Endocrinologist and Diabetes Specialist, Sarah Fishman, M.D.

0:01 Hi, it's Doctor Robert Seikard with Episode #22 of the Doctor Podcast Show. Thanks for tuning and watching again. We hope you enjoy these programs. And if you do, please press on the subscribe button. And if you like the episode, please click on the like or repost button as well. Today I'm really pleased to have as our guest here Doctor Sarah Fishman. Doctor Fishman is a board certified internal medicine doctor as well as an endocrinologist. Dr. Fishman is also a Professor of Internal Medicine and Endocrinology at the Mount Sinai Medical Center in New York City, as well as an attending physician at the Lenox Hill Hospital, which is part of Northwell Health in New York City as well.

0:52 Sarah, thanks very much for coming today. We really appreciate it. I know you've got a really busy schedule, so I appreciate your taking the time to come here and talk. Thank. You for inviting me? I'm happy to be here. Yeah, one of the hottest topics these days, it's on the news every day. Every place I read about it is diabetes. There. There is a epidemic of diabetes in the USA and around the world. Can you tell us what diabetes is, what the different types of diabetes there are, and why is there an epidemic?

1:19 Yeah. So there definitely is an epidemic. There's about 38 million Americans living with diabetes, predominantly type 2 diabetes. So about 90 to 95% of Americans with diabetes are living with type 2 diabetes. The remaining people living with diabetes typically have type one diabetes. So those are going to be the two most common types of diabetes. There are some other lesser known types of diabetes. There's a type of diabetes that women may develop during pregnancy called gestational diabetes. Typically that resolves with delivery of the baby.

1:54 There are some genetic forms of diabetes. There's diabetes associated with cystic fibrosis and some other conditions. But typically when we refer to patients as having diabetes, we're referring to either type one or type 2 diabetes. Right. Type 2 is the more common one that occurs in people as they age and as they put on wave. Is that is that right? That's right. So, so there's definitely more of a prevalence of type 2 diabetes. It's about 90% of people, 90 to 95% of people living with diabetes.

2:24 Do you have type 2 diabetes? Type one diabetes is also known as juvenile diabetes. Diabetes because it does typically present in childhood, although can present really at any age. And more and more often we're seeing individuals diagnosed in their teen years or even in their in their early 20s. So type one diabetes is an autoimmune condition. The patient has antibodies that instead of attacking bacteria and viruses turn on the patient themselves and specifically turn on the pancreas and destroy cells in the pancreas that make insulin.

2:59 And it's not really well understood why this happens. There's a genetic component to it. There is various theories about what triggers this reaction and and susceptible individuals and unfortunately we don't have great treatments at the moment for prevention or for eliminating type one diabetes once it's occurred. The only treatment for type one diabetes that's been effective is the use of insulin because type one diabetes eliminates pancreatic production of insulin. So without insulin you can't live and so those those individuals do require insulin type 2.

3:38 Yeah, yeah. Diabetes by the way, that's that's an abnormal metabolism of of sugar or glucose in the body is is that. That's right. So diabetes actually comes from a Greek word. The full name is diabetes mellitus, which means to pour out sweets because it used to be diagnosed by looking at the urine of individuals with diabetes. And ants would would, you know, kind of congregate around, preferentially around the urine of individuals with diabetes because they had sugar in the urine. And so that's why back in, you know, in ancient days, the Greeks name this condition diabetes nauseous, meaning to pour out sugar because they had extra sugar in the in their urine.

4:22 And this has been around for centuries. Centuries. Not a new disease. Definitely not a new disease. There's evidence in ancient Egyptians of having had actually type 2 diabetes, and certainly type one diabetes has been, you know, around for ages. So. So type 2 diabetes is definitely the more prevalent type of diabetes at this time and in our country. And type 2 diabetes is not a failure to make insulin, but it's an inability of the body, the body to really use the insulin that's being produced effectively.

4:58 So cells need insulin in order to process sugar and specifically to turn the sugar into energy. The sugar needs to get into the cell and insulin is what allows the sugar to enter cells and then be metabolized into energy. So without insulin, the sugar, the sugar can't get in. When you have type 2 diabetes, your body still makes plenty of insulin. In fact, some some would say it makes too much insulin, but the cells don't respond to the insulin accordingly. So we call that insulin resistance. So it takes higher and higher levels of insulin in order to get the cells to open up and let the the glucose in the sugar in so it can be metabolized.

5:37 So typically individuals with type 2 diabetes don't need insulin in order to treat their disease. They can use other medications that will help lower the insulin resistance and basically reset those cells to be more susceptible to the insulin that our bodies make natively. Right. So now if the glucose and sugar can't get into the cell, then it increases in your blood, it floats around in your blood and that causes a high blood sugar. Basically, that causes right the the sugar to stick around in your blood, and when it sticks around in your blood, it can add on to other tissues in your body, such as your nerves or your muscles, and interfere with the way they work.

6:20 So one complication of diabetes is called neuropathy and that's where glucose molecules actually attached to the nerve fibers and don't allow those nerve fibers to conduct electricity and and interfere with how the nerves work. So patients with this complication, they don't feel properly things in their feet. They report having numbness and tingling, or they can't feel when they step on on objects that are sharp because the nerves aren't conducting those signals properly because of the glucose attached to the nerves.

6:50 So they can get sores and infections in their feet and ulcers and that's why you hear sometimes diabetes have patients with diabetes have amputations of their feet and. Legs due to sores that they don't feel that then become infected and and lead to all sorts of complications. Another kind of well known complication of diabetes is something called diabetic retinopathy. And that's a problem with the eyes, where certain parts of the eye, you know again, when sugar molecules, glucose molecules attached to them, they can't function properly and that can lead to blurry vision and if I'm treated, can lead to blindness.

