Search for tag: "diabetes"

Interviewer: In spring of 2022, there were some headlines going around almost every news outlet saying that the FDA had finally approved a new weight loss drug, one that would promised 10% to 25% weight loss with little more than just a weekly injection. The drug is called tirzepatide, or a brand name Mounjaro.

Now, it seems a little too good to be true. So, today, we're going to be looking at what exactly is the drug and what can it actually do for weight management.

Joining us today is Juliana Simonetti. She is the medical co-director of the Comprehensive Weight Management Program at U of U Health. So she knows a thing or two about weight management.

Dr. Simonetti, thank you so much for joining us.

Dr. Simonetti: Yes. Thank you so much for having me here today. I'm very excited to be talking about this new drug.

Interviewer: So why don't we start there? What is tirzepatide and what does it do to the body?

Dr. Simonetti: I'll start by just telling a short story. I was at an endocrine meeting in California two weeks ago when this drug got approved by the FDA for the treatment of diabetes. And we were doing a lecture, and all of a sudden, everyone started clapping and announced that this drug had been approved by the FDA for the treatment of the diabetes. So that's the kind of excitement we're getting with this drug.

It is a new class of medication for the treatment . . . Currently, it's only approved for the treatment of diabetes. However, we have seen really significant amounts of weight loss with the medication, and they are doing clinical trials at this point, and they have the results of the clinical trial for the treatment of obesity with this drug as well.

Tirzepatide is unique in the sense that is a dual incretin medication. It attaches to two different receptors. So we have a class of medication that has been in the market now for about 15 years called GLP-1 receptor agonist. And some of the drugs I think are well known at this point, both for diabetes and for weight loss. All those drugs were initially developed for the treatment of diabetes, and then they found that they led to significant amounts of weight loss.

So some of the drugs currently on the market that are GLP-1 receptor agonists are Victoza, Ozempic, Trulicity, and those drugs really have revolutionized the treatment of diabetes in the sense that they bind to receptors in our body that stimulates our own pancreas to produce insulin. And at the same time, they cross the receptors in our brain and tell us that we're full.

Therefore, when you start eating, you feel fuller sooner. It leads to induced satiety, so therefore people eat less, and it promotes the release of our own insulin so you have better glucose control, better sugar control for the treatment of diabetes. And we have this induced satiety that leads to people eating less, feeling fuller, and therefore losing significant amounts of weight.

Interviewer: So tirzepatide has been approved by the FDA to help manage and treat types of diabetes. But there's a lot of evidence in their, I guess, Phase 3 trials that are showing real potential to help with weight loss. What are they finding?

Dr. Simonetti: That's right. So their clinical trials for diabetes show . . . for those participants that had diabetes, it led to a significant amount of weight loss. And so they also then did clinical trials for this medication for those without diabetes for the treatment of obesity.

And what they found is that they highest dose of the medication, which is 15 milligrams, can reduce body weight on average by 28.4 pounds, which is nearly about 14% of the total body weight. So, for someone that weighs about 200 pounds, they will lose on average of about 28 pounds on this medication, which is really, really significant.

Interviewer: Wow. That sounds like a lot of weight loss for people without diabetes, but what does it do for people who do have type 2 diabetes? What kind of results have they been seeing with them?

Dr. Simonetti: Yeah, the results, it's really interesting because the results for those with type 2 diabetes, on the highest dose, show that those participants lost almost 21% of their total amount of weight, which is really, really impressive. This is more than anything else, any other medication we currently have in the market.

Interviewer: So if I get this correct, there are other . . . I've seen other drugs out there that fill your stomach up, the Plenity or whatever it's called, or they claim to impact your metabolic system, etc., but this drug actually impacts your pancreas in a way to help with glucose levels and help suppress hunger.

Dr. Simonetti: Yes. So the class of medication I was talking about is the GLP-1 receptor agonists that already exist that have been in the market now for about 15 years. The newer ones, one of them being semaglutide, or the other name is Ozempic, has been the latest.

They also got approved for the treatment of obesity and leads to very significant amounts of weight loss and improvement in the sugars in our blood because it stimulates the pancreas to release insulin and tells our brain . . . So it works on the appetite centers of the brain.

