic index compared to orange juice, whenever possible. Foods with a lot of fiber like whole wheat pasta have the lowest glycemic index and work the slowest. Also, remember that physical activity affects your glucose levels, so exercise after a meal will help slow the rise in glucose.
If you have a question for Dr. Alexander, please email [email protected]. Due to the number of submissions, we are not able to answer every inquiry, but we'll do our best and always appreciate readers taking the time to write in.