7:27 Right, Yeah. And the eye, I know as an ophthalmologist, I see patients with diabetes not controlled well. It damages the blood vessels inside the eye and causes bleeding in the eye. What about the heart? It's it's known that people who have diabetes that's not controlled well have an increased risk of heart attacks and also strokes. Yeah. Why is that? Absolutely. Well that's because patients with type 2 diabetes typically will have will develop atherosclerotic disease. So they'll get a lot of build up of plaque in the vessels around their heart.

7:59 And the sugar can lead to a lot of the high sugar levels can lead to a lot of inflammation which stabilizes those plaques and increases their their narrowing of the blood cells doesn't allow to blood the past through and that's what leads to the strokes and the and the heart attacks. Right. So why is there an epidemic of type 2 diabetes? Yeah, that's a great question. I think a lot of it has to do with some of our lifestyle choices since the industrial revolution when we've been less active. Also the available, the availability and the, the low cost of processed foods.

8:33 So adding, you know, fruit, high fructose corn syrup to foods, the use of condiments on our foods, fast foods, you know, things that are are easy to make do tend to have a lot of sugar and that can lead to increased risk of diabetes, right? Things like soda, where you're drinking. Sugar. So lots of added sugar in our, in our products and the lack of, you know, easy access to fruits and vegetables makes things like cookies and chips more attractive, right? I mean, it's easier to go grab a bag of chips than to, you know, make yourself a whole salad.

9:08 So I. Prefer Oreos to chips, but. Wow, That's even worse. So. But also other also. The lack of of exercise, right. I mean, a lot of us, you know, now spend time sitting at desks, sitting at computers, sitting in cars, whereas before, you know, hundreds of years ago we would walk, we would work on farms more and we would just be more active in general. So that also plays a role, right? And why does weight gain cause diabetes? Is there a direct relationship or are they just kind of associated people put on extra weight and their blood sugar goes up?

9:45 Yeah. So. So not everybody who's overweight or obese develops diabetes, but a very large percentage of people do. And that's because as we develop more fat, the fat interferes with the way our bodies are able to metabolize sugar, especially fat that accumulates on our liver or on our other organs. It interferes with, for example, the liver's ability to to process sugars and to process fats, and increases our risk for insulin resistance. I see. So the the more fat you have or the more weight you have or obesity, the more insulin resistance you get.

10:24 Typically, yes. The the glucose or sugar can't get into the muscle cells and the cells where it's supposed to be. Instead, it goes up in your bloodstream and winds up in different organs and damages them. Yeah. So and in in early in early stages of Type 2 diabetes, it's really in a in a kind of self continuing cycle because the sugar is high and so the pancreas tries to make more insulin. So then that sugar is able to get into the cells. But if the individual is not moving around or using all that energy, that energy that gets stored as fat and so the patient now has more weight on them and has more insulin resistance and then the pancreas has to work even harder.

11:07 And it's it's this vicious cycle and at some, some point the pancreas just can't keep up with the insulin demand and so the sugar goes up and up and up in the blood instead of being utilized. Right. So that that's why there's an epidemic people. I've read statistics that show people are are gaining weight, there's there's obesity epidemic that goes along with the diabetes. Epidemic as well. Now I see a lot of patients who tell me they're not diabetic, they're pre diabetic. What, what does that mean?

11:37 What is pre diabetes versus real diabetes and is is that a arbitrary name or or is there really such a separate entity as pre diabetes? I mean that's a great, that's a good question because to some extent it is a sort of arbitrary definition of pre diabetes. So we define in medical terms pre diabetes as those individuals that have a hemoglobin A1C, which is something we can measure in your blood between 5.7 and 6.4%. And we classify patients as having diabetes when their A1C is 6.5% or higher. We typically aim to maintain our hemoglobin A1C below 7% in individuals with diabetes.

12:21 So those that are 5.7 to 6.4 are classified as having pre diabetes. But really it's the same disease process as having type 2 diabetes. It's just that your risk for developing complex diabetes complications is not high in the pre diabetic range, whereas once you get to have a hemoglobin A1C above 7, seven and a half really for the long term, you are more at risk for developing complications of diabetes so. 7A1C of 7, is that cut off where you're getting into the dangers of exactly? So, so we set a level of 6.5% as the diagnosis for type 2 diabetes.

13:00 So that we do give people some, some room, right, so that they can bring it down from there and you know they're not going to be at risk for for complications. But before that, you know it's it's it's almost like a warning. You know, if you keep this up, you know it's going to get to the point where you are going to get complications, but it's really a spectrum of the same disease, so. I'm not an endocrinologist, but I I think it's a mistake to call it pre diabetes because I see a lot of patients who have diabetes and many of them say, oh I don't need to worry.

13:31 I have pre diabetes and every time I see them they put on more weight, doing less exercise, eating more. Because I'm pre diabetic, I don't need to worry about it. Yeah, the. Time to control it is when you're in that pre stage and you don't go into the full stage, yeah. So, so it is you know I think it was developed as a way to warn patients like hey heads up, you know this is coming your way, you're pre diabetic but really you know referring to it as as insulin resistance would would be a more accurate term.

14:02 So all right now. If you lose weight, does your A1C go down so that? Depends. Often times it does, but really the A1C is a reflection of your average glucose. So. So hemoglobin A1C is really a measurement of hemoglobin. So hemoglobin is a protein in our blood that carries oxygen to all of our tissues and everybody has hemoglobin in their blood, right. And hemoglobin, A1C refers to the percentage of the hemoglobin that has a sugar molecule on it. So if you have a lot of sugar floating around in your blood, the sugar is going to bind to the hemoglobin in a concentration dependent manner.

