Diabetes Care: Kovler Diabetes Center

Hello, and welcome to a special At the Forefront Live, where we will discuss diabetes and some of the efforts to treat this condition. We'll go inside the Kovler Diabetes Center and show you the incredible work they do. And we'll take you inside a laboratory, where scientists are working on treatments and possible cures. We will introduce you to doctors and researchers who will answer your questions about diabetes. That's coming up right now on At the Forefront Live.

Joining me to start today's program is Dr. Lou Philipson. Dr. Phillipson is the director of the Kovler Diabetes Center and is the James C. Tyree professor of Diabetes Research and Care in the Departments of Medicine and Pediatrics at the University of Chicago. Welcome, Dr. Phillipson.

Hi. Good afternoon.

So tell us a little bit about the Kovler Diabetes Center. And what are some of the exciting things that are happening there?

Well, we've had the name, Diabetes Center, now for going on two decades. And we're excited to continue our role here. I think the idea here was to have a holistic treatment place for care and education, that our patients could effectively manage their diabetes. We have really four pillars. Research, clinical care, education, and then outreach to the community. And all of those things I think combine to make what we have in the past called both a high tech and a high touch approach to care.

Diabetes is a big problem in the United States, but it's also a big problem in our region specifically. Can you talk a little bit about some of the efforts in South Chicago, and then if you want to expand on that, to the rest of the United States, you can as well.

Yeah. I think many people have made wonderful observations about health care disparities. I mean, overall, diabetes of all kinds affects about 9% of Americans. And on the South side, it's a higher percentage. It could be 10% or 11%. So it seems to preferentially afflict people of minorities and socioeconomic as well. It's reducing lifespan. Our head of our emergency room has pointed out that there's an impressive multi-year gap in lifespan in diabetes, and its complications are a big part of that difference.

One of the things we're trying to do is address that lifespan for all kinds of diabetes. And one of our doctors, Dr. Celeste Thomas, has recently shown that disparity happens as well for type 1 diabetes. So we're very interested in addressing the disparities, improving identification and treatment, and improving the lives of all people with diabetes.

And I know your team has done some wonderful work on outreach and just trying to work with community members and really improve those numbers. We've got work to do obviously, but you've done some wonderful work in that area. Can you talk just a little bit about the genetics of diabetes, and maybe some of the research that we see happening here at UChicago Medicine?

Absolutely. We are one of the national leaders in the impact of genetics in diabetes. And there's different aspects of it. So there's what we call many genes. That's been called polygenic, which I think is the more usual thing. But rare forms of diabetes. So single genes, like what might make difference in blue eyes and brown eyes, can also be responsible for diabetes. And they come in different varieties. So there are very, very rare situations where people are born with diabetes essentially. And we have several of those folks across the country that we follow and help. And then there's a larger group of people who develop diabetes as they grow up. And those are also sometimes single genes.

So we have a registry now of over 4,000 individuals. We also have a national study on atypical diabetes, where we're attempting to identify new kinds. So it's been a very exciting development with great interest from individuals and diabetes faculty all over the country.

That's great. Thank you, Dr. Philipson. We do need to take a quick break. When we come back, we'll talk with young diabetes patients who will share their inspirational story.

Welcome back. We are very fortunate to be joined by a young woman who's living with diabetes. Johana Kenison is not letting diabetes control her life. In fact, she's worked hard to turn the tables. Johana joins us now. Thank you very much for doing this with us today.

You are welcome.

So I understand that you have a pretty great story to tell. You are 13 years old. You have diabetes. And you play basketball and more recently made captain of the team. Tell us a little bit about that.

I was on this team last year for sixth grade. So I already had the experience with this coach. And she's great with helping me through playing basketball. So this year, I just got made captain.

That's awesome. You must be a pretty good player then. So tell us a little bit about living with diabetes. You're 13 years old. And we were talking a little bit before we did this recording, and you mentioned to me that you don't let diabetes control you. Tell me more about that.

I don't let it control me because there's no reason to really be precautionist about it and like on top of it all the time because it's just going to make me like go crazy some of the times. And I just want to let it. I want to be just regular I guess. But obviously, I can't always do the same things everybody else does. But I try.

Yeah. And so I don't get in trouble with the doctors or your mom, you do take precautions. You check your levels and that sort of thing, right?

