>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> Incredibly, more than one out of three American adults has prediabetes, and 90% of them don't even know.

Joining us today on "Second Opinion," primary-care physician Dr. Lou Papa from the University of Rochester Medical Center... >> Being not diabetic and being diabetic -- it's not this purgatory.

There's risk that's associated with it, right?

There's still risk with prediabetes.

>> ...diabetes expert Dr. Joshua Joseph from the Ohio State University Wexner Medical Center... >> You know, type 2 diabetes is the greatest risk factor for kidney disease in the United States, as well as the greatest risk factor for blindness in the United States and a huge risk factor for cardiovascular disease, including strokes and heart attacks and heart failure.

>> ...expert in preventive medicine and health equity Dr. Linda Clark from Common Ground Health... >> I look at the epidemic of obesity, but I also look at the epidemic of things like racism.

Diabetes and prediabetes travel more frequently in non-white individuals.

>> ...and here to share her personal story, Wendy Ruhland.

>> Well, with lifestyle change and plant-based diet and exercise, you know, we can turn this around.

>> I'm Joan Lunden, and it's all coming up on "Second Opinion."

♪ Thank you all so much for being here.

Wendy, I guess it was just about, what, seven, eight months ago you were feeling bad.

How bad?

What was going on?

>> So, yeah, it was back in February.

I hadn't been to see my doctor, Dr. Papa, in about two and a half years.

And COVID, of course, was in there.

So, for one of those years was COVID, and not many people were going in for a visit.

So -- And I always felt fine.

I never felt like I needed to go to the doctor.

I just went because I do have high blood pressure, so Lou likes to keep a check on that.

And so in February I had been feeling really bad for a few months, blurred vision, just not feeling good.

I don't even know how to explain it, but I just knew something wasn't right.

And so I thought, "Okay, I need to go in and make an appointment."

But my weight was really bad, so I thought -- I scheduled the appointment.

I canceled it, gave myself another two weeks to lose a few pounds, and then went in to see him.

>> I mean, that's a top, number-one reason why women give for not going to a doctor.

>> Mm-hmm.

>> And so you can see -- We've had this debate as to whether they should take on the scales... >> We need the information.

>> ...at their office.

But were you otherwise pretty healthy?

>> Pretty healthy.

Over the years -- Lou's probably been my doctor for, what, close to 20 years maybe?

>> Maybe even more.

>> Maybe even more.

And so my cholesterol was always a little borderline, which runs in my family, and I've been to him many times where he's said, "Okay, I'll give you six months to try and get the number down."

>> Otherwise, get it in shape.

>> Yes.

So, I would always go home and walk more, try and eat a little healthier, watch the processed foods, and would go back, and it really wouldn't change a whole lot.

So, when I went back this time in February, we did blood work.

And I really -- like I said, I knew things were not gonna look good.

I'd never signed up for MyChart before.

I went on and signed on for MyChart 'cause I wanted to see my own results.

And what I saw was very shocking.

Before he even sent me a message, I knew it was not gonna be a good message.

So -- [ Laughs ] >> So, now, this is not always the case that we have the treating doctor... >> Right.

>> ...with a patient who's with us.

But she is your patient.

>> She is my patient.

She's actually been good friends of ours for 30 years.

We both have twins.

>> Tell us about this appointment, and how did you work up her case?

What did you do?

>> He usually schedules me for the end of the day, just so you know, because we end up talking for a long time.

>> It's true.

So, I knew it was gonna be -- You know, there's a plus and a minus to knowing your patient as a friend.

The minus is I have to have a very serious conversation with her about this blood work.

And there was a couple of things about her blood work.

She has hypertension.

And by the time -- You know, I said, "I want you to come in."

By the time she came in, her numbers revealed that she was in the obese range for her, you know, height and weight.

And her cholesterol numbers came back, and what I told her previously about her cholesterol numbers was, her 10-year risk for a heart attack was not that high.

The difference now was that her LDL was 190, which changes the game.

So then we had a lot of stuff to talk about, but especially what I was also worried about was her risk was higher because her fasting blood glucose was higher than I'd like it to be, not in the diabetic range.

Her hemoglobin A1C was higher than I'd like it to be, but not in the diabetic range.