14:42 The more sugars in your blood, the more hemoglobin is going to have sugar molecules on it. So when we measure the hemoglobin A1C, it's letting us know the percentage of hemoglobin with sugar on it and that's a direct reflection of your average blood sugar. And because hemoglobin molecules last for about 3 months each molecule, it's really an average marker of how much blood, how much blood, how much sugar is in your blood over a three month period. So for example, a hemoglobin A1C correlates with an average blood sugar of about a hundred 150 grams per deciliter, whereas a hemoglobin A1C of 6% would mean an average blood sugar of about 120 milligrams per deciliter.

15:25 So it's a way to give patients and providers an indication of of how their blood sugar is doing on average, right? Now I'm surprised that I would say about 1/3 of my patients who have diabetes or pre diabetes, they tell me they have that don't know what their A1C is. Is it because they're kind of ignoring it or denying they have diabetes Or in some cases patients tell me their doctors don't tell them, they just say, oh you have pre diabetes, don't worry about it, you know, walk a little extra. Do you tell all your patients what their A1C is?

15:59 I do. Tell my patients what their, what their A1C is, but mostly to let them know what their likelihood of developing complications are. So you know the higher your A1C, the higher your sugar is on average and of course you're you're more likely to develop complications. So I usually do take the time though to explain to them like I just did, about what hemoglobin A1C means, so that it means something to them, right. So just telling somebody your hemoglobin A1C is 7 is like, you know, OK what am I going to do with that information.

16:28 But when you say you know your hemoglobin A1C is is 8 and that means that your average blood sugar is 180 and you know normal is under 150, then it sort of resonates with them as oh, I need to, I need to work on that. Or when I tell somebody, you know your hemoglobin A1C is 12, that means that on average your sugar is running, you know, over 300. What? You know, 300, I mean. So I think you know when you hear 12, you're like, OK, the difference between 12:00 and 7:00 doesn't sound so big, right. But when you hear, Oh, my sugar is 300 and it should be 100, you know, I think that resonates with with people a little bit more.

17:05 What should? The fasting blood sugar. Be in a person who doesn't have diabetes. Like if they check their blood in the morning before they eat breakfast, Yeah. So so the guidelines are to keep it under 125 but I I'll be honest I I move away from I I don't recommend finger stick testing in general to my patients. I really prefer to steer patients with diabetes even pre diabetes towards the use of continuous glucose monitors because measuring a finger stick glucose tells you what your sugar is right this minute right now and blood sugar can change super quickly it can change within 20 minutes.

17:42 If you get up right now and you go take a hot shower and come back your blood sugar could have changed by 2030 points. So when we asked patients to check their fasting blood sugar, fasting could be, you know, two hours in the morning from the time they wake up to the time they have, you know, a cup of coffee. If they're commuting or they're eating, you know, it's it's a long period of time. It's not one specific point in time. And you know, even the alarm clock ringing can can change your blood sugar.

18:08 Not a ton, but enough to be the difference between 1:15 and 1:30, which would, you know, put you on on either side of this cut off of 125. So I really like to use continuous glucose monitors for for home blood sugar monitoring because it gives you a lot more information. It measures your blood sugar every minute or every 5 minutes, depending on your advice, throughout the whole day, 24 hours a day, seven days a week, and the. Number appears on your phone the. Number appears on your phone so you can see it.

18:37 Show me that when I. Ask them. And and even better, you can share the data with your provider. So I can do a lot of remote glucose monitoring, which was very helpful during the pandemic when patients didn't want to come out. And we can talk about treatment plans remotely. And I can say, you know, I see last night you had trouble with something. You know, what was going on? What did you eat? What did you do? And you know, and or if a patient, you know, calls me in a panic and says, you know, hey doc, my sugar is, you know, 52, what do I do right.

19:07 I can look at the tracings and see, you know, is this a real 52? Has he's been running, you know, 52 all day or you know it just it gives you a lot more information to see the patterns so. With these machines that patients carry, it's how does that work? They put it on the TV show, the commercial show it on their arm how do how do Yeah, so. There's there's two main suppliers of continuous 2 brands 2 main brands of continuous glucose monitors. Which are they? Yeah. The one is called Libre. It's made by Abbott.

19:38 The Libre Three is the newest model. It's the size of two stacked pennies and it is worn on the back of the arm and it communicates with the phone sending a reading every minute by Bluetooth from the the little sensor to the phone. And then, you know, as I said, a provider can also see it remotely, it it will send the data to the cloud. So that's the Abbott Libre. And then there's another another one made by Dexcom. Dexcom is, is a little bit bigger. They're at their seventh version, the Dexcom 7.

20:11 It's a touch bigger and it could be worn either on the arm or on the belly or on the leg anywhere, anywhere. We have a little bit of room to spare, so primarily belly, leg and and arm. And it works the same way. It communicates with the phone, can integrate with providers and the nice thing about the Dexcom is for patients with type one diabetes, it can also integrate with insulin pumps, so. It's pretty amazing. Now, how does that read the the sugar or the glucose? Is there a little needle in that device?

20:43 So there's no. Needle. But there is a little tiny little catheter that's about 2mm in length and when the sensor is put on there, there is a needle to insert it it it hurts almost nothing. I mean you know, far less than a a flu shot or a COVID shot.

21:01 And then the the catheter resides, it's just right under the skin as I said a couple of millimeters. And what it's measuring is the glucose in the fluid between the cells. So it's not measuring blood, it's measuring what we call interstitial fluid. And the blood in the interstitial fluid take about 15 minutes to equilibrate with each other. So it does lag a little bit behind the glucose behind the the blood, but not in a way that's clinically, clinically too significant, right? So it's pretty equal to the blood.

21:30 How long can you keep this device on your arm or wherever you put? Yeah. 14 days, 14 days. So both the Abbott Libre and the Dexcom G7 sensor will last for 14 days. They're completely waterproof. You can shower with them, bathe with them. You forgot that they're there, You don't feel them and they're they're really wonderful devices. So that's dramatically. Change how patients can monitor diabetes and also you as well. They actually send the data to you and you'll see and. I can see exactly what's going on.