Yeah.

So how is that? What do you do? You have to check your sugar, but you also probably watch your diet a little bit. What would you tell another kid who might be in your position? What kind of things do they need to be aware of?

You really need to be aware of how much insulin you're taking and your doses. You want to make sure what your blood sugar is before you take your insulin. And make sure it's not too high or too low because if it's too low, then you want to eat something before you take your medicine and maybe take a little less medicine before you start eating if you're low. But also take more insulin if you're higher.

So kind of the moral of this story is you can be careful, and you can watch things. But again, at the same time, you can enjoy your life. And you've done a pretty good job of that so far. So talk to us a little bit. One of my notes here that I saw, it was an email that came to me. It said that you tied for first place in a youth groups diabetes knowledge contest and won a prize here at Kovler Diabetes. What was the contest? Did you have to take a test? Or did you write something? Or what was that?

Well, I just showed up for the Zoom meetings, and stayed through, and learned what they were teaching us about it, and answered questions about what they were asking us about.

That's good. And apparently, you did quite well with that. So we got one more question for you. If another child came to you and said, hey, I've got this challenge in my life because I think you are an inspiration. What kind of advice would you give that other person?

Just have a positive mindset. And don't let it control you. You can control it. So just take care of yourself. Make sure you check your blood sugars. But you can do all of these activities, and sports, and go bike riding with your friends. But obviously take your necessary things with you, like your Dexcom to check your blood sugars. Take your emergency pen. And take a snack with you. And be responsible with what you're doing.

That is fantastic advice. Johana, you are an inspiration. Thank you very much for being with us today. Coming up next, our doctors will take your questions concerning diabetes. That's right after this.

And welcome back. In this segment, we'll talk to physician experts and take your questions. You can type them into the comment section. We'll try to get to as many as we can here in the next few minutes. Now let's start off with each of you introducing yourselves and telling us a little bit about what you do here at UChicago Medicine. Dr. Mirmira, you're actually up at the desk with me. We are trying to be socially distant. This is why we do this. So we'll start with you.

Yes. My name is Ragu Mirmira. And I'm a professor of medicine and endocrinology here at the University of Chicago. I've been here about two years now. And my sort of role here is I do see patients. I see patients several times a month. And beyond that, my focus is primarily research in diabetes and using what we call preclinical models to move new therapies into the clinical setting.

Great. And Dr. Thomas, we heard your name in an earlier portion of the show. I'm going to ask you a couple of questions about what Dr. Philipson was saying here in a moment. But let's go ahead and hear about your work.

So my name is Celeste Thomas. Thank you. I'm an assistant professor in the section of the Department of Medicine, the section of endocrinology. And my role here is primarily taking care of patients with all types of endocrinopathies, including diabetes. A lot of my work has involved trying to improve the quality of care of patients who are hospitalized and happen to have diabetes. And so I do that in the clinics and in the hospital.

And I'm going to jump right into this, Dr. Thomas, because I think this is interesting, and it's certainly an issue that we need to address. And I know you folks in Kovler are really working hard in this area, but talk to us about health disparities, particularly when it comes to diabetes. And I thought it was kind of fascinating when Dr. Phillipson mentioned type 1 in particular. And I'm trying to figure out why that would be happening.

Right. Thank you for that question. For me, it was looking at the quality of care for our hospitalized patients with diabetes. And then just observing initially these increased early complications from type 1 diabetes. So we talk about the small vessels in the body that can be impacted by diabetes and cause problems with vision, something called retinopathy. Cause problems with the kidneys and even cause nerve damage, which is that contributor to those preventable amputations, those non-traumatic amputations.

And what I saw was just early, early complications and very young adults with blindness and end stage renal disease. And that was just my observation here. And then we went to the literature to understand what is being observed across the country. And there's this group of clinics for the type 1 diabetes exchange. And they are following patients as well with the diagnosis of type 1 diabetes.

And one of the things that they found is that those disparities present early on in the development of type 1 diabetes. So we understand that one of the things that Dr. Phillipson mentioned was that we can have diabetes in the neonates or in an infant. And we usually think about that kind of being diagnosed before six months of age is most likely being a neonatal diabetes.

