Disorders of the pancreatic beta-cells
More 30 million US citizens are thought to have diabetes, a disease characterized by too much sugar in the bloodstream. Almost 7 million of them, however, have not yet been diagnosed with the disease. If you have diabetes, you will want to learn as much as you can about how to take care of yourself. A healthy lifestyle with a good diet and regular exercise together with available, modern therapies will help you lead a full and healthy life – and we are here to help! Dr. Schneider trained at one of the best Diabetes Centers in the country (with Irl Hirsch MD and Dace Trence MD at the UW Seattle) and has conducted diabetes related clinical trials, published in leading journals, presented at major conferences and led educational seminars for health care professionals throughout California, the United States and Europe.
Diabetes occurs when cells embedded in the pancreas (pancreatic beta-cells), do not produce enough of the hormone insulin. Insulin is necessary to carry sugar from the bloodstream into the cells. Once inside the cells, sugar is converted into energy for immediate use or stored for the future. That energy fuels all our bodily functions and helps the body brake down waste products. This process is known as metabolism.
Here is what happens during normal metabolism:
During and just after a meal, the body digests food into its “basic building blocks.” In this way, the body breaks down carbohydrates (starches) into sugar. Glucose is the primary form of sugar the body needs for energy.
After the meal, glucose is absorbed into the blood.
The rise in blood glucose tells the pancreatic beta-cells to make insulin, which goes out into the bloodstream. About 10 minutes after a meal, insulin is at its highest level.
Insulin helps the glucose enter the body's cells. The glucose either is used right away for energy or stored in the liver and muscles for future use.
About two to four hours after eating a meal, the body returns to low levels of blood glucose and starts using stored glucose for energy.
Here is what happens in diabetes:
The pancreas is unable to produce enough insulin to meet the body’s requirements.
Without enough insulin to move sugar from the bloodstream into the cells, the blood glucose level rises too high.
As blood glucose rises, extra glucose passes into the urine and is bound to porteins in the blood stream before the body gets the energy it needs every day.
The body reacts to a prolonged sugar imbalance and, eventually, the person may develop major health problems. This is why it is important to get tested for diabetes and begin treatment as soon as possible.
What causes Diabetes and Diabetes Types:
Type 1 Diabetes
is the more severe form as it is caused by a total lack of insulin. T1D is a so called autoimmune disease: the body is mistakenly attacking and destroying its own pancreatic beta-cells. T1D was thought to be more commonly seen in children and used to be called “juvenile diabetes”, but new studies showed, that it may occur at any age and that most people with T1D are diagnosed as adults.
People with T1D need daily insulin injections to survive. Steadily increasing insulin prices are putting these people in front of great difficulties and Dr. Schneider is a strong advocate for better insulin accessibility. Is there a cure for T1D? Dr. Schneider's research focus is T1D, click here to read more.
Type 2 Diabetes
is the most common form of the disease, affecting 90-95% of people with diabetes. In T2D, the body is resistant to the action of insulin, meaning it cannot carry sugar into the cells. Although the body makes insulin, it is not enough to overcome this resistance.
Does diet cause diabetes? While there is a strong genetic component to T2D, being overweight adds to insulin resistance. Therefore, as more children and adults become overweight, many more are developing type 2 diabetes.
Can Diabetes be cured? People with type 2 diabetes sometimes can control the condition with exercise and diet that lead to a return to normal body weight. Many may need medications, however. These medications can either improve insulin secretion by the pancreas or decrease insulin resistance. Some individuals may also need to take insulin.
Type 1.5 Diabetes
Type 1.5 diabetes, also called latent autoimmune diabetes in adults (LADA), is a condition that shares characteristics of both type 1 and type 2 diabetes.
LADA is diagnosed during adulthood, and it sets in gradually, like type 2 diabetes. But unlike type 2 diabetes, LADA is an autoimmune disease and isn’t reversible with changes in diet and lifestyle. We actually believe, that diabetes occurs on a continuum, with LADA falling between Type 1 and Type 2 Diabetes.
These are diabetes forms associated with certain medical conditions (e.g., Cystic Fibrosis) or certain treatments (e.g., steroid induced diabetes).
Diabetes during Pregnancy
Women with Diabetes (Type 1 or Type 2 Diabetes) before pregnancy
Keeping blood glucose levels as close to normal as possible before getting pregnant, as well as during pregnancy, is very important for the health of a woman and her baby.
Poorly controlled diabetes can cause malformations to a developing fetus. These typically occur before the seventh week of gestation. Research has shown that when women with diabetes keep blood glucose levels under control before and during pregnancy, the risk of birth defects is about the same as in babies born to women who don’t have diabetes.
It’s important for a diabetic woman to plan her pregnancy, with care beginning before she conceives.
Possible complications of diabetes, such as retinopathy, nerve damage and kidney damage can make pregnancy more risky for both woman and baby.
Blood glucose levels have to be extremely tightly monitored and controlled during pregnancy.
