Dr. Alan Marcus: Practicing Innovative Type 2 Treatments

Is your doctor up-to-date and willing to spend time with you? Dr. Alan Marcus certainly is. Dr. Marcus is one of the most innovative doctors we have ever come across. His unique perspective on diabetes and patient driven health care is truly inspiring.
Scott King: The latest figures show that only five percent of diabetes patients see a diabetes specialist. Is there something seriously wrong here? What is your feeling about diabetes care in America today?

Dr. Marcus: In fact, the number is more like three percent. Everyone with diabetes should be seen by a diabetologist. I also think that the patient should make sure that his or her physician is capable and up-to-date. Physicians love car analogies, and an appropriate one would be if you had a car and it kept breaking down and was constantly in the shop, I doubt you would continue to bring the car to the same mechanic. Your body is much more important than any car, and can’t be replaced. I am not sure why people continue to put up with poor care.

S.K.: Are doctors responsible for poor health care?

Dr. Marcus: It is an unfortunate fact that a large number of doctors are not committed to taking care of patients with diabetes. To do so would mean being accessible to the patient. I feel strongly that if a doctor wants to care for patients, it is necessary to find time to see them and follow up on their care. This is the definition of diabetes care at its best. Still, patients are ultimately responsible for their own care and need to participate actively with their physicians.

S.K.: Many people think that type 2 diabetes is not as serious as type I. Do you agree?

Dr. Marcus: Absolutely not. It is reasonable to assume that if excess glucose is as poisonous as the DCCT said, than type 2 diabetes is as serious as type I diabetes. It is often the case that people diagnosed as type 2 have had diabetes for more than 10 years and only recently developed some of the complications. Both the diabetes itself and these complications are often treated with pills.

Unfortunately, the patient and doctor tend to be lulled into a fantasy world, where if they just take some pills everything will be okay. The pills just treat a symptom of type 2 diabetes. A real treatment would be to address the cause of the disease as well.

S.K.: Do you have any innovative approaches to treating type 2 diabetes?

Dr. Marcus: Yes I do. Most doctors divide type 2 DM into five stages. In stages one through three, blood sugars go too high after meals. In stages four and five, the liver also produces too much sugar while sleeping. If blood sugars rise above 200 at any time, the blood can turn into a tar-like liquid, moving extremely slow through the body. A natural example of this is molasses, which moves slowly because of a high sugar content. These different types of type 2 diabetes require different therapies. In the later stages, insulin is the most effective drug to stop the liver from producing too much sugar. Hence, it is necessary to take an injection before bedtime. In the early stages, however, some people will respond effectively with diet, blood sugar measurement and exercise. But if this doesn’t work, then it may be necessary to begin pill or insulin therapy.

The problem early on (in stages one through three) is not too little insulin, but too much insulin and too little response in the cells. Lowering insulin levels by controlling glucose levels after meals is clearly the first step.

S.K.: Should all people with diabetes test their blood sugar at home?

Dr. Marcus: Absolutely. Blood testing should be mandatory. There is no way you can have diabetes and think that a 15 minute doctor’s visit every three months is going to adequately determine your continued daily needs. It is just not possible. And we now know that it is the high blood sugars that are the prime cause of diseases such as hardening of the arteries, hypertension, eye disease, nerve damage and kidney disease. Hence, it is vital to test 60 to 120 minutes after completing a meal. Testing your blood sugar provides a little window into your cells, helping you understand what is happening inside your body. It tells you if the food you ate, the exercise you did and the medicine you took is keeping you healthy – “healthy” meaning a normal blood sugar level.

S.K.: You mentioned the importance of food. Is it important for people with diabetes to understand nutrition?

Dr. Marcus: I think so. It is always enlightening to see which foods are causing your blood sugars to rise. We all know that fruits and fruit juices make blood sugars go sky high. But potatoes will actually raise your blood sugar as much as a chocolate pie. Plus, overcooked pasta actually raises blood sugars because you are breaking down the starch. But if you eat the pasta al dente (cooked lightly), it is possible to eat a lot of it and still keep normal blood sugars. (The boiling water changes the starch in the pasta to sugar as you cook it.) Chinese foods, as shown by the Center for the Study of Disease in the Public Interest, can significantly raise blood sugarsbecause of the sugars and oils used. Oil-popped popcorn can raise blood sugar levels as well, while air-popped doesn’t.

An interesting way to think about nutrition is that your body uses a universal currency exchange. No matter what you take into your body, whether it be fats, proteins, or sugars, your body transforms it back into glucose, then converts it back into fats, proteins and sugars as needed. Eventually, everything gets converted into sugar. Essentially, people with diabetes need to be experts on their external and internal environment. They need to know how food, exercise, stress and medicine affect them. They need to know the internal facts about blood pressure, cholesterol, thyroid and kidney functioning. One important tip I give my patients is that your pancreas is not working great, but God didn’t take your brain away. Your brain needs to think as a pancreas. You look at the foods, and you think, “What I would do if I was a pancreas?” As taught to me by Kris Swenson, we need to think of people with diabetes as “pancreatically impaired.”

S.K.: If people with diabetes need to be experts, how do we get this information?

Dr. Marcus: It takes time. There is a limit to the amount of information that a person can retain in any one visit. That is why you should not see your doctor, dietician, and nurse educator all in the same day, because you won’t retain all the important information. It usually takes 30 to 60 days in a concentrated education program for newly diagnosed diabetics to obtain the important knowledge. Follow-up education, taking notes, asking questions and seeking information from experts is vital as well. Not to sound like a “paid political announcement,” but I think DIABETES HEALTH is a major source of information written in a way everyone can digest and understand.

S.K.: Everybody realizes the importance of paying close attention to eye care. What should people be most concerned about?

Dr. Marcus: Good glucose control is the key factor. In fact, eyesight can actually improve (eye complications can reverse) with tight diabetes control. Also, don’t forget the importance of a yearly retina examination by a retinologist – this is mandatory.

S.K.: A recent study showed that one in 25 young diabetic patients may die in hypoglycemic comas. How could this number be so high?

Dr. Marcus: The greatest risk and greatest incidence of low blood sugars occurs from 2 a.m. to 4 a.m. nightly. The major predictive test of low blood sugars during sleeping is a bedtime blood sugar of less than 90. Therefore, I do not allow my patients to have a blood sugar of less than 90 before falling asleep. They test their blood sugar at bedtime and eat a snack if it is less than 90. Exercise tends to lower blood sugar for 5.5 hours, therefore pancreatically impaired patients on insulin are told to not exercise at night.

S.K.: Any final thoughts?

Dr. Marcus: The greatest revolution in diabetes care in my lifetime has been the introduction of home blood glucose monitoring. I look forward to bloodless glucose monitoring. If testing can be made bloodless, people are going to test more often. This will force their doctors to do something about abnormal results and give patients more control of their lives. The combination of patient knowledge, along with the demand to do something about it, will improve patient care considerably. If the patient demands that something be done, something will be done. Education is the key. We need people to understand that diabetes does not have to be the cause of all these complications. Most of them are preventable. As Mark Twain said, “Even if you’re on the right track, you’ll be run over if you just stand still.”

(Editor’s Note: A study has shown that between 60 percent to 80 percent of all diabetes-related complications are preventable with proper education and treatment. Empower yourself through education!)

Reprinted and updated from the Winter 1991 DIABETES HEALTH