Dr. Cameron Herr, D.O.

So sorry to hear your mother has thyroid cancer. How is she doing? How are YOU doing?

Thyroid cancer, like many cancers is rare. Also like other cancers, it comes in a variety of different types depending on the underlying tissue: Papillary thyroid carcinoma, follicular thyroid carcinoma, medullary thyroid carcinoma, anaplastic thyroid carcinoma.

Some thyroid cancers (namely medullary thyroid carcinoma aka MTC) have underlying genetic syndromes associated with them. In this case, it is very important to have genetic testing done, and in many cases preventive thyroid surgery. The other thyroid cancers have some genetic component but no available commercial genetic testing.

However, if you're like many, the most common is papillary thyroid carcinoma (PTC). This is potentially curable by thyroid removal and depending on the extent of cell spread can be treated with radioactive iodine.

The biggest risk factors for thyroid cancers are exposure to radiation in the neck area (ie: treatment for other cancers like lymphoma, etc).

To protect yourself, I would recommend becoming familiar with the thyroid by looking and feeling it in the mirror. Doing a daily (or at least weekly) thyroid neck exam on yourself is a nice preventive tool. Much like doing a self breast exam, this would note any new lumps/bumps or changes day to day. Should you notice a change, then an ultrasound could be done to confirm an abnormality.

Routine ultrasound screening is generally not recommended given how common thyroid nodules are. Less than 5% are cancerous.

I value people knowing their body and in your case, becoming familiar with your thyroid and neck area is the best method of protecting yourself.

Let me know if you have other questions!

CH

Great question and you're not alone in needing to know the difference!

TYPE 1: Insulin deficiency or absence. This is typically due to antibodies against the insulin making cells of the pancreas. Many doctors (Endocrinologists) will test for these antibodies against the beta cell of the pancreas (IA-2 antibody) or an enzyme in the pancreas (GAD65). The face of type 1 diabetes is typically children and adolescents. However, many adults can develop type 1 diabetes. We sometimes call this "Latent autoimmune diabetes of adulthood" or LADA. Because the problem in this type of diabetes is an inability to make insulin, the therapy is to give insulin.

TYPE 2: These people often make insulin, however, their body is RESISTANT to using the insulin. Namely, fat tissue (adipose tissue) does not like to use insulin. I often think of sugar/glucose/carbohydrate as a "lock" and insulin a "key". A patient with type 2 diabetes has tissue cells "doors" that do not like the locks and keys. We call this INSULIN RESISTANCE. We can beat the insulin resistance by weight loss (decreasing fat tissue) or by providing more 'locks' and 'keys' to open the door of the cells. In this, the cells will store the glucose/sugar or use it as energy. Many medicines are designed to provide more insulin (keys). Some are aimed at reducing fat tissue (doors). Some are targeted to reduce glucose (locks) in the bloodstream by urinating it out.

This is such an important question, and often many people are incorrectly diagnosed. Subsequently they're put on the wrong treatment.

Great question and thank you for asking!

Diabetes is an issue of glucose excess, insulin resistance, or insulin deficiency.

Regardless of the type of diabetes, the ultimate is elevated sugar in the bloodstream that causes havoc/inflammation. Hence, sugar/carbohydrate/glucose excess should be avoided. Enter many sugar alternatives like Stevia, Equal, Splenda, Truvia, etc.

I recommend that my diabetic patients use artificial sweeteners if they HAVE to have it in their food/drink. Most patients hate the idea of switching from regular soda to diet, but for a diabetic any sugar is like FUEL ON A FIRE.

In most cases, fructose/glucose /sugar excess should be avoided (except low sugar aka hypoglycemia).

The debate on the harms of our artificial sweeteners is ongoing. As it stands, these are less harmful to you than excess sugar (aka brown sugar). For those that look online, you'll find tons of "research" against Stevia and other artificial sweeteners. Those that dive deeper will find this is typically political or money-driven.

In the end, use everything in moderation. For diabetics, use artificial sweeteners if you must. This is preferred over straight sugar, including brown sugar. Do not fall into the branding trap of "natural" and "organic". These are branding tactics only. If you want a 100% safe answer, drink water and unsweetened drinks.

Hopefully this helps guide you.

CH

Sorry to hear you're not seeing the success you deserve! It is important that you have a correct underlying diagnosis of type 2 diabetes.

