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Understanding Diabetes Head to Toe. (Symptoms, Treatments & Blood Sugars)

This article is a transcribed edited summary of a video Bob and Brad recorded in July of 2021. For the original video go to https://www.youtube.com/watch?v=ap6kn3DfmZw&t=414

Brad: Bob is not here today, but we have someone even better to help us out, Chris the pharmacist. Today we are going to talk about understanding diabetes head to toe, symptoms, treatments as well as blood sugars and how you measure those. This is pretty comprehensive. It's not very short. This is a very complicated disease and we want to cover all the aspects. So if you want to learn everything about diabetes, if you have been diagnosed or a family member has been recently diagnosed and you really want to get some good information, this is going to give you everything you need to know. So bear with us. If there is a part that you don't understand, I'm going to help Chris. He sometimes gets too complicated. I'm going to see if I can have him explain it so that everyone can understand it, including myself. So very good. Both physical therapists and pharmacists work with diabetics all the time.


Chris: Correct.


Brad: And there are things that therapists have to know about treating a diabetic so they maintain good health and we can help maintain, monitor, and have good results with the patients and problems.


Chris: Absolutely.


Brad: And with pharmacists, you are very acute to what's going on with them and how to talk to them and educate them. Am I correct on that?


Chris: Quite correct, it's an unbelievably prevalent disease worldwide. You're talking about 480 million people on the planet. Within the United States, we're roughly around 35 million people.


Brad: So that is about 10% of the United States population has diabetes. And then there's type one and type two?


Chris: Correct. There is type one and there's type two. Within the bigger framework is diabetes mellitus. Within that framework, you've got type one and type two. Type one is what was usually recognized as what they call childhood onset. But that's not really true. It does occur in childhood often or in adolescents, but it can occur later in life as well, even into your 20s. And that's the type that is insulin-dependent diabetes exclusively.


Brad: So that means they have to get a shot?


Chris: Yep, without insulin being introduced into your body, you would die.


Brad: So you can't treat that or change it with your diet?


Chris: No, but diet and exercise are still very, very important. We'll talk about that between the two. But it's interesting with type one diabetics, they tend to be, they are thinner patients. They tend to be pretty lean in general. But it has a variety of complications that we can certainly get into.


Brad: So the pancreas is what produces insulin and puts it in your digestive system. So those type one people, it doesn't produce insulin or just not enough?


Chris: We don't really know fully why you become a type one diabetic. But what we do know is that whether it's a viral cause or just simply autoimmune, our immune systems attack our pancreas and you have alpha cells and beta cells and your beta cells are the ones that make insulin. So when we eat food, our body generates insulin so it can take up sugar and put it into our cells for further use for energy. When we're exercising, walking, doing life.


Brad: So with that, with type one, that pancreas is not doing that sufficiently.


Chris: Those specific cells die off. The immune system for whatever reason said "I don't like these things and I'm attacking it." And there's a lot of research going into that as to how we can fix this medically. So there are doctors doing research on transplants using stem cells and artificial pancreas.


Brad: What about genetics, is type one genetic? If I have it, are my children likely to have it?


Chris: There is a possibility. There's a strong genetic component with both type one and type two. So it's one of those things where, if you have a diabetic parent or parents, there's a higher likelihood that you will get it. I see it all the time, we see diabetic families. I've seen where one parent is type one and the other is type two and the kids are all type one. It just kind of depends. You can't always outrun that. It's very complicated and researchers are trying to figure it out.


Brad: Sure.


Chris: And they don't have the key, they're getting better and better at things, but it is not easy. Worldwide it's really interesting and in countries that don't have access to care as the United States does, sometimes it can actually be missed because sometimes it looks like other things. Time is everything because there's this thing called diabetic ketoacidosis, which actually can be fatal if not treated right away. And that's how a young diabetic or an adolescent, or just a type one approaches, they're really acidic, their sugars are through the roof. And so we want to make sure that we're looking at everything.


Brad: Let's talk about type two. So type two, is that the kind that typically comes with older people, so the onset is because of lifestyle?


