Diabetes 101

November is National Diabetes Awareness Month. To do my part, I’ve been sharing information each week about Diabetes - symptoms, causes, impact on the body and most importantly, about prevention. To wrap up the month, I’m putting it all together here on the website, in Diabetes 101.

Diabetes 101

Diabetes is the 7th leading cause of death in the United States, and the numbers of people living with Diabetes are increasing. Since I’ve been alive (I’m under 40, but over 35 for those of you wondering..), the number of cases of diabetes have QUADRUPLED. Trends project that by 2050, 1 out of ever 3 American adults will have Diabetes. 

While there are different types of Diabetes, the vast majority, 90-95%, have Type 2. While Type 2 Diabetes does have some genetic component, this is a preventable type of Diabetes. And for the folks in the back - THIS IS A PREVENTABLE DISEASE! Not only is it preventable, but people typically are often made aware by their doctors that they are developing it, and there are concrete ways to reverse course and normalize your blood sugar regulation to prevent progression to full course diabetes. Of the 86 million adults in the United States who are prediabetic, 15-30% will go on to develop full Type 2 Diabetes within 5 years. The key to prevention? Changing your habits and lifestyle to foster healthy eating habits, weight management and regular physical activity, But before I go on, and on and on, about the benefits of physical activity (have you heard this one before?), here is a quick primer on Diabetes.

Diabetes Is:

Diabetes is: a group of metabolic diseases that cause unmitigated blood sugar (hyperglycemia). While the body relies on sugar for energy production, too much free floating, unstored sugar, can wreak havoc and cause damage and dysfunction, and eventual failure, of organs throughout the body. Diabetes most commonly affects the eyes, kidneys, nerves, heart and blood vessels. Long term effects of Diabetes can include:

• Retinopathy

• Nephropathy

• Peripheral Neuropathy (leading to skin breakdown, foot ulcers and often amputations)

• Autonomic Neuropathy (leading to gastrointestinal, genitourinary and cardiac symptoms)

• Atherosclerosis

• Cardiac Artery Disease

• Peripheral Artery Disease

• Cerebrovascular Disease

• Hypertension

• Abnormal Lipid Metabolism

There are a few different types of Diabetes. Type 1, or what used to be referred to as Juvenile Diabetes, is not preventable. This form is an autoimmune disorder where the body attacks the insulin-producing Beta cells in the pancreas, thereby preventing insulin formation. Without insulin, the body cannot break down sugar effectively leading to diabetes. People with Type 1 Diabetes rely on careful diet and exogenous insulin (injections) to manage their blood sugar, and while healthy diet and exercise is still important for someone with Type 1, it will not prevent Diabetes in this case. Type 1 Diabetes accounts for about 5% of Diabetic cases.

Type 2 on the other hand, develops over time, most frequently as a result of lifestyle choices. In the case of Type 2 Diabetes, insulin deficiency is relative, and due instead to insulin resistance. Between overexposure to sugary foods and carbohydrates, and lack of physical activity, more and more insulin must be produced to have the same effect, leading the body to become less sensitive to this hormone and leading to this state of insulin resistance. While Type 2 Diabetics may require pharmacological management (medications that improve insulin sensitivity) or exogenous insulin (injections), many can manage their disease with diet and exercise alone.

Symptom Presentation:

Whether you are experiencing Type 1 or Type 2 Diabetes, the symptoms that you experience are a result of either blood sugar that is too low (hypoglycemia) or too high (hyperglycemia). Symptoms of hypoglycemia include hunger, nervousness, shakiness, perspiration, dizziness, lightheadedness, sleepiness and confusion. Symptoms of hyperglycemia include frequent urination, increased thirst, sweet smelling breath and when progressed too far, ketoacidosis and coma. Initial signs of Diabetes can be a mix of these. Typically, the first signs of Diabetes include:

• Blurred vision

• Polyuria (Increased Urination) and Nocturia (nightime urination)

• Neuropathy (pain, tingling and numbness in hands and feet)

