On this Diabetes Alert Day, March 28, 2023, we present a conversation with Carolina Solis-Herrera, MD. Solis is chief of endocrinology in the Joe R. and Teresa Lozano Long School of Medicine, which is part of The University of Texas Health Science Center at San Antonio. She speaks about both diabetes and obesity, which she treats in patients at the UT Health Physicians diabetes, obesity and metabolic health practice.
Q: Dr. Solis-Herrera, what is one of the newer medications for type 2 diabetes and obesity?
A: Thank you for the opportunity to talk about this important topic. Semaglutide is one of the medications we have at our disposal to treat patients with these conditions. In addition to treating diabetes, one of its additional effects is that you lose weight because it curbs your appetite.
The following has not been addressed often in the media, and it is very important for the public to know. Some clinics are announcing semaglutide for $25 in social media. It is not clear the formulation or the dose the patients will be receiving, which creates safety concerns. We advise patients to see their physicians to be prescribed any medication.
Q: What class of drug is semaglutide, doctor?
A: It is a GLP1-receptor agonist and is what we call a second-generation drug for diabetes and obesity. Currently, more medications are in the pipeline for treating these conditions.
Q: Do you think people underestimate the risks of obesity?
A: It is very important for the public to know that, just like diabetes, obesity is a chronic inflammatory disease that needs to be addressed immediately with lifestyle intervention and FDA-approved medications. Obesity is as important as high blood pressure, high cholesterol and diabetes, and has just as many complications that if untreated increase the risk of heart attacks, strokes, increased blood pressure and diabetes. It also decreases life span. It is very important, if you are overweight or obese, to seek medical attention.
Obesity can affect every organ, from your brain and lungs to your heart and kidneys, among many other organs. Obesity is associated with and increases your risk of multiple cancers including colon, liver and pancreatic cancer, and it seems to also possibly be associated with dementia.
The obesity pandemic needs to be treated as an emergency. According to a recent study, for the first time in our lives we’ve noticed life expectancy in America starting to go down. After a century of increasing life span, in 2020 the average longevity dropped 1.8 years and in 2021, it fell another 0.9 years. That is the biggest two-year decrease since the 1920s.
The drop is even greater in minority populations, including Hispanics and Blacks, and it is in part because of diabetes and obesity.
Q: You don’t have to be diabetic to be obese, right?
A: Correct. However, patients with obesity may have insulin resistance, which might later translate into type 2 diabetes. Inversely, about 70% of patients with diabetes are overweight or obese. As you gain weight you become more insulin-resistant, and this is how both pandemics of diabetes and obesity go hand in hand.
Obesity and diabetes are associated with the potential development of fatty liver, fatty kidney, fatty pancreas and fatty heart as fatty acids continue depositing in different organs. We usually only talk about fatty liver, but damage in the other organs is also devastating.
About 80% of patients with diabetes have fatty liver. The American Diabetes Association recommends that 100% of patients with diabetes get screened for it. Why? Because a percentage of these patients will develop liver cirrhosis and end-stage liver disease and will need a liver transplant.
Q: And they are at risk for liver cancer.
A: Yes, obesity and fatty liver may increase the risk for hepatocellular carcinoma. Therefore, screening for fatty liver is so important. The best treatment for fatty liver is weight loss. When patients lose weight and improve their glucose control, we are also treating the fatty liver.
Q: New drugs help patients lose weight, but what about lap bands and gastric bypass to treat obesity?
A: Bariatric surgery certainly has a place in the management of obesity. First, not every patient is a candidate for a GLP1-receptor agonist such as semaglutide. If they have a history of severe pancreatitis or they cannot tolerate the medication, we will need to use other resources to help them lose weight.
Oral medications that we call first-generation obesity drugs, which came before semaglutide, may help patients lose about 5% to 8% of their body weight, which is still very good. As you lose more weight, there are better outcomes in your diabetes control and the complications of obesity.
Our goal is to help patients lose about 10% to 15% of their body weight. Their sugar will get better, their fatty liver will get better and their overall health will significantly improve. Blood pressure will get significantly better. They will be able to cut down on their medications.
Patients who have a body mass index over 40 and other comorbidities, and go through a specialty assessment, could be good candidates for bariatric surgery. This type of surgery will help them lose a significant amount of weight, with the goal of improving their health and life span. However, they need to start with changes in lifestyle and, if possible, anti-obesity medication.
It is important for all patients to be treated in a multidisciplinary way, meaning they receive a continuum of care encompassing proper nutrition, behavioral therapy, medications and, if indicated, bariatric surgery. Following a bariatric procedure, they need follow up, because after surgery, the body might have some vitamin deficiencies and also might regain some of the weight.
This is why obesity is a medical condition that requires long-term follow-up. It is just like high blood pressure. The day that you remove the medication, your blood pressure goes up. For obesity, the day that you remove the medication, the weight comes back, and if you already have comorbidities, they come back as well. Education of primary care providers and patients is greatly needed in this area.
Q: That is an important message for the public. These and other medical conditions need continuous education and action every day, not only on Diabetes Alert Day, correct?
A: Yes. Remember, we are in a part of the United States where type 2 diabetes prevalence is among the worst in the country. About one in six people (16%) in San Antonio have it and many of them don’t even know it. In the Rio Grande Valley, it is closer to one in five people. The public needs information about diabetes and obesity to help communities stay healthy.
Q: Hemoglobin A1C, the three-month test for diabetes, is interesting to people. You can be lulled into thinking you are OK because your HbA1C looks good, right?
A: Yes, because you can have a lot of highs and lows in your sugars and HbA1C, which is an average of your sugar values over time, will not reflect it. This is where continuous glucose monitoring, or CGM, is important. CGM is a service that we provide here at the UT Health Physicians diabetes, obesity and metabolic health practice.
CGM can show you if the patient is having significant episodes of low or high sugars, and we are able to adjust medications accordingly. The device is the size of a quarter or a penny depending on the brand. It feels like a little shot as it is attached. Patients wear it for two weeks, then return. We download the report, and it’s a great teaching tool for the patients and physicians. The device also has alarms, which are a great advantage for patient safety. If a significant low or high are present, alarms will alert you to check your sugar, and take action before there are any negative outcomes such as severe hypoglycemia (low blood sugar).
CGM devices represent a technological advance that improves outcomes in patients, decreases hospitalizations and likely saves lives.
Q: Thank you for this timely discussion, Dr. Solis-Herrera.
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