The difference between some of these drugs and what you're talking about, Plenity . . . So Plenity is considered a device because it's three capsules that kind of inflate in your stomach and therefore makes you feel fuller, so you have the physical sensation of fullness. However, the GLP-1 receptor agonists work in your brain and in the appetite centers of the brain. It works in the brain to tell you that you're full, so you don't have those cravings and then sensation that you wanted to keep on eating. It really leads to the feeling of feeling fuller.

With tirzepatide, why this is so exciting and different is that this not only works with the GLP-1 receptors, but also works in another receptor called GIP, which is a glucose-dependent insulinotropic peptide. It's a mouthful, but it's really another hormone in our body that is usually . . .

Both of those hormones are released in response to us eating food. So when I eat carbs or sugar, it goes in my stomach and then reaches my stomach and my intestines, my gut. My body says, "Whoa, we got nutrients here." We release the GLP-1 and this other one called GIP hormones that then say, "We got food, we got carbs, we got sugar. Let's tell our pancreas to release insulin," because we just got some food in our body. We got some sugar in our body. And then it crosses the brain and tells the appetite centers in my brain that, "I just got nutrients. We should stop eating." It should make me feel a little fuller.

The issue with our natural hormones in our body is that they get taken down, they get broken down very quickly. They only last a few seconds. And these new drugs bind now to those two different kinds of hormones and lead to this really much heightened sensation of fullness and to a much more significant response lasting much longer than what our own body would produce.

Therefore, that's why they're so effective. And therefore, that's why they are also given once a week, which is really kind of neat for a lot of those medications. So you don't have to take a medication every day. It's a small injection once a week.

Interviewer: Wow. So I guess when I first came into this interview, I'm used to doing stories about how some new drug that came out is not actually going to help you with weight loss when you really look at the research. But with your professional opinion, as a doctor who works with patients suffering from obesity or helping them live healthier with their weight management, why is this drug so exciting like you keep saying?

Dr. Simonetti: It is so exciting because the amount of weight loss we are seeing with the clinical trials from this drug is much more significant than what we had seen previously.

So as a measure for FDA approval for a drug for weight loss is usually about 5%. And with the latest drug, which is semaglutide with the other name of Wegovy, we saw a significant more amount of weight loss, around 14%, 15% with the higher doses. And with tirzepatide, we are seeing weight loss of around 20% with the higher dose of the medication, which 20% is a lot of weight, right? So it's a really significant amount of weight loss that we are seeing with these new classes of medication.

And as we know, weight loss is extremely difficult, right? This idea that if we just diet and exercise, we should just be able to lose weight. And it's not true. Eighty-five percent of those that diet and exercise actually, unfortunately, end up gaining the weight back and this weight loss is not sustainable.

And there are a lot of reasons for that, right? There is genetics. So 60% to 70% of the way we are, we know that it's related to genetics or the way we accumulate fat.

There's also our environment, and then there is this regulation in a lot of the hormones. There are these regulation appetite hormones. There is this regulation with insulin. The more weight that we gain, the more insulin-resistant we become. Therefore, there is this combination of insulin resistance.

So 90% of those that have diabetes also have excess weight. And some of the older medications that we had for diabetes, like the glipizide, glimepiride, and even insulin would lead to more weight gain, which then meant more insulin resistance and then making the condition just worse.

And with these new drugs, we see significant improvement in weight. Therefore, you also see significant improvement in decreasing in insulin resistance and also improvement in the glucose control and the sugar control in the blood because it works in conjunction. You have the stimulation of the pancreas and decrease in appetite.

Reading through the clinical trials again, and I just had done a quick review before we sat down for this interview, really it's quite impressive. One of their trials, they compare this drug for participants that have diabetes that were taking insulin and they gave them the tirzepatide. And those that took the tirzepatide lost weight versus those that were taking insulin actually by itself gained weight. So this is, again, quite significant in the amount of weight loss as well as in the amount of glucose control that we get with this medication.

Interviewer: So for all of the people who are thinking, "Oh, hey, this is the drug that's going to make me lose all my weight, finally," it's not ready for them, right? Is that what I'm understanding correctly?

Dr. Simonetti: That's right. So this medication is not yet approved for weight loss. I believe it will be, hopefully, within the next year or two. They are just finishing the Phase 3 clinical trials for weight loss.

Currently, this medication is approved for those with diabetes, and I think it'll be a wonderful tool for those that have diabetes and excess weight, overweight or obesity. This would be just a wonderful medication because it leads to a significant amount of weight loss and improvement of their diabetes.