• High blood prssure

• Fatigue

• Confusion

• Itchy, dry skin

• Slow healing wounds and recurrent infections 

Diagnosis:

So how do you know if you are diabetic? There are two primary tests used to screen for, and diagnose Diabetes. Most commonly, if you are at risk or over a certain age, your primary care physician will order an A1C check. This provides an average of your blood sugars over the prior 2-3 month period. A normal value is under 5.7%; a prediabetic reading falls between 5.7 and 6.4%; and a test over 6.5% indicates Diabetes. If you have fasted, your doctor may take fasting blood sugar reading. This reflects your blood sugar, at the current place in time and results under 100 mg/dl indicate you fall in the normal range. Results between 100-125 mg/dl indicate you are prediabetic, and values over 126 mg/dl indicate Diabetes.

Concerned you may be at risk? There is a great resource available on the American Diabetes Association Website that helps you calculate your risk of developing this disease. You can access it here:

When in doubt, simply ask your doctor at your next visit about your risk of Diabetes, and what you can do to prevent it.

Prevention and Management:

Whether you find yourself at risk, diagnosed with Prediabetes or living with Type 2, lifestyle intervention can prevent or stop the progression of this disease. There are three keys to the prevention of Diabetes: Weight Management, Healthy Diet and Physical Activity.

While focusing on a healthy diet is important for everyone, weight management is a particularly important step for people who are overweight or obese. Eating a balanced, healthy diet, while increasing activity and energy expenditure should help to balance out your energy intake and improve your weight management. While I won’t go into too much detail here, the important thing is to identify if this is an issue for you and if so, seek support. A nutritionist, diabetic educator or the Dietary Guidelines for Americans are all great places to start. Choose My Plate.gov offers great online tools you can access here: 

I will, however, go into more detail about physical activity. If you’ve been on the HAE website before, I’m sure you’ve already heard that getting 150 minutes each week of moderately intense physical activity (plus strengthening twice a week) is incredibly beneficial and is THE most effective way to promote healthy aging. This is the same for Diabetes. Not only does regular physical activity help with weight management, but it lowers blood sugar, lowers cholesterol, improves blood pressure, and lowers stress, anxiety and improves mood. While counseling for patients found to be prediabetic includes encouraging increased physical activity, in my experience, there is a reason inactive people aren’t active in the first place. If it were that easy to simply start being active, chances are, they would have done it years ago. But pain, fear, inexperience, lack of time, lack of knowledge...these factors, unaddressed, are all barriers to exercise. 

Role of Physical Therapy in Diabetic Prevention and Management:

Physical Therapists are physical activity and exercise experts. We are experts at finding ways for everyone, in every shape, to become ACTIVE, safely and effectively. Exercise and physical activity can be life changing. It can ward off depression, manage anxiety, improve sleep, prevent disease like heart disease and some cancers. And it can reverse prediabetes and PREVENT DIABETES. 

Exercise lowers blood glucose and improves insulin sensitivity. It improves body composition and reduces adiposity (fat tissue), which when increased, is in itself a risk factor for development of Diabetes. It aids in weight management and makes you FEEL BETTER, and often, that alone, can help with making better food choices. 

So, climbing off my soapbox: this was my long-winded way of saying, good grief, if you have been told you are prediabetic, or had an impaired fasting glucose reading, now is the time to get ACTIVE! And if you need help, ask a PT:)

In summary, Diabetes is a quickly growing problem in the US. However, for the vast majority, this is a preventable disease! Learn about it, make healthy choices and get active. Great resources exist on the internet (ADA), but as always, your primary care physician is the best place to start. Ask the questions, make the changes and get stronger, fitter and healthier! 

the HAE series: the Pulmonary system part III

Part III, and my favorite part to write, reviews the concrete steps we can take to prevent pulmonary disease and slow age-related changes to the lungs.

