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.

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: There's a new way to monitor blood sugar levels for people with diabetes. Michelle Litchman is a nurse practitioner from the Utah Diabetes and Endocrinology Center. Tell me about real-time glucose monitoring.

Michelle: Real-time, continuous glucose monitoring is essentially a sensor that gets worn underneath the skin that transmits glucose in real time every five minutes onto a receiver. And one of the interesting things about it is not only are you getting your glucose level every five minutes, but you're also getting Tran data. You'll get arrows that will determine how fast your glucose is moving in a direction either up or down. And that information helps people make better decisions about their diabetes management.

The great thing about this is that you can actually set alerts that will alarm you before you get into a dangerous glucose level. Continuous glucose monitoring is available by prescription. Please talk to your healthcare provider if you're interested.

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

Interviewer: Someone who is thin can end up with diabetes. And yet an obese person may be surprisingly healthy. Why is that? We'll talk about research today that addresses that question.

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

Interviewer: I'm talking with Dr. Scott Summers and Dr. Bhagirath Chaurasia, in Nutrition and Integrative Physiology at the University of Utah College of Health.

You know, I thought one way we could start talking about this is that this type of research has a personal connection for you. If we're talking about thin people who get diabetes, which is kind of not the stereotype, that's something that you've faced in your own life. Not with you personally but with a family member?

Dr. Summers: Yeah. I was 14 years old when my father, somewhat precipitously, developed diabetes. He was 38. He was a fairly athletic individual. And to be honest, after he got diagnosed, he became sort of an exercise addict, and this was the way he would control his diabetes.

But despite all of his efforts and the fact that he was incredible fit and won countless road races, his diabetes worsened and became quite severe. So that was sort of the impetus for me to study diabetes in my career.

Interviewer: Right. So that profile is a surprise, right? Because what's more typical?

Dr. Summers: Yeah, he's an unusual diabetic, but he's not the only one. There's actually a fair number of people that can develop diabetes. We have kids that develop it, a classic type 2 when they're obese and we have adults that develop diabetes when they're thin. I think, actually, what we're learning is that distinction of type 1 and type 2 is much muddier than we realized and there's a lot of types in-between.

Interviewer: So often I think of diabetes as being a problem with the body's management of sugar. It turns out that's part of it. But what you two are looking at is the role of fats in diabetes and maybe it's sort of a mismanagement of the way fats are stored?

Dr. Summers: Yeah, I think so. I think the issue is really what's the type of fat, right? So fat has a lot of different terms, right? Sometimes when we're referring to fat we mean the tissue and sometimes we actually mean the food we're eating. But at the end of the day when fat is eaten, it's converted into something called fatty acids which are then taken up into cells and then they're restored in fat tissue as something called triglycerides.

Ceramides is another way that those fatty acids get metabolized. Instead of getting stored effectively or burned for heat, they sort of spill over into this and they conjugate with a certain protein derivative, protein metabolite. So it's just this different type of fat and metabolite that accumulates and it seems to have a whole series of actions that really are almost part of a universal stress response and a lot of the damage they do seems to be relevant to most of the diseases associated with obesity.

Interviewer: And do we have any idea why one person might be more able to store the fat as triglycerides versus going into that ceramide pathway?

Dr. Summers: Not as much as we need to. No, we really don't. When fat makes the decision to either be stored, burned, or go to ceramides there are some regulatory factors. We know that inflammation, infections will drive it into the ceramide pathway. We know that cortisol stress will.

We don't know as much about the dietary component as we should. We know ceramides are made from saturated fat and a certain type of protein that's a conjugation of those two. We don't as much as one would think about how much you eat, whether that influences it or not. And there may be a genetic component, too. About 20% of Utahans have a mutation in a ceramide synthesizing gene and those that do tend to have diabetes or hyperglycemia.

So I think there are a lot of factors that are driving it and we're trying to . . . that's sort of the holy grail of our research is to figure out those two questions - how ceramide works and what's driving its synthesis.

