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(Bob) 5.8 percent means she's
been elevated for a while. You
don't want to call it normal if
it's 5.8. Hers probably ought
to be 4.8. (Dr. Salgo)
So that brings the obvious
question. What does it tell
you about our patient? Female
Voice: She probably has diabetes
and if she doesn't have
diabetes she's going to get
there very soon. (Dr. Salgo)
How soon? (Bob) And maybe the
real answer is it doesn't make
a lot of difference whether
she's a diabetic or not
diabetic. The pre-diabetic
state, that family history with
diabetes, hypertension. And
that is a big iceberg below the
water. And as that iceberg
gets above the water we call it
diabetes but when it's below
the water it's a huge
cardiovascular risk. (Dr. Salgo)
Well I'll tell you what the
doctor tells Dolores. She says
you're on your way to having
Type II Diabetes. And again,
just nail it. What in this
history, just point by point
would have led the doctor to
tell her that? (Dr. Harris)
Her hunger. Her increase
urination. Her thirst. Her
borderline fasting blood
glucose. Her elevated
hemoglobin A1C. (Reggie)
Her obesity. (Dr. Harris)
Her obesity. Her hypertension.
(Dr. Salgo) I should have asked
what doesn't fit this pattern.
(Dr. Harris) Right. (Bob)
And. (Dr. Salgo) You know we've
gone this far. We haven't
really gotten a definition of
diabetes. We know there's Type
I, Type II. Somebody want to
give me a bullet for each of
these? (Bob) Type I Diabetes,
Peter, is an autoimmune disease
where your beta cells that
produce insulin become
destroyed. You can be skinny.
You can be fat. It really is,
has nothing more than you just
lose beta cells. You lose
insulin producing cells. Type
II Diabetes is really
characterized by resistance to
the action of insulin. (Dr.
Salgo) Laura, when you're
sitting in the doctor's office.
You've gone there in a panic.
(Laura) Absolutely. I left
work and went to the doctor's
office. (Dr. Salgo) You did.
Were you worried about diabetes?
(Laura) I was. Yes. I was
worried about everything.
(Dr. Salgo) So let me ask the
docs this. If you're saying,
not seeing a doctor, not
exercising contributes to the
development of Type II
Diabetes, are you blaming
Dolores? Is the old blame the
patient game? You got diabetes
because you didn't do what we
told you. (Reggie) Well I think
we have to recognize that part
of what we're seeing in this
country is the result of the
obesogenic environment we now
have created. Fast foods are
prevalent. The availability of
healthy foods, although very
easily obtained in some
neighborhoods, are very
difficult to obtain in other
neighborhoods. They're more
expensive. We have ways of not
exercising anymore. We've
eliminated things in our
schools. (Dr. Salgo) Let me
interrupt you. I think I'm
hearing a yes. I think I'm
hearing that. Multiple Voices:
No. (Dr. Harris) She lives in a
toxic environment. (Reggie)
Yeah, she. That's exactly
right. She lives in a toxic
environment. She has some
control over her environment
but until we really recognize
that we have to not only have
to not only look at what
individuals are doing but
what's the environment that
they're living in is doing.
Until we tackle both we're
going to continue to have these
problems. (Dr. Harris) The
answer to your question is no,
we should not blame her.
That's not even the issue. The
issue is you have this problem,
what can we do to help you
overcome it. (Dr. Salgo)
So the answer that you're
giving me is it doesn't matter,
let's fix it. (Dr. Harris)
That's right. (Dr. Salgo)
Alright. Let me tell you more
about Dolores. She's
African-American. And point of
fact, does that make a
difference in her diabetes risk?
(Reggie) This is a complicated
issue. The easy answer is yes,
minorities, particularly Native
Americans, particularly Latinos,
particularly African- Americans
have a greater incidence of all
these issues. When you drill
down a little deeper, however,
you discover some other things
that were kind of surprising.
For example, where you live
geographically. An
African-American who lives in
the south is going to have far
more problems than an
African-American who lives on
the west coast. An African-
American or a Caucasian, for
that matter, who lives in the
south and is living in poverty,
actually experiences the same
incidence of all these problems
as the general population in
the south. So it appears to
not only be racially determined,
culturally determined,
genetically determined, but
also you're socio-economic
status or your poverty rate.
And all of these things are
interrelated. (Dr. Salgo)
Now Laura, what did your doctor
tell you to do? (Laura)
My doctor told me to go home
and this was after a lot of
blood work had come back. I
got a phone call and it was
actually a nurse and says,
here's your results. We want
you to low fat. Eat low fat.
We want you to change your,
just switch to whole grains and
we'll see you back in a few
months and let's see. We'll
take the same blood test again.
So I said okay. I can do that.
Surely I can do that. Hang up
and, you know, try to manage
your way through that maze. I
said I have no idea what that
means. (Dr. Salgo) Dolores'
doctor says pretty much what
you heard. (Laura) Right.