Chris: That was the older framework. You can have a type two diabetic that's 10 years old. So I would say it's more lifestyle maintained.


Brad: But usually is it 10-year-olds or is it in 30 or 60-year-olds?


Chris: It is going to develop later in life but what we're finding, particularly with childhood obesity is that we're seeing more and more children being diagnosed with type two diabetes, which in previous generations was just not a thing.


Brad: So type two is influenced heavily by lifestyle?


Chris: Lifestyle and yep. So the thing that happens in type two, that's kind of a hallmark characteristic, we have plenty of insulin floating around in our bodies, but the cells that use it are resistant to it. So it's an insulin resistance category. And so when we don't exercise well enough, we don't eat properly and we are overweight, and if there's a genetic predisposition towards it, it's a high likelihood that type two could develop.


Brad: So with type two, they typically are not taking insulin injections like type one?


Chris: No. No, they won't start there typically. The first thing when you get your first diabetic diagnosis, if it's a type two, is they're going to talk to you about modification of lifestyle choices. So diet and exercise are the first two things. If you're going to be on medications, the first thing we're going to talk to you about, no matter what, is to exercise well and eat well. And they're going to probably put you together with a diabetic nutritionist, so a specialist. They'll probably have a nurse care specialist, you are going to have an endocrinologist, there's going to be a team. And then the pharmacist will come in when we're talking to you about your medication.


Brad: So as far as exercise as a therapist, this doesn't mean that you need to start running 5K's, 10K's, and marathons.


Chris: Absolutely not.


Brad: We're talking about probably walking 30 minutes a day or work up to that.


Chris: Yeah, basically the guidelines are, they want you to do 150 minutes a week. So five by 30 minutes. So things like walking, gardening, ballroom dancing, swimming, biking, and running. You actually need to be kind of be careful with exercise and diabetics too, because there are certain things like say weightlifting, where let's say there's maybe some diabetic retinopathy kind of issues, or with your kidneys, sometimes we're pushing really hard or straining on a big, heavy lift. They can cause some problems and obviously, in your arena Brad, we have to be super careful with that with diabetes.


Brad: So the big picture is, exercise does not mean you have to become an all-out exercise geek. You're just going to go five days a week, 30 minutes, like we said, walking, being active with things around your house is good for that. As far as diet, I think there's no real special diet. There is a lot of getting rid of your processed foods or the high sugar.


Chris: The processed foods. Yeah, and I mean especially in the Americanized diet, we've got fast food and we've got processed food and those are go-to because they're quick, they're easy and you get quick energy.


Brad: Relatively inexpensive.


Chris: Yep, and that's one of the things that I think makes it so dangerous is everything is so cheap. All the stuff that tastes good, that's not good for you, it's cheap. And so if we can stay away from things that are in boxes and bags, I think that's a big thing. You want to go to whole foods, lean proteins, fruits, and veggies. If you talk to a nutritionist or a diabetic educator, they're going to talk about what are good fruits and veggies versus bad ones, and veggies, not so much, but fruits, some have more sugar than others. And they talk about the glycemic index which can probably glaze everybody over if I start into that.


Brad: For example, I know grapes have a high sugar content. So I don't eat many grapes. I like them, but I like to stick to the berries, that kind of a thing.


Chris: Yeah, berries, blueberries, and bananas are a little bit lower on the glycemic index about 63. So I mean in the middle of the road. So it just kind of depends on the things that you choose. And again, a diabetic educator and, or a nutritionist, you will be talking with both when you get these diagnoses because it's so important to incorporate those lifestyle changes early. And Rome's not built in a day and diabetes is, like I said, it's one in four of all healthcare dollars in the United States are spent on diabetes.


Brad: 25%.


Chris: 25%. So you're talking about the average diabetic patient spends $9,000 a year annually out of pocket costs. So that's not the insurance guy, it's out of pocket.


Brad: We just had an amputee in here. They were talking about dealing with the amputee and the prosthetist talked about the percentage of people that get amputated in the knee, arm, or whatever, typically the legs are highly oftentimes diabetic.