Furthermore, there are predictable changes in insulin needs throughout pregnancy and also special considerations for breastfeeding, which requires an adjustment in the mother’s diet and possibly an adjustment in insulin dosages. If you have diabetes and plan to have a baby or have found out that you are pregnant, please contact us immediately.
True Gestational Diabetes
About 4 percent of pregnant women develop gestational diabetes, which may be diagnosed at any time during pregnancy.
During weeks 23 to 28 of pregnancy, a screening test is done to check for the presence of gestational diabetes.
If the tests indicate gestational diabetes, your gynecologist or obstretician will refer you to us for initialization of treatment. We will work closely with your gynecologist to provide you with the best possible care for your diabetes.
Diabetes Signs, Symptoms, and Diagnosis
In early stage Type 2 Diabetes, an individual may experience mild - if any - diabetes symptoms, whereas in Type 1 Diabetes most of these symptoms appear suddenly and are severe:
Symptoms of diabetes (hyperglycemia) include:
1. Increased thirst
2. Increased urination
3. Constant hunger
4. Weight loss
5. Blurred vision
6. Fatigue, or a feeling of being tired
People with T2D may also develop:
1. Frequent yeast infections e.g. thrush
2. Very slow healing of wounds or sores
Hypoglycemia - Is low blood sugar dangerous?
Hypoglycemia is defined as the combination of blood glucose levels below 55mg/dl, symptoms of hypoglycemia at the time of the low glucose level, and symptom relief with treatment of hypoglycemia. For many decades, endocrinologists have focused on treating high blood glucose levels and only recently we have learned, that too low blood glucose levels are extremely dangerous - and oftentimes remain undetected. Symptoms include shakiness, dizziness, confusion, inability to concentrate, hunger, paleness, or headache. Some people, mostly with Type 1 Diabetes, may feel any symptoms or have very non specific symptoms like sluggishness, difficulties to focus or dizziness. People on insulin or Sulphonylureas, who tend to have hypoglycemia, should have glucagon injection or nasal spray (Baqsimi) at home and instruct family or friends about their use. Please talk with us about these aspects.
Treatment of Diabetes
Diet, exercise, regular self monitoring of blood glucose levels and adherence to medications are critical to the successful control of blood sugar levels in all diabetes types.
Insulin - What is the best insulin? Does insulin make you fat?
For people with T1D insulin is vital and indispensable. Some people with T2D must also take insulin, usually when other treatment forms stop working. Most people take several insulin injections (MDI) every day or use an insulin pump (see below).
Types of Insulin - what is the best Insulin for you?
Different types of insulin are classified by how fast they work and how long they work in the body.
Mealtime (or “bolus”) insulin. Bolus insulin is given before meals to control the rise of blood glucose levels after eating.
Short-acting (e.g. lispro, aspart) starts to work after 15 minutes and works for 3-5 hours.
Very-short-acting (Fiasp, Lyumjev or inhalative insulin Affrezza) starts to work after 5-10 minutes and works for 1-2 hours.
Basal insulin. Basal insulin controls blood sugar levels between meals and throughout the night. It is usually given once or twice daily and can be used alone or in combination with oral medications or bolus insulin.
Intermediate-acting (NPH) starts to work in 1 to 3 hours and works for 12 to 16 hours.
Long-acting (glargine, detemir, degludec) starts to work after 1 hour and works for 20 to 26 hours.
Non Insulin Medications
Different types of oral anti-diabetic agents work in different ways. They can be used alone or in combination with other agents or insulin. The most common types of oral anti-diabetic drugs are:
Metformin is the most common anti-diabetic agent used to treat diabetes. It decreases the amount of glucose produced by the liver and helps the body respond better to insulin. People with kidney or liver failure cannot use metformin.
Sulphonylureas (e.g. Glipizide or Glimepiride) increase the amount of insulin produced by the pancreas, which in turn lowers blood sugar levels.
Thiazolidinediones (e.g. Pioglitazone, Rosiglitazone) help the body respond better to insulin and have seen a major revival recently. A major side effect is heart failure in some people and weight gain due to water retention.
GLP1 agonists (Liraglutide, Semaglutide) and (older) DPP-4 inhibitors (e.g. Sitagliptin, Saxagliptin) help the pancreas produce insulin more efficiently. They may also lead to a decrease in appetite and to weight loss.
Sodium-glucose co-transporter 2 (SGLT2) inhibitors interfere with glucose reuptake in the proximal tubules of the kidneys, increasing urinary excretion of glucose and thereby lowering glucose in the bloodstream. The drugs were brought to market to treat diabetes, but they’ve been found to have unexpected benefits — a discovery that has been called serendipitous: large studies have shown, that these medications potently prevent heart failure and cardiovascular death, with additional effects on blood glucose. Their real benefit, and the reason we use them, is because of their effects on heart failure, diabetic kidney disease, and cardiovascular death. Dr. Einhorn has been involved with this class of drugs from the very beginning and his expertise is unmatched.