And one of her liver function tests were elevated, which raised my concern for something called nonalcoholic steatohepatitis, which is fatty liver, all of which are risk factors for diabetes.

>> So, you put all these things together, and you saw the perfect storm.

>> Yes, exactly.

>> So, I want everybody to understand, though, what we're talking about when we talk about prediabetes.

So, Dr. Joseph, educate us.

What is it?

What causes it?

>> Yeah, great question, Joan.

And when we think about prediabetes, it's that stage between normal and diabetes.

It's when individuals don't quite have enough insulin.

And as you've talked about before on this show, insulin is like the key that unlocks a door.

And that door is the insulin receptor.

And when it unlocks that door, it lets the sugars out of the blood vessel and into the heart, liver, kidneys, brain.

And so what prediabetes is, is when the sugars in that blood vessel are a little bit higher than they should be.

And for most people, it's due to an inability to open that door.

The key is just not working as well to open that door.

Or they have a lack of keys or a lower production of insulin from the pancreas in the abdomen.

>> And so, in other words, once you aren't producing that insulin and those little doors of the cells don't open, so the sugar just stays, what, all in your bloodstream?

>> It stays right there in your bloodstream.

And as those sugars elevate in the bloodstream, people can go from normal to prediabetes and then to, ultimately, diabetes.

>> So, I mean, this is the -- this is the "aha" moment, though.

I mean, you're being told that if you don't do something, you're gonna have type 2 diabetes.

How did you react to this news?

>> Well, and he wasn't even that -- Like, his message to me was not, "You need to do something now."

You know?

But I have a little bit of a history with diabetes.

I worked in a nursing home when I was in high school.

I saw what our residents who had diabetes -- what their lives were like.

I saw people with amputated limbs, going blind, just not a good life, not a good quality of life at all.

My stepfather was type 1 diabetic since he was 25 years old.

So I saw what his life was, and the good news is he is 80 now and doing wonderful.

>> Oh, wow.

See?

That gives people hope.

>> Made a lot of changes in his life.

So, in my mind, diabetes was always one of those things that I thought, "I don't want to go down that road."

>> How do you remember the conversation?

>> So, it was -- She was ready.

I mean, she's like, "I know what it was," and I wanted to make it clear to her that, you know, being not diabetic and being diabetic -- it's not this purgatory.

There's risk that's associated with it, right?

There's still risk with prediabetes.

It's not like you walk in one room to another.

It's more like a slope of risk.

So, there's still risk with being prediabetic.

So, it wasn't just trying to avoid becoming diabetic, but to also avoid the risk, the cardiovascular risk that's associated with that.

So, lifestyle change was gonna be important.

It couldn't just be, "We're gonna set a timetable for it and keep moving back that timetable."

It would have to be a serious discussion on how you're going to make those lifestyle changes and what your goals are gonna be.

>> Dr. Clark, I want to bring you in here.

I mean, you know, if you look at the numbers of people who have prediabetes, I mean, I think it was one in three?

>> Mm-hmm.

>> It's kind of startling.

And it kind of almost looks like it runs in tandem with the obesity rate.

So, how big of a problem is this in our country?

>> Like you said, it's a huge, impactful problem, you know?

And when you've got almost 90 million people with this condition, you know, headed towards issues with diabetes, it's very concerning, especially because diabetes is associated with other issues like heart issues or problems with your kidneys.

You know, it can be quite impactful on a person's lifestyle, their work, et cetera.

But, you know, as you said before, it gives you the opportunity for a wake-up call 'cause you're not quite at diabetes.

>> Why is that so many people just don't even have a clue that they're prediabetic?

>> Yeah, I think the major thing there is getting the tests done.

And as you mentioned earlier, there are various challenges with that.

Over the last couple of years, the major challenge has been we've been doing a lot of telehealth visits and we've been doing less laboratory work... >> Yeah.

>> ...during that time period.

And so the other challenge with that is that, for most individuals, we get a hemoglobin A1C, which is one measure that we use to measure blood sugar.

That measures your average sugar over three months, and the range there for prediabetes is 5.7% to 6.4%.

But there are also other tests that we can do, including fasting blood sugars, where -- a fasting blood sugar, meaning you haven't eaten for eight hours.