Dr. Chaurasia: Yeah, and that's exactly the next steps that we are following onto.

Interviewer: So you did some research in mice. What did that work show you? You had too many ceramides in mice.

Dr. Chaurasia: So what we showed is that if you delete out one of the initial enzymes required for ceramide synthesis, specifically in the adipose tissue, these animals tend to be more insulin sensitive. They tend to burn more calories and they tend to deplete out what we call the bad fat, white fat, into something called brown fat which actually turns them to other [inaudble 00:04:30] fat, actually and which allows them to burn more calories. And that's why we think that these animals are much more skinny and much more metabolically healthy.

Interviewer: Okay. And those are the ones where they had less ceramides?

Dr. Chaurasia: Those are the ones where we have less ceramides. And also we found in both the mouse cellular models as was the human cellular models is that if you treat them with increasing concentrations of ceramides, they tend to down-regulate, the expression levels of certain genes which are required for browning and increasing energy expenditure.

Interviewer: Which is actually helpful?

Dr. Chaurasia: Which is helpful, exactly.

Interviewer: Yeah, because it takes that away from white fat which is the more toxic fat.

Dr. Chaurasia: Exactly. Yeah.

Interviewer: Okay. Are you looking into ways to maybe manipulate those pathways to see if that can be used to treat diabetes?

Dr. Summers: Yeah, absolutely. So we've known before that if you treat with . . . there are drugs that you can give to mice but not to people and if you give that to them it prevents diabetes, it prevents fatty liver disease, it prevents hypertension, and cardiomyopathies, and things.

And so we're trying. You know, a part of our lab is trying to develop new drugs that will mimic that. We're testing some natural products that actually are out there that people can eat that might be able to deplete ceramides. And we're looking at dietary interventions, as well. Or we'd like to at some point, at least, look at dietary interventions to see if we can try and modulate this in addition to looking at the genetic components.

Interviewer: And so you think interfering with the ceramide pathway has a potential to help a lot of people?

Dr. Summers: I do. I mean, we've been working on it for a long time now. So it's been 15 years plus.

Interviewer: You're pretty motivated.

Dr. Summers: So, yeah, I'm still a believer at this point. You know, there are a number of things that can prevent diabetes in mice. So the fact that we can do it with this is there are other people that can do it, as well. And turning that into an effective therapy, I'm rather convinced ceramides can contribute to the development of diabetes.

Whether we can actually target that safely in a person is unclear because the reality is ceramides are actually . . . they do good things, too. So it's only when they get above a certain threshold that they become toxic. So can we titrate them in a person? Can we get them to make just, you know, not too little, not too much and remain healthy, is going to be a challenge for us.

But this is what we're trying to do and what I believe passionately we should do.

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

Dr. Gellner: You just learned that your child has type 1 diabetes, or you're worried that your child might have it. That's a scary diagnosis for any parent to consider. What you really need to know on today's Scope. I'm Dr. Cindy Gellner.

Announcer: Keep your kids healthy and happy. You are now entering "The Healthy Kids Zone," with Dr. Cindy Gellner on The Scope.

Dr. Gellner: Every year in the United States, 13,000 children are diagnosed, and more than 1 million American kids and adults deal with this condition every day. In type 1 diabetes, your child's own immune system attacks and destroys the cells in the pancreas that produce insulin. Once those cells are destroyed, they won't ever make insulin again. Although no one knows for certain why this happens, scientists think it's a combination of genetics and other external factors combined that triggered this immune system reaction.

Type 1 diabetes cannot be prevented, and there's no real way to predict who will get it. Parents often feel guilty that they've done something to cause this, but parents need to understand it's nothing they did. Unfortunately, type 1 diabetes is a lifelong condition. Kids and teens with type 1 diabetes will depend on daily insulin shots or an insulin pump to control their blood sugar levels.