22:03 And I think it also helps patients to be to take more ownership of their condition and their disease and and be more involved. You know, they can see in real time what's happening with their sugar. So if they, if they do eat ice cream or a doughnut or you know, even alcohol, you know, an alcoholic beverage, they can see, you know, every every minute, every 30 minutes, exactly what happens. And I know for myself, when I first started wearing a glucose monitor, every now and then I would stress eat some Jelly beans and, you know, an hour later I would, you know, feel terrible, A little nauseous.

22:39 Not terrible, terrible. You know, just like, why did I do that? You know, that feeling that you get when you make bad choices of like, oh, you know, I shouldn't have had that. And what I found is that my sugar would expectedly go way up from the Jelly beans, but then it would crash down to even, you know, way lower than it was before I ate the Jelly beans. And just such a rapid fall in blood sugar, maybe, you know, 20-30 minutes from peak to through. And you know, then it it was mindful for me to think like, Oh well, that's why I feel crappy after eating all these Jelly beans, because now my sugar has plummeted and that's.

23:14 Because the Jelly beans trigger a sudden release of insulin for insulin. Exactly. Drives the blood sugar down? Yep. And it drives it down. It's not that it goes low that makes you feel bad. It's the speed at which it's going low. So because Jelly beans are so easy to to digest, they're just, you know, it's like just drinking sugar, you know, So something like, you know, a bagel or ice cream is going to take longer to make your sugar rise, but simple sugars are going to raise your sugar and then they're going to plummet right afterwards.

23:44 So yeah. You mentioned alcohol. Alcohol raises blood sugar as well it. Raises and then lowers. So, so you see a spike and then a a drop. Yeah, because alcohol can trick the body into thinking that it's sugar. Because the the shape of alcohol molecules is very similar to sugar. So it gets mistaken for sugar and can lead to a a delayed release of insulin. But then there's no sugar, so the the actual blood sugar drops I. See. But if you're drinking wine and and things like that, you're actually drinking sugar in addition to the alcohol, yes.

24:18 Yes, especially drinks. Yeah, so. So cocktails with with juice and whatnot are are particularly problematic, right? So how do we treat this type 2 diabetes? You mentioned insulin that's that's been the standard of of treatment. Why aren't all diabetics type 2 diabetics on insulin? Yeah. So I think treating individuals with type 2 diabetes with insulin is completely counterproductive because as we talked about, type 2 diabetes is not a problem with insulin production, it's a problem with insulin resistance.

24:53 So their bodies in the early and middle stages of type 2 diabetes is perfectly capable of of producing insulin. It's just not good at using the insulin. So yes, we can overcome that hump by adding more insulin, but it doesn't really get at the disease process. It doesn't make them any better. So what I tell patients in my office is, you know, let's say I have a glass of red wine, right, and I spill it on your carpet over here, you're going to have to stain on your carpet. So I can go and get another carpet and put it on top or I can get the detergent, get on my hands and knees and clean up your carpet for you, right.

25:30 Either way your your floor is going to look fine, right? So giving insulin to patients with type 2 diabetes is like just putting another carpet on top. It makes the sugars go down, right? Prevents the complications of diabetes, but it doesn't really make the disease any better. If I clean up that stain then I've fixed your floor, I've restored it to it's it's previous configuration. So using alternative medications, non insulin medications can can help improve the Physiology of the individual overall.

26:01 So the medications that I like to use, there's Metformin which is kind of tried and true that works on the liver to help the liver process process glucose and that does help with insulin resistance. So it makes the cells more susceptible to to insulin and then some newer medications called SGLT 2 inhibitors. So Jardiance and Farxiga are the most popular. There's a couple of of other options as well, right? See them advertised on TV all the time, Yeah. So those are great medications for reducing insulin resistance.

26:34 They help the body to excrete excess sugar into the urine. But for reasons that are are not well understood, they do seem to reduce inflammation generally in the body, particularly in the kidneys and in the heart. And I've shown to have a very, very slight weight loss in some individuals and they also help with blood pressure as well. So I think through all these mechanisms they help improve insulin sensitivity and that you know, helps individuals with diabetes actually be healthier. And then the, the other type of medications that I like to use in patients with type 2 diabetes are the GLP one agonist.

27:12 So those are the once weekly injectable medications, very popular at the moment. Ozempic, Manjaro Trulicity is an older version by Dorian was another brand. I don't think it's used anymore, but it's one of the original GLP One agonist medications, right? So I see ads for Ozempic all time on TV. That Jingle, I wake up singing the Ozempic Jingle OO Ozempic, which is actually based on an old rock'n'roll song, but that's a separate issue. And then there's Rebelsis, which is an oral form of that. Can you tell us what's the difference between Rebelsis and Ozempic and Wugovi?

27:54 They're they're all the same. So they. Are all essentially the same thing exactly. So they're the the generic name for all of them is simaglutide, and that's the active, active ingredient in all of them. Rebelsis is an oral form. It comes in higher doses and the highest dose of Rybelsus is about as effective as the second dose of Ozempic. So it's quite a bit less powerful. And the reason for that is that it's very hard for the body to absorb simablitide through the gastrointestinal tract. So when you take Rybelsus, you have to take it first thing in the morning on an empty stomach and you have to wait at least 30 minutes or more before you eat or drink anything else because it's very, very difficult for the medication to be absorbed into your system and that's why it's not super powerful.