Type 1 diabetes: Insulin deficiency CAN happen in adults.

The natural progression of most diabetics is that they have less insulin-making capacity. Thus, using medicines to make you make more insulin are not effective. This would be the sitagliptin (Januvia).

Often is the case that people need insulin because their pancreas simply is not able to make enough insulin to keep up with the sugar intake. It is not your fault. Genetics play a huge role. There are other medications out there to help that work in a different manner. New medicines make us urinate out excess sugar, thus decreasing blood sugars and help diabetes. In the end, insulin replacement is best (and safe if dosed correctly).

I am proud you're exercising daily! I am sure the sugars would be higher if you didn't do this!

CH

If not already done, an easy test to do would be some blood testing for your son! You're rightly concerned and increased urination (polyuria) can be a sign of diabetes, excess sugar in bloodstream.

Weight loss, increased thirst, and increased urination are the staple signs of diabetes. This is due to sugar spilling into the urine (through the kidneys). Where sugar goes, water follows. This leads to frequent urination and subsequently, increased thirst. In true diabetes, body perceives a state of starving since it cannot use the sugar from blood (due to lack of insulin). This leads to muscles and fat breakdown. Weight loss.

Doing a screening sugar value by fingerstick and some blood work will put this question to rest.

Praying he doesn't have diabetes! If so, no fear! He has a great parent in his corner to help.

CH

You're not alone in this question. As a physician who specializes in diabetes, I find this to be such an important question.

I do not prescribe a particular diet. When it comes to low glycemic (sugar) foods, I like the idea. I tend to ask people to do everything in moderation. I have no tolerance for regular soda as it has no nutritional value. As for food, aim for ~50-75 grams of carbohydrate per meal (or less).

In this, you'll not be in excess. High sugar content food in most diabetics (and pre-diabetics) should be avoided as they're "fuel on the fire".

CH

Great question. The fact you know what your sugars are doing after lunch is great! Way to be checking and keep that up!

There are a ton of medications for diabetes that can help prevent blood sugar elevations for meals. This is the most common issue I see for diabetics. There is an insulin resistance that we need to overcome at meal time.

Medications designed to make you MAKE MORE INSULIN can sometimes help. These are glyburide, glipizide, glimepiride, Januvia, Onglyza, Tradjenta, Byetta, Bydureon, Trulicity, Tanzeum, Victoza. If these medications are not effective in reducing the sugar levels for meals, then we often recommend using a fast-acting insulin to cover that meal.

Just because the level is 280 doesn't mean you NEED insulin. If the sugar value comes down within a few hours with pills or other medication, then you're fine.

Many factors help me determine need for mealtime insulin. The average blood sugar values, hemoglobin A1c value > goal, current medications, duration of diabetes, weight, etc.

Diabetes is not a one-size-fits-all. I like to use combinations of medications to suit patient preference and lifestyle.

CH

I am sorry to hear your mother-in-law is struggling with her diabetes.

Diet is so important. I do not prescribe a particular diet (they all work if you can adhere for long periods). I do recommend everything in moderation, with exception to regular soda which has no nutritional value.

Humans should have ~50 gram of carbs per meal (or less). In America, we a carbohydrate-driven society. It is tough to eat less than that per meal (or snack).

I ask my diabetic patients to use everything in moderation and limit to somewhere between 30-90 grams of carbs per meal. Most people eat 3 meals per day. The idea is to not have excess carb/sugar intake and subsequent need for more insulin/medication.

50-75% protein / veggies
25-50% carb / fat

The greener, the better. If there is enough elevation in creatinine, meaning chronic kidney disease, there may be further dietary restriction for the kidneys. This would be to prevent potassium and phosphate excess.

I often defer to our local dietitians. They provide such excellent, detailed insight (beyond me) into the day to day foods to choose. Find people you trust and that will do best by you and your mother-in-law.

CH

What an important question. Thank you for asking!

I suspect (assume) you have type 2 diabetes. In this case, the most common cause is underlying obesity (excess fat tissue). For many people with diabetes, weight loss can reduce their medication, including insulin dose. I have been surprised at how many people will make lifestyle changes and no longer require as much medication/insulin. The chances of making your diabetes / insulin "go away" are best if you lose weight (sometimes through bariatric surgery).