This is great, and I think this is going to really improve the care that we can provide. However, we need to remember that obesity is such a complex disease, right? There's a multitude of issues that go with it. So this is addressing maybe some of our physiology, but we still need to do lifestyle modifications with modifications in our diet, increasing physical activity.

Behavioral health is a really important piece. Oftentimes, we eat in response to feeling sad, depressed, because when we eat in particular foods that are sweet or high caloric foods, it releases dopamine and serotonin in our brain. So it actually makes us physically feel better at the moment. And therefore, we go back and eat more because then I need another hit and then I feel better. And it becomes that very vicious cycle that once you start eating certain things . . . know for me, it's a piece of chocolate, right? I'm having a bad day at work, I eat a little piece of chocolate and my life is better at that moment. However, that doesn't help me because then my sugars crash and it makes me want to crave it more.

So really trying to address as many things as possible, and that's why in our program, we have this multidisciplinary team approach. We have the registered dieticians. We have an exercise physiologist. We have two Ph.D. psychologists. We also have other options such as surgery. So we work with the bariatric surgeons.

So again, it's wonderful to have one more tool, a very effective tool in our toolbox, but this is a tool. We are able to use it, and the more tools that we have, I think the better offer we're going to be, but we have to address all these other pieces as well.

Interviewer: So, obesity, it is not as simple to treat as just getting a new injection, even with some of these great new drugs. So I guess we'll just keep a look on the headlines, see if this is approved for obesity treatment in the next couple years, and maybe we'll have you back on and we can talk about how you guys can utilize it in your toolbox to battle obesity.

Thank you so much for joining us, Dr. Simonetti. I really appreciate you taking some time to talk to us about this new drug.

Interviewer: When you've been out and about, you may have seen it driving or in a parking lot in South Salt Lake, Ogden, Provo, Kearns, Glendale, or maybe some place else in the Salt Lake Valley. And you've always wondered, "What is the Wellness Bus and who can take advantage of this free resource?"

Nancy Ortiz is the mobile health program operations manager, which includes overseeing the University of Utah Wellness Bus. Nancy, let's just start off with what is the Wellness Bus?

Nancy: So the Wellness Bus is a mobile prevention and education clinic that is focused on really making communities healthier. So it's a 39-foot Winnebago that has been outfitted to travel around to different communities and provide free screening services for not only diabetes but other chronic disease.

So when you come to the bus, you can get . . . Everything is no cost. It's free. You can get a simple glucose test, and if your sugar is high, we can also do what's called an A1C test. Additionally, we can test your cholesterol, a whole lipid panel. We test your height, weight, your BMI. We test your waist circumference. And then, additionally, we have a registered dietician that offers free nutritional counseling or coaching on the bus.

Again, all services are free. And we go to the same locations because we want people to come back. We want to help people manage their diabetes or their pre-diabetes, or prevent pre-diabetes or diabetes, or help them with their high blood pressure. So we encourage people to come back and that's why we go to the same locations every week.

Interviewer: And the individuals that come and visit the Wellness Bus, what is the impetus? What inspired them to actually go into this bus, into this situation that they might not be familiar with? What got them there?

Nancy: That's a great question because as we found out, just because you build it or park it there doesn't mean they come inside, right? A lot of people just go walk by out of curiosity, like, "What is that?" But people, they do want to know, and we hope more people want to know. As we say, what are your numbers? What is your glucose? What is your blood pressure? What is your cholesterol? What do those numbers look like? Sometimes they can be a burden.

We don't diagnose on the bus because we don't have medical providers. We work with community health workers. So we say we identify. So the person that does finally make that decision to come into the bus, we do the screenings. And of course, they hope that their health looks pretty good. But in the event that it doesn't look . . . the numbers aren't ideal, we can help them find a provider if they don't have one.

And studies have shown that lots of times, people will not seek care because of the cost. They don't want to burden their family. Money is already tight. So we have services available where we can help people get either free or low-cost medical care. So we are there trying to help the person find affordable resources.

Interviewer: That would be a scary thing, finding out that you have a health condition, and definitely a reason why you just walk on by as opposed to finding out.

Nancy: Exactly.

Interviewer: So it's great that you're connecting people with community to resources that can help in their situation. Tell me about somebody. Walk me through somebody comes in, they find out, "I've got a high fasting glucose. I might have diabetes." You connect them with some resources. What's the journey like after that point?