Ranging from 100 to 125 would be prediabetes.

And then the last one that is really uncommonly done in today's world is called an oral glucose tolerance test.

Some individuals on this call today may have gotten one, for instance, in pregnancy, is a common time that we do them.

But for normal, routine screening, we don't do them quite nearly enough.

And so that's another way that we can determine who has prediabetes, by giving some sugar and then evaluating that response to the sugar.

>> Dr. Clark, who's most at risk?

Are there certain demographics that you just know that might be more at risk?

>> I look at the epidemic of obesity, but I also look at the epidemic of things like racism.

Diabetes and prediabetes travel more frequently in non-white individuals, such as African-Americans, indigenous people, Latino Americans.

So, you know, the question is, you know -- And a lot of people say, "Well, is it genetics?"

But we understand there's not truly a genetic basis, right, to race.

And a lot of it has to do with the circumstances, I believe, that people find themselves in.

And it's kind of part of the inequities that we see in health in different populations in our country.

>> Well, as I listened to all the different tests that Dr. Joseph was talking about, I couldn't help but think, "Gee, is everyone in the United States going to those annual check-ups?

Do they all have a primary-care physician that they see every year?

And are those primary-care physicians all administering these tests every time they go?"

That, to me, just points that there's got to be disparities.

>> Right, right.

And where are our healthy eating opportunities, for instance?

You know, if you look at some of the most deprived places, they don't have fancy grocery stores and the ability to get fresh fruits and vegetables.

And of course that's a very important part of preventing prediabetes and diabetes, is our diet and lifestyle.

And so you live in places where you don't have easy access to the food, or you may live in a place that you don't feel comfortable taking a walk around the block or, you know, getting the exercise that your environment limits you in.

And sometimes, you know, when we live in the suburbs and places that are not impoverished, we forget some of the benefits that we have and take for granted that can really impact your lifestyle.

>> Dr. Joseph, what about some of the things that you can't control, as far as where you live, like your age, maybe relatives, first-degree relatives?

How much does this come into play?

>> It's a major factor.

So, we know, for instance, in type 2 diabetes that one out of four individuals above the age of 65 has type 2 diabetes.

Age is the largest non-modifiable risk factor for prediabetes, as well as for diabetes.

Some of the, you know, other factors that you mentioned are your family.

And, you know, your family -- As Dr. Clark said, a lot of the work that we've done around genetics has been pretty limited as far as how much genetics influences risk of diabetes.

But what I think we all know is that, you know, most apples don't fall too far from the tree.

And what I mean by that is we take on a lot of the characteristics of our family members.

We grow up eating a certain way.

We grow up being physically active in a certain way.

And we grow up in a certain environment, whether that environment is a good environment or whether that environment may be toxic to our health.

>> If there are typically no symptoms to prediabetes... >> Right.

>> ...how do you decide who to screen and who not to screen?

>> So, you know, it's -- We have so many people that fit the category, and the guidelines are actually changing.

Right now, to screen for diabetes, they say age 45 or greater, especially if you're overweight or obese.

And that's a guideline, and they're actually dropping it to 35 because it's such an issue in our country.

And those are guidelines.

I mean, for most clinicians like myself, there are other people we have concerns about.

So, I do screen people that have been overweight or obese since childhood.

I do screen individuals a little bit more aggressively if they're African-American or if they have a family history.

And, you know, unfortunately, prediabetes travels in a bad crowd.

Most of these people will have hypertension or they'll have a gout attack or they'll have high cholesterol.

So I'm getting blood work for one reason, so I'm gonna be checking for another reason.

>> What happens to a person if they don't get this under control?

>> Yeah, so, two things, Joan.

The first one is that if you don't get prediabetes under control, at some point you'll develop diabetes.

Most of the data says 5% to 10% of people per year who have prediabetes and are not actively working to change that, to lower weight, as was discussed earlier, that 5% to 7% weight loss, and increasing physical activity and all those important things, most people, you know -- 5% to 10% of those individuals will develop type 2 diabetes in a year.

And the challenge with that -- I mean, we use this term "type 2 diabetes" and we talk about it, but what it really, you know, kind of gets at is what Dr. Clark was mentioning earlier.

