Diabetes is all over the media these days: A recent article in the Wall Street Journal talked about one woman’s struggle being misdiagnosed with Type 2 diabetes when she actually has Type 1. Women’s Health Magazine published a piece about the dangers of being Young, Thin & Diabetic. And as I mentioned in my bio, one of the motivating factors for my starting this blog was my own experience learning about diabetes after a loved one was diagnosed. Well, I was fortunate enough to interview Dr. Kevan Herold, Professor of Immunobiology and Edocrinology at Yale University (yes, Yale!) on his personal and professional knowledge of the disease. Read on & as I always say, ‘learn from the best’!
1. Thanks so much for doing this interview! Can you tell us a little about yourself?
I was trained as an endocrinologist and an immunologist. My original immunology training
involved investigations in mouse immunology since much of our understanding of basic
immunology comes from these systems. However, the ultimate goal of my work has been to use the information from rodent studies to develop treatments for human Type 1 diabetes which I have done for the past decade. In addition, I work as an endocrinologist seeing patients in the out and inpatient settings.
2. You have a unique perspective on diabetes because you are a medical expert who is himself diabetic. Can you tell us about your own diabetes diagnosis? How did you learn to manage the disease when you were newly diagnosed?
I had just gone away to college – a few weeks after high school ended when I developed
symptoms and began to lose a great deal of weight. I was eventually hospitalized in diabetic
ketoacidosis – not a great way to start the first term at college. When I left the hospital, I still could not read from the hyperglycemia effect on the lens and so I had to start recording my classes on tape and then going back through the lectures until I could read.
Adjusting to the food at school was quite a challenge. Fortunately, at my school there was a very good nutrition department that had characterized the food that was being served in the dorms. Treatment was simpler but not nearly as good as it is today. You took 1 injection, maybe 2 of NPH insulin, perhaps with some regular insulin, and the only way to monitor things was with urine testing. You only knew of hypoglycemia when you had symptoms.
3. Wow, that sounds like a tough experience! For readers who don’t know, can we go back to basics for a second? What is diabetes? What are the different types and what differentiates them from each other?
Diabetes is a disorder that results from the inability to make sufficient amounts of insulin that is needed for normal metabolism. Insulin is needed for survival in order to metabolize all nutrients and therefore, the complete deficiency of this hormone was lethal until the isolation and use of insulin in the 1920’s.
The more common form of diabetes is Type 2 diabetes in which the demand for insulin, which is increased because of resistance to its action, cannot be met.
Type 1 diabetes is less common overall but the most common form in childhood and also accounts for about 10% of adults with diabetes. It is due to the immune mediated destruction of the insulin producing cells.
Patients with Type 1 diabetes produce little or no insulin. Patients with Type 2 diabetes can produce some insulin but an insufficient amount to meet metabolic demands.
4. What do you think are the major misconceptions about diabetes?
For sure people do not often distinguish the forms of diabetes which is important in treatment. Type 1 diabetes is treated with insulin and diet whereas Type 2 diabetes can frequently be treated with drugs that generally are effective in treating diabetes together with diet. One of the major misconceptions about both forms is the importance of diet.
5. You mention that 10% of Type 1 diabetes occur in adults, not children. I’ve heard this referred to as “latent autoimmune diabetes” (LADA). Is this a new type of diabetes (Type 1.5)?
No, I don’t consider it new. The fact that many adults develop autoimmune or Type 1 diabetes has been known for quite a while. Frequently, however, physicians who only see adults fail to recognize this form of diabetes and to change the treatment approach when it is identified.
6. Your research involves coming up with a drug treatment to slow the progression of Type 1 diabetes in newly diagnosed patients. Can you tell us a little bit more about this research and the progress of the drug’s development?
It’s not just new onset patients but also for prevention of the disease. We have spent a lot of effort on testing anti-CD3 antibodies in patients and in studying the way that it works in preclinical models. My own view of the clinical data is quite positive. Some have been disappointed that the clinical trials have failed to be as successful as one would hope from the mouse studies, but that is probably too much to ask with a single drug. There have been 5 completed studies that have shown how treatment with the drug can preserve insulin production. My view is that getting a treatment approach approved, even if it is not a complete cure, would represent a great achievement for eventually reversing the disease entirely.