Nancy: Right. Again, they've gotten this bad news, but we are there to encourage and say, "Through education and lifestyle changes," which is why we have a registered dietician on the bus, "you can really manage it."

We're here to educate you on ways to reduce your sugar levels or you're high cholesterol levels. And we highly encourage you to see a medical provider because it could be that you they need to be on other medication or insulin.

And once you've met with the provider, we encourage you to come back to the bus. We are here, again, for support. And a lot of times, Scot, it's just the social support.

We have an individual. He had diabetes when he came onboard. He comes to the bus pretty much every week. And his glucose levels are improving because I think that social interaction. He knows the people on the bus, like, "Hey, Alex. Hi, Maria. Hi, Veka." That really helps people, I think, pay attention more to their health and make them feel like somebody cares.

We try to make people feel comfortable. We try to break down on the bus as many barriers as possible.

People can come on the bus and remain anonymous if they want. We ask them general information, name, address, a little bit of medical history, but you don't have to fill it out. If people don't want to give their information, and some don't for fear that it's going to come back to them in some bad ways, it's like, "You don't have to give your real name. You don't have to give your address." We don't want that to be a barrier.

We have Spanish speakers on board, so we have that language, but we have an interpretation service that we use that we have access to 240 languages and dialects. We can get someone that speaks their language within a minute on the phone. So we don't want that to be a barrier.

We travel to communities that have high rates of diabetes and chronic disease, trying to make it easier for people to come to the bus. So just trying to break down those barriers of . . .

You asked me previously why someone would or wouldn't come on to the bus. We're just trying to get as close to them as we can and say, "Just please come on board. Let's just have a conversation. Let's look at your blood. It's just a finger prick. We're not doing blood draws out of the arm. It's just a simple prick on the finger."

So it's just about letting you know where you are, again, on the spectrum of good health versus ill health, and that's what we want people to know. We are not there to shame anybody. So, again, we want people to feel comfortable that we're not here to judge you on your weight or how you eat.

Interviewer: It's no reflection of a personal shortcoming at all.

Nancy: It's not. It part, lots of times, it's about education.

Interviewer: What would you say to somebody that might see the Wellness Bus parked some place and they're thinking about coming in but they're not sure?

Nancy: Don't even give it a second thought. Just open the door and come on in. Our staff is so friendly. They're going to make you feel like you're just sitting in your living room while you're getting your finger poked.

I mean, please, don't hesitate to come in. Just find out what your health looks like. Just get a baseline. And if it needs improvement, we can help you make those improvements. And if the numbers look good, that's even better. You can walk out of there feeling, "Hey, I'm even healthier than I thought I was," or, "There are little improvements that I need to make," or, "Wow, I do need to see a doctor or a provider at this point."

But again, we are there to help you on this journey not just today and say, "Oh, this is what your numbers look like," but, "Hey, come back. We are here every week whatever location we're at. We will help you on this journey to better health." So please, hop on board.

Salt, sugar, and fat, what's not to like? Well, there is such a thing as too much of a good thing, and salt may be one of them.

We evolved as humans in a low-sodium environment, the inlands of Africa. We have taste buds specifically for salt, sodium chloride, and most of us like salty things. We may be the sweatiest animal on the planet, and we lose salt when we sweat from heat and vigorous exercise. So we do have dietary needs for a little bit of sodium chloride, the chemical we usually mean when we use the word "salt" in terms of food. But is there such a thing as too much salt?

We know that drinking seawater is remarkably unpleasant because it's too salty, and you can't survive by getting your water needs from seawater. You'll die.

And when we eat a lot of salt in our food, potato chips followed by boxed macaroni and cheese for lunch and a store-bought pizza with cheese and pepperoni for dinner, we get thirsty. We drink a lot of water, and we wake up all puffy. And who wants to wake up puffy? And all that puff shows up on the bathroom scales. Well, being puffy means that your body has held on to water to help dilute all the salt in your blood that you ate yesterday, and holding on to extra water means that your blood pressure can go up. And when your blood pressure goes up, it puts you at risk for heart disease and strokes and kidney failure.

America's high-salt diet, on average 3,000 to 6,000 milligrams a day, has been linked to high blood pressure, a leading risk of heart attacks, strokes, and kidney failure. More than 4 in 10 American adults have high blood pressure, and among black adults the number is 6 in 10.