28:42 So I'll be honest, I don't use it very often. I do typically steer patients more towards the injectables. They're easier for dosing, easier for compliance and and they do work more effectively. And it's just a once a week injection of yeah, so. Once a week Injection Tiny. Needle. So it doesn't, Absolutely. Tiny, you know, hurts less than than even putting on the glucose monitor, which, as I said, barely hurts like a. Mosquito bite. Give that. And so Ozempic has a tiny little needle on it with Govi which is also some magnetized just packaged differently approved for weight loss independent of of diabetes.

29:21 That's actually a self injector. So you don't even see the needle. It does just pop in and out quickly. It's a you know one use pen that's disposable. So you use it once and you toss it and then it's pre filled with the dose, so once a week. So I have many patients who have diabetes around that and and it works great for them. But I also have a lot of patients now are using it just purely for weight loss and I've I've seen many patients who've lost forty 5070 lbs in in nine months or so. Is is that pretty common for Wacovia and Ozempic?

29:57 Yeah. Patients with on Ozempic and Mugabe do typically lose a lot of weight. The weight loss that was associated with these medications, you know, was originally a side effect of the medication, but you know it's obviously a beneficial side effect. And so you know we've now seared patients to these medications who can benefit from weight loss. So yeah, so in studies patients on Ozempic can lose 15 to 20% of their initial body weight in about a year. That's you know a pretty average sort of finding and like you've seen, I've also seen patients losing up to 30% of their initial body weight in in you know 6 to 12 months.

30:37 So how does? That work, is it that they're eating less? Because I asked them, are you eating a lot less? They go, yeah, I'm just not interested in in food as much, so I'm eating less. But there seems to be another mechanism because it's not like they're starving or totally, well, that that. Is a They're not totally eliminating food, but they there is a very strong appetite suppressing effect of of Ozempic and some bagatite I should say. Ozempic will go beyond and rebels is it does work on receptors in the brain, in the hunger section of the brain that do make you feel less hungry.

31:13 A lot of patients say they have less food anxiety. They're just not thinking about food as much. So you know people who are sitting at their desk all morning wondering, you know what am I going to have for lunch? Where am I going to go? What what what time is lunch all those kind of anxious feelings. Yeah, you know or you know, I wonder what we're going to eat for dinner tonight. It just doesn't even. It's a thought that doesn't even occur to them. Now that they're, you know, taking Ozempic and it there it is, you know, well established that there are receptors in the brain for GLP and these are GLP one agonists.

31:48 So they increase the amount of of GLP One and receptors in the brain respond to it and and sort of shut down those thoughts, shut down appetite. So that's one of the primary ways that Sobacco's had leads to weight loss. But it also slows gastric emptying so that you feel full with less food. So if you're somebody who typically eats 2 slices of pizza, now you're eating one or or 2/3 of a slice, you know, like, you know, I, you know, kind of full, I don't you know, or you eat half your sandwich. Instead of a whole sandwich, half a pie from a whole pie.

32:20 There you. Go So, yeah, so, so people do eat less. And then for diabetes, it also helps improve insulin sensitivity and makes the pancreatic release of insulin just more efficient. In general, it's it changes the timing of insulin release to better match how much glucose is circulating in the blood so that you get a more efficient use of insulin as well. Sounds like a miracle drug. And recently I've seen results from some clinical trials that were published where it also reduces the risk of heart disease and kidney disease.

32:57 Is that right? That is. Right, Yes. So, so patients are less likely to have heart attacks, less likely to have kidney dysfunction and and develop chronic kidney disease. And unclear why exactly that is, whether that's just a byproduct of weight loss in general or a you know, an action specific to these to these medications. But either way, a a welcome, You know development, right? So if you take Farxiga and Ozempic, you're guaranteed to live till like 120 because no strokes, no heart attacks, no kidneys.

33:29 Well, not. No, you still have to do your part. It's skinny, so you you do still have to do your part, So one. Exercise a little bit as well well. It's it's not little, right. So I I do think that a lot of people are, you know, kind of lulled into a false sense of security with the GLP one, GLP one medications. Because they're not, they're not going to work forever if people don't do what they need to do. So yes, they'll suppress your appetite for the time being. They'll make you feel less hungry.

34:00 But over time, a lot of our eating habits are exactly that, their habits. So, you know, they, they are reinforced by our choices. And so you know it's easy to slip into bad habits. So if historically you've been somebody who you know late night snacks or somebody who eats their feelings. Yes, initially when you're on Ozempic you won't feel so hungry. But over time, you know if you're not, if you're not careful and mindful and and doing your part, some stress will will flow your way and you won't be able to to overcome it anymore.

34:36 You know. So you do have to do your part to be mindful and you do have to exercise because I've seen now that we've use these medications in individuals as type 2 diabetes that if they're not mindful about their diet and they don't increase their exercise even with Ozempic after a couple of years, their diabetes stays well controlled, but the weight does start to slowly, slowly creep back despite being on high doses of of Ozempic. So. So it's not as much of A mirror. It it's, it's a great jump start.

35:11 It's a great motivator and a great booster and a great help to people that, you know, think that they're doing everything right and and may believe that. But I think once you start using a medication like this, it sort of helps you realize where maybe you weren't doing things as well as you thought you were so. Lifestyle changes are are still critical in very. Absolutely. So because the the benefits of these medications, I'm not so sure that they're going to you know, be with people for 10 years without without any sort of changes, one of.

35:46 The criticisms I've seen is that once you stop the medication, then you gain weight back and your blood sugar goes up again. But I don't know if that's a legitimate criticism because that's true of any medication. If you're on metformin or let's say you're even on insulin, if you stop it, your blood Sugar's going to go up. So like any other chronic disease, you have to take the medication chronically? Yeah, I think that, you know, when it comes to obesity, there is a very, very large lifestyle component to obesity.

