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Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole. Joining me today is Dr. Fernando Ovalle. He's the director in the division of Endocrinology, Diabetes and Metabolism at UAB Medicine, and he's here to discuss the latest treatments for type one and type two diabetes in the diabetes belt. Dr. Ovalle, it's a pleasure to have you with us as we get into this topic, and we're hearing more and more about the epidemic and the obesity epidemic, and we're gonna talk mostly about type two here today. But can you tell us just a little bit about the prevalence of diabetes in central Alabama? What you have been seeing in the trends?

Dr Fernando Ovalle: Oh, hi Melanie. Thank you for having me. Well, the prevalence of diabetes as, you probably have heard this, is high and it keeps going up. Right now in Alabama, think the state prevalence is, roughly around 12%, 13% depending on how you count it. But there are some counties in central Alabama, where the prevalence is as high as 19% or almost 20%, and that means almost 20% of all adults, and I'm talking about adults, have, diabetes, that's one in five people over age 20. If you look at people over age, 40 or 60, 65, then the prevalence goes even much higher. Sometimes as high as, 50%. so the prevalence is, very high.

Melanie Cole (Host): Well then with that increasing prevalence, what are some of the complications that you see most commonly in this population?

Dr Fernando Ovalle: It's a mix of things and I think we have different groups of people who tend to get different, complications, but if we pull them all together, all people with type two diabetes, then I would say neuro. it's one of the most common ones. I would dare to say that almost all people would tap to diabetes by the time they get diagnosed, have neuropathy. Whether it's symptomatic or asypmptomatic, that's a different question and whether, what tests you need to do to determine that, that's a different question.

But there are papers out there all papers that suggest that 70, 80% of people at diagnosis already have neuropathy. And that's pretty much probably what I see in clinical practice. As a matter of fact, if somebody comes to see me with a diagnosis of type two diabetes, and I find that they have deep tender reflexes in the ankles still present. That is one of the rest flag to me like, You know, am I dealing really with tap two diabetes or am I dealing with some other type of diabetes? Because I expect it to be present.

Now, I don't expect everybody to complain about it or to have pain, but what I expect them to have some degree of loss of sensation, that's very common. Then the other very common, especially here in the southeast, is, kidney disease. The number of people who have protein on the urine or having in the urine, or a decrease in their kidney function is just staggering. I would say that probably over 50% of the patients that I get to see have, chronic kidney disease. And that much more dependent on the subtype of diabetes and the background of the patient who has diabetes.

And if you are African American, the chances of having kidney disease are much greater. If you have a family history of that, it's even greater. And then retinopathy. Retinopathy tends to be a little more difficult diagnose for the routine, physician who's not an ophthalmologist because, you have to be trained and, spend time looking at their eyes. And the equipment that we have in the regular offices is usually not adequate enough to allow us to do a good job of screening for that.

But I pride myself having good training on that and being able to look for that. Then I also find it quite common. A lot of the people, who have kidney disease already have retinopathy as well, mild or, beyond. So all of them are very common. But I would say that by far the most common is neuropathy.

Melanie Cole (Host): So as we're talking about those complications, there's also many comorbid situations going on, maybe high blood pressure, or as you mentioned, kidney disease. What are some clinical interventions that you've seen to be most effective when you're combating those common complications and comorbid conditions?

Dr Fernando Ovalle: Thank you for asking that because, it's very important to note that, almost everybody would have two diabetes, are obese, or at least overweight. And that's the one common denominator for type two diabetes. The one thing that if we were to address it, we will tackle everything if you treat diabetes, if you help, people lose weight, their blood glucose gets better and therefore anything related to blood glucose gets better. If the blood pressure gets better and anything related to blood pressure gets better, and then anything directly related to obesity also gets better and insulin resistance, et cetera.

So, That is at the root of the problem in type two diabetes. That's not to say that there is other things that we need to worry about, and there are people who are not obese. Now, when you talk about people who are not obese, then you start getting to semantics that we're really talking about type two diabetes. And isn't that a different subgroup? And it depends how you interpret the current definitions of type two diabetes that have been proposed by the American Diabetes Association and the second, by others organizations around the world. But even with a lose definition of type two diabetes, obesity is quite prevalent. And I, would, say that is, where you get the most [inaudible].

Melanie Cole (Host): So you're working on those comorbid conditions, and specifically as you've said, the prevalence of obesity is what complicates so many of the situations. Now, as we're talking about that increasing prevalence, How much do you rely on patient provided data when it comes to your management strategies? There are new technologies that we're hearing about Dr. Ovalle, like continuous glucose monitoring. Speak about that role in diabetes management, professional versus personal CGM use in clinical practice.

Dr Fernando Ovalle: It's really transformed the way we manage patients and it's really helped our patients a lot and it's helped us a lot as physicians as well. Makes everything more clear, less frustrating. We're guided, we're doing something with data. Even if you do nothing else, if you just give somebody a sensor, and I'm talking about they continue to glucose monitors that patients can actually read and see. By just giving it to them and putting it on them, you empower them. And that is very important.