Diabetes management went through a radical transformation in the last years due to technology: the diabetes patient community found a strong voice online, continuous glucose monitors are taking the place of finger pricks, digital patches and insulin pumps make the dosage of insulin more predictable, and connected devices promise the era of artificial pancreas real soon.
We strive to become a leading Diabetes Center in San Diego for use of technology to assist in the treatment of diabetes. You can be confident that our team will download and review your CGM insulin pump data at each visit, assess your overall control, identify any issues that may be leading to hyperglycemia or hypoglycemia and recommend changes that can help get you on the right track to taking better control of your diabetes and insulin pump. What is the best CGM? What is the best insulin pump? Ask Dr. Einhorn or Dr. Schneider.
An insulin pump is a device worn outside the body that pumps insulin through a flexible tube to a small needle inserted under the skin. The pump can be set to give small amounts of short-acting insulin continuously through the day and additional doses before meals.
Would I be a candidate for an insulin pump?
Type 1 and insulin-requiring Type 2 patients
Recurrent hypoglycemia, nocturnal hypoglycemia, activity-induced hypoglycemia and hypoglycemia unawareness
Recurrent diabetic ketoacidosis (DKA)/recurrent hospitalizations
Patient preference, meal-timing flexibility and normalization of lifestyle
Very ow insulin requirements as in Cystic Fibrosis related diabetes
Ask our doctors about different pump systems and if a pump would be a good thing for your treatment.
Continuous Glucose Monitors (CGM)
Continuous Glucose Monitors measure tissue glucose levels at preset intervals and confer the user the unprecedented possibility to get the "whole" picture of his glycemic control without having to use finger sticks or wake up at night. Modern CGM have built-in alarms for low glucose levels and communicate directly with insulin pumps. The Endocrine Society recently issued a Clinical Practice Guideline recommending continuous glucose monitors (CGMs) as the gold standard of care for adults with Type 1 diabetes.
Dr. Schneider has the expertise to help you find the right CGM for you whether it be the Dexcom G6 and soon Dexcom G7, the Freestyle Libre 1 and soon Libre 2 which are now approved for Medicare patients in addition to most commercial insurance plans, or the newly approved first ever implanted CGM Senseonics Eversense (which can be implanted in our office)
Ask our doctors about different CGM systems and if a wearable sensor would be a good thing for your treatment.
Hybrid Closed Loop (HCL)
A hybrid closed loop (HCL) system integrates continuous glucose monitoring with an insulin pump and an algorithm which automates insulin delivery and constantly self-adjusts to keep your sugar level in range. This groundbreaking technological achievement brings us closer to the "artificial pancreas".
If you are interested in the Hybrid Closed Loop System (Medtronic 670G plus Medtronic CGM or Tandem X2 plus Dexcom G6 CGM) speak with our team.
Living with Diabetes
Both types of diabetes can cause dangerous complications if not well controlled, furthermore, diabetes increases the risk for heart disease, strokes and kidney failure. However, with modern therapies and technology and careful management people with diabetes can live a normal, fulfilled life and have a normal life expectancy.
If you are living with diabetes, lifestyle is an important element of your care. It is extremely important that you eat a good balance of foods every day and exercise regularly. You will hear and read a lot about many different diets believed to improved diabetes care (very low carb, keto, etc). Talk with us or your dietician before engaging in any of these diets.
We can discuss with you all aspects of your care and provide you with guidance in regard to treatment, diet, exercise and avoidance of complications. We work closely with the Scripps Whittier Diabetes Institute, a great place offering vast resources for people with Diabetes.
While diabetes long-term complications can be delayed or prevented with appropriate medical care and active self-management and the use of modern technology, all this takes time, knowledge, and a lot of energy. Many people experience diabetes burn out due to the daily struggles of diabetes and its presence in every single aspect of their lives. Many people with diabetes experience anger, guilt, depression, fear, and feelings of hopelessness.
Addressing these real-life emotional aspects of diabetes is critical for long-term success and should be given the same attention in medical practice that is given to medication and technology. We are here to help people with diabetes identify, understand, and tackle problems, and if we cannot help we will guide you to finding someone who can help.
Hyperinsulinemia. What is an Insulinoma?
Hyperinsulinemia is a condition where your body makes too much insulin. This can happen in people who've recently developed Type 2 Diabetes, where the pancreatic beta-cells try hard to overcome insulin resistance by making more and more insulin. It can also happen in people who've undergone bariatric surgery (gastric banding, or sleeve gastrectomy, or Roux-en-Y surgery) who would typically develop hypoglycemia shortly after eating a meal rich in carbohydrates.
Sometimes this condition is called nesidioblastosis, where beta-cells fail to adjust to the actual insulin needs.
In very rare cases, hyperinsulinemia is caused by a pancreatic tumor called insulinoma. Insulinomas belong to the group of NETs (neuroendocrine tumors). They are rarely cancerous. Their main symptom is severe fasting hypoglycemia due to the overproduction of insulin. Insulinoma treatment involves pancreatic surgery.