Where this type 1 diabetes can be diagnosed any time in the lifespan. And when the type 1 diabetes exchange was looking at people diagnosed and as children, the disparities present early on after the diagnosis. And one of those things that they saw was the introduction of technology. And so the introduction of something we call continuous subcutaneous insulin infusion or insulin pumps. There's a disparity in the introduction of that technology. And there's also a disparity in the introduction of continuous glucose monitoring systems.

And so that seemed like a problem that we could solve, which would be to introduce those technologies into our patient's care and see if we could address some of those disparities.

And I think that's something that clearly you as a physician, you probably see this a lot just with health care disparities in general. We talked about type 2. And Dr. Mirmira, I kind of want to get your thoughts on this too because I think a lot of times, we think about disparities, health care disparities with type 2 because food deserts and food swamps. There are lack of grocery stores, or what food supply is available isn't necessarily the most healthy. So that's kind of a common thing I think that people think about. But it goes quite a bit deeper than that obviously with what Dr. Thomas was mentioning with type 1.

That's a great point because it's really access to quality food. And it's access to health care and the latest technologies. In type 2, we tend not to use pumps as much, but we do use glucose monitoring devices. We do use sort of new medications that you don't use in type 1, like pills and other types of injections. So it's access to a lot of this. So it gets very complicated for both diseases in terms of the disparity and access to, as I said, quality food and quality health care.

Absolutely. So I don't want to disappoint our viewers because we are already getting questions from viewers. So we always try to get to as many as possible. I'm just going to start in on those if that's OK with the two of you. And let's go with you, Dr. Thomas, first as we enter into the lightning round of questions from viewers. What should you look for regarding your feet for type 2 diabetes? I guess just things to be aware of.

So this is a great question. And I'm so pleased because this is one of those things that we talk about how those amputations and those diabetic foot ulcers can be preventable. And the way that we prevent it is by doing that kind of self foot exam. So one of the things that the health care team will do, at least annually, is to examine for sensation. So there are a couple of ways that we can see. Has there been a decrease in sensation?

And for those individuals who have noticed a decrease in sensation and even before then, just kind of looking at those feet. So one of the challenges is that if you can't feel something, then you can have an injury and not be aware of the injury. And so if you're looking at the foot, then you can see if there's an injury there and seek care before there's evidence of an infection.

And so if there is anyone out there who already has kind of that neuropathy. So in addition to that foot exam, think about what we're exposing the feet to. And so we want to make sure that we're using those closed toe shoes. And unfortunately, when there's that neuropathy, even in the house, because there can be objects on the floor, that you want to have a hard sole shoe.

In addition, when you're putting your shoe on, if there's still that sensation in the hand. You want to either kind of hit that shoe against a hard object or put your hand into the shoe. And make sure there are no foreign objects in the shoe. And that way, we can avoid some of those injuries and ulcers, which then can lead to preventable amputation.

That's really great advice. And I imagine a lot of people probably wouldn't even think of that. Dr. Mirmira, here is one for you. I'm 66 years old with type 2 diabetes and chronic pancreatitis. Which of the modern injectable medications could be considered for my type 2 management?

Yeah. So right now, we have several injectable medications for type 2 diabetes. And certainly, insulin. That's been around for a long time. But even within the insulins, now we have really more technologically advanced insulins that can come on at different times after injections. And I think we look at insulin as sort of a mainstay, particularly in people with diabetes and other complications, such as pancreatitis.

There are other medications. You hear about them. There are a lot of commercials for them, like Ozempic and others. We tend not to use them so much in patients with hepatitis because we're concerned sometimes a little bit about those medications actually causing pancreatitis. But they are very useful medications in the right individuals because they actually can cause substantial weight loss. And that, of course, has impact in terms of blood glucose control. And they've also now been shown to reduce risk of cardiovascular disease, which is something that's associated with diabetes as well.

But we have lots of oral medications that are also quite good now. So not just injectables. And so we like to do combinations of injectable medications with oral medications. And they work really well in people with type 2 diabetes.

Fantastic. Dr. Thomas, we're going to come back with you to you on this one. I am 70 and told I'm pre-diabetic. I take 1,000 milligrams of metformin twice daily. Morning blood sugars are still in the 130s. Is that acceptable for prediabetes? Last A1C was 6.7. And I told you, our viewers sometimes get very specific, but they do ask great questions. We have great viewers.