(Dr. Salgo) I want you to lose
weight. Go do it. (Laura)
Right. (Dr. Salgo) In addition
her doctor wanted her to start
taking Metformin. What's that?
(Bob) Metformin is a drug that
is used to lower glucose levels.
(Dr. Salgo) It's a diabetes
drug? (Bob) It's a diabetes
drug. And now when someone is
diagnosed with diabetes,
instead of diet and exercise
and exercise and diet, its diet
and exercise plus Metformin.
But no question as Laura has
seen. (Laura) I was going to
ask that because. (Bob)
Exercise and diet is the most
important. (Laura) Right. Well
there was a short discussion
about medication and I asked do
I need to go on medication. And
the quick response was let's
try to control this through
diet, which I was happy in
hearing you say that. I
wouldn't have wanted to mask
what I was already doing,
eating poorly with a medication.
(Reggie) The problem with what
we're discussing here is that
we as a medical profession tend
to treat obesity and diabetes
as if it were a strep throat.
(Laura) Right. (Reggie)
Here's the test result. Let's
write a prescription. (Laura)
And you're done. (Reggie)
Patient's going to take the
prescription and everybody's
happy. Where we need to really
approach these problems as a
chronic disease, which is what
threSohe proper way to
ma nutritionist. To see
somebody that will interview
you to see where you are in
your willingness to change your
behavior, change your diet,
look at the entire family
because you can't go into a
household and eat healthy foods
and everybody aroyou is
continuing to participate in
this toxic environment.
(Dr. Salgo) Well let me walk you
through a few of these things,
if I met. Metformin is a
diabetes drug. Is her doctor
basically saying to her, to
Dolores, you've got diabetes,
have Metformin. Or is her
doctor saying take Metformin so
you don't get diabetes?
(Lisa) There was a study that
looked at a group of people
that liked Dolores where on the
diabetes expressway, going to
get there or were likely to get
there. And some of them were
given just Metformin and others
were put on a very rigorous
program to change their diet,
impose exercise, and see if
they can get them to lose some
weight and control it that way.
And the people who did best, who
had the lowest risk of
developing diabetes were the
people who lost weight through
diet andxercise. Metformin
also worked in terms of
preventing or postponing the
development of diabetes for any
of these people. (Dr. Salgo)
So this is an insulin issue.
Either she doesn't have enough
or she's resistant to what
she's got. Why give Metformin?
Just give her insulin. Why not?
(Dr. Harris) Well insulin in of
itself is not safe to just give
to everybody. And you can run
the risk of hypoglycemia, a low
blood sugar, which is more
dangerous than having an
elevated blood sugar. (Dr.
Salgo) What are the effects of
diabetes we're trying to
prevent here? Just lay it out
for us just once. Somebody.
(Dr. Harris) Blindness.
(Bob) Numero, uno, is
cardiovascular disease. (Dr.
Harris) Heart attack, stroke,
blindness. (Bob) But Lisa
you're right, you ask patients
what. (Dr. Harris) Kidney
failure, amputations. (Bob)
What complication of diabetes
they're most likely to get.
(Dr. Harris) Going blind.
(Bob) They'll say blind.
Blindness. (Dr. Salgo)
So blindness is one.
Cardiovascular disease, what
else? (Bob) Well blindness is.
(Dr. Salgo) Kidney failure is
another one. (Bob) But the
biggest is cardiovascular.
(Dr. Salgo) Bad stuff. Let me
tell you what Dolores is told.
Dolores and her doctor speak
together and they discuss the
benefits and the risk of the
Metformin, inspecific, and
together they decide that she's
going to start taking Metformin.
What do you think the outcome
is going to be? (Dr. Harris)
She's going to have diarrhea.
She's going to stop taking it
and if she doesn't change her
diet and she'll be back with
elevated blood. (Dr. Salgo)
You are a professional cynic.
(Dr. Harris) I certainly am. I
see a lot of diabetics.
(Dr. Salgo) Do you all agree?
the trigger on adoctors t
medicine and feik Like this is
penicillin, we're done. But
it's not like that at all.
It's really on ongoingissue.
(Dr. Salgo) Can somebody give
me a number? How many Type II
Diabetics are there in this
country? Do we know this
number? (Reggie) Yeah, about
twenty-five million.
Twenty-five million. Let me
stop. (Bob) And about a third
don't know it. (Reggie)
that is equyou a parallel
disturbing. Eighty percent,
8-0 percent of Type II
Diabetics in this country are
obese. The problem I have with
giving them Metformin without
all the other stuff is that
we're treating their blood sugar
and we're not treating all the
consequences of obesity.
(Dr. Salgo) Alright. Let's
just pause for a moment. I
want to sum up what we've been
discussing d ene'll pick
it uom the, shall we.
Type II Diabetes, a huge
d the isingthe United State
a
dangerous disease andeonitand t
Dolores starts her Metformin.