Chris: Yeah, the number one, when we talk about peripheral artery disease.


Brad: Yeah, we'll get into that. I do want to talk about typical symptoms before we get any farther because we are going to cover seven different topics that they're all kind of interrelated, but we tried to break them apart. Let's say that you are not type-one diabetic or whatever, you're type-two, what do you feel? What does a typical diabetic notice before they're diagnosed?


Chris: It's kind of odd, whether it's one or two, they're somewhat similar. In diagnosis circles, they're going to talk about the three Ps. It's going to be polyphagia, which is you're hungry all the time. Polydipsia where you're thirsty all the time and polyuria where you go to the bathroom all the time. So the three Ps.


Brad: So all three of them or just one of them?


Chris: No, all three of them are kind of characteristically all together. You'll see those as kind of a hallmark thing. Then there will be subsequent fatigue and you just don't feel well and things aren't right, you're not thinking clearly.


Brad: Is this consistent day to day to day to day? Or does it come and go where you feel you have it for a few days then you're fine?


Chris: No, no, it's going to be, think of a crescendo. It's going to start here and it's going to keep getting worse and worse and worse. So if you think of a big wave developing, you know how it starts kind of small, and then when it comes into shore, it gets bigger and taller.


Brad: Could it go up and down, depending on your diet?


Chris: No, when you first get diagnosed with type one, there's this honeymoon phase where you can actually somewhat spontaneously recover, but that's very short and it's less than six months.


Brad: You said again, type two is what percentage of diabetics?


Chris: 95% are type two, and 5% are type one. The problems all remain the same with the complications that are associated with it. Leading up to a diagnosis, there'll be asking you questions about your family. They'll look at your age, they'll look at things that have been going on around you. Did you have an infection? So they'll look at the autoimmune aspects for type ones if it's a younger diabetic patient. So there are a lot of things that are very, very complicated for a doctor or a clinician to try and figure out at the onset of this. You come in, something's not right. One of the first things we're going to do is take blood work to make sure that they see and the astute physician is going to look at your A1C, which is a diagnostic criteria. They're going to look at your glucose level and they say, "wow, it's 500. This is insane." And then they're going to immediately go into crisis mode and try to figure out how we can protect the body. And then they'll start to figure everything out.


Brad: You don't go in to see a doctor in one visit and they say, "oh, you're diabetic." They're going to ask a lot of questions, do a lot of blood work, a lot of other tests and you're going to come back and they're going to analyze it.


Chris: It can be really scary stuff, I mean, it can be a crisis situation. You could have a kid that's unconscious. You don't know why they're not arousable, in a type one particular case. Whereas an adult type two, the onset is much slower. If we weren't eating well, we're not exercising well and we're gaining weight, it builds up. I mean, they hypothesize that there's at least 8 million people in the United States walking around that don't even know they have diabetes, but they're diabetic. Again, that's going to be a type two. Type one it's medical crisis. You don't get that treated, you're dead. I mean, it's that serious?


Brad: As far as symptoms, a typical symptom that I've worked with patients, is they get lightheaded. It's like, oh, they're diabetic and then we come down and the nurses come down or whoever, or we get something like orange juice or something.


Chris: Yeah, when their sugar is low, it's called hypoglycemia or low blood sugar.


Brad: Yeah, and that's when you get that lightheaded feeling.


Chris: Yeah, they can almost behave drunk. So yeah, there are a lot of things to be aware of. Let's say that you weren't feeling well that morning and they brought you down for treatment and maybe you didn't eat breakfast that day, but you took your insulin, or you took your meds, and all of a sudden you're crashing. And so you can be unstable, almost drunk like, just talking about things that don't make sense. I mean, they can present in a variety of different ways. And so, yeah, a little bit of orange juice, sometimes they'll tell you to chew on lifesavers. We have glucose tablets in the pharmacy or glucose gels. There's a variety of different ways. If it's really serious, they're going to give you a shot of glucagon to stimulate blood sugar production.


Brad: And what if it goes high, if it spikes, what are the symptoms?