Lifestyle Factors

First and foremost, cessation of smoking and avoidance of second hand smoke is, of course, the number one lifestyle modification you can make to protect your pulmonary system. Smoking is the greatest risk factor for developing COPD. Those who smoke more than 10-15 ‘pack years’ (1 pack of cigarettes per day for a year is ‘1 pack year;’ 2 packs of cigarettes for 1 year is ‘2 pack years.’) are at higher risk to develop COPD and the exposure to secondary hand smoke and other environmental irritants and air pollution can also increase your risk. Visit SmokeFree.org for some amazing tools to help you or your loved one quit.

Exercise and the Pulmonary System

Exercise also can have significant impact on the risk of developing, and the management of, pulmonary disease. Both aerobic exercise and strengthening activities play a role in your pulmonary health. Participating in the recommended 30 minutes of moderate exercise most days of the week works to improve the way the body is able to access and utilize oxygen. Aerobic exercise strengthens the cardiovascular system; with a stronger heart and healthier vascular system, the blood stream can transport the oxygen-rich blood with increase ease and efficiency. Participation in a regular strengthening program improves gas exchange within the musculoskeletal system. When the blood stream reaches the muscle, a stronger muscle is able to more quickly and efficiently extract the oxygen, which it can then use to make energy and contract more successfully.

Lastly, focused breathing exercises can improve the muscle function of the structures responsible for the act of breathing. These include the diaphragm, located under the lung set, the intercostal muscles found between the ribs and the accessory breathing muscles, located throughout the neck and abdomen that help with the work of breathing. These muscles, in particular, tend to become overused and overdeveloped in pulmonary disease states that frequently lead to dyspnea or shortness of breath. Physio-pedia has an excellent set of videos that illustrates how these muscles work together to support the cycle of breathing here if you want to check it out.

Respiratory Training

There are three exercises I typically take my patients through to strengthen both breath control and respiratory strength. Pursed lip breathing, belly breathing and straw breaths all work to teach proper breath sequence, timing and help to strengthen the muscles responsible for the cycle.

To perform pursed lip breathing, try following these steps:

1. Take a slow inhale through your nose, counting to 3-4 seconds as you go.

2. Pause, then exhale this breath through pursed lips (like you’re holding a straw) trying exhale slowly, doubling the time you spent on the inhale. If you inhaled for 2 seconds, exhale for 4. If you made it 4 seconds, exhale for 8.

This exercise can be used proactively to strengthen, and also reactively, to address shortness of breath. You can watch a video of pursed lip breathing here. Pursed lip breathing is especially important to people with COPD; this extended exhale allows the breather to exhale trapped carbon dioxide more effectively, further normalizing the breathing pattern and improving the associated feeling of shortness of breath.

Diaphragmatic breathing, or belly breathing, helps to normalize the breathing pattern, and better utilize the diaphragm, leading to deeper and more effective breathing patterns. In states of respiratory distress, instinct tends to trigger short, quick, repeated breathing. However, this pattern is less effective than deeper, diaphragmatic breathing and tends to exacerbate the shortness of breath instead of alleviating it. Practicing this technique at rest is helpful, so it can be used more effectively in states of dyspnea with less effort and more ease. To perform a proper diaphragmatic breath, follow these steps.

1. Sit comfortably with feet flat on the floor, or lay down flat in bed. Place hands on your belly and try to relax your body.

2. As you breathe in slowly through your nose, imagine filling your lungs to the very bottom and watch your hands rise as your belly expands.

3. As you exhale, watch your hands fall back down and your belly return to resting state.

This video link will show you diaphragmatic breathing in action.

The third exercise worth mentioning is straw breathing. It is similar to the pursed lip breathing above, but can sometimes be a little easier to coordinate. To perform, find a plastic straw and sit comfortably in a chair. Breathe in slowly through your nose, then exhale fully with lips wrapped tightly around the straw. Try to repeat 5 times and rest.

