It’s a disease that directly affects more than 29 million Americans and over 25 percent of the country’s seniors. More than 8 million cases go undiagnosed and the disease remains the seventh leading cause of death in the United States. As of 2012, 86 million Americans over age 20 had prediabetes, a rising statistic. But despite the numbers, medical experts say that with proper education and care, diabetes can be almost entirely manageable. 

SRQ: To start basic, tell me generally what diabetes is and what is happening in the body?

Albert Novak DO, Family Practice Physician, Sarasota Memorial Hospital and First Physicians Group: There’s type one diabetes and type two diabetes. Type two diabetes is when the body develops insulin resistance, and most times it’s due to obesity. Insulin is the key that goes to the lock on the door that allows glucose to get into the cells, to give the cells energy. And when you develop type two diabetes, the key doesn’t quite fit right. Gudrun Novak, dietitian and certified diabetes educator, Sarasota Memorial Hospital and HealthFit: As a result, the blood sugars tend to go up and, on top of the insulin resistance, the pancreas is losing its ability to make insulin. A. Novak: With the insulin resistance in type two diabetes the glucose levels are going up in the blood and it signals the pancreas to produce more insulin to try. The pancreas eventually burns out, and that’s type two diabetes. Linh Gordon registered nurse and certified diabetes educator, Sarasota Memorial Hospital: There is a slow progressive pancreas disfunctioning in type two, and with type one it’s an absolute “no insulin.” What will happen to the body if this is unmanaged or untreated? What potential side effects are there? A. Novak: You’re talking cardio-vascular disease; you’re talking kidney disease, circulatory problems, neuropathies, nerve problems, eventually amputations, dialysis. It’s something you would want to catch pretty early. So it affects the entire body? A. Novak: Absolutely. Gordon: It could affect almost every single cell. Think of a bowl of sugar with a little bit of water in it - it’s thick and syrupy and it is going to be trying to get through every small and large blood vessel with difficulty. It sticks to the blood vessel walls and makes vascular issues.

What are the risk factors or poor behaviors that can lead to Type 2 diabetes?

G. Novak: There’s family history. If you have a family history you’re going to be at higher risk for type two diabetes. Being sedentary, not exercising, smoking, sleep habits. Gordon: Minimal abdominal weight gain, high blood pressure, high cholesterol; so, metabolic syndrome, when you have all of those combined. How does Sarasota fit the national average? Gordon: We are actually much lower than the whole national average in Sarasota and Bradenton. Do you have any idea what’s behind that. Is it lifestyle? We have nature’s gymnasium, like a long beach. We have warm sunny weather year-round so there aren’t people hibernating. We have lots of fruits and veggies, lots of walking trails, lots of biking trails and more people that have higher income levels so they can get gym memberships and things like that. G. Novak: Just having more sidewalks and having more trails, that makes a big difference too. And just to tag onto that. There are a lot of people who are under-lean and have a higher risk.

Being too lean, too skinny, places you at risk for Type 2 diabetes? G. Novak: They don’t have enough cells to store the glucose, so the blood sugar can go up from that too. That’s where the exercise comes in as a great treatment, particularly persistent exercise where you are increasing your muscle mass. It’s recommended by the American Diabetes Association two or three times a week as part of a good treatment plan. In terms of management, have we moved beyond the hourly stick test? A. Novak: Well it depends what type of diabetes and how well controlled it is. In a type two diabetic that is very well controlled, I tell them to check their blood sugar once a week.


A. Novak: If their hemoglobin A1C, which is a measure of how well you are controlling your diabetes, is in the fives or sixes, there is no need for them to have to punish themselves because they obviously have a good understanding and have good control. As that hemoglobin A1C starts to increase and approach the high sixes or seven, then I have them start checking once a day and then keep a food diary to try and catch what’s going on. There are type one diabetics that are very brittle, or newly diagnosed diabetics, that do have to check their blood sugars every hour or every few hours just to really keep a close eye on things.

How has the emergence of insulin pump technology affected daily management? Is it a freeing development? Does it allow more control?