Chris: Well, if it spikes high, that's where you're not going to feel right, you're going to be fatigued, lethargic, and cloudy thinking. They sound kind of similar, don't they. So it makes it kind of tricky. They'll probably give you a bolus of insulin, so they will treat you specifically with insulin. When you have blood sugars over the marking would be 240 and that's milligrams per deciliter.


Brad: What's normal, what's normal blood sugar, 120?


Chris: For healthy people, it's going to be 80 to 120.


Brad: So what numbers are high?


Chris: After 120, but I mean, if you have what they call postprandial FTE after you eat, our sugar's going to go up, so it wouldn't be uncommon for you or me to be like a 200 if we had a really starchy meal. So let's say we had some pineapple and I don't know some coconut and some rice and some chicken. I mean, it's going to go up.


Brad: That's normal.


Chris: Yeah, it's got to be variable with what you eat, but it's going to come down right away because your body's going to uptake those sugars, put them in the cells, and then it'll be expunged when you have energy needs. So with somebody that's well, whether one or two and their blood sugar is way high, we have to watch out for that risk of diabetic ketoacidosis. And that can be actually fatal if not treated properly. The blood becomes acidic, the sugars are super high, so the clinician is going to recognize this.


Brad: So if you're at home and you're diabetic, and you get these symptoms, it's probably time to go to the ER.


Chris: Yes. Yeah, and with new diabetics, most doctors coach them, but you should have a kind of a diabetic rescue plan. And your family members and friends should know about it. Diabetes can be a long-term, frustrating situation for people to deal with. It's a big blow when you say "Brad, I'm sorry, but you're a diabetic." I mean people think, oh my God, am I going to die? And no, the answer is absolutely not. It's a very treatable disease state that you can live a great life. You can still have all your hopes and dreams can come true. It's not the end of the world. It's going to require work. And so we have to be willing to put the time in and make some of those changes if it's a type two. Type one, you make your peace with using your insulin and doing all the things that are necessary.


Brad: Can we go onto our list of seven here, it's circulation, neuropathy, vision, internal organs, heart disease, mouth, and age-related issues. So let's start with number one, circulation. That's a big one.


Chris: Yep, I mean our cardiovascular system, when you are a diabetic, whether it's one or two, and this will be a standard thing, the longer you have diabetes, the more these risks become more prevalent. So whether you're, let's say a 30-year-old type two diagnosis or a 15-year-old type one diagnosis, it's not as advanced, but when we're 65 and we've had diabetes for a number of years, the cardiovascular disease becomes a very real risk. And I mean, it can affect you in your 40's, your 50's, your 60's.


Brad: So cardiovascular, we're talking about the heart then?


Chris: Yep, the heart because basically with sugar, every single problem that we have in diabetes is a circulatory issue. So cardiovascular disease is much higher, I mean, you've got a much higher risk for heart attack, much higher risk for stroke. Part of those changes are because of the sugars in our blood, it causes the breakdown of vessels, and causes fatty deposits to develop. So it can cause atherosclerosis, which is the hardening of your arteries and clogging of your veins. It can lead to peripheral vascular disease in your extremities, which can cause circulatory issues. It can cause issues in our kidneys. Obviously issues around the heart. You can get just fatty deposits in your arteries. And then basically that can break off and become a stroke. So we have lots and lots of risks and they actually talk about vascular issues and for microvascular and macrovascular. So macro think of bigger, micro is in smaller, smaller at the capillary level. So it becomes unbelievably complex as a clinician because the diabetic umbrella is so encompassing. So you list off those seven things. And one of the things too, with respect to that is so what do you do? What do you do to protect yourself? Well, there's going to be medication therapy, for sure. So whether you're going to be put on a statin, is going to be absolutely critical to protect you. Obviously, hypertension, managing your blood pressure issues.


Brad: This isn't all diabetics, this is where it can lead to this, but if you change your lifestyle?