36:17 And so if you use the time that you're on a medication like Ozempic or Wagoobi or or Manjaro to to really, you know, buckle down and and establish good habits, I do think that it might be possible to come off of it if you're starting, you know, at A at a very large Wade where your diet consists of soda for breakfast and McDonald's for lunch and maybe Shake Shack for dinner, you know, with an ice cream at the end of the day and you're not doing any exercise. And now, you know, you start on one of these medications and you change your diet.

36:51 And you know, you change your diet to be, you know, a low fat yogurt for breakfast and a grown chicken salad for lunch and you know, piece of fish and and broccoli for dinner and you start going to the gym. Then, yeah, maybe you can't come off of it, right, because now you've made the lifestyle changes that you need to maintain your weight. If you're somebody who's mostly been doing things right, then it gets a little dicey. So. I've seen rumors that just about every Hollywood celebrity is on Ozempic or Wugovi trying to lose weight.

37:27 But what happens if you don't have diabetes and you take these drugs? Is your blood sugar going to fall below what's a normal level? Yeah. So typically no, because the way ozempic and emmegovia manjara, the way these medications work to improve your blood sugar is they reduce the peaks of blood glucose that you get after eating. So if you're eating less, it's not likely to make your glucose fall, but it will prevent it from rising. So that's typically how it helps people with diabetes, right? Now some of my patients told me they had bad side effects from it and I only only have a small sample.

38:08 You have a lot more patients. What percentage of patients have to go off the Ozempic or Govi because of bad side effects and what are those side effects so? Very few of my patients discontinue the medication because they can't handle the side effects. I think a really important part of starting patients on these medications is, is teaching is telling them, informing them what to expect. So I would say about 30 to 50% of patients who start the medication have some side effects. They feel something that they don't like typically nausea, Constipation, occasionally abdominal cramping, but the the most common is nausea and Constipation.

38:53 Almost all individuals are able to overcome that in the first two to three weeks of of using the medication. So I always let patients know that about a day after their first injection maybe you know 18 to 24 hours later, they probably will feel some nausea. I usually describe it as a motion sickness type feeling. So you're, you know, going about your day and all of a sudden you feel like I really, you know, that, you know, was a sharp turn or, you know, I'm on a boat, something like that. They may throw up once or twice.

39:28 It's not so common to have excessive vomiting for, you know, more than one, you know, one or two episodes of vomiting. But it can happen and that's not super uncommon. And then usually the nausea is relatively short lived. You know, half an hour or so might come back later in the day, might come back three times in the day and that usually lasts about three to four days. The first week that you do the injection. The second week it's about two to three days. The third week it's one day. And by the 4th week, you know, almost all patients of my practice are are OK if they're going to be OK.

40:03 So if you can get. Through the first month you're you're pretty set. Generally speaking, people are are fine. I think a mistake that some, some providers and individuals make is starting at anything other than the lowest dose. So I think a lot of people are, you know, kind of excited to get started and you know, they feel like, oh, just, you know, just give me a big dose right off off the bat. You know, I can handle it and you really can't handle it, you know, because it, it does take some getting used to.

40:30 And you know, going slow and steady is really, really the better way to go. Now there are individuals that really never overcome the nausea associated with Ozempic but do just fine with Manjaro and the reverse is true as well. So I've certainly had patients who you know really never got past that initial hurdle for one, but switched to the other and we're completely fine. So yeah, so you you've had to. Switch some patients I have. So it's rare and there's there's very few patients in my practice I would say fewer than 5% that can't tolerate any of them.

41:06 Have you seen any very serious side effects or complications from Ozempic or Munjaro or Logobi or or not I? Fortunately, have been very blessed not to have. My patients have complications, but it certainly does happen. I've seen, you know, patients in the hospital who have had complications. Pancreatitis is a big one, but it's. Rare It's. Super, super rare. It's a serious. Complication but rare but rare. And manageable. I mean, you have to deal with it. You can't ignore it, but it is manageable.

41:37 But quite a number of patients have side effects from rapid weight loss. So they will, you know, advance their their dose too quickly and lose a lot of weight in a very short amount of time. And that can lead to kidney stone development, gallstone development, which can be pretty serious side effects. They can develop nutritional deficiencies because they're just not eating the right stuff. They're not getting enough nutrients in them. Hair loss is not not an uncommon effect of rapid weight loss.

42:10 And so patients will say, you know I'm, I'm losing hair and we'll have to have a discussion about how that's not because of the Ozempic per SE, but that is a side effect of weight loss, so. Now, is the weight loss all fat or is it some muscle as well? It's actually. Predominantly muscle, really. Mostly that's not a good thing, is it? It's. Not a great thing, no. So I really stress with patients that when they start on a weight loss plan, especially with these medications, that strength training and exercise has to be a part of the plan because they will start to feel weak, tired, fatigued from from the muscle loss.

42:48 So that is a a big concern when using these medications, especially in more mature or elderly individuals that have a hard time building up muscles. You know, as we get older, it gets harder to to build muscle. So when the elderly especially muscle loss is is a problem. Yeah, what? About I've been reading lately black market or counterfeit Ozempic and actually the FDA came out with a warning warning people not to buy these products that are made some pharmacy. What do you know about? Yeah, so. So that typically that's going to be compounding pharmacies and you know Ozempic or Globia Manjara are all on patent.

43:31 So the exact formula that is in those pens is proprietary, that's owned by the company and it's it's not public knowledge. The active ingredients, the maglutide is a chemical that you know theoretically you can buy at a chemical store or I assume So if you are a chemist and you think that you know how to dilute the magnetite into a formula that's fit for injection into human beings, then a compound in pharmacy can certainly attempt to recreate OZEMPIC, but it's not going to be the exact thing and it's not going to be FDA approved.