Parents often ask me to check their children for diabetes because their children drink all the time and urinate all the time. It's an excessive amount of drinking that we often see and the urination isn't just drops of pee in the toilet. It's a full bladder of urine. Kids who have long been potty trained and have never wet the bed all of a sudden start to have accidents day or night. Kids will often seem to eat a ton as well and never gain weight, or they might actually lose weight.

Now, parents all the time are concerned that their child isn't eating like they should, but it's what happens on the growth curves that lets pediatricians know if this is a normal phase that kids go through, or if it's something more worrisome. Sometimes, these symptoms are easily identified and pediatricians catch the disease early with a simple finger stick to check your child's sugar level.

If diabetes isn't caught, chemicals called ketones can build up in your child's blood and cause stomach pain, nausea, vomiting, fruity smelly breath, breathing problems, and even loss of consciousness. This is a serious condition called diabetic ketoacidosis, and it requires fast action in the emergency room to correct. The good news is that treating diabetes and keeping your child's sugar level in check can help prevent long-term damage seen in adults, especially to the heart, eyes, and kidneys.

The bad news is there are going to be a lot of needles to do this. Your child will need to learn to check their blood sugar levels several times a day and give themselves insulin shots since their bodies aren't making it anymore. They need to eat a healthy diet low in carbohydrates and sugars. And we all know that's a challenge for anyone, especially a kid.

You and your child will start seeing a doctor called an endocrinologist. This is a pediatrician with additional training in hormone issues, including diabetes. The endocrinologist, you, and your child will all work together to come up with a plan on how to keep your child's diabetes in check. Living with diabetes is a challenge no matter what age a person is, but young kids and teens often have special issues to deal with. They may have a hard time understanding why they need so many needles, why can't they eat what their friends are, why did this happen to them.

If you have a teen with diabetes, they may feel different from their peers, and they may want to live a more spontaneous lifestyle than their diabetes allows. Not to mention that puberty hormones can make diabetes control even harder. Having a child with diabetes can seem overwhelming at times, but you're not alone. Your child's diabetes care team is not only a great resource for the medical side of things but also for support and helping you and your child cope with this long-term condition.

Until scientists have figured out a better way to treat, and possibly defeat diabetes, you as a parent can help your child lead a happy, healthy life, by giving constant encouragement, and helping them stay on top of their blood sugar control every day. This will let your kids do all the things that the other kids do and remind them to enjoy being a kid instead of feeling like a pin cushion.

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Dr. Jones: Good bacteria and bad bacteria. We are being bombarded by information about the bacteria with which we share our bodies, but what about our babies? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University Healthcare, and this is Babies and Good Bacteria on The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: We have previously talked about how babies benefit from exposure to different kinds of bacteria. Babies who have a wider exposure to bacteria may have less obesity, diabetes, asthma and autoimmune disease. So it is okay to put your baby on the floor, and it is okay, mostly, to let your dog lick your baby.

Now, a baby in the uterus the day before it is born is living in a mostly sterile environment. The passage through the mom's birth canal during labor allows mom's bacteria to colonise the baby, and breastfeeding allows some more.

The vaginal bacteria in healthy pregnant women are largely lactobacillus, which is a bacteria that can help babies metabolize milk, but what about babies that are born by cesarean section? There are some data to suggest that babies born by cesarean, and that is about 30% of babies in this country, may have more autoimmune diseases like asthma, type 1 diabetes and other conditions, and food allergies than babies that were squeezed out through the mom's vagina, especially babies that were born via cesarean, without moms having been in labor for a while.

Okay, so it isn't a huge difference in which babies get some diseases, but if you were planning a caesarean, could you do something about it? A short report has just been published in the Journal of Nature Medicine suggesting that you can. This was a very small study of 18 moms and their babies at the University of Puerto Rico in San Juan. Seven babies were born vaginally and 11 babies were born by elective cesarean section without labor.