Chris: No, it's going to be all diabetics. You're going to have those lifestyle changes but if you don't make those lifestyle changes, this is your future. It's going to be managed with chemistry. We still want you to exercise. We still want you to eat well. I mean, that should be number one, "A" number one no matter what you do.


Brad: What about neuropathy? Now that's a term that I think a lot of my patients will say "oh I have neuropathy." But with diabetics and neuropathy and the physical therapy world, we're always concerned about people's feet.


Chris: Feet, feet, feet.


Brad: Circulation is not good down there, and then you become numb and tingly and you don't have good sensation. Let's say you put your shoe on too tight or you have a wrinkle in your sock and it pushes into the skin and the skin breaks open.


Chris: You've got the ulcer.


Brad: Then you've got an ulcer that will not heal very well with a diabetic. And it can lead to an amputation. I've worked with a number of amputees as a result of a fold in their sock, or they stubbed their toe, broke something open and it will not heal as a result of circulation and the other effects of diabetes. So boy, keep your feet and your footwear properly fitting.


Chris: Proper fitting shoes. Wearing wicking socks that are not like loose and droopy, I guess.


Brad: Yeah, we can't have the folds on the socks.


Chris: No, no, you want to make sure that everything's well-fitting. I mean, from the toolbox in your shoes, probably like what I'm wearing today would not be probably good diabetic footwear.


Brad: You are not going to wear the pumps of the high heels where they're pointy.


Chris: No, no, because you're going to be cramping your toes. That's one of the things with neuropathy, it's a progressive issue too. It starts out in a lot of cases, as pins and needles or burning, and then eventually, it's just numbness. It can affect their gates, it can actually affect the bone structure of their foot. And sometimes people just can't see their feet. And yet the ball of the foot is where most of those ulcers start or your toes. And so again, it's the footwear issue. So we want to make sure we're taking care of that. You want to make sure you have regular doctor visits. You should inspect your feet daily. After you dry off, you should put a moisturizer on them. Vaseline is a very simple way to help to maintain that, but you don't want to put it between the toes because that's where sweat collects. Then, you can get a variety of different skin infections too. So we'll talk about some of that as well.


Brad: This is sounding pretty gloomy, but I do want to give some bright sides. I personally know a diabetic, she wears a pump so she has insulin in her system from a pump. You would never know it, she's got a very good job, she's very active, she's athletic, which helps. And she deals with it well. So again, I just want to say, if you choose to do your lifestyle changes, do whatever you have to do, what your doctor and whatnot coaches you.


Chris: Absolutely.


Brad: It's not all doom and gloom, but again, it potentially could go that way.


Chris: But you have to work at it. And you have to realize that there are days when patients feel frustrated. Let's say you just went to a wedding last weekend. Well, I mean, there's always great food and there are always things that we're maybe not thinking about. Do I have the piece of wedding cake? Do I not have the piece of wedding cake? What kind of ramifications are we going to do? Did I do enough dancing at the wedding to kind of burn off some of those calories? Or am I going to have to take an extra walk or what's going to happen to me tomorrow? There are so many things with diabetes that makes it so incredibly complex to treat. And as a patient, it can be frustrating, but realize that if you can take a team, have a family member or a friend that can help support you, and have a plan to work on things. These are things that will help to minimize that. Most people on a pump are type one diabetic, but that's not always the case. You can have people on pumps with type two. And those pumps are incredible. It's kind of like having a fake pancreas. It's just put into you and it literally gives you a basal level of insulin. That's that baseline level. And then when you eat, you can program it for your meals, what you are going to eat. So they're incredible these days. So your endocrinologist is certainly going to be paramount in doing this. It's certainly something you don't see at the pharmacy level, other than the people coming in to pick up their insulin for their pumps. But it's certainly something that has been life-changing for many people.


Brad: Good.


Chris: And again, diabetes is a very livable disease. There's no reason why it's the kiss of death. If you don't take care of yourself, you can end up with an early grave. So I don't like to scare people, but it's certainly something that we have to be an active participant in managing our own disease states. So if we move to the neuropathy, I mean, it's circulatory at the end of the day, those nerves are not being bathed properly. But again, so we move on to vision where we start talking about diabetic retinopathy. That's the leading cause of blindness in working-class people throughout the world.