Kathy Namolik, registered dietitian and certified diabetes educator: It allows more flexibility in their lifestyle. I’m an insulin pump trainer, and one of the things I always tell my clients is that this is not going to fix your diabetes, and it is not going to take away the blood sugar testing and the watching your diet. All of that has to still go on when you are on an insulin pump. But it does give you the flexibility of not having to take six injections a day, so it takes that part out of it. Gordon: It is a more precise delivery system, basically. A. Novak: In a normal functioning body, the pancreas is delivering a low rate of insulin continuously, and the pump tries to mimic that with a basal rate. So there is that low rate of insulin and then with meals, the normal pancreas will increase the amount of insulin based on the meal. The pump tries to mimic that, but the person has to have a clear understanding so they can let that insulin increase. Namolik: Right, so we see less low blood sugars when they are on an insulin pump and we see better control, as long as they are doing what they are supposed to be doing. That means counting their carbs and checking their blood sugars, because the insulin pump needs that information in order to give them the right dose of insulin. If they are not counting their carbs correctly, or they’re not checking their blood sugars often enough, that insulin pump is not going to do them any good. A. Novak: A non-compliant diabetic without an understanding of diabetes does not belong on an insulin pump. They have to have a complete understanding because they still have to manually pulse their insulin.

What’s the relationship between doctors and certified diabetes educators (CDEs)?

Namolik: We are accredited by the American Diabetes Association and need to have a doctor’s referral for people to come into our program. So it is a part of a team approach where the physician is managing the medication and we are educating them about eating and exercise and reducing stress and all of those types of things. It is definitely a team approach. Gordon: We have CDEs that are dieticians, some are registered nurses, we have a pharmacist that is a CDE in our program and some CDE programs have social workers. It’s a team approach because our goal is to empower the patient and you need lots of different arms to try and handle this. Namolik: Motivators behind the patient, always encouraging them to keep an eye on things. G. Novak: Diabetes is one of those diseases that actually has to be managed by the person day in and day out. Taking the medication helps, but unless that person has a good understanding of what they eat and their lifestyle and how that impacts their blood sugars, they are not going to succeed in managing their diabetes. So that is where we come in, we give them that education and support. A. Novak: Controlling diabetes is a science. A lot of times the patient may just inject a little more insulin to try and get the blood sugars down, and they get really frustrated because the readings are consistently high. They just kind of burn out and their spirit is broken. But if you let them know that it is a science, and if you know how to count your carbohydrates on the plate, and you know what your ratio of insulin to carbohydrate is and what your correction factor is, you’ll have perfect readings every time. It’s like learning math. If you know what you’re doing, then it takes the guesswork out of it and you can really succeed. G. Novak: Studies have shown that initial education is great at lowering A1C, but six months to a year out, we see those A1C levels creeping up and we realize now that people need that ongoing support and they need that follow up. Diabetes is a gradually progressive disease, which gets more challenging. So, a year from now, if their A1C is creeping back up, they need to come back in for a refresher and get that support. And that is what diabetes education and educators do. Gordon: They can come and see us annually, also. Two hours each. So there is ongoing education.

What are the most common misconceptions with new patients that you have to explain to them or hurdles that you have to get them over to properly manage the condition?

Namolik: One of the most common is that about 90 percent of the people who come into the office think that you need to reduce or cut out your carbohydrates in order to control your blood sugar. So probably one of the biggest “aha” moments is getting them to understand that they need a certain amount of carbohydrates because the glucose is the fuel for all of the cells.