That's wonderful that you're taking the metformin and monitoring the glucose levels. An A1C of 6.7. So you want to talk to your health care team about that because that may actually be consistent with a diagnosis of diabetes. And so you want to know what your glucose levels are perhaps in the morning and two hours after meals. So sometimes, you want to check to see if your glucose levels are above the target range after eating as well.

And so generally, the American Diabetes Association recommends that fasting glucose level to be between 80 and 130. These ranges are individualized because we do want to avoid low blood sugars. So in people who are at risk for low blood sugar, we'll adjust. But metformin generally doesn't cause low blood sugar. And so being on that dose of metformin seems appropriate. Your health care team will evaluate whether or not you need any adjustments based on kidney function.

But one of the things that we just mentioned that we want to consider as well are what are those things we might call comorbid conditions. So if you've ever been told that you had coronary artery disease, or if you've ever been hospitalized with something called heart failure, then you want to know if there's another medication that could potentially be added to the metformin to reduce your risk for those complications.

Great questions so far. These have been really good. Here's another one. So this one is for you, Dr. Mirmira. So why is it as you get older, that if you eat something sweet or certain medications can make the urine have a sweet smell or fruity smell? Does that necessarily mean that you have diabetes and should be checked? Is that something people should be alarmed about?

So a couple of things. First off, as you get older, your risk of diabetes increases. So the prevalence of diabetes is higher in older individuals than in younger individuals. So that's something we should all be aware of. But beyond that, the term, diabetes mellitus, literally means sweet urine. And so that was really how the disease was identified and defined back a thousand years ago roughly.

And so certainly, if that happens, and you do smell sweet urine-- you know, anybody who's older I think should be having regular checkups with their physician. And I think that's something that you should alert your physician to. It may or may not mean anything, but it should be checked.

Yeah. Always when in doubt, talk to your physician. And we certainly encourage that. Dr. Thomas, here's another good one. I was diagnosed with type 2 diabetes two years ago today I have been doing well with maintaining my sugar. But two weeks ago, my sugar level skyrocketed skyrocketed, and it will not stabilize. So my question is, what can I do to keep such episodes from reoccurring?

What you can do is kind of the same thing that we had learned from the Diabetes Prevention Program, which is introducing some exercise, some adequate sleep, and then looking at that plate and deciding if there are certain things that are in the glass, especially sweetened beverages with sugar, or even the big culprit would be high fructose corn syrup. So avoiding sweet beverages. Avoiding sweetened teas. And then making sure you're having that healthy plate with lots of vegetables and whole grains being the primary carbohydrate.

And then whatever we'd make is our habit, having that be those healthy foods. And then having some of those concentrated sweets as we come upon the holidays. Having those be more occasional as opposed to the habits.

I'm sorry. I'm so glad you brought up holidays because I think that's a real challenge for a lot of folks. And I apologize for interrupting you, but can you kind of talk a little bit about that, expound on that, and just maybe give people something to keep in their arsenal to battle it because that's hard.

Right. So I think it's important to celebrate, especially now that we are able to have even our five-year-olds kind of vaccinated against the COVID-19. But we also have to think about portions. And so I think we don't want to completely avoid things. Everyone has to know what's good for them as an individual and what's that amount that they can tolerate.

And don't feel frustrated by having some slightly elevated glucose levels. But what you don't want to do is not check. So you want to know what your glucose levels are. It's empowering. So you can know should I have that extra slice, or should I avoid it this time?

That is great advice. We we're about out of time, but I do have one more question that I want to get to. So Dr. Mirmira, I'm going to throw this one to you. A question about Lantis. What is the proper time to take it? Every time I have a new doctor, they change it. One now says to take 25 units at bedtime. I've mostly taken one dose of 12 to 15 units twice a day, 9:00 AM, 9:00 PM. Is one better than the other? And I again, we always kind of defer to your physician, but if you have any thoughts.

So the best thing I can say is that good physicians will tailor diabetes regimens. There isn't always one way to do something. Generally, we give Lantis once a day. It could be in the evening. It could be in the morning. There are some people, just because of variations from individual to individual, where more than one injection a day might be appropriate. Typically, no more than two.

