Dr. Jacqueline Lonier is an Assistant Professor in the Department of Medicine at Columbia University and an adult endocrinologist at the Naomi Berrie Diabetes Center. Her clinical practice focuses on adults with type 1 and type 2 diabetes.
Dr. Lonier joined Dr. Hyesoo Lowe on an episode of Columbia Surgery’s podcast Conversations and Curbsides. The two doctors discuss diabetes from diagnosis to treatment to removal of stigma and shame.
The following is a transcription of the discussion, and is lightly edited for context and clarity.
Jump to a Section:
- What Is Diabetes?
- Complications From Diabetes
- Managing Blood Sugar Levels
- Device #1 – Continuous Glucose Monitoring Sensors
- Diabetes Device #2 – Insulin Pump
- Seeking Help Without Shame
Dr. Hyesoo Lowe:
Today I have with us Dr. Jackie Lonier, who is an endocrinologist here at Columbia University Medical Center and she has a specialty in diabetes.
We're going to talk a bit about diabetes, which is a huge topic, but hopefully she can help break it down for us. Hi Dr. Lonier, it's so nice to see you today.
Dr. Jacqueline Lonier:
Hi. Thanks for having me.
Dr. Hyesoo Lowe:
Great to talk about this very important topic that has affected so many lives in the world and there's a lot of new things to talk about as well. So let's get into it. To start for the general public as a top line intro, what is diabetes exactly and what is the goal of treating diabetes?
What Is Diabetes?
Dr. Jacqueline Lonier:
So diabetes is not just one disease, but it's a group of diseases, a group of metabolic diseases in which the main issue is the body's inability to process glucose or sugar appropriately.
In some cases, diabetes can be due to something called insulin resistance. Insulin is the primary hormone that regulates blood sugar levels. So if your body does not respond to insulin appropriately, blood sugar levels can be high. Another reason why diabetes might develop is insulin deficiency from the pancreas, the organ that produces insulin is not making enough insulin to keep blood sugar levels in the normal range. So there are a lot of different reasons why someone might develop diabetes, but ultimately the result is high blood sugar levels.
This can be problematic over the long term because high blood sugar levels for many years, 10, 15, 20 years increases the risk of vascular complications. So people hear about diabetes complications, and they often have preconceived notions about what that means, but we actually mean very specific complications.
Complications From Diabetes
Dr. Jacqueline Lonier:
When we talk about diabetes complications, we're primarily concerned with disease of the eyes, the retinas, and the back of the eye. The blood vessels in the back of the eye are very sensitive to high blood sugar levels for a long time, and those blood vessels can be damaged if blood sugar remains high over the course of years.
Similarly, blood vessels in the kidneys are very sensitive to high blood sugar for a long time and damage to those blood vessels can lead to kidney disease and peripheral nerves. Small nerves that innovate your limbs similarly can be damaged by high blood sugar levels for a long time.
Larger blood vessels in the body are also affected by high blood sugars for a long time and that can increase the risk over time of a cardiovascular event or a heart attack or a stroke. So the goal of treating all kinds of diabetes is to prevent these complications from happening. And the best way that we can do that is by keeping blood sugars in the target range. We know that if we can keep blood sugars over time, largely in the target range, the risk of these vascular complications goes down dramatically.
Managing Blood Sugar Levels
Dr. Hyesoo Lowe:
And for someone who has diabetes, what is the target range for blood sugar levels?
Dr. Jacqueline Lonier:
We use a test called hemoglobin A1C to both diagnose and monitor diabetes over time. So hemoglobin A1C is a reflection of your average blood sugar level over the two to three months before the test is drawn.
We diagnose diabetes when hemoglobin A1C is 6.5% or higher. Once someone has diabetes, the goal for most people is to keep A1C below 7%. So we know if we can keep A1C below 7%, for the most part, for many years, the risk of developing diabetes complications is much reduced.
Dr. Hyesoo Lowe:
And to keep the A1C in a good range, sometimes people need to check their blood sugar and monitor it on a daily basis, either once a day or multiple times a day. And that leads me to my next topic, which is technology in diabetes.
Device #1 – Continuous Glucose Monitoring Sensors
Dr. Hyesoo Lowe:
So there's been an explosion of technology in healthcare with wearables, we can know our pulse, we can know our heart rhythm sometimes with various things that we can wear on our bodies, and there have certainly been a lot of innovations in diabetes technology.
So can you tell us a little bit about the various gadgets and technological advances that have been done to really help us manage diabetes?
Dr. Jacqueline Lonier:
Sure. Some people with diabetes, depending on how they're treated, need to check blood sugar on a regular basis in order to adjust the dose of their medication or to make sure that their blood sugars are staying within the gold range. In the past we usually prescribed finger stick glucose, which involves your finger and putting a small drop of blood on a glucose test strip and inserting that into a glucose meter to get a reading of the blood glucose concentration.
Now we have something called continuous glucose monitoring. So these are really cool devices. They involve inserting a small sensor underneath the skin and the sensor measures glucose concentration, not in the blood but in the skin, which is basically the same as the blood glucose concentration.
So these devices work with Bluetooth to an app on the phone or to a separate reader device. And people with diabetes no longer need to prick their finger to learn their glucose reading, they can look at their app or their reader and see what their number is just by opening up their app.
Dr. Hyesoo Lowe:
So this is a huge advance because it hurts to do a finger stick and that's how it's been done for decades. How accurate is it when you use a sensor?
Dr. Jacqueline Lonier:
They're quite accurate. It depends on the model of the device, but they're quite accurate. In the past, previous models of continuous glucose monitors did require calibration with finger stick blood glucose, but the newer models no longer require calibration. So the accuracy has been much improved over the recent years.