44:12 And so you really don't know what you're getting and it hasn't been tested. And it's essentially an individual's or a chemist's best guess about what Ozempic is. So I tell patients it's like, you know, buying counterfeit anything. So some counterfeit objects are spectacular. You can't tell the difference. You know you can buy AI don't know a Chanel bag at, you know, the Chanel store and you know you're getting a legit bag. Or you can go to Canal Street and you know some some Chanel bags are great, but some of them are going to fall apart after, you know, two days.

44:47 I know a. Really good place so. OK, you wouldn't. Be able to tell a difference. Right, but you know when it comes to something you're going to inject into your body? You know. I I'd be a little hesitant. You know, a bag. No big deal. Yeah, I'd. Be very hesitant. It might not be sterile. You could get an infection and might have other ingredients and now they're putting fentanyl and everything. Stay away from. So I do not recommend compounded medications under any circumstances. I I know they're pricey, I know they're hard to get, and it's it's a problem for individuals who do really need these medications and can't afford them or can't get them.

45:27 But I think resorting to to compounding is not the way to go. Do you have? Patients coming to see you who don't have diabetes, don't look overweight, their BMI is pretty good and they want a prescription for Ozempic because they want to take off another 10 or 15 lbs. And what do you do with those patients? Yeah, it's. It's it's difficult, right? Because on the one hand, we don't want to promote body dysmorphia or unhealthy eating or, you know, body shaming issues like that. And on the other hand, we do want to be sensitive to the concerns of our patients and understand where they're coming from, but also realize that our society, for better or worse, seems to accept, you know, using medicine for cosmetic purposes, right.

46:20 So you know if somebody goes to the plastic surgeon and says, you know, I want a new nose, we don't really think twice about it or we don't judge them. We don't. I mean maybe we privately judge them, but as a society, you know, we don't judge them and and we've accepted that that's an OK use of of medical ability and and medical tools. That's a great. Analogy I like that so. I feel like in some ways it's it's very similar and just as a plastic surgeon explains to their, their patient who wants, you know, rhinoplasty that they look great, their nose is fine, but you know, it's bothering them, it's you know, for whatever reason their their nose still works just fine, right.

47:00 But OK, you know, they they get a rhinoplasty and our society accepts that. So I think it's very similar when individuals who are not overweight are are looking for these medications. So I think as providers we have to be very careful and of course we never, you know first do no harm. So we do have to be sure that, you know, the patient knows what they're doing, that they understand the risks and the benefits and you know, understand what their motivations are in in pursuing this type of treatment.

47:35 Is there an age below which you you won't prescribe these drugs, assuming they're not diabetic, just for weight loss? I mean in in my practice I I see adults. So I see adults. I mean the the youngest, yeah, the youngest I see in my office is about 1617. So. So I don't really have any experience with the the use of these medications in in a really pediatric population, right? But they're OK to use and people in their upper teens I. Think the biggest issue with young people in the in their teens and early 20s is, is the end game, right?

48:13 So are they going to stay on it forever, especially in women? They're not approved in pregnancy. We don't know what the effects are on a fetus. So a young woman, you know, teenager, early 20s, even late 20s, you know, who hasn't started her family yet. If that's on her agenda going forward, what's the plan here? You know, how are we going to come off of it? What's going to happen? You know, what do you do with a a teenager who's about to head off to university or to college And you know, that's a time full of changes.

48:42 So are they really in the best position to establish good habits? What's what's going to happen? So, so there's a, you know, you really have to take it on a on a case by case basis. I wouldn't say there's, you know, a hard age limit of, you know, 18/17/16 where it becomes appropriate or or inappropriate. It's more about, you know, understanding, you know, the individual and their life and, you know, making sure that they know what they're getting into, right? I'll go back to insulin for a minute.

49:11 We mentioned earlier that insulin is used for type one diabetes. That's the drug of choice. And some type 2 diabetics need insulin as well. There's been a controversy about the pricing of insulin. Insulin insulin's been around a long, long time, but the prices for some reason went way up and there's been a lot of fighting between governments and the companies. What's going on with with insulin and pricing? Yeah. So, so as you mentioned, insulin has been around for a long time, but older insulins don't work as well as newer insulins.

49:45 So we now have many different types of insulin. So there's long acting insulins and shorter acting insulins. So long acting insulins are typically administered once a day and it's sort of a background level of insulin that even if you don't eat keeps your sugar in check. And then we have short acting insulins for when you eat to keep your sugar you know appropriate in response to the meal. So those those are newer insulins and they work better than the older insulins which were sort of in between.

50:14 They would work for you know 8 to 12 hours, which is really not super helpful, right, because you want a background insulin that's going to work the whole day and then you want a short acting insulin that's only going to work for you know a couple of hours after your meal. So these newer insulins by and large are still on patent and so they they can be you know priced pretty high and they can be very expensive for for certain individuals to afford. So recently the government, the government enacted some legislation to cap the price of all insulins at $35 a month.

50:49 And I think that this is great for individuals with type one diabetes who are completely dependent on insulin the way you and I are dependent on oxygen. So we're almost, almost there about, but for most individuals with type 2 diabetes, there's very few individuals with type 2 diabetes that have such advanced disease that they actually require insulin. So if you've had uncontrolled type 2 diabetes for for a long time, your pancreas does eventually become unable to to make enough insulin and those are the individuals that that do need insulin.

51:29 But for most people with type 2 diabetes, they're not at that stage yet and so using these newer medications will actually help them prevent developing the need for insulin. The issue with the pricing is that if you have a choice of paying a co-pay of $200 a month for Jardiance or $35 a month for insulin and you're on a a limited income, what are you going to choose? Right. You're going to choose insulin and if you're telling your provider, well, I can't afford the Jardiance, your provider is going to say, well, I want you to, you know, have medication.

52:05 So I'll write you for the insulin. And so I think this government cap is going to funnel individuals who would benefit from SGLT twos and GLP ones into using insulin instead because of the price differential. And I think that that is really counterproductive in the long run to to their health as well as to the treatment of of type 2 diabetes, so. It would be better to just lower the price on the Jardiance and the. And the GLP ones make those more more affordable rather than capping the price of insulin.