And then of course, as I mentioned, there are newer insulins now that really eliminate the need for twice a day, whether it's Atlantis or some other type of insulin. So there are some new insulins that can do that too. So again, I think good physicians tailor diabetes regimens for individuals, their lifestyles, and how they respond.

Yeah. I think this again illustrates why it's really important to establish that relationship with your physician, build that relationship, and be open with your physician because that's what you all are there for. You want to talk to your patients. And it certainly is helpful, I think, to establish those lines of communication. Well, you are fantastic. Thank you very much. You're great.

That's all the time we've have for this segment. We're going to take a quick break. When we come back though, we're going to travel inside the lab to look at some of the exciting research that's happening here at UChicago Medicine.

And welcome back. Research is an exciting part of what happens here at UChicago Medicine. In fact, our research scientists in the labs are among some of the very best in the country. And one area of research where our experts constantly are working is of course, diabetes. Today we're going to take a look inside one of our labs with an expert guiding us. And Dr. Ryan Anderson is joining us for a quick tour of the lab and to tell us a little bit about what's going on there. First of all, welcome. Thank you, Dr. Anderson.

Thank you for having me.

Great. So let's just start off. I understand you have a little bit of a show and tell set up for us. What do we have to look at today?

We'll start over here at the show and tell kind of a pet store of research. So in the lab, we study the development and the function of the pancreatic islets, which are key for studying the disease, diabetes, and the pathogenesis of diabetes. And we use a range of different models in the lab to move all the way from singled cell organisms, like bacteria, which we can use as a tool, up through more advanced organisms, like zebrafish, that have their own unique experimental advantages. Up through mice, which are a mammalian system that are more closely related to humans than zebrafish are.

And then of course, the closest model that we use to humans are cells and micro-organs isolated from humans. So we've also got human islets here in a tissue culture dish. And all systems that we use in the lab can be exploited for their unique characteristics and advantages for doing sort of experimental medicine in a research lab.

So tell us a little bit about the zebrafish. I know you have some things on the microscope back there that you wanted to show us. What is the advantage of using zebrafish?

Well, the great advantage of using zebrafish is first off, they are a vertebrate organism that share much of basic body plan and organ structure with humans. And so they can be a very good model for humans. But the experimental advantages are that we can use the zebrafish embryo as a sort of a miniature in vivo system to study cells like pancreatic beta cells in their natural context.

And in addition, we can study how those cells develop from the singled cell zygote, all the way up to the complete organism. And so when we understand those processes by which cells can develop, we can exploit those to make new cells for therapeutic purposes.

So zebrafish have the advantage that they produce a lot of progeny that we can study. And that those progeny can be manipulated genetically very easily. And those embryos are basically transparent. So we can look into the internal organs of the organism while it's still alive and study how they're functioning and how they're developing.

And you have an example that you're going to show us on the microscope right here?

I do. So similar to this Petri dish here, these are some embryos that were collected a couple of days ago. So they are two days post fertilization. And if you look down here at the bottom of the microscope, this is just the Petri dish full of embryos. And each one of these embryos is just a couple of millimeters long. But by two days, this embryo, if you now look over here at the monitor, this is being projected from a camera on the microscope.

And this is a living zebrafish two days old. And you can see that it already looks like a fish. It's got a head. It's got the tail. It's got the eyes. And you could even see the beating heart here. But what we're particularly interested in is the development and the function of the pancreas and the pancreatic islet and the cells that are in that pancreas that make insulin.

And so these fish have been genetically modified, so that they have a fluorescent pancreatic islet. So if I turn on the fluorescent light here, and you look at the picture of the embryo, you can now see this green spot here. So I'll just flip it off and then back on. So we're illuminating these with fluorescent lights. And a molecule that's being produced in the pancreas in those beta cells is now emitting fluorescent green light. So these are about 50 cells at this stage in the zebrafish's life. And they're already making insulin. And those cells are functioning to regulate the blood glucose in those animals.

Interesting. Well, I tell you, I know we only gave you about five minutes, and we could probably spend hours in the lab. And we are going to actually do a follow-up with you because I'd love to do that in the future. But thank you very much for that fascinating look at some of the science that's happening around diabetes treatment and cures.

That's all the time we have for the program today. If you want more information about diabetes and diabetes care, please visit the Kovler website at kovlerdiabetescenter.org. Thanks for watching. I hope everyone has a great day.