The issue of salt in food is a complicated one. Of course, some people are sensitive to increased amounts of salt in their diet. Research studies have defined this salt sensitivity as people for whom an increase of 1,000 milligrams of sodium, about half a teaspoon of table salt, increases their blood pressure by 5%. Now, that doesn't sound like very much, but it's a significant difference when it comes to health outcomes. Some people are genetically salt sensitive, and some people are salt sensitive because they already have a chronic medical condition that gets worse on a high-salt diet.

Of course, there are studies that suggest that people who eat sodium at the 3,000 to 6,000 milligrams per day and say they don't necessarily have bad health outcomes. An international study of more than 100,000 people suggests that while there's a relationship between salt intake and high blood pressure, if you don't already have high blood pressure and you're not over 60 or eating way too much salt, salt won't have much impact on your blood pressure. However, most research suggests that a lower sodium diet is good for people who are older, over 50, who are African American descent, who have high blood pressure or diabetes, or whose blood pressure is gradually creeping up.

The Institute of Medicine, the Dietary Guidelines for Americans, and the American Heart Association recommend limiting your sodium intake to no more than 2,300 milligrams a day. That's about a teaspoon. People with heart failure and kidney disease are advised to keep their sodium at about 1,200 milligrams a day or about half a teaspoon. And for the very significant percent of Americans who have kidney stones, including yours truly, excess salt in the diet contributes to the formation of the most common kinds of kidney stones. Ouch. I had to have that explained to me by my urologist.

Now, low-sodium diet, that's easy, you say. You wouldn't put half a teaspoon from your saltshaker on your food each day. It turns out that the major source of sodium in our diet comes from prepared foods from the store, that boxed macaroni and cheese, prepared soup, bread, prepared salad dressings. About 70% of the sodium people consume comes from premade or packaged foods according to the FDA.

With that in mind, the FDA recently issued voluntary guidelines for the food industry to lower the amount of sodium in prepared foods, manufacturers, restaurants, and food service operators. These guidelines are voluntary and temporary to seek to decrease average sodium intake from approximately 3,400 milligrams to 3,000 milligrams per day, about a 12% reduction over the next 2.5 years. Now, that isn't very much, but it can make a difference in a population of people.

A recent study published in "The New England Journal of Medicine," done in China in 600 rural villages, randomized households to using regular salt in their cooking to a salt substitute, which switched out about 25% of the sodium chloride in their saltshaker with potassium chloride. This isn't enough for most people to taste the difference. They were encouraged to use a little less salt in their cooking, but could use other sources of sodium, like soy sauce, in the usual way. This is a very small dietary change. The control villages did their regular cooking. There were about 21,000 people in the study, with an average follow-up of about 5 years. The average age of the participants was 65 years. Half of them were women. About 72% had a history of stroke, and 88% had hypertension. That's a pretty high risk group. There was about a 15% decrease in strokes and major cardiovascular events and deaths in the salt substitute group over this 5 years, which would be quite significant if you're talking about a billion people or talking about 10 years. So it was kind of a big deal.

Other studies have shown similar effects in the U.S. in people who adhere to the DASH diet, which stands for dietary approaches to stop hypertension, sort of a Mediterranean diet with lower sodium. They have lower blood pressures.

So how much sodium in your diet if you're mostly healthy? About 2,300 milligrams or one teaspoon of table salt. If you have genetic or medical conditions that predispose you to greater risks with salt, even less. If you're like the average American and get 70% of your sodium intake from prepared and packaged foods, read the label.

Americans consume a lot more salt in their diet today than they did 50 years ago. Largely this is a change in how we cook or rather how we don't cook. Many more meals are pre-prepared from the store, and many more meals are eaten out with a lot of salt. Women are often in charge of the food shopping and food prep in the house. Clearly this isn't always the case, and there are many days many people just don't cook. They eat out and they eat foods in restaurants that are often very high in sodium and few actually will give you the amount, but sometimes you can look it up online. Or they eat in prepared or prepackaged foods.

Sodium is important enough for your health that the FDA food labels on the back of the package let you know how much sodium there is per serving. Your local pizza place with high sodium crust, high sodium cheese, and high sodium pepperoni, yum, won't have the sodium content. You can make choices in the food you buy. Many prepared food companies, like Campbell Soup, have offered lower sodium soup options in their canned soups. Even the chip aisle in the grocery store has chips with lower sodium.