G. Novak: There’s a lot of bad information on diet out there. People come in over-restricting their food intake thinking they can starve their blood sugars down. Gordon: So it falsely looks low initially, and they think, “I don’t have diabetes,” and that is the other misconception. They think that they can get rid of it. And that’s a good question. Once you have it, especially type two, is there any way to get rid of it or is it permanent? A. Novak: Once you have diabetes, you have it. You can’t get rid of it. It can be controlled diabetes, but that is it. Gordon: Yes, really well controlled, but there is no cure.G. Novak: Yes, if they go back to their normal eating habits, the way they were before, it is going to come right back. Well I can tell people are often frightened by the diagnosis, but if they educate themselves, listen to you guys and try to keep a handle on it at home, what kind of effect will it have on them and their quality of life? Can they have a relatively normal life if they keep educating themselves to it?A. Novak: Absolutely. It is work, but yes they will. There might be some who have grown up in a family of diabetics and seen their aunt and uncle lose their eyesight or legs, and so their vision may be “I have no control, I am doomed.” But, if they see people who succeed with diabetes, they might have better insight. Gordon: At least in this day and age we can well maintain it. This is a progressive disease, but it doesn’t need to progress to complications, it just means that things might change. And we need to stay up on it. G. Novak: There are many successful people who are living healthy lives with diabetes. There are athletes with diabetes who are doing great. Gordon: Some people eat out for every meal. They tell us “I don’t eat breakfast, I don’t really eat lunch, we just go out for dinner.” This is bad. The American Diabetes Association teaches consistent carbohydrate meal planning, so they are actually supposed to eat to rev up their metabolism, and that helps them to lose weight. But some people can go all day, meaning they have a very slow engine, and then they eat a big, big meal and then they go to bed. G. Novak: Yeah, the biggest mistake that I see as a dietician is people don’t eat enough during the earlier part of the day, and they don’t consistently distribute their food throughout the day, they eat that one big meal at night. And that sets them up for problems. So if you’re skipping breakfast, that is one of the cardinal rules of what not to do. Now I understand that it is very important to be careful, but having diabetes doesn’t mean you can’t eat cake again G. Novak: Correct. Namolik: Just less frequently. G. Novak: And in controlled portions. The diet that I teach for someone who has diabetes, is really a diet I would teach to anyone trying to lose weight or control heart disease.

What is coming in the future in terms of diabetes management research and treatments that gets you guys excited? Is there anything down the pipeline that could be a game-changer or revelation?

Novak: There’s a smart insulin that’s being researched and it is a once-a-day injection, but the insulin becomes active or inactive based on the blood sugar level automatically. So people who are having to take four shots a day of insulin may only need to take one shot, and the insulin is going to do its job without them needing to check their blood sugar levels. Gordon: The Juvenile Diabetes Foundation has a lot of money into type one diabetes, so there are a lot of really interesting type one things, which will essentially affect type two as well. For example, they are going to do encapsulated insulin beta cells. So the beta cells that produce insulin, they are going to encapsulate them and put them under the skin and supposedly for 24 months give them their insulin. We’re still five to 10 years out, but that is what they’re doing right now in studies. G. Novak: In the near future, I think the closed loop pump system is going to happen eventually. Gordon: They’re going to call that the artificial pancreas. G. Novak: Yeah, the artificial pancreas. Right now there is an insulin pump where you wear a continuous glucose sensor that measures your interstitial glucose and it sends a message to the pump if the blood sugars start dropping low and the insulin pump will shut off. The problem is getting it to help the high end, when the blood sugars go up. Once we get that part of the loop fixed, or figured out, then we are going to have a continuous closed loop system, or an “artificial pancreas.”

Where do people find certified diabetes educators and when should they know to look out?

A. Novak: Physicians also need to be educated that this help exists and to be able to channel the patient that way. A physician has maybe minutes with a patient. You can’t educate anyone within a few minutes. And a lot of times people with diabetes have other problems that need to be addressed like high blood pressure, high cholesterol, that kind of stuff. So in a physician’s office, you have 15 minutes to half an hour with patients. These guys have hours with them. Gordon: We have 13 hours total covered with medical nutrition therapy (MNT) and diabetes help management education. So it is comprehensive. G. Novak: Yeah, we can sit down with a client for an hour and really get some good education in, where they don’t have the time to do that. But if someone is researching, American Diabetes Association will have a list of recognized diabetes education centers. A. Novak: Patients should ask for and demand education. Why is it important to have educators in this field? A. Novak: Education is the building block for controlling diabetes. G. Novak: In my old job running a diabetes center in North Carolina, my frustration was that there were a lot of people who either didn’t know that we existed or didn’t feel like it was necessary to have that education. It’s very frustrating people don’t generally recognize it as an important tool in managing diabetes.