Brad: So that means that as a result of the diabetic issues in your system, your retina becomes damaged.


Chris: Yeah, damaged, and so it becomes part of the microvascular portion of diabetes. So this is the small blood cells. And so in our eye, it can affect our lens, it can increase the risk for glaucoma, and it affects the retina and the macula. I mean, there are all parts of the eye that are all in tune so we can see clearly. And what happens is that because it becomes a circulatory issue, it breaks down the little capillaries in the eye that feed the retina and the macula and the optic nerve and everything else. Just think of blood as your lifeline. When those vessels are broken down because sugar has basically screwed up the whole mechanism for delivering nutrients and oxygen in the blood, problems occur. And so in the simplest fashion, I mean you can get floaties, your retina can become detached, so your eye checkups are very critical.


Brad: So again, with this same thing, the maintenance, your lifestyle changes and get things under control and actively manage it persistently.


Chris: Every single solution that we have comes down to lifestyle modification, eating well, and using your medications appropriately. I mean, there is no in-between, there's no negotiating at this point. It's kind of like playing monopoly where you go to jail. It's like, do not pass, you go directly to jail. If you don't treat your blood sugars well and with respect, it's going to create a cavalcade of problems.


Brad: Let's see, anything else? Like what about the mouth? Are there some issues with the teeth?


Chris: Yeah, so again, circulatory. So, if we aren't getting good oral circulation in our gums, it can cause gum disease, and it can cause periodontal disease. And we're a diabetic too, so we don't heal as fast. So when we were talking about the neuropathy of the foot, diabetic foot ulcer, we don't have that rich source of blood to come and just try and oxygenate and help that foot heal. And so there are a variety of different things that doctors do with that, but the same thing with the dentist. You see how this adds up with the healthcare costs. So you've seen your eye doctor, you're seeing a kidney doctor, maybe, you're seeing your foot doctor, you're seeing your endocrinologist, you're seeing your regular GP. So it's a team-wise approach. And then you go into the pharmacy to get your stuff, and maybe you're paying your physical therapist to help you to improve your lifestyle. Which a lot of cases, physical therapists are paramount in developing exercise programs, how to do things properly, warn the patients what to look for. So, I mean, they are so paramount in treating and actually a lot of cases like with peripheral artery disease, which is circulatory again, physical therapy is better than drugs. So it's huge.


Brad: Yeah, so appropriate exercise.


Chris: Correct. And so going back to the mouth, because I just digressed, I'm sorry, I do that. Again, it's circulatory, keeping your sugars in check and making sure that your dentist is looking at those teeth. Because actually one of the things is, when you have a bad dental disease, you're not eating properly because you can't chew the right foods. So what do you go to? All the easy mushy sugary stuff. Worldwide, sometimes nutrition is hard to come by or at least good nutrition is hard to come by. And so with the mouth, it's very important. Our internal organs when we're talking about our kidneys, our livers, our hearts. So you talk about diabetic nephropathy as one of the leading causes of kidney damage. And so we have a little filter called the glomerulus and those fatty deposits into those little microvascular changes can cause damage.


Brad: So you're compromised throughout your gut if you will.


Chris: Everything, the average adult has basically 100 million miles of blood vessels. If you lay them end to end, that would wrap around the planet a few times. So that's what they theorize. The child has 60 million. So it's an incredible amount. And so circulation is key and to manage it, it all comes down to blood sugar management.


Brad: So let's get to that. How do you measure? Because that's going to be a key thing. Once you're diagnosed, you are going to be responsible to measure your blood sugars on a daily basis.


Chris: Every day it should be done.


Brad: And that's where you poke your finger and you get a little drop of blood.


Chris: That's one way.


Brad: Okay, how many ways are there that you can measure?


Chris: Well, it's going to be a finger prick or it can be through constant glucose monitoring. And that's one of the newer things that we have, they're wearable, implantable devices.


Brad: Put on your arm.