So what do the labels on the front of the box mean? Sodium free or salt free, each serving in this product contains less than five milligrams of sodium, very low sodium. Each serving contains 35 milligrams of sodium or less, low sodium. Each serving contains 140 milligrams of sodium or less, reduced or less sodium. The product contains at least 25% less sodium than the regular version, but in the case of some soups that may mean going from 700 milligrams of sodium per serving to 500 per serving, and that is still a lot. Unsalted or no salt added, no salt added during processing of food that normally contains salt. So this could still be salty.

So make a commitment to cook more food at home from scratch and more whole foods, whole grains, veggies and beans, and don't add salt when you cook. Let people add the salt at the table if they need. Adding spices, pepper, or lemon can increase the flavor in your home foods without adding extra sodium. Do you like sea salt on your chocolate chip cookies? Forget adding salt to the dough and sparingly grind a few flakes, a very few flakes on the top of the cookies.

Even though you and your family might not be salt sensitive or have risk factors that would make a low-sodium diet important, some of you will someday. Getting out of the salt habit, eating more food cooked at home by somebody is good for you and the people you love. Have everyone become involve in food shopping choices and cooking at least some of the time and guide these choices, and that will help everyone be more independent in their sodium, sugar, and calorie choices and maybe your face won't be so puffy after pizza night.

The following is a summary of this episode.

High-impact discoveries at University of Utah Health are transforming how we think about the causes of diabetes and solutions to combat the disease. These advances could hardly come at a better time. The disease is a big problem in the U.S., leading to an estimated $327 billion in health care costs. What’s more, while 1 in 10 American adults have diabetes, 1 in 3 have prediabetes, a sign that they are well on their way to developing the disease.

In impediment to solving the diabetes conundrum is the complexity of the disease. People with both Type 1 and Type 2 diabetes have difficulty controlling their blood sugar, leading to serious health complications if left untreated. But the causes of the two are distinctly different, as are many of the downstream effects. New research is unraveling these complexities, revealing previously unrecognized opportunities for intervention. Combining these insights with a lot of work—and a little luck—could one day make diabetes a problem of the past.

In this episode, host Kyle Wheeler interviews Scott Summers, PhD. Dr. Summers is the Co-director of the Diabetes and Metabolism Research Center at the University of Utah. He is also a professor and the department chair of Nutrition & Integrative Physiology.

Dr. Summers and Kyle discuss a variety of discoveries that have happened at University of Utah Health related to diabetes. The topics range from Dr. Summers’ own research has led to an understanding that ceramides may be a better harbinger of bad metabolic health than cholesterol to the involvement of the microbiome in obesity. They also discuss the prospect of an insulin inspired by the sea and the complex causes of type 1 diabetes.

Announcer: Examining the latest research and telling you about the latest breakthroughs. "The Science and Research Show" is on The Scope.

Interviewer: Millions of Americans with diabetes inject themselves with insulin every day or multiple times a day to manage their disease. While that's hard enough, the soaring price of the drug has made things that much harder. I'm talking with nurse practitioner and researcher Dr. Michelle Litchman, about living with diabetes and the lengths people are having to go to just to stay healthy. Hi, Dr. Litchman, thanks for joining us.

Dr. Litchman: Hi, thanks for having me.

Interviewer: Many people with diabetes can't live without insulin. Tell me about how people with diabetes rely on this drug for their health.

Dr. Litchman: Everybody with type 1 diabetes, and about a third of individuals with type 2 diabetes require insulin to stay healthy and well.

Interviewer: Why is that? What does the drug do for them?

Dr. Litchman: Insulin is required to lower blood sugar. It allows glucose to get into the cell and to be used for energy.

Interviewer: And so if they don't have those shots of insulin, what can happen?

Dr. Litchman: If glucose gets down dangerously high, it can result in complications. It can result in diabetic ketoacidosis, otherwise known as diabetic coma. And it can also lead to death.

Interviewer: This drug is necessary for these people to stay healthy, and yet it's getting harder and harder for them to get. The cost of insulin has risen a lot in the last few years. By how much? What are we talking about?

Dr. Litchman: In the last decade, it has at least doubled.

Interviewer: Which is quite a shift for patients who rely on this drug every day.

Dr. Litchman: Absolutely. Access to diabetes medications and actually also supplies is really challenging for people with diabetes. People are faced with a dilemma. Do I pay for the health-related expenses that I need – my medications, my supplies – to survive? Or they're having to make the choice of do I ration my medications and supplies so that my family can have the things that they need like the food, shelter, making my house payment, making my car payment, having gas to get from point A to point B. And so rationing happens on one end or the other. It's either on the side of health and diabetes medications and supplies, or it happens with the family basic needs.