I would NOT recommend stopping medication outright. However, in reducing sugar intake and losing weight, you may notice day to day glucose checks getting lower and lower. Eventually, it may get to a point where you can move back to pills or nothing at all.

It is not 100% permanent depending on type of diabetes, duration of diabetes, quantity of insulin units / dose, family history, etc. Many factors contribute. Most important is to keep your sugars "out of the danger zone" to prevent complications like eye disease, kidney problems, and nerve issues. This is by average sugar less than 150 or hemoglobin A1c under 7% (in most cases).

Nothing is permanent. Nothing is permanent.

I hope you're able to find success! Great question!

Very good question.

First, knowing the TYPE of diabetes is important. Type 1 diabetes is a lack of insulin and subsequent elevation in blood sugars. Type 2 diabetes is insulin resistance (can't use it) and subsequent elevation in blood sugars. Insulin is anabolic. This means it promotes the machinery of our cells to grow and divide. Hence, insulin deficiency (type 1 diabetics) are often quite thin in contrast to type 2 diabetics (make insulin) who are generally obese (or at least overweight).

Extremely elevated blood sugars, regardless of type, can put your body into a sense of starvation. Regardless of underlying type of diabetes, body perceives "low sugar" as "low energy" because it can't get into the cells for use. This prompts breakdown of muscle tissue and to a lesser extent fat tissue, causing weight loss.

For most people, good control is defined by a hemoglobin A1c < ~7% or avg sugar around 150 or less.

If you're on adequate therapy with good results, then I would take a quick look into thyroid and bowel habits. Make sure all else is well outside of the diabetes. There is no rule in medicine that states you can only have one disease process at a time.

A healthy body mass index (BMI) is 19-24.9 (unless Asian).

Doing a food/calorie log and taking it to your doctor can help guide you and provides tremendous insight into your day to day intake.

CH

I am sorry you have to deal with PCOD (aka PCOS). This is short of polycystic ovarian disease (or syndrome).

Glycomet, known traditionally by its generic name metformin, is a medication frequently used in PCOS. This is a medication that is also used as first-line therapy for type 2 diabetes. It is NOT a weight loss medication and will not decrease your insulin levels. It is considered by me (and nearly all Endocrinology Specialists) as a "weight neutral medication". In this, it causes neither weight gain nor significant weight loss.

The main mechanism by which this medication works is to reduce to amount of glucose (sugar) storage in the liver and to reduce the release of glucose. It reduces a process called gluconeogenesis, which is "new" "glucose" "making".

Our bodies are designed to store energy / glucose in the liver. This is stored as something called glycogen. When we are fasting (often while sleeping overnight) we release / make glucose to give us energy. We need this energy to maintain our breathing, temperature, dreaming / brain function.

Metformin, in a sense, dials this down.

For those with PCOS, the mainstay is to focus treatment at symptoms. Some people suffer from excess androgen (male hormone testosterone or its derivatives). Some people suffer from abnormal menstrual cycle.

The goal for a medical doctor like me is alleviate those symptoms. For abnormal menstrual cycle we use oral contraceptives (or IUD). For excess male hormone we can use an androgen blocker like spironolactone.

PCOS does not CAUSE weight gain but is made worse by excess adipse (fat) tissue. Hence, we should direct treatment to weight loss. This often can normalize periods and alleviate the insulin resistance and excess male hormone. This may mean meeting with a Registered Dietitian (RD). This may mean doing a Food Journal and documenting calories. Or, this may mean all of the above with medications directed at weight loss.

Hope this helps provide some insight. We doctors are not always good about giving realistic expectations.

Best of luck to you!

This is a great question!

Simple answer is no. Eating sugar / carbohydrate / glucose (all synonyms) doesn't CAUSE diabetes mellitus. However, excess adipose (fat) tissue can lead to insulin resistance, and subsequent diabetes.

I often think of sugar as a "lock," insulin as a "key," and our cells as "doors". In diabetes, adipose tissue is very resistant to the "locks" and "keys" and as such we need to provide more "keys" to open the door of the cell to store sugar or use it as energy.

This is why we use medications to make us make more insulin (keys) or medications to make us urinate our sugar (locks).