Dr. Hyesoo Lowe:
That's very cool stuff. So how long does a sensor last? You put one on your arm, for example, or on the abdomen and then amazingly you can check your phone and know what your blood sugar is, right?
Dr. Jacqueline Lonier:
That's right. So depending on the brand of the sensor that you're using, you would change it every 10 to 14 days. You can shower with it, you can sleep with it, it stays on you for the entire time and it's very comfortable. Most people put it on and forget that it's even there.
Dr. Hyesoo Lowe:
Great. And I bet that kind of data can really inform because it's continuous feedback, it can inform food choices, what you're doing, whether you're getting into trouble or whether things are going just fine.
Dr. Jacqueline Lonier:
Yeah. So a traditional finger stick glucose just gives you one reading in time, but it doesn't tell you anything else about what was happening before or after that glucose reading, and your blood glucose levels are changing all the time depending on your food, your activity, your stress levels. So the ability to have not just one glucose level, but continuous glucose levels and trends of glucose levels along with predictions in whether you're rising or falling, is really helpful for people with diabetes in order to adjust their medication doses, their diet, make changes in the moment to optimize their blood glucose control.
Dr. Hyesoo Lowe:
Yeah, that makes sense. That extra data would be really helpful to control your diabetes. How about people who don't even have diabetes or people who have pre-diabetes, can they put one of those on and is that helpful in any way?
Dr. Jacqueline Lonier:
That's a great question. I think there's a lot of interest in that. I don't think there's any particular reason for people who don't have diabetes to wear one of these. They're quite expensive. They might be fun to wear once in a while just to get a sense of how your blood sugar is changing, even if you don't have diabetes. But there's no real reason to wear them. There's no real medical reason to wear one if you don't have diabetes.
Diabetes Device #2 – Insulin Pump
Dr. Hyesoo Lowe:
Makes sense. Let's switch gears from checking blood sugars to managing blood sugars. What is the bionic pancreas, tell us about the insulin pump?
Dr. Jacqueline Lonier:
Well, the bionic pancreas is like the holy grail of type 1 diabetes management. We do not have a bionic pancreas yet for Type 2. For people with type 1 diabetes, which is an autoimmune condition in which the insulin producing cells in the pancreas are the target of immune destruction by the body. These people are insulin deficient and the only treatment for people with type one diabetes is insulin replacement.
One way that we have to do this is not just with insulin injections but with insulin pumps. So insulin pumps deliver small amounts of insulin continuously and can also deliver larger amounts of insulin at the time of meals to prevent blood sugar from going too high. The benefit of using a pump over injections is greater flexibility in insulin dosing, allowing you to match your insulin doses more precisely with your body's requirements at the time.
Now we have insulin pumps that work with continuous glucose monitors. So there's a link between the two, a Bluetooth link between both devices. You wear two devices, a pump and a sensor. The pump has an algorithm that takes the data from the sensor and makes some automatic adjustments to insulin delivery in the background for the patient. It doesn't do everything. Doing everything would be the bionic pancreas, which is something that patients are waiting for because the less input the patient needs to give, the less burdensome diabetes management is for them.
For now, we don't have that, but we do have incredible advances, recently, in these kinds of devices where patients are having great results with using what we call hybrid closed looped insulin pumps. So there's a partial connection between the pump and the sensor.
Dr. Hyesoo Lowe:
That's a huge long way from the old way of doing things, which is when I learned about all of this, which is the patient has to prick the finger, know what their blood sugar is at that moment, if it's high or low, they have to respond to that, decide what they're going to eat, decide on their insulin dose, inject the insulin dose into their arm or after mineral leg, and then wait until the next time they check their blood sugar, which might be the next mealtime. And now everything seems to be going the way of much more integration with a couple of wearables, but definitely doable. Definitely doable.
Seeking Help Without Shame
Dr. Hyesoo Lowe:
Great. So what is the one thing that you feel would be really helpful for everyone to know, whether it's about diabetes, maybe you could do an add-on with pre-diabetes. What do you think everyone should know?
Dr. Jacqueline Lonier:
I'd say I would want everyone to know diabetes is not one thing, diabetes is different for everybody with diabetes. With social media, people often go onto social media and find diabetes influencers and then they come in and they say, “My blood sugars don't look like this other person’s” or “My A1C is not as good as this person's.”
And I think it's very hard to compare one person's diabetes to another, even if they have the same type of diabetes. Not all type two diabetes is the same and not even all type one diabetes is the same. So I think there often is a lot of shame and isolation associated with having a diagnosis of diabetes. No one asks for it, it's not anyone's fault that it happens.
I think that sometimes it is portrayed in the popular media as something that people bring onto themselves with their lifestyle choices. But, although it can be influenced by diet and exercise, it's not something that anybody chooses. And it's really burdensome and stressful for people who have to live with this. So I think it's important for everyone to know that this isn't something anyone asks for, and this is not something that is the same for every single person who has it.
We do know that people who have pre-type two diabetes can make lifestyle changes that are highly effective at preventing the onset of overt type two diabetes. But again, not everybody with type two is the same. So people are trying hard doing their best, and I don't think we should shame people for doing that.
Dr. Hyesoo Lowe:
That makes a lot of sense. Well, thank you so much for that intro to diabetes and management, and it's been really fun to chat.
Dr. Jacqueline Lonier:
Thank you.
FURTHER READING
- Conversations & Curbsides Podcast Series
- Metabolic and Weight Control Center
- For Patients — Columbia Endocrinology CUMC
- More than Willpower: Obesity’s Many Causes & Factors | Columbia Surgery
- Understanding Obesity and Treatment Options