Interviewer: And how crazy is that? Just to stay alive you can't live a normal life.

Dr. Litchman: Absolutely. People are under immense stress and guilt related to the cost of medications. A lot of people in our study felt remorse that they had to put their family in such situations. And it's not fair.

Interviewer: I mean, some people are even questioning whether they deserve to live.

Dr. Litchman: Absolutely. We found that people were feeling guilty about the cost and questioned whether or not their life was worth the cost of insulin to even continue living.

Interviewer: It's quite a thing that we've come to this point, don't you think?

Dr. Litchman: Absolutely. I mean, it should never be the cost of medications and supplies is worth somebody's life.

Interviewer: How are you going about even finding out this information? Is this through conversations at the clinic or something else?

Dr. Litchman:So as a clinician, I'm seeing this all of the time where patients are coming to me with concerns related to their ability to afford medication and supplies. It's actually consuming a lot of the visits not only for me, but also my colleagues. And so this is really affecting our visits.

From a research standpoint, we conducted a cross-sectional survey of adults living with diabetes or caring for somebody with diabetes like a child. And we found that many people are financially struggling. In fact, financial distress is higher among those with diabetes than those without diabetes. And we're also finding that financial distress is related to interpersonal issues because of the cost of insulin. So people are having disagreements or guilt-related issues with their family members because of the cost of diabetes.

Interviewer: So it's not only affecting their ability to get the care that they need, but it's affecting their family life in a lot of different ways.

Dr. Litchman: Absolutely. And when they go to a healthcare provider to seek help or discuss these issues, healthcare providers are somewhat limited in the solutions that they can offer. So clinicians can offer patient assistance programs that currently exists. Not everybody qualifies for certain patient assistance programs, but they're also very time consuming. So it's not just an easy one piece of paper to fill out, it's a lot of papers that needs to be collected and a lot of signatures that are required in order to make the paperwork process move.

Also people who have Medicare fall into the donut hole about halfway through the year depending on the person's circumstances, and not all patient assistance programs are for people with Medicare, and so that's a barrier as well. And we're also finding that some clinicians aren't aware of all of the services that are available, nor do they have all of the support necessary to make sure that patients get what they need.

Interviewer: And so a lot of patients aren't getting assistance. And what are they doing instead?

Dr. Litchman: Patients are having to go through unique channels to access what they need. So in our study for those patients who really want to stay well, some of them are engaging in trading behavior. So I'll trade you this if you can give me these supplies or that insulin. People are engaging in the purchase of medications and supplies from sources that are not approved to be selling those. So, for example, people are leaving the country or they're buying them on the internet.

One of the things that we found that was interesting is the altruism that people are having with regards to donation. So if people had extra supplies or extra medications they were willing to donate. We saw this not only in this survey, but we also saw this on crowdfunding sites where people would list in the comments, you know, if I live near you, I'm happy to send you some insulin if you really are in need.

Interviewer: Then, of course, that's not a long-term solution.

Dr. Litchman: Absolutely, not a long term solution. And people also would only spare the extra that they had, so they needed to make sure that they themselves had the insulin they needed to take care of themselves, and they could only spare the extra.

Interviewer: It seems like it's underground behavior, right? I don't know if it's quite criminal, but it's certainly not what healthcare providers would recommend. You know, it strikes me as being pretty dramatic if people have to resort to that.

Dr. Litchman: Well, again, people have to make a decision, do they stay well? And if so, what are the things that they need to do in order to stay well, and in some cases, people have had to go to extreme measures. One of the concerns that some people have had in these trading communities is that some of them are being shut down, and so that's causing even more access barriers to people. And so there's this ethical dilemma that we're facing, should people be able to access what they need through this underground trading? And if not, what are the solutions that exist so that people can actually get what they need without having to engage in this activity?

Interviewer: I'm wondering if you know, over the course of time that you've been performing these surveys, I mean, if you've seen some changes in attitude. I mean, I imagine people are getting pretty jaded, you know, jaded with the healthcare system, jaded with pharmaceutical companies. Do you observe any of that too?

Dr. Litchman: Absolutely. I see that in the research and I see that clinically. People are getting frustrated, and they want solutions. And they are almost feeling like there's no way out. And it's really sad to see.