Chris: Yep, so they just have a special mechanism and it has a little capillary that if you could picture, would go in right below the surface of the skin.

Brad: So something pokes into your skin.


Chris: Yep and you'll wear it for 10 to 14 days, depending upon the manufacturer that you choose. And you have a little unit and actually, it's even integrated with cell phones, but you just wave it right over the sensor and it'll give you a real-time picture of what your blood sugar is at that moment in time.


Brad: Wow, otherwise you're poking your finger, blah, blah, put it in the little machine and it takes some time. It's not a big deal, but yours is easy.


Chris: It's not a big deal. But when you talk to patients, the one thing with the finger prick is it's a little sting, so they get frustrated with it. It can cause thickening of the skin. So we're talking about diabetics when they come in and actually checking, you want to use the side of your finger, not the tip of your fingers, a lot more nerve endings here. So it hurts more if you use the tip. So you want to use the side. Some people their circulation's not great, so they can run their hands under warm water to kind of work that up. Or you can actually rub your hands together and create a little friction, so you get a better sample. So sometimes it can get hard, especially for lifelong diabetics that are checking it three to eight times a day.


Brad: Oh really that often?


Chris: It can be, so that's why the constant glucose monitoring is a bit easier and a lot of the pumps now are integrated with that too. So like Medtronic and a variety of different companies.


Brad: So they put the pump on that monitor?


Chris: Yeah.


Brad: And that goes for more than 14 days, as long as the pump is in?


Chris: Yeah, and the pump to pump, they have different varieties because they're going to load it with their insulin. And then also it also integrates with their blood sugar.



Brad: That gets pretty specific per patient.


Chris: Yes, yes, yes, yes. But in so far as just self-monitoring, I mean the money's in the strips. When we talked about one in $4, I mean, test strips, I mean just an average box of 100 test strips is 180 bucks.


Brad: Oh, really?


Chris: Most insurance companies cover those. But if you take the new diabetic, the constant glucose monitoring, so there's the Freestyle Libre, Libre 2 and then there's Dexcom, which are the three units I'm most familiar with. They all, like the Dexcom are 10 days sensors and the Libres are 14 days sensors. They're a little bit cheaper than the strips, but interestingly, most insurance companies don't cover the constant glucose monitoring, which is strange because it's the most cutting edge, best possible information you can get to give yourself. And plus you don't have to prick your finger. So it's getting more comfortable. I mean, there are people like the Freestyle Libre product, you can swim with it.


Brad: Oh really?


Chris: Yeah, yeah, they stay right on, you can bathe, I mean, you don't take it off, you wear it for 14 days.


Brad: Yeah, that information is documented, so if you can refer back to it for future reference possibly.


Chris: Yeah, yeah. Like I said, you heard me say the test strip is about 180 bucks for 100 strips, for a sensor it's about 60 bucks. So it's cheaper. But for some strange reason, many insurance plans don't seem to cover those sensors. And I don't fully grasp why as a pharmacist. To me, when I talk to patients that use these devices, they love them. Their sugars improve. It tells them real-time, they're like, oh my gosh, I'm low, it's time for me to grab a quick snack or I'm way too high of, gosh, I'm going to have to go out and take a walk.


Brad: You get to learn your body.


Chris: You learn much more effectively, all of a sudden, wow, I went on this and I lost 11 pounds, my sugars are great, I'm feeling better, I'm more active, more energetic. I mean, they really are an incredible tool because of all these things that we talk about, as complications. It's the simplest thing that we can do to help ourselves on a day-to-day basis. And a doctor uses a different tool called an A1C, which has done about every 90 days. And that's a snapshot of how well you've been doing. And that's what the clinicians use. But if you're using your blood glucose, your self-home monitoring devices, hopefully, it will mirror what the physician sees every 90 days or six months, or whenever you come in for your checkups. So it is a critical, critical step in us helping to conquer the disease state itself, is just being in the know.


Brad: I wanted to cover this earlier and I should have brought it up earlier, I feel bad, but people with type two, if you catch it early enough and you're not too far off, is that the point where your lifestyle changes could reverse it?