We doctors don't know everything when it comes to diabetes and obesity. We all know that one friend that has drank 6 Mountain Dews (or Dr. Pepper) per day for 20+ years and has not developed diabetes. This leads us to believe there is a genetic predisposition. We are working on the genetics every day!

In short, everything in moderation! For those that have diabetes mellitus, sugar is like "fuel on a fire". I advise people WITH diabetes to avoid sugary beverages because it leads to increased need for insulin and provides no nutritional benefit.

Hope this helps!

First, congratulations on reducing your hemoglobin A1c!

Your hard work and dedication has obviously served you well.

I would like to first point out that the test 'HEMOGLOBIN a1c" is a test that may not always tell the truth. In that, I mean the term hemoglobin loosely refers to red blood cells. Our red blood cells typically live to be 90-120 days. Our hemoglobin is changed in such a way (glycated) when our glucose is at a particular level and we can pick this up in a blood test called hemoglobin A1c. As such, anything that affects the RBC/hemoglobin will alter the HbA1c result. In example, getting a blood transfusion (somebody else's blood!) will lower the HbA1c.

Hence, as an Endocrinologist, I corroborate the HbA1c to fingerstick sugar checks to make sure they are close.

Regardless, it sounds like you have worked hard enough "to beat" diabetes. Diabetes unfortunately has an underlying genetic component (albeit we aren't exactly sure what gene/s), and you will still have some predisposition to diabetes.

In short, you're always at risk, given you had diabetes at one time. I would also caution that if this was not traditional 'type 2 diabetes' that you may have something called 'Latent autoimmune diabetes of adulthood' or 'LADA', in which people can "honeymoon" for many years without need for medication or insulin. This is unlikely, but a consideration.

Hope this helps and congratulations again on your extremely impressive efforts!

CH

This is a great and VERY important question.

Women have a shorter urethra (urine tubing), and as such are more apt to get urinary tract infections (UTIs). Diabetes and hyperglycemia (high sugars) precipitate UTIs. Like humans, bacteria and fungi love sugar. So when our sugars are high, they spill into our urine and "collect" unwanted bacteria and fungi. These cause inflammation and we perceive this as pain.

Hence, controlling sugars is important. One class of medications called SGLT2-inhibitors, you may want to avoid. These medications work by increasing sugar excretion into the urine.

I would consider a urinalysis to see if it is truly BACTERIA or FUNGI / YEAST. It may be that you need a medication directed at yeast like fluconazole.

Aside from good sugar control and using appropriately targeted antibiotics and antifungals, there is not much option.

Hope this helps and sorry you're going through that!

CH

This is an insightful question! Nicely done!

First: Is she taking any medications for diabetes? The most common reason for waking up in the middle of the night or early morning is TOO much basal insulin (long lasting insulin like Lantus / Toujeo / Levemir / Tresiba / etc).

For diabetic patients, it is important to first get them stable through the night. This means checking a sugar BEFORE BED and then when waking in AM. The goal is to keep it steady overnight (i.e.: bedtime sugar of 150 to AM sugar of 150).

I personally do not like people going to bed hyperglycemic and drifting down ~100 points overnight (ie sugar of 200 to 100). This is because should we go to bed one night with a sugar of ~150 it may drift down 100 points to ~50, a low.

In short, take a close look at the insulins or medications on board and make sure we have not given too much long-lasting basal insulin.

The elevated sugars at noon are likely related to not enough insulin (or medication) given at breakfast to cover for the sugar / carbohydrate / glucose influx with breakfast.

I hope this gives you some guidance and feel free to post another message should you continue to run into issues!

CH

What a terrible thing to have to go through.

First, I am sorry you and your mother are having to suffer low sugars.

If she is diabetic, then I would take a serious look at what medications can be contributing to hypoglycemia. Namely, we are looking at insulins and oral hypoglycemic agents like glipizide, glimepiride, glyburide. If any of these are on her medication profile, then I would HOLD them.

We often use "The rule of 15" to correct for low sugars. Give 15 grams of sugar and check in 15 minutes. If > 100, then you're out of the "danger zone". If this is needed more than 3-4x, then I would consider being seen in an Urgent Care/ER setting. The most concerning thing is a 'long lasting insulin' that just is in the system too long and requires time to excrete.

At this point, there is not enough information at hand to advise an ER visit, but if there is enough concern, I would certainly error on the side of being seen in person.

Best to you,
CH