More than 10% of Americans have diabetes. Type 2, the more common one can be prevented with healthy habits, like managing stress levels, or having a healthy relationship with food. In this excerpt from the Conversations on Healthcare podcast, co-hosts Mark Maselli and Margaret Flintner visit with Dr. Robert Gabbay, Chief Scientific and Medical Officer for the American Diabetes Association. The topics include weight loss drugs, current diabetes technology, and needed access to healthcare for those who suffer from or are likely to suffer from diabetes. The conversation begins with host Mark Maselli asking Dr. Gabbay about current statistics about diabetes that many may not know about.
Full Transcript:
Mark Masselli
But I wanted to start off with some facts that I don't think many Americans know, that the cost of diabetes to the U.S. healthcare system is over $400 billion a year, and that 1 in 7 American adults have type 2 diabetes, now up from 1 in 20 in the 1970s. I want to start off, though, with the cost of insulin. There's a Medicare cap on the cost of insulin, and 25 states in the Washington D.C. have cost limits on insulin. But what about the rest of the country? What can and should be done to make sure that all Americans have equal access to these reduced prices?
Dr. Robert Gabbay
The American Diabetes Association has really been engaged over the last several years in ensuring that all people that need insulin have access to insulin. And so that battle has taken us a lot of different places. As you mentioned, we've been successful in many states from the Medicare perspective, but we still need more work to be done to extend it to all states and ultimately for all payers.
And we continue to engage in efforts to ensure people have access to insulin.
Margaret Flintner
Well, Dr. Grave, let's talk about some of your recent updates. Your association has updates on cardiovascular health for people living with diabetes, including some new screening recommendations for heart failure. Tell us about these changes.
How are they going to help with the overall wellness of this population?
Dr. Robert Gabbay
You know, one of the things that we know is that people with diabetes are at greater risk for heart failure. And we now have new treatments that can prevent any progression of the earliest form of disease. And so as a result of that, we've made recommendations for those individuals that are at high risk for developing heart failure.
In other words, they might have type 2 diabetes, high blood pressure, obesity, lipid cholesterol issues. Those individuals should get screened with a blood test, a relatively simple blood test, BNP. And based on that, you can tell whether somebody may actually have heart failure and evaluate them further.
Mark Masselli
You know, there are a lot of new words that get added to the English language each year. I think ozempic falls into that category of new words. And it's really one of the biggest pieces of recent diabetes news has obviously been the approval of injectable weight loss drugs such as ozempic.
They're leading to a reduction in blood sugar levels. I wonder if you could share with our audience what the latest research on these drugs is and what's your view on their use?
Dr. Robert Gabbay
Well, there really have been a very exciting new entry into the ways of managing individuals with diabetes and helping them achieve their goals. And we know that weight is so critical for most people with type 2 diabetes. But honestly, even for people with type 1 diabetes, about a quarter of them live with obesity as well.
And obesity leads to all sorts of potential complications, not only worsening diabetes, but increasing the risk of heart disease, sleep apnea, a whole series of other issues. Up until recently, the only medical treatments that we've had, you know, we've certainly had lifestyle, and that continues to be important. And the only medical treatments we've had have maybe resulted in 5-7% weight loss.
And then these newer medications come on the market and they result in anywhere from like 15% weight loss or higher. Something almost what we previously had seen with surgical options. And so they've really been an important tool in helping to manage diabetes.
Mark Masselli
Is there any shortage of ozempic and that type of drug right now? Maybe you could talk about that. And I know it's also off-label being used in different parts of the world.
Dr. Robert Gabbay
We have been monitoring the supply chain and the availability of these medications because there has been a big demand for them. This seems to be getting better as time goes on, and the hope is that anyone who needs and would benefit from these medications would have access to them.
Margaret Flintner
Well, Dr. Gabay, you've written, and I think I'm quoting here, that obesity is included in the litany of chronic diseases that plague 6 in 10 Americans, except by Medicare, which consistently refuses to cover treatment for obesity until it causes significant health problems like diabetes or heart disease. I have a feeling you've given a lot of thought to this issue, so take a moment and fill us in on your perspective, and do you see this changing as Medicare seems to be committed to continuing to work towards a more preventive-oriented agenda?