All three of these exercises are best performed when you are calm and at rest. Try to choose a time to perform them each day to create a habit; spending 5 minutes focused on each one 3-5 times a day can be extremely beneficial and will make using these strategies with the onset of shortness of breath more automatic and let you return to a resting state with increased ease.

the HAE series: the Pulmonary System part II

Normal Changes with Aging

As with all areas of the body, with advancing age, the lungs can be come less efficient. The diaphragm muscle responsible for the inhalation and exhalation can become weaker, decreasing the amount of air you can take in and out each breath. With thinning ribs and arthritic changes, the rib cage can become less flexible and cause some restriction on your inhalation. Combined, these two changes can increase the work associated with breathing. Other accessory muscles involved with respiration can also become weaker, interfering with your ability to cough and in turn, clear your airway. With age also comes a weakening response of the immune system; the white blood cells that usually provide some defense to invading pathogens within the lungs become less effective putting your at increase risk of infections like community-acquired pneumonia Lastly, within the lungs, the alveoli lose their shape and this in turn makes gas exchange more difficult. Aside from the changes occurring naturally with age, I’ll review some pathology common in older adults. (But don’t fret, next week I’ll share how we can slow or reverse these changes through our actions!)

What Can Go Wrong

Pneumonia: As mentioned above, weakened immune systems can leave the pulmonary system at risk of infection. Infection within the lungs is called pneumonia. The result of inflammation at the alveoli, the gas exchange is impaired and the body can end up in a state of hypoxia, or decreased oxygenation. Other symptoms are typically cough, fever, back pain (typically near the site of the infected lung) and audible ‘crackles’ that can be heard through auscultation. More progressive cases can cause confusion, altered sleep and wake cycles and failure to thrive. Risk factors for pneumonia include immune compromise and immobility. The ability to move air throughout the lungs can help clear out pathogens and as such, it is of critical importance to use strategies like incentive spirometry or deep breathing during periods of immobility after a surgery, during a hospital stay or during a state of illness. Pneumonia is typically treated with an antibiotic if is caused by bacteria, however, some strains of pneumonia can be prevented prophylactically with the pneumococcal vaccine.

COPD: Chronic Obstructive Pulmonary Disease, or COPD, causes difficulty breathing by way of ‘air trapping.’ In the case of emphysema, destruction of the alveoli due to exposure to irritants like cigarette smoke, causes impaired air exchange and the trapping of carbon dioxide. With chronic bronchitis, inflammation within the bronchial tubes make it harder to inhale and exhale and with chronic asthma, the obstruction is due to inflammation within the airways causing bronchoconstriction, or narrowing of the bronchioles. These disease states leave the lungs less elastic and airways more prone to collapse and this combined, obstructs expiration. People experiencing COPD will have symptoms associated with hypoxia, or decreased oxygen, like coughing, difficulty breathing, confusion and fatigue. Treatment mainstays include keeping the airways open longer during the exhale phase with strategies like pursed lip breathing or spirometry, use of bronchodilators (inhalers) and supportive oxygen in later stages. 

Restrictive Lung Disease: As introduced above, disease and disorders that affect the muscles and bone structure can cause an external restriction in the ability for the lungs to expand. Restrictive disease can be classified as either intrinsic or extrinsic. Intrinsic causes include general fibrosis of the lung parenchyma and extrinsic causes involve the lung pleura, chest wall, respiratory muscles or neuromuscular disorders. Neuromuscular conditions like Parkinson’s Disease and musculoskeletal changes like rib fractures and thoracic kyphosis and scoliosis can cause structural changes to the rib cage and lost flexibility. Increased body weight and obesity can block the diaphragm from descending fully and can make both inhale and exhalation more difficult and cardiovascular causes, like pulmonary edema from heart failure can restrict lung expansion from the inside. Presentation involves dyspnea compensated for by rapid shallow breathing and patients will demonstrate a decreased total lung capacity, modestly preserved FEV1, increase airway resistance and a decreased FVC that results in a FEV1/FEV ratio greater than 80%, as well as a reduction in functional residual capacity (FRC), or the amount of air in the lungs that remains when respiratory muscles are fully relaxed.

Treatment for these conditions must address the etiology; stretching, range of motion and postural reeducation may help in cases that have not yet progressed to severe and treating the CHF through pharmacologic management and lifestyle modification will address the cause in the case of pulmonary hypertension. 