Four women who were scheduled to have a caesarean had a bit of gauze put in their vagina, then removed and put in a sterile container before the cesarean was performed. A few minutes after the babies were born they were dried off and four of the babies had gauze wiped over their skin. Eleven other babies did not. Over the following month, the moms and their babies had their microbiome, their bacterial ecosystem, assessed. The babies who were treated with the gauze had skin bacteria more like their moms and more like the babies born vaginally. The babies born from cesarean who did not have the gauze treatment had bacteria more like that from the hospital environment, and less like their mom's vaginal environment.

The babies who had the gauze treatment weren't exactly like babies born vaginally in that their gut bacteria weren't as varied and abundant as babies born vaginally. This could be for several reasons. One is the fact that moms getting a cesarean often get antibiotics to decrease the risk of infection in their cesarean incision or their uterus. Infection is relatively common in cesarean incisions, and that is why we give women antibiotics routinely who are having a cesarean.

So lots goes on in labor that involves moms exchanging bacteria with their babies. Now we don't know if these babies with the gauze treatment will grow up to be healthier or not. And we don't know if there are some moms with bacteria or viruses in their vagina that shouldn't be shared with their babies.

A bigger study is ongoing right now at New York Hospital. However, this idea is being disseminated in mothers' blogs and magazines, and women are asking for it. The professional medical organizations haven't recommended it yet, and I am pretty sure I would add the statement, "Don't do this at home," but if you're interested you should ask your OB.

There is so much to think about when you're going to be a new mom, and this wouldn't be number one on my list, but it is something to know as we learn more and more about the world in which we live and into which we bring our babies.

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Dr. Jones: Diabetes and the bladder, you never think of these two things going hand in hand. You think of a cupcake and diabetes, not the bladder and diabetes, but today we're talking about diabetes, the bladder. This is Dr. Kirtly Jones and this is The Scope.

Here in The Scope studio, we have Dr. Sara Lenherr, who is a urologist by training, but subspecialty trained in neurology. Today we're talking about diabetes because diabetes is a complex disease. It affects every part of the body and the bladder is the final common pathway of both nerves and sugar and trouble. Welcome to The Scope, Sara.

Dr. Lenherr: Thank you for having me.

Dr. Jones: I think in my own practice sometimes I diagnose diabetes because of women's urinary frequency. So can you tell us a little bit about how the first signs of diabetes might affect the bladder?

Dr. Lenherr: Sometimes women with poorly controlled diabetes end up having a bladder that spasms too frequently, and that can be very bothersome. It makes them feel like they have to go more frequently and urgently.

Dr. Jones: Also, sometimes people who don't know they have diabetes yet, their sugars are high, the kidney is trying to dilute that sugar, and they just pee a lot.

Dr. Lenherr: Yes, frequently these patients make too much urine because their kidney function is affected, and so they just make more urine than the bladder can handle, and it makes them feel like they need to go more frequently, and they do.

Dr. Jones: So peeing a lot in large volumes, for me, I remember that from medical school, was you better make sure they don't have diabetes.

Dr. Lenherr: Exactly.

Dr. Jones: Over the long term, though, diabetes affects your nerves in your feet and affects other parts of your brain, but talk about the bladder in long-term diabetes.

Dr. Lenherr: Diabetes in patients that have had it for a long time can affect the fingers and toes, and all that sensation also affects all of the nerves that go to the bladder, and so the bladder doesn't necessarily contract at the right time. Either it's overactive, or it's underactive. It doesn't contract well enough, and so therefore it doesn't squeeze when you want it to and you don't empty your bladder completely.

Dr. Jones: So in terms of diabetes, we certainly want people to be in good control, because that might help early on a lot of their bladder symptoms, meaning if their sugars are in good shape, their bladder will probably be in good shape. But for people who have been diabetic for a long time and they weren't in such great control and now they have more permanent damage, how do you make that diagnosis?

Dr. Lenherr: Usually, we check and see whether or not the bladder empties completely, so once you go, we can then check and see if you have a residual left over in your bladder, and then we can also check bladder function tests where we measure the pressures inside the bladder and see how your bladder behaves with filling and then trying to empty your bladder.