Dr. Robert Gabbay
It really is important that we try to get upstream of diseases. We know that obesity is a disease. It's a big driver to the increasing numbers of people developing diabetes, and it's important that people have access to treatments that are effective, and at least at this point, Medicare is not covering those treatments, and that's something we've been advocating for.
Margaret Flintner
And it would seem that we would have the same issue with Medicaid, and hopefully at a much younger age, since Medicaid is the primary public insurance for children, and certainly the issues of obesity in children are very paramount in our prevention agenda. Anything that you're doing in that area to focus on the school-aged children, for instance?
Dr. Robert Gabbay
Well, school-aged children are another group to be considering. There's really an opportunity with them to do a number of lifestyle interventions that can really be beneficial, and we'd like to see more of that spread across the country.
Mark Masselli
Well, I want to pick up on your theme of access to treatment, and certainly you understand that in here, in the community health center movement, school-based health services, access to care is very important. And also, for racial and ethnic groups, some very troubling data points that Black Americans are 60% more likely to be diagnosed with diabetes by their provider than white adults, and Blacks with diabetes are three to four times more likely to have a limb amputated than a white person with the same conditions. The rate of amputation seems to be getting worse.
I wonder if you could just describe what initiatives are underway to address these disparities.
Dr. Robert Gabbay
It's an incredibly important issue that the American Diabetes Association has really leaned in, and over the last several years, we started with really a call for health equity now, and as part of that, a bill of rights that really speaks to everybody having access to the things that help them live healthy with their diabetes, whether that is medications, technology, screening tests, and healthy food. Many of these statistics that you describe are driven in part by the zip code people live in and the availability of care, healthy foods, safe exercise, and so all of those things have been areas where we've been working a great deal.
On the issue of amputation, I'm glad that you brought that up because most people don't realize that that's one of the few complications of diabetes. It's actually getting worse. We've made progress on many others but not around amputation, and so in our standards of care, the Global Guidelines for Diabetes, we've also included information about early screening for peripheral arterial disease, one of the reasons why people may get amputations and working effectively in that area to really identify people early to prevent amputations.
Margaret Flintner
Dr. Gabay, I have to say you're just making a great case for people need access to really excellent primary care. The screening for the peripheral arterial disease, for the retinopathy, for the kidney disease, for nutrition education and counseling, thanks for making that so clear. We have just got to do something about those increasing rates of amputation.
But tied into all these concerns, and I think it's another area where we see a real disparity between people based on, as you say, the zip code perhaps as a marker for economics and education and access to resources, but it's the need for access to the best diabetes technology that we have today. Certainly an example of that that many people are familiar with is continuous glucose monitoring and being able to maybe do that remotely with your results being channeled to your primary care provider. I know you and others are involved in this initiative to make it more widespread where appropriate.
How is this working again, particularly from a racial equity viewpoint?
Dr. Robert Gabbay
We've had some success, but we honestly have more to do. One of the first steps in coverage for technology is really derives out of our standards of care and providing the evidence. Last year, we made the unequivocal statement that anybody with diabetes on insulin, whether they're a child, an adult, or an older adult, should have access and availability of a continuous glucose monitor.
As a result of that, we were successful in getting Medicare coverage, and we were really pleased about that for those populations. Now I've been working state by state with Medicaid, which, to your point, is really the mechanism that we can address the inequities in terms of access to treatment. The other thing I'll sort of point out is we've been doing a lot of educational efforts targeting primary care in particular to ensure that they're comfortable with the technology, with interpreting the results, and be able to guide their patients to manage their diabetes effectively.
Mark Masselli
I want to pick up on your theme earlier about complications with diabetes, and while Americans wish that COVID was in our rearview mirror, it is here, still with us, and quite prevalent. But there are serious complications that can arise if one gets COVID and has diabetes. Maybe talk a little bit about that.
Also about the research that's needed in this area, particularly around the issues around long COVID and the others. Sort of a waterfront of issues to handle there, but I think for most Americans, COVID is still very present somewhere in their community or within their families.
Dr. Robert Gabbay
We've been fortunate that things are better than they were, but at its peak, COVID pandemic really devastated the diabetes community. At one point, as many as 40% of the deaths were with people living with diabetes, and so really staggering. Individuals with diabetes, when they develop COVID, tend to do much worse, much more likely to be hospitalized, increase mortality, all of that.