Pulmonary Hypertension: PH is a condition in which mean pulmonary arterial pressure is greater than 25 mmHG at rest. Pulmonary Arterial Hypertension (PAH) is a specific clinical condition of PH in absence of other causes of precapillary HTN. It is quite rare (1, 1000,000-1,000,000). PH is less uncommon, 1% of the population, and is often associated with other hypoxic cardiopulmonary disease like COPD and diffuse parehnchymal lung disease. In setting of hypoxia, pulmonary arterial smooth muscle contracts to cause vasoconstriction to promote ventilation matching, but in chronic hypoxic lung disease, the increased pulmonary vascular resistance resulting from hypoxic pulmonary vasoconstriction causes the development of PH. Symptoms usually include dyspnea, fatigue, general signs of cardiovascular dysfunction (syncope, angina, heart murmurs) and signs of pathologically elevated systemic blood pressure (ascites, edema, jugular distension). Exercise capacity is limited, and individuals with PH experience increased dyspnea due to inspiratory and expiratory muscle weakness.

HAE series: the Pulmonary system

The Basics

While the heart may seem like the most important organ in your body, it would be quite lonely without the pulmonary system to which it is attached. The pulmonary system is responsible for the critical task of gas exchange - or the transfer of fresh oxygen into the bloodstream, and the removal of carbon dioxide from it. Oxygen makes all the things happen. WIthout oxygen, there would be no energy. Without energy, there would be no functioning tissues, organs or muscles. In fact, the brain can only function about three minutes without oxygen and if cut off for any longer, will likely sustain some degree of brain death (*except in cases of severe hypothermia, but that’s a story for a different time.) All said and done, you inhale and exhale approximately 2000 times a day, exchanging 11,000 Liters of air by the time you start the next. 

This process occurs in four different stages. Pulmonary Ventilation initiates the cycle by drawing air into and forcing air out of the lungs. The muscle that forms the base below your lungs, the diaphragm, contracts and relaxes to create a vacuum effect; the oxygen rich air from the atmosphere is drawn in through the nose and mouth, and into your system by way of a series of pipes. The air first enters the pharynx, then passes into the larynx. The larynx becomes the trachea and the trachea splits into the two primary bronchi, which then each split into secondary bronchi, each of those then splitting into more and more segmental bronchi. This elaborate splitting and resplitting creates the tree-like shape that makes up each lung. The right lung is broken into three lobes; the upper lobe, the middle lobe and the lower lobe. The left lung only gets two, because it leaves a notch open where the heart sits and has an upper and lower lobe only. Each of the very last bronchioles in the tree ends at an alveolus. Multiple alveoli bunch together to form an alveolar sac. This is where the action happens. 

The alveolar sacs are responsible for the External Respiratory phase. Each sac looks like a tiny cluster of grapes and this is where the lung tissue connects to the blood stream. Blood leaves the right side of the heart by way of the pulmonary arteries and ends as capillaries who wrap around the alveolar sacs where they can proceed to transfer their gasses. (If you’re quick on the pick up, you’ll realize this is totally counter intuitive as arteries are usually associated with red, oxygen rich blood, but the term artery actually just indicates direction. An artery is simply a blood vessel which goes away from the heart, which in this case, it does.) During this gas exchange, carbon dioxide is deposited back to the lungs to be exhaled, and oxygen is transferred from the alveoli into capillaries to bind to hemoglobin and enter the blood stream. This, now oxygen-rich, blood travels along the pulmonary vein into the left side of the heart to be pumped out into the body. (Get the counterintuitive reference now? Though veins are usually oxygen-poor, these are oxygen-full because a vein simply indicates it is returning to the heart.)