7. Diet is a critical part of managing diabetes. In your experience, what would you say are the greatest obstacles to people changing their diets after being diagnosed? What advice do you have for someone who is diabetic and having trouble changing their diet?
I certainly agree with your first statement. I would say that it is essentially impossible to maintain good glucose control without a careful diet. I think it is important for people to realize that there are not prohibited foods, but there are foods that they most likely would choose not to eat because glucose control will be difficult if you choose to eat them. At the same time, a “diabetic” diet is the type of diet most individuals should be eating to maintain their weight and to promote health.
One of the issues that I don’t think that people recognize is that the word “diet” does not
necessarily mean it is good for someone with diabetes. Often, to reduce fat content, foods
termed “diet” have increased amounts of sucrose. That creates problems with glucose control.
8. For adults who have diabetes, there is often a concern about drinking alcohol. How does alcohol impact blood sugar levels? Can/should diabetics drink?
Straight alcohol has 7 cal/gram and does little to affect glucose levels. However, it can interfere with counter-regulation in the setting of low blood sugars and for that reason, a number of people have been given the suggestion to also eat when they drink. I don’t suggest eliminating alcohol to my patients –nor do I- but there are certain things to consider when you drink.
First, dry wines are a better choice than others that are not dry because of the carbohydrate content. Second, you could also have mixed drinks but you need to consider what is being added to the mixed drink. For example, tonic water and Coke are available sugar free, and fruit juices are fruit juices. Finally, an important restriction is that one needs to be in control when drinking. In addition to being able to recognize hypoglycemia, choosing foods wisely, dosing insulin accordingly, and others, it is difficult to recognize hypoglycemia and hypoglycemia can be mistaken for drunkenness so that appropriate
treatment will not be given.
9. Many people of color come from families with a history of diabetes. How much does family history factor into the eventual development of diabetes? Is it more important than diet/exercise? Equally as important?
Type 2 diabetes has a very strong hereditary component. It’s particularly important for individuals who come from families in which Type 2 diabetes occurs not become obese since that is the most frequent precipitating factor. Type 1 diabetes also has a hereditary
component. However, the risk overall for Type 1 diabetes in first degree relatives is lower– closer to 5%.
10. What advice do you have for caregivers and family members who are caring for/living with someone with diabetes? What is the best way to be helpful to someone who is learning to manage this disease?
I think it is very helpful for those who live with and care for someone with diabetes to have some understanding about what causes the disease and how to manage it. I think it is important to realize that the optimal approach to managing the disease involves keeping blood sugars (and lipids and blood pressure) in a range similar to normal individuals. Diet is particularly important. For example, it is very difficult to follow a diet if the food that is served is not appropriate for someone with diabetes but this happens frequently. In addition, it is helpful to be aware when someone with diabetes has a low blood sugar since they may not have someone to assist them in identifying when it occurs and helping with treatment.
11. Is there anything else you want to add?
I think it is important for families to realize that there has really been progress in this field. The ability to measure glucoses at home, to determine what the average levels of glucose have been, delivery of insulin, and even the forumulations of insulin as well as other new therapies were not available as recently as 10 or 20 years ago. So I think it is important to take advantage of these new developments. Ultimately, however, the optimal treatment rests with a patient him or herself. It can’t be dictated by others, which is why education and close interactions with diabetes care teams are so important.
(To learn more about Dr. Herold, his research and clinical trials related to his research, click here.)
*** Is there anything new you learned about diabetes from Dr. Herold? What myths/rumors have you heard about diabetes? Comments from those with diabetes (or those with loved ones who have diabetes) are welcome! -CFC ***
- Confusion Over Diabetes Types Adds to Patients’ Woes (health.usnews.com)
- Differentiating between Diabetes Mellitus Type 1 and Type 2 (epicahealth.com)