52:40 It's tricky though, right, because patients with type one require insulin, right. So what are you going to do is say it's capped for some and not for others? I mean, I, you know, I don't know. So yeah. That'll be. Right. And that's, you know. Forms, Yeah, I. Mean and that's you know insurance companies to to regulate and it's tough it's tough industry right. You mentioned earlier about insulin pump. Can you explain what that is? Who uses that, who benefits from it and how it can interface with the glucose monitors?

53:09 Yeah. So it's primarily used by individuals with type one diabetes, although individuals with type 2 who need insulin would certainly benefit as well. And insulin pumps are are small devices that you fill with three days worth of insulin. So if you figure out or you estimate approximately how much insulin you're going to need for about 3 days. And then when you apply it to your skin, it does have also a little catheter. And the pump is programmed to release a small amount of insulin every few minutes running in the background.

53:44 And then the patient can interface with the pump and let the pump know when they're going to eat, how much they're going to eat. And the pump will calculate how much insulin they need based on parameters that have been put in there by the provider as well as what the patient is telling the pump they plan to eat it at that time. So the pump will calculate how much insulin is needed and will deliver it without the patient having to actually inject insulin every time they want to eat. So it really saves on injection and also allows for more individualized dosing.

54:20 So because the pumps can deliver you know tenths of the unit as opposed to whole units which we typically do with with the injections, so. Keeps your blood sugar is pretty level, prevents spikes, that's. The that's the idea and now with newer what we call closed loop systems that do integrate with continuous glucose monitors. The readings from the glucose monitor can communicate directly with the pump, which can integrate that information through, you know, various proprietary algorithms and essentially have you know AI decide how much in insulin the the individual needs at any moment in time.

54:58 It's. Almost like a mechanical external pancreas. Exactly. Yes. That's why it's called an artificial pancreas system, so. Are there companies that are making that now? Is it available? Yeah, there's a. Few of them. There's one that's made by Medtronic. There is another company, Tandem, the Tandem Insulin pump, and a third company called Omni Pod. Those are the three main players. There is a a new pump, it's a bionic pump that actually has, it's the newest one. I haven't personally used it yet. That is is very simple and all you have to do is tell it your weight and it has an algorithm built in and you just go so yeah, that's.

55:38 Pretty amazing. What about? I've been reading about pancreas transplants for patients with type one diabetes. Where is that? Definitely. It's definitely emerging. You know all sorts of transplants have various complications with rejection of of the tissue and the need for lifelong immunosuppressives. But it's certainly an an emerging area and I think once we get a little better and and more efficient at figuring out how to do it, it'll definitely be a a great treatment. There's also stem cell treatments that are emerging where, you know, we try to recreate a patient's own pancreas from their stem cells.

56:18 I think for type one, that's really the way of the future. Right. Stem cells or you can make any, just about any organ you want. So I think in the next 5 or 10 years, yeah, where is the management of diabetes heading in the next 5 or 10 years, you think? Well, I think with with type one it's certainly heading towards you know better AI to for to establish better closed loop systems that as you said are essentially an artificial pancreas an emerging stem cell treatment. There's also a very new treatment and it's been out about a year that's a monoclonal antibody treatment that attacks the antibodies and preserves pancreatic function.

57:05 So at the moment it's, it's approved for patients that have evidence of autoimmunity. So antibodies that are are going to be attacking their pancreas but still have some remaining pancreatic function. So they're not there yet, really they're not diabetic yet, but they are well on their way to becoming type 1 diabetics. So this treatment called T seals, it's a an infusion, it's given once a day for 14 days and that's been shown to delay the onset of type one diabetes by two years at least. And I think there's more research being done on whether repeated treatments might help delay it even more.

57:48 And I think that's, you know, a very cool emerging treatment for prevention of type one diabetes. Sounds fascinating. Just just to close, How often should people be checking their blood sugars, and at what age should they start checking that to see if they have or don't have diabetes? Yeah. So you know, I recommend that most individuals have their A1C checked at least once a year with their with their primary care provider. I think if you're overweight or obese, you'd certainly want to start earlier, but I would, I would think starting around 4045 is probably going to be the right age for for more.

58:28 You know, for people who are are normal weight, if you're a smoker or you're overweight or a big drinker or other kind of poor lifestyle habits, you probably want to start earlier, maybe as early as as 25 even to get your A1C checked. But you know, there's really, I, I really think that continuous glucose monitors are going to go the way of step counters and pedometers where, you know, individuals can already use them, you know, just by choice. So there's many companies on on the on the Internet calibrate Nutrasense which will sell you a glucose monitor, show you how to put it on and we'll give you a report of your data.

59:09 So I know many athletes are are using continuous glucose monitors to get information to help their performance to see how how their blood sugar moves and and relates to their athletic performance. So I think that blood sugar monitoring is definitely going to be something we're going to be seeing more of by individuals without diabetes going forward. Apple, this is a great opportunity. Your next watch should have a glucose monitor built into it right there. There are some emerging non invasive mechanisms.

59:42 There are some smart watches out there. Actually they're not very good to to be honest they're not great, they're not so accurate. But it's it's definitely a a hot area, yeah. This has been very fascinating. I learned a lot about diabetes things. I thought I knew but but didn't know. So now I think our audience love this as well. Everybody out there is now a diabetes expert. Excellent. Yeah, I'd like. To thank you very much for taking time coming today. Thank you for having. Me here? Yeah, this.

1:00:13 This was really awesome and I think everybody's going to watch, really enjoy it. And if you do enjoy it, please again, click the like button and the repost button and please send your comments so we can make even better programs on the Doctor podcast show. Thank you.