You know, type 2 diabetes is the greatest risk factor for kidney disease in the United States, as well as the greatest risk factor for blindness in the United States, and a huge risk factor for cardiovascular disease, including strokes and heart attacks and heart failure.

>> So, Wendy, let's talk about -- Once you heard that -- And I'm sure you studied and found out all about prediabetes, just meeting you and learning about you.

So, what'd you do?

>> I came home that day.

I saw my results.

I literally started drinking water by the gallon because I thought maybe I can -- >> Had you been a water drinker?

>> Flush it out.

>> I could flush it out of my system somehow.

I did not -- I couldn't -- I was not a water drinker.

I could go weeks without drinking a full glass of water.

>> Oh, my gosh, but that's a horrible health habit.

>> I mean, I would drink, like, a little bit of water, yeah, but not -- water was not my thing.

And I literally started drinking nothing else but water.

I started Googling everything.

"How much sugar is in this?"

"How much sugar is in this?"

"What doesn't have sugar?"

Started eating tons of vegetables.

I kept a log of everything that I was eating.

My husband was totally on board.

He was like, "Yes, she's finally gonna cook healthy!"

We joke because broccoli was his thing -- "We need to eat more broccoli."

>> More broccoli.

>> So we eat a lot of broccoli now, Joan.

And anyway, I just started really preparing food, having vegetables cut up, washed, cooked, so that it was easy, so that I didn't have to go to those bad alternatives.

>> So that it can become a habit also.

>> Habit.

Absolutely.

>> It really helps to have your spouse supporting you on this, doesn't it?

>> Oh, for sure, for sure.

>> It's critical.

>> Yeah.

>> It's critical.

>> I lost 32 to 34 pounds.

He lost 30 pounds.

And in the first week, I mean, I lost, I think, 7 pounds.

And then that inspired me because my goal was not to lose weight, really, going into this.

My goal was to get that number down that looked so horrible to me on my MyChart that said "prediabetic."

I said, "I got to get that down somehow, some way.

If I can do anything about it, I'm gonna do it."

I started walking more.

I started getting more sleep, believe it or not.

I was one of these people that I stayed up till 2:00, 3:00, 4:00 in the morning sometimes.

>> Just because.

>> Just because I got a lot done, you know?

I was just one of these people that I have energy, I could do it.

I didn't think it bothered me.

But what I realized is that not getting good quality sleep does affect you in other ways other than just being tired the next day.

So, just making a lot of, as my doctor said, lifestyle changes.

And I remember walking with my neighbor and good friend that night and telling her this whole story and saying -- And Lou's message said, "Well, with lifestyle change and plant-based diet and exercise, you know, we can turn this around."

And I went, "Just change my whole life," you know?

>> And was it also hard because everybody's been cooped up?

>> Oh, sure.

Oh, COVID hit me hard.

I mean, I no doubt gained 20 pounds last year.

>> Really?

I hear that from so many people.

>> I really did.

>> So, COVID 19.

>> COVID 19.

And when I look back at what I was eating -- I love peanut butter and jelly sandwiches on fresh white bread, you know?

>> Okay.

>> So sometimes I'd eat two in a day and now I look at how much sugar is in jelly and it was like 34 grams of sugar in a teaspoon.

And I can guarantee you I was putting more than a teaspoon of jelly on my sandwich.

And now I try to keep my sugar intake to under 30 grams a day.

So, losing weight obviously was just a natural thing from not eating so much -- >> By becoming aware, by tracking, by educating yourself, right?

>> Exactly.

>> I wish I had more patients like you.

[ Laughter ] That's fantastic.

I think -- Yeah, I applaud you.

There are so few people that can do what you do and what you're doing.

And that's exciting.

And it's so hard, though, for most people, myself included.

>> For me, the biggest thing is I'm not looking at this like it's a punishment.

I'm not looking at not being able to eat certain things as a bad thing.

I'm really looking at it as, this is a new way of life.

People will say, "Well, what program did you do?"

or, "What diet did you go on?"

I said, "I didn't do a diet because that won't work for me."

I can't be on something that restricts me.

I have to find foods I like to eat... >> Yeah.