And then the other interesting piece that has been evolving is whether COVID itself may lead to the development of diabetes. And there have been some studies seeing an increase in type 1 diabetes and also in type 2 diabetes. So that's an area that needs to be further studied, how the virus itself may be causing diabetes.
And again, as you started this program with the rising numbers of individuals developing diabetes, the last thing we need is anything fueling that further.
Mark Masselli
Is PaxLovid sort of drug of choice at that point if somebody with diabetes gets it? Are you looking at any of these? Maybe talk a little bit about long-term COVID and its potential treatment.
Metformin, other things that might be being used in treating this?
Dr. Robert Gabbay
PaxLovid certainly is something indicated for people with diabetes developing COVID because they are at much higher risk for more dangerous complications of COVID infections. So that is very much a recommendation. Long COVID is something that we're still honestly defining and in many ways really trying to understand how common it is.
But early studies suggest that people with diabetes are once again more likely to develop long COVID. All the more reason to avoid infection and then treat that infection with PaxLovid.
Margaret Flintner
Dr. Gervais, I want to pick up my theme again around the importance of the routine screenings in diabetes care that we know are so important, often pose access barriers for many people and one of them is certainly in the prevention of blindness. I think people perhaps in years past thought it was inevitable that there might be loss of vision in diabetes but we know that with early detection we can actually remedy that and of course we need to talk about artificial intelligence and its role in all of this. So tell us about the emerging artificial intelligence technology and the role it might play in eye screenings, which is so important and can this eye screening take place in routine primary care?
Dr. Robert Gabbay
Very important issue. You know, diabetes continues to be a leading cause of blindness and it is largely preventable. And how do you prevent it?
It's really catching it early and how do you catch it early? Yearly eye exam and despite that being very clear, only about 60% of people living with diabetes get a yearly eye exam. So everything we can do to make that more accessible and more available is really important.
Having that done in primary care with retinal cameras is one way to be able to do that. The technology is really advanced to be able to take a picture of the eye and be able to diagnose early disease and then refer somebody to ensure that they don't lose their sight. And the technology is now advanced with artificial intelligence to be able to read those retinal images effectively and be able to tell significant disease versus you sort of have it all clear and just come back next year for that eye exam.
The FDA has now approved several technologies that use AI to interpret those retinal photographs and our hope is and our recommendations and our standards of care were that those are an effective tool to be able to use to increase the number of people that get eye exams done, particularly to your point, in primary care where most people with diabetes get their care.
Mark Masselli
The intervention for diabetes is really sort of being reframed in a much broader context and the Federal Commission on Diabetes recently delivered a national report to Congress on diabetes and it was really the first of its kind in 50 years and what was interesting is that, as I said, it reframes the diabetes epidemic as social, economic and environmental problems and not just health issues. The experts suggest improving access to healthy foods and rethinking transportation networks are part of the answer. I'm wondering how the ADA feels about this larger reframing and maybe any initiatives that you have going on that might address some of these areas outside of the four walls of the medical office, which are very important, come on in for your primary care, but also where you live, breathe, pray and enjoy life is also important.
Dr. Robert Gabbay
Very much so and diabetes probably more than any other disease is so dependent on what the individual living with diabetes does in terms of their self-management and helping them to do that is really the role of the healthcare system and at the same time they're only seeing their healthcare professional once every two or three months, so what happens during all that time in between it's all the decisions that they need to make on their health and part of that really falls onto this broader area that is often referred to as the social determinants of health and it turns out that those social determinants where you live, poverty, access to healthy foods, safe places to exercise, transportation to go to your appointments all of those things turn out to be as important as what the healthcare system delivers and so there's been interesting work where healthcare systems have engaged in community interventions and we at the American Diabetes Association have been doing that in a number of communities in Chicago working to ensure access to healthy foods for many of these individuals that we've been partnering with it's the first time they're really having access to fresh vegetables and then teaching them what to do with them because sadly this is not something that they've had access for so really important issue
Margaret Flintner
Dr. Gabay, I'd like to give you a chance to maybe shine a spotlight on an annual research report of the ADA that highlighted efforts to improve outcomes specifically for the deaf community living with diabetes through some specially designed programs. Tell us about that
Dr. Robert Gabbay
We fund a great deal of research and have I think 171 active grants that we are managing right now and one of them is a really exciting one by an investigator Michelle Litchman who is solving the problem of individuals with hearing loss and how do they learn about diabetes and it turns out there's a huge gap there they tend to do far worse with their diabetes than individuals that have normal hearing and because of the communication, because of the understanding, they may or may not know sign language there really needs to be better ways to reach out to them and this research project has been developing those tools to help that community
Mark Masselli
Such an important issue. You know you were talking earlier about social determinants of health and really want to talk a little bit about the mind-body relationship with diabetes and people with diabetes are 20% more likely to experience anxiety than people without diabetes and 40% of people with diabetes have said they have struggled with their psychological well-being since being diagnosed I'm wondering how the ADA is addressing these psychological issues to go along with the physical ones.