The role of the elaborate vascular system is now to enable the Transit of Respiratory Gases. Blood travels throughout the body through arteries to every single muscle, tissue and organ in your body and provides the oxygen needed to created energy to keep those cells functioning. As these arteries turn into smaller capillaries and terminate at their designated tissue site, the fourth and final phase, the Internal Respiration completes the cycle. Oxygen transfers from the bloodstream into the tissues, and the tissues trade out the residual carbon dioxide that has been left there as a byproduct from energy production. I’ll leave you with a fun fact: Once that carbon dioxide is exhaled back into the air, it is used by plants for photosynthesis  - which then creates more oxygen for us to breathe. #CycleOfLife.

You can watch a pretty sweet Nat Geo video about the lungs here.

Core Values

I attended a webinar last night the speaker asked us to identify our core values. What I found particularly interesting, is she specified that our core values should be both relevant to our personal lives and our business practices, because contrary to popular belief that you should keep your professional and personal life separate, a business can be most successful and fulfilling when these values align. As an independent practitioner, I found this concept resonated with me longer, as one of the things I value most so far about running my own practice is that I get to do things MY way. While I started HAE/PT simply as a way to be able to continue to work while meeting the unusual demands I now face at home due to the pandemic, it has transformed into something else entirely. It has given me an opportunity to to use my skills and experience in the best way I know how to help my patients in more meaningful ways. In thinking about it in this light, of course my personal core values should line up with my professional ones, and I can see how making these a regular part of the way I do my business will be the best path to success.

The core values, and the values I strive to live my life by and design my business around, are Strength, Support and Stability.

Strength:

I’ve always found myself striving to be strong. As a person, in my athletic pursuits as a swimmer and as a physical therapy clinician. Strength fosters resilience. When life becomes challenging, physically or emotionally, it is your strength that helps you remain resolute, that helps you achieve your goals and remain whole when you emerge on the other side. This is a value I work on daily in myself. It is an attribute I work on at each visit with my patients. And it is a value I wish for as I develop my business.

Support:

I’ve been in the ‘helping’ field as long as I can remember. My first job was a mother’s helper when I was somewhere around nine or ten. I started volunteering at eleven as a swim teacher for kids with disabilities. I continued in this role until I left for college. I worked at various camps and recreation programs for people with disabilities from my teens into my early twenties and when it came time to choose a career, it felt like a given to make a choice within the helping professions. There certainly weren’t any other careers that piqued my interest, and the only jobs that felt worthwhile to pursue were ones that would allow me to support other people. I strive to support my friends and family when they struggle, and I feel like being able to support my patients as they recover from illness and injuries is best part of my job. In opening my own practice, I have given myself the flexibility to expand the ways I support my patients. I have developed programing to support patients before, during and after physical recoveries and under a greater umbrella of health and wellness, and can now provide support during my visits without the constrains of productivity standards and other factors that limit how I choose to spend my time.

Stability:

Stability is successful maintenance of balance. Stability has far reaching implications in all areas of health - mental, physical, emotional and spiritual. While some people yearn for freedom, flexibility, or adventure, and while I also value all of those things, I believe that you can only truly grow when you have a stable base to keep you grounded. I’ve always been drawn to images of trees with giant sprawling roots, and wear a necklace each day with that depicts a tree of life, embellished with my children’s initials. I feel most at peace in the woods, among tall trees, in fresh air, on a clear fall day. While I can’t completely put into words how why I feel this way, I can tell you how it makes me feel. It makes me feel calm. It makes me feel like I can see the ‘forest for the trees’ - it helps me put my problems in perspective and see my world on a larger scale. When I’m stressed, or overwhelmed, I can take a walk in the woods and emerge feeling renewed and optimistic. While I don’t consider myself spiritual, per say, there is a passage that always catches my eye during the high holidays each year. Paraphrased, it reads:

“Will you be troubled every passing wind or be the calm within the storm?”

I strive to live my life as the calm within the storm - and want the very same for my patients. I want for them to experience stability in their health by providing them with an education beyond what a physical typical therapist may provide. I want them to be stable, literally, so they can avoid falls and remain free from injury. I want to be able to support each of them, to help them develop the strength and the stability they need to age successfully. I believe these values, my core values, are what makes HAE/PT special and I look forward to sharing them with you.