Chris: Yes.


Brad: But not cure it, but at least make it very manageable without medication.


Chris: Yeah, absolutely, 100% yes. So I mean, and you can be a type two for five years and then you just find religion and say, I'm done with all this stuff. You exercise, you eat well, you do everything, your nutritionist says, your doctor says, you can get off the meds. It is a goal that I talk about with many of my patients, like, "Hey, if you can work at this and you commit to yourself." Because I think you're your own best asset. And so if you treat yourself as a billion-dollar commodity, you're a billion-dollar corporation, and it's like, well, I want to make this corporation last for a long, long time because I want kids, I want grandkids or I want to write a book.


Brad: I want to live.


Chris: You want to live. I mean, whatever your goals and dreams are, it should not crush them, is my point. This is very livable. And if you're active, if you pursue it actively yourself, you can beat the disease is not quite the right word because it's always going to be there in an underlying fashion, but you can reverse it and to the point where you don't need medications.


Brad: Sure.


Chris: This is a little bit of a side note, but like there are patients that are candidates for bariatric bypass, which is the special stomach procedure that doctors reduce the surface area and you're going to reduce caloric diet and very, it's very regimen and very difficult, and you have to be psychologically ready for something like that. But a lot of people lose 100 pounds and all of a sudden they're off all their diabetic meds, all their blood pressure meds.


Brad: Oh, really?


Chris: So it's an option for people that just can't quite get it done. Sometimes we just need a little help.


Brad: It's a select group of people.


Chris: A very select group, but it's something that's out there. And when you see all of a sudden, they're like, I am no longer classified as a type two diabetic because I've made these changes. But they're also exercising and eating well. A lot of times too they can clip a nerve that turns off the ability to even sense hunger. So there's a lot. It's pretty amazing stuff.


Brad: Is that something that's pretty new?


Chris: Newer. Well, I don't know, I guess you'd have to talk to a gastroenterologist that specializes in bariatrics. Probably, it's not new to them, but it's newer I think to us in the real world.


Brad: I don't want to give people the idea that everybody should have it done. Get the nerve slipped for hunger and they're okay.


Chris: No, it's not that simple. And there's a cost to those things too because people can forget to eat. They have to set an alarm to be sure you eat at this time. So again, that's a sidebar. It's not the end all be all. I guess the point being is that if you can commit to those lifestyle changes, you will see improvement, you will see your blood sugars under better control, and you will see overall better health. The one thing with all these things that we're talking about with complications is, that the longer we're diabetic and the less well-controlled we are, the more severe and the more frequent these complications can become. And so that's that diabetic umbrella. That's everything that's under there. I mean, it's the heart, it's the mouth, it's the nerves. I mean, it's everything, it's stroke, it's vascular disease, it's your circulatory, it's your eyesight, it's kidneys, it's the amputations. When we talk about all these things, it sounds pretty dire. But if we are willing to put in the work, we can live with it and we can manage it and we can manage it very effectively.


Brad: And prosper it sounds like.


Chris: Exactly!


Brad: So that puts you in control of it, which is a big relief. And I know when I have my patients with pain, particularly back pain, if I can show them some exercises or some things not to do, and it puts them in control, it's like, oh, I can control this pain. Their whole life changes. They just have to realize and accept what they need to do and you do it.


Chris: Yeah, you have to almost treat it like a job. I mean, and it's just like, all right, I'm packing my lunch box with healthy food and I'm going to work. It's one of the things that, cured, no, treated, yes. And I think if we're willing to commit to it, you can have a great life, an even better life. And I mean, there are athletes, there are movie stars, there are presidents.


Brad: Everyday people that you may not even know.


Chris: That you don't even know. They just don't talk about it.


Brad: Yep, all right, very good. Hopefully, we've covered it. I think we covered it quite well. Maybe too well, I don't know. But good luck with it. It can be a problem, but you can certainly overcome and live well with it. So take care and thank you, Chris, for coming on and sharing all your knowledge.


Chris: Absolutely.



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