Dr. Robert Gabbay
Well one of the important ways we've been doing that just from Margaret's last question is around supporting research each year we target different areas to make our investments and one of the big areas over the last year has really been about mental health so those statistics are really concerning it also turns out that about a third of people with type 2 diabetes are at risk for depression as well and we know that individuals with diabetes that have any of these mental health issues tend to do a lot worse so thinking through the interventions that can be done to help we've also established a mental health directory to help health care professionals as well as people living with diabetes find a mental health person that they can work with to be able to address their issues.
Margaret Flintner
Dr. Gabay we've had a chance to talk about the very important work that ADA is doing around prevention around helping people live better lives with diabetes about preventing the complications I'm thinking this year brought us the big news around sickle cell disease and the hope of a cure through CRISPR technology and some of the things that we look forward to playing a greater role in the future. Would you like to take a moment to tell us is there anything on the horizon undergoing research that looks at a cure for diabetes at this point?
Dr. Robert Gabbay
Very exciting period right now and probably the most promising and something that's been active research for a number of years is the idea of being able to replace the cells that are either destroyed in type 1 diabetes or not functioning appropriately in type 2 diabetes, the insulin producing cells. There is now the ability to take a blood sample, isolate those blood cells and devolve them into stem cells and then grow them into insulin producing cells then potentially transplanting them into individuals and that's happened with some early success and the next level of problem to solve is dealing with the immune system that these cells do not, would not get destroyed and to your point, one of the technologies that's being used is actually CRISPR technology identifying what it is on those insulin producing cells that attracts the immune system and can you alter that cell surface so that it won't be recognized as something to destroy and allow these cells to thrive, continue to produce insulin and not require people to take immunosuppressive drugs that have the downsides of just broadly suppressing the immune system.
Mark Masselli
Tell us a little bit about yourself. How did you get to where you are today?
Dr. Robert Gabbay
Really for me, professionally I've been in the diabetes world my entire professional career and I started as a basic scientist working in the laboratory trying to understand how insulin signaled at the cell level. Finishing my PhD, I realized that I wanted to be, have a greater impact in a more applied and direct way and so I went to medical school and became an endocrinologist over time and treating patients and I still see patients at my former institution the Jocelyn Diabetes Center. I had led before coming to the American Diabetes Association and for me it's really about how to have an impact on as many people as possible and that's the wonderful thing that the American Diabetes Association does.
We fund research towards a cure, towards solutions to help people in the here and now. We advocate for people living with diabetes and we engage the healthcare professionals to guide them on how to deliver the best possible care in lots of programs from establishing what those benchmarks and clinical guidelines are in our standards of care to educating and working directly with clinicians to help them change their practice to deliver care better. One of the ways that your audience can engage with the American Diabetes Association is through our website diabetes.org where there's a wealth of information on a lot of what we've talked about, how to live healthy with diabetes and what kind of research we're doing and all of the things that we've been talking about. In addition, an opportunity if they want to support this important mission so we can do even more to help people living with diabetes and those at risk.
Mark Masselli
Speaking of support and you're down in the Washington, D.C. area. Congress is still, haven't passed a budget. What are the implications for diabetes research and treatment and where should people be looking to focus in on in addition to the monies that come to the ADA?
Where is the bolus of dollars in the federal budget?
Dr. Robert Gabbay
One area that we've been advocating and we continue to is really around research funding and that is largely through the National Institute of Health that has the sort of largest opportunity to fund diabetes research. Tends to be more at the basic level and then there's the Center for Disease Control that has many programs to help people with diabetes and also to prevent the development of diabetes. Advocate for increased funding to those agencies that can really make a difference.