Dr. Jones: Is that very comfortable? Reassure me that that's not going to be a painful test.

Dr. Lenherr: It's a very simple test that's done in the office. We put a very small catheter that's smaller than the mouse cord that goes to your computer, and we place that inside your bladder, and we place also a very similar small one inside the rectum. This helps us look at how the bladder behaves with filling and emptying to measure those pressures and see whether or not your bladder nerves are not working properly.

Dr. Jones: Okay, maybe I would have this test. Okay, I'll have this test. So, I had this test and my bladder isn't contracting very well. What are you going to do? What can you do to help me with this?

Dr. Lenherr: Depending on how much your bladder is injured, sometimes we have to have patients actually just pass a small catheter every four hours while they're awake to empty their bladder as opposed to trying to pee it out. But if you have a little bit of bladder function, then sometimes we can actually give you a bladder pacemaker that helps your bladder contract in a much more efficient manner, and therefore you're able to empty without having to use that catheter.

Dr. Jones: How about as people get older? I think of the elderly patient with what we call comorbidity, so they're older, they have diabetes, they have heart disease because it's affected their heart, maybe they had a stroke. Urinary incontinence is the number one reason to be admitted to a nursing home. So what do we do for older people? Can they do their own catheterizations, or is this something a family can help them with?

Dr. Lenherr: The complex patient with incontinence is definitely some of the more challenging cases that we have, and it's a balance between figuring out what the goals of care are. Some patients are very happy to have family help them catheterize if they need that to be done. Sometimes patients would rather not have their family members be going down there and helping them pass a catheter, and depending on how the bladder works, it can be a very good option to leave a chronic catheter in place.

Usually we try to place that in a suprapubic location, so right above the pubic bone below the belly button, and that helps drain the bladder and improves quality of life in a lot of patients. But these are really specialized conversations that we have with both the patients and their families to determine who is going to help out the patient and who is going to be able to help keep the patient safe and happy.

Some of the more rewarding conversations are having these discussions where you have patients understand these are my choices and this is what my goals of care are, and it's not always a quick fix, and it's not always the most complicated solution. Sometimes it just needs to be something simple that everyone agrees this is what I want to have my life be like, and I'm there to offer those solutions for them.

updated: November 24, 2021
originally published: December 23, 2015

Interviewer: How exercise is key for managing prediabetes and diabetes by improving the body's ability to use sugar. We'll talk more about that next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Tim Graham is a diabetes expert. He's also an assistant professor of medicine, biochemistry and nutrition at University of Utah and is the medical director for the diabetes, obesity, and metabolism programs here at University of Utah Health Care.

I want to drill down a little bit into the importance of exercise for prediabetes, those who have been diagnosed with it, and diabetes, almost more important than nutrition, is what I've heard. Is that accurate?

Dr. Graham: Yeah, it's at least as important. We tend to, in our society, focus so much on body weight, and partly because we look at skinny people and they're the people that we see in Hollywood.

Interviewer: They look so healthy.

Dr. Graham: Yeah, they look so healthy, and yet without activity you're not so healthy. So it's not just about body weight, but it's also about keeping your body moving.

Really, prediabetes and diabetes are diseases of glucose metabolism. Normally, when you take a meal, your body produces insulin from the pancreas. Insulin circulates through the blood and tells the muscle to take up glucose so that right after a meal you might have a rise in glucose, but then when insulin kicks in, it causes the blood sugars to go down pretty quickly, because it tucks it away into muscle where you can use it later as glycogen when you're exercising.

The problem with diabetes is not necessarily that people don't make enough insulin, although in the case of Type 1 diabetes, we do see that. We can talk about that as a separate issue, but Type 2 diabetes, which is by far the most common type of diabetes, is a problem where people don't respond normally to insulin.

You make the insulin, in fact, you tend to make more insulin than the average person, but your body just doesn't respond normally. The skeletal muscle won't take up glucose in response to insulin. We call that condition insulin resistance, and that's really the classic Type 2 diabetes type problem.