>> ...that are healthy, that are good for me, and -- >> That's such great advice for -- that's what everybody needs to do.

Dr. Joseph, I don't think that Wendy went on medications, right?

>> I didn't, not for the prediabetes.

>> But tell us what some of the medications might be that would be used to treat prediabetes.

>> Yeah, Joan, happy to.

And before I get to that, you know, first off, I just want to congratulate Wendy.

That's fantastic work... >> Thank you.

>> ...that she's done in changing her lifestyle.

And, you know, there were a couple things, Wendy, that you said there.

You know, we all know about, you know, physical activity.

I think it's common in the lay press that we talk a lot about physical activity, we talk a lot about diet and what we eat.

We also talk a lot about weight.

You know, earlier Lou mentioned kind of your height and your weight and how that impacts diabetes risk.

But you said a couple other things there that are critically important, as well.

You mentioned sleep.

And so trying to get seven or more hours of sleep tonight -- there's multiple studies now showing that lowers risk of diabetes.

And then one of the things that kind of goes along with that that our research works a lot -- our group works a lot on is stress and the impact of cortisol on the body.

This is our major stress hormone, and we've shown now I three or four studies how it increases risk of diabetes, as well.

And so just kudos to all that great work.

>> Thank you.

>> And for folks, you know, who are listening, just, you know, keep in mind about some of those other factors, too.

You know, the body needs rest.

It has to take a break.

And we are not built to be stressed every day from 6:00 a.m. to midnight.

We have to take mental rest, as well.

In terms of medications that are used for prediabetes, the major medication that is on the market for that is metformin, and it is a medication that works by actually helping to open those doors that I talked about earlier, those insulin receptors.

I call it kind of like WD-40 for those doors.

Just kind of helps them open up much easier from the insulin.

And that's the major one.

We have other medications that we use for weight loss that also have an impact on prediabetes.

But if we're talking about kind of tried and true and have been around a long time, it would be metformin.

>> So, cut three months later.

Wendy, you go back in.

>> Yeah.

>> You have the blood work done again.

>> Yep, I went in for my blood work, checked my MyChart, and everything looked great.

And Lou's message to me was, "Your numbers look fantastic.

No more prediabetes."

>> So, you reversed prediabetes with lifestyle changes.

Doesn't cost any money.

>> Nope.

>> But you did your homework, you did your research, and then you paid attention to everything that you were putting in your body -- and exercising?

>> Absolutely.

And exercising.

Yep.

And I said, "I didn't realize how bad I really felt until I didn't feel that bad anymore.

>> Right.

It is important.

I mean, you know, the medications are a great breakthrough, but the medications are not the first choice for two reasons, right?

One is the data actually supports that, if you look at metformin and you look at lifestyle change, when people do the lifestyle change, it has a bigger impact than the metformin reducing your risk for diabetes and prediabetes.

The second thing is, you're going to have to make the change anyway, right?

'Cause we talk about other things that we offer people in terms of medication and even bariatric surgery, which I've discussed with patients about to reduce their risk, but the reality is that you have to -- If you do these things, you can't rely on technology and pharmacology alone.

You're gonna have to make those lifestyle changes.

>> Yeah.

So, Dr. Clark, ending words for people listening?

>> Well, I think that there's hope.

You know, you heard Wendy's story, and I think a lot of people feel like they don't have some of the advantages that she may have had, but there's still a way to get to the point where you need to go.

And it's just finding that motivation within, exploring those different alternatives, and really being able to come to the point where you're able to make some of those lifestyle changes.

>> Thank you, Wendy, for being such an inspiring patient.

And thank you to all of our doctors today.

Great information for something that affects so many Americans.

And thank you to all of our medical advisors who are with us every step of the way to ensure that we bring you evidence-based, accurate medical information.

And of course to everyone at home, thank you for watching.

From all of us here at "Second Opinion," we encourage you to take charge of your health care.

I'm Joan Lunden.

Be well.

♪ ♪ ♪ ♪ >> Find more information about this series at SecondOpinion-TV.org.

You can also follow us on Facebook and YouTube.

>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> "Second Opinion" with Joan Lunden is produced in conjunction with UR Medicine, part of the University of Rochester Medical Center, Rochester, New York.