Interviewer: Do you think there are downstream implications for that? Do you think it might erode the trust that some of these patients have? I don't know with who, with their providers, I don't know. If this alternative means of getting healthcare becomes a new norm for them, is that going to carry over for maybe for other conditions that they may be having too? Maybe they think, oh, if this works from treating my diabetes, maybe I can do some on the side trading to treat my migraine, to get drugs for treating my migraines or something like that.

Dr. Litchman: There is research showing that there are people who are trading for other conditions such as asthma, and so I think that it's absolutely true. If you can't access a medication and you need it for some reason, then people will go to extreme measures in order to make sure they have what they need, because they want to be healthy. I think that some downstream consequences is, you know, if we don't have a trading system, then we have people in the ER, every time they need a dose of insulin. And what does that do to this system? How much will that cost? We need to have solutions in place that don't just make sense financially, but for actual people that are on the receiving end.

Interviewer: In collecting this information, I mean, what do you hope to accomplish with that? What do you hope to do with that information?

Dr. Litchman: I think the first step is awareness and making sure that people understand what is happening not just on the patient and provider level, but on the health policy level as well. We need people who are willing to step forward to make sure that diabetes management is accessible and if we don't make insulin and other medications and supplies accessible now, we're going to have major consequences later, we're going to have a higher rate of complications and costly hospital stays, and even death. And we need to stop it.

Interviewer: I'm wondering, are there any specific stories that you've kind of picked up in your work that might illustrate this that you feel like you're able to tell?

Dr. Litchman: I've taken care of people who had Medicaid as a child, and who, once they became an adult no longer qualified for childhood Medicaid, and didn't have parents who had health insurance. And they are really struggling to afford what they need because they don't have insurance at all. They can't get adult insurance. And I've sat down with people to try and help them get Medicaid on my off hours because the application process isn't simple. You know, people oftentimes need help with this. And it's a struggle and that person struggles today.

Interviewer: And so have you seen people's health deteriorate as a consequence of what's happening?

Dr. Litchman: Absolutely. And it's not just the physical deterioration, it's the mental. I think that people feel like there's a system in place that doesn't care about them as a person. And despite our efforts, and in trying to find ways to access insulin that's affordable, it's still hard. And you know, people will argue that there is generic insulin that can be purchased without a prescription. But it's not the same as the medication, the insulin that has become the gold standard that's more physiologically matched to people who with food and the way that our liver puts up glucose. And so I think that we need to help people get access to the best medication possible for the diabetes that they have.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

Interviewer: If you have pre-diabetes, exercise is one of the best ways to prevent it from escalating into full blown diabetes. Dr. Tim Graham is an endocrinologist and diabetes expert. So how much exercise do you recommend?

Dr. Graham: Frankly, as little as 150 minutes per week. Now that sounds awful, 150 minutes, but you break that down.

Interviewer: Sounds like a lot.

Dr. Graham: Yeah, if you break that down though, that's only 30 minutes, 5 times a week. And we're not talking about going to the gym and working out to the point where you're exhausted. We're talking about some brisk walking five times a week.

Truly anything that causes your heart rate to go up for a sustained period of time, causes you to sweat, most likely is having a good benefit from the standpoint of diabetes prevention.

Interviewer: So if you have pre-diabetes, pick something you like doing and do it for 30 minutes a day, 5 days a week. That will go a long way for preventing your pre-diabetes from turning into a full-fledged diabetes.

updated: October 14, 2021
originally published: January 1, 2018

Announcer: The Health Minute, produced by University of Utah Health.

Interviewer: Some kid smells are normal, some aren't. Pediatrician Dr. Cindy Gellner, what kid smell should concern parents?

Dr. Gellner: So most smells that kids have can be attributed to them being active little explorers and can easily be washed off with soap, water, and a toothbrush. But some smells aren't normal. If the stinky smell is coming from their mouth and they brush their teeth regularly and are properly hydrated, it could be their tonsils. Red, swollen tonsils with white gunk on them could be strep. If your child's breath smells fruity and they're complaining of stomachaches or have new onset bedwetting, get their sugar levels checked. That might be type 1 diabetes. And finally, there's the backside. If your child smells like they're constantly having gas but they're not, check their pants. Some kids get really constipated. It's more common than you might think. It's very embarrassing and they won't want to say anything but your pediatrician can help.

Announcer: To find out more about this and other health and wellness topics, visit thescoperadio.com.