One of the beauties of exercise is that it bypasses that defect by directly stimulating glucose uptake by muscle, so even if your insulin isn't working great, you can get your skeletal muscle to take up glucose more avidly or more efficiently just by exercising on a regular basis.

Interviewer: Can that condition be fixed by exercise, or is it just a workaround?

Dr. Graham: It's both. If you are exercising regularly and you have diabetes, you'll notice your blood sugars are more well-controlled with less and less insulin. Ultimately, if you have prediabetes and you can exercise regularly, you very likely will prevent yourself from developing the worsening condition of diabetes.

Interviewer: So it's a condition that can be taken care of.

Dr. Graham: By all means, yeah.

Interviewer: What kind of exercise are we talking about? People are busy; people don't like to be in pain.

Dr. Graham: There's been a lot of work done to figure out exactly what is enough exercise to have an effect. 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: 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.

Interviewer: Or getting out in the garden or some house . . . I was vacuuming the house this weekend and I was sweating moving the furniture and bending down.

Dr. Graham: Yeah, 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 exercise, key for managing diabetes, for reducing your chance of getting it. If you have been diagnosed with prediabetes, to backing that off.

Dr. Graham: Absolutely.

Interviewer: Anything else that I need to know about exercise?

Dr. Graham: If you already have diabetes and you've had it for a sustained period of time, we do recommend that people get evaluated by their physician before they undertake a more rigorous exercise program. That's only because when you've had diabetes for a while, there's an increased risk that you might develop some heart problems, so we do recommend that people go out and at least get some evaluation to make sure that that's not a risk factor that they have before they undertake more rigorous exercise.

But the vast majority of people don't fit into that category who are contemplating starting exercise. Many people will have prediabetes, and frankly, they should feel comfortable just going out and getting it done.

Interviewer: If a little bit of exercise is good, is a lot of exercise even better? Do the benefits increase linearly?

Dr. Graham: They actually do. There are always people who we can see that develop syndromes of over exercise and sometimes that's associated with bulimia and other problems. But in most cases, people exercising more intensely for longer periods of time will be beneficial for people overall.

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Interviewer: When do you need to see a diabetes specialist? We'll talk about that next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Tim Graham is a diabetes expert. He's also the medical director of the diabetes, obesity, and metabolism programs for University of Utah Health Care. When do you need to see a diabetes specialist? When is it beyond something that your primary care physician can help you with?

Dr. Graham: That's a great question, and it's actually somewhat debated even in the medical community.

Interviewer: A hot topic.

Dr. Graham: Yeah, it is. It is. It's important because every time you escalate care it costs more for the patient, and it may or may not benefit them in the long run. So we do take seriously when to escalate care and when we get the most out of that extra bang for the buck when we send someone to a specialist.

Basically, we tend to look at diabetes as a general medicine problem, and it really is. It's a chronic condition that can generally be managed with the knowledge of a good internist, or a good family physician or generalist.

However, sometimes some patients don't fit into the usual protocols that we use in general medicine. So when patients start to develop recurrent low blood sugars or if they've been hanging out at a high blood sugar for more than six months and working with their primary care physician they're not really achieving the target blood sugar that they would like to get to, or the one that they need to get to to be more healthy, then I would recommend that they consider seeing a diabetologist.

Diabetology is just a fancy name for something we do in endocrinology. So it's always been endocrinologists or hormone doctors who tend to oversee the specialty care of diabetic patients.

Interviewer: So the primary care physician in how many cases would you say is able to handle through exercise, maybe medications, helping them with nutrition?

Dr. Graham: I would say at least 80% to 90% could be easily handled by the primary care physician. However, there are these patients that their physiology just doesn't fit into the normal sort of mold, the normal care protocols that we use. So really there's no reason to hesitate to take it outside the primary care setting to see the specialist physician at some point to get some additional input into the care plan.

Interviewer: Are there some specific indicators that a patient would see that would indicate that maybe they would want to request to be elevated to the next level?

