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.
Why is recurring diabetic ketoacidosis happening?
Dear Dr. Alexander: I have a 31-year-old son who has had type 1 diabetes since age 7. He was recently admitted to the ICU with DKA for the second time in three months. I am interested in any resources available or information on navigating this challenging time. He wants to be left alone to manage it himself, yet DKA has occurred twice. How do other parents help their adult children with medical supplies being delayed or the high cost of the pump supplies for a young adult? How can I be involved in a helpful but not intrusive way?
Answer: Recurrent diabetic ketoacidosis (DKA) in an adult with type 1 diabetes is a significant and increasing challenge for healthcare professionals as well as the person’s family. Sometimes the cause is just a lack of financial resources to afford insulin and supplies needed to prevent DKA. Up to 20% of U.S. adults with type 1 diabetes report rationing insulin due to financial issues, which is strongly associated with increased DKA risk.
Assistance programs include federal initiatives, state programs, manufacturer-sponsored patient assistance programs, and nonprofits. Putting him in touch with social work or community resources (including at the hospital where he was treated) may help to connect him with available assistance. Other times, there is a psychological or emotional aspect to recurrent DKA. A psychologist or social worker may be helpful if the problem is more than financial.
Can French fries cause diabetes?
Dear Dr. Alexander: I read an article recently that said eating French fries increases the risk of developing type 2 diabetes. I have also heard from friends that sugar can cause diabetes. Is this true? Can food cause diabetes?
Answer: The short answer? No. There was a large study recently published that evaluated whether potato intake had an impact on type 2 diabetes risk. The study concluded that eating potatoes in the form of French fries (compared to baked, boiled, or mashed) was associated with a higher risk of type 2 diabetes. Though “associated with” does indicate a type of connection, it’s not proof that French fries cause diabetes. Other factors, like weight gain, may be involved, which could account for the association.
So, yes, there may be other potato preparations that are healthier than French fries, but eating French fries is not going to increase your risk of diabetes. Whether it’s French fries or sugar, any food on its own does not cause diabetes. Before people are diagnosed with diabetes, they commonly are thirsty and may drink large quantities of sugar-containing beverages. Of course, when they finally learn that they have diabetes, they blame the sugar.
Diabetes is caused by a lack of insulin from beta cells in the pancreas and insulin resistance, meaning the body does not produce enough insulin and can’t use it effectively to bring down blood sugar. However, consistently eating foods that contain added sugars and are high in fats can, over time, lead to weight gain and also impair insulin function – two factors that can lead to type 2 diabetes.
What we can take away from this is that substituting more nutritious foods for less nutritious ones is beneficial. For example, swapping potatoes (particularly French fries) for whole grains, brown rice for white rice, whole fruit for fruit juice, fried veggies for baked ones, and lean or plant-based proteins instead of high-fat meats are all great ways to reduce your risk overall and maintain health generally.
Why is my blood sugar high while fasting?
Dear Dr. Alexander: I am newly diagnosed with type 2 diabetes. I decided to wear a FreeStyle Libre 2 sensor to see what my blood sugar levels were doing and to show me what my diet was doing to my blood sugar. I have noticed that my blood sugar is running high while I am fasting! All through the night I run almost a steady line between 159-161 mg/dL. Therefore, when I go in for those fasting glucose checks, they are not good. What can I do about this? Does it mean something to run high while you are fasting? I have only tried metformin so far, but that did not work out for me, too many side effects.
Answer: Your question confirms the limitations of fasting glucose checks. A continuous glucose monitor (CGM) like the Libre 2 is much better than checking blood glucose while fasting. Using a CGM sensor either intermittently (every 3 to 4 months) or continuously would be very helpful to know how any treatment is working.
Have you had an A1C test done? What was the result? What does the sensor read during the day? If it is reading about the same during the day, then your average blood sugar is actually pretty good and close to the recommended level for people with diabetes. If it’s higher or a lot higher during the day, what does the sensor read out as your average daily blood sugar or glucose management indicator (GMI)? I would suggest that you speak with your healthcare provider regarding treatment of your type 2 diabetes – there are many options beyond physical activity and diet, which are very important.
What are resistant starches?
Dear Dr. Alexander: I am interested in learning how to use the concept of resistant starch to incorporate foods I have been limiting or avoiding (like potatoes, pasta, bread, and rice). Could you please clarify if this is an effective science-based option? Thanks for your time with this.
Answer: Resistant starch is classified as a type of dietary fiber due to the fact that its effects are similar to dietary fiber. Examples of raw starch (one of the types of resistant starch) are in foods such as green bananas, raw potatoes, and high-amylose maize starch. Other examples include whole or partially milled grains and seeds. As you might guess, cooking the food or letting it ripen can change it, so it’s no longer considered a resistant starch.
When considering fiber content as well as vitamins and other nutrients, brown rice is better than white rice, and whole grain bread or pasta is better than white bread or regular pasta. However, some people don’t like brown rice, whole grain bread, or whole grain pasta. In addition, it’s important to know the glycemic index of the food you are eating – that is, how quickly the food raises your blood sugar. For example, although the glycemic index of whole grain pasta is lower than regular pasta, both are considered to have a low glycemic index.
Finally, you need to consider the carbohydrate content of food. While whole grain pasta has more vitamins, other nutrients, and a lot more fiber than regular pasta (as well as a low glycemic index), the calorie and carb content are similar to regular pasta.
Why is my diabetes triggering skin issues?
Dear Dr. Alexander: Since developing type 2 diabetes almost four years ago, I have developed all kinds of skin issues. The most annoying (and dangerous) is uncontrollable itching following a bug bite. To date, neither my primary care provider nor my endocrinologist has offered much help, beyond various creams and antibiotics. My question is: Why is this happening? Am I doomed to have cellulitis every summer? No one seems to be able to guide me in what steps I might take to mitigate these problems. If the super minds at diaTribe could please address skin issues with diabetes, I’d be most grateful. I doubt I’m the only one trying to make sense of my body’s new normal.
Answer: Unfortunately, diabetes is the most common endocrine disorder, and many skin disorders are associated with diabetes. Primary care providers and endocrinologists need to be familiar with these skin conditions. Most of them can be managed by PCPs, but a referral to a dermatologist is occasionally needed – as your experience shows. As the incidence and prevalence of diabetes increases, skin problems associated with diabetes will unfortunately become more common. Here are some skin care tips that may help, as well as what to do if your diabetes device bothers your skin.
Do seizures impact blood sugar?
Dear Dr. Alexander: 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.
Why do I need cholesterol medication if my blood work is normal?
Dear Dr. Alexander: 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.
Why are my hypos getting worse over time?
Dear Dr. Alexander: 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?
Does metformin cause side effects?
Dear Dr. Alexander: 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.
How do I manage sugar cravings?
Dear Dr. Alexander: 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.
What is my life expectancy with type 2 diabetes?
Dear Dr. Alexander: 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.
Why are people 65 and older excluded from clinical trials?
Dear Dr. Alexander: 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!
Answer: 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.
How does menopause affect diabetes?
Dear Dr. Alexander: 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.
Answer: 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.
Which foods have slower blood sugar spikes?
Dear Dr. Alexander: 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 type 2 diabetes. Thanks.
Answer: 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 contact@diatribe.org. 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.