Dr. Graham: Well, a couple things. If your primary physician isn't helping you set goals and telling you where you should be in terms of your hemoglobin A1C, which is the number . . . It's a blood test that we often follow to tell us where a diabetic patient is on a three-month basis for their blood sugars. If that goal isn't being set, then you need to address that with your primary physician. Say, "Hey, let's set a goal and let's make sure I'm getting there, and I'd like to talk about how to get there."

Now, maybe you have a goal that's been set, and maybe it's been communicated to you. But it's been six months and you're still not there. I think that's time to bring up the discussion with your primary physician, "Do you think we should escalate care a little bit and see a diabetologist?"

Now we've, at the University of Utah, taken a new approach to this. We want diabetic patients to be seen in their medical home with their primary care provider. So what we're actually doing is bringing diabetes specialty services to each of the community clinics in the University of Utah healthcare system. That way we don't have to have patients making this uncomfortable discussion with their primary care physician about whether they need to be referred out for something that the primary care physician may not be able to achieve easily in the primary care setting.

So instead, the primary care physician can literally just, at the click of a button, have the patient seen by one of our diabetes care teams right there in their own clinic where we've integrated into their practice. So we think that's easier for both the primary physician to deal with and easier for the patient to deal with.

Interviewer: That's something that primary care physicians kind of like. It's a checklist meaning, "If it's to this point, I'm just going to go ahead and refer."

Dr. Graham: Yeah. In fact, we're working with our primary care colleagues to decide really where exactly to activate the referral. At what point do we identify a patient who's been, say, lingering with a high blood sugar for six months or has had multiple episodes of low blood sugar? At what point do we pull the trigger, if you will, to get them hooked into one of these community care teams?

Interviewer: Then at that point, what would that expert do?

Dr. Graham: So typically what happens is, when they see the community care team, they get a lot more face time. They'll either see a specialist nurse practitioner or an M.D. physician such as myself, who's a diabetologist endocrinologist, and we'll sit down and do some problem-solving. We'll look at their medication list and we'll try to figure out what they aren't getting or what they might be able to get, from a medical standpoint or pharmaceutical standpoint, that would improve their blood sugar better.

Or maybe sometimes it's the timing of the dosing. Or maybe it's the types of foods that are being eaten. So we also tend to have them see a dietician nutritionist no matter what at those visits, as well. We'll often bring in our colleagues in pharmacy who are very good at helping adjust complex insulin regimens.

Interviewer: So a lot of tools that you have if the standard treatments don't work.

Dr. Graham: That's exactly right. I would emphasize, I like the term, it takes a village to care for a diabetic.

Interviewer: Yeah. Okay.

Dr. Graham: There are a lot of aspects of diabetes care, including even things like exercise, physiology, physical therapy, and we try to bring all of those to bear on these care teams. So we have people who are experts in behavioral health that work with the care team. We have specialist physical therapists who can work with people who have neuromuscular problems that makes it hard for them to be active.

We have exercise physiologists who can work with just the average person to come up with a good exercise regimen. Then of course, the nutritionists and diabetes educators, and then the pharmacists. All of those, that village of care is what the primary care provider gets when they reach out to one of these teams.

Interviewer: I guess what you're learning is that the old adage of eat better and exercise, you can't just tell a patient to do that because it's a lot more complicated than maybe a lot of us get.

Dr. Graham: Oh, yeah. Absolutely right. We've been doing that for years, telling patients to eat better and exercise.

Interviewer: It can be overwhelming.

Dr. Graham: In fact, no one really complies well with that because we all kind of know anyway we should be doing that. Right? So hearing one more person say it doesn't really change anything. However, it's really about strategizing.

So if you have people telling you not just that this is what you ought to do, but exactly how to do it and how to make it work for your life so it's actually personalized to you, we know that the impact is much more substantial. The more times you have people telling you that the better. So the other thing these care teams do is they bring more face time to the patient, basically.

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