People like to see data too, even if they don't know it, if they're not very, tech savvy. If you give a goal, if you give them a number, it's just like giving them a little game. People respond to that. And, some people it's because they're competitive. Some people it's because they get concerned. Some people it's because they needed some guidance and they just, don't know whether what they're doing is correct or not. They don't know what's making things worse, what's making it better, and that by itself makes people do better.

There is evidence out there that shows if you put somebody in a continued glucose monitor with nothing else, their aA1C improves by about 1%. And we see that all the time. Some people even better than that. So that's, very important. Also, when you say about how do we trust people there? I trust it. I trust it a lot there is always a few, bad apples where you know, they're not telling you the truth, but you once you put them on this continuous good monitors, everything becomes more clear. But in most cases, in 98% of the cases, you can trust what the patient tells you.

They're not gonna come and, waste their time with you. They tell you what's going on and I trust their data. Frequently, much more than I trust the A1C. A1C has a lot of flaws and we've learned over the years. We knew some of these flaws even before we had so many continuable monitors, available out there. It's even become much more clear now that, we're missing a lot by just trusting the A1C alone. So the technology, it's been helping a lot and it's improving rapidly. It's a great advancement.

Melanie Cole (Host): Doctor tell us what's going on in medication intervention. How has that changed over the last decade or so? What are some of the developing diabetes treatment options that you feel are most promising and the role that physicians have in seeking new and developing diabetes treatments as you're working with these patients and you're seeing what works?

Dr Fernando Ovalle: So there's several medications. There are several classes of drugs that have been developed over the last, 10, 20 years, that have just now being started to get used more commonly. And they're taking off, and I'm talking about the two cluster of drugs I'm talking about are the sodium glucose, called transport inhibitors. And, what we call SGLT2 inhibitors and the GLP1, receptor agonist. And now the, dual GIP and g l P one receptor co agonist and those are, the classes of drugs that have, really come to make a huge difference in the management of diabetes.

Not just because they're very effective in terms of, blood glucose control because, we could have done a lot of this beforehand. before we had these drugs, we could just give more insulin and get the blood glucose down or use other drug therapies that we had and a very effective of blood glucose. But the problem was, that's all they did. or, most what they did was just lowering glucose. And while that's important, very important, we don't wanna, come across as saying that lowering glucose is not important, because that can easily be misinterpreted.

There are many other things that were not doing with the previous drugs that we used and that now we are, to start with, these drugs are addressing other things that we didn't before. And, one of them is the role of the kidnies, in glucose metabolism. we know that the glucose blood is, a direct, effect from what we eat, the exception is glucose intake. Plus what we make and the liver makes two thirds of it and the kidney makes one third of that. So, we were missing a chunk of the, pieces of the puzzle in there.

And now we have a way to not just understand it better, but also to manipulate it. The other, is the role of the GI tract and the role of glucagon. And, for that we have the incretins, GLP1 receptor agonist, and now the dual agonist, which have also kind of reminded us that it's just not insulin. We're dealing with, we're dealing with a whole set of other hormones that regulate glucose metabolism, and these other hormones are just as important as insulin. Now, insulin, if you compare them all, alone as how, insulin of course, is very powerful and it's one of the most important.

But that doesn't mean that the other ones are not important and they are extremely important and we're learning and learning more about glucagon and not just glucagon itself, but the glucagon like peptides and their effect on the receptors, and how. complex that is, it's just if you activate one receptor, each of those receptors by themselves, the effect that you get is different as, compared to when you activate them all together. So the field is really advancing rapidly and become a much more, complex, but at the same time, it's been very helpful to have these tools nowadays.

Melanie Cole (Host): Well, it certainly is rapidly advancing. And before we wrap up, I'm gonna ask you to recommend to primary care physicians about anything you would like them to know, whether it's using diabetes technology in their primary care practices or update on anything that you would like them to know. But before you answer that, I'd like you to just give us some latest recommendations on diabetes lifestyle management, because as lifestyle management remains very basic to long term management of diabetes and there's no one size fits all rules. And so you were discussing a little bit earlier and the prevalence in Alabama, so speak about lifestyle management and then segue into a summary of what you would like other physicians to take away?

Dr Fernando Ovalle: What we can all do right now is, obviously make sure that we don't lose sight of the fact that, diet, and exercise. But most important diet makes a huge difference in all these metabolic diseases. Diabetes been, the most, obvious out there. But we don't wanna stop emphasizing the need for a diet and changes in diet and not just tell people you need to lose weight. Because people, they've heard that a million times and we know it's extremely hard. You gain 10 pounds and it's just so hard to lose it.

So we have to make sure that we're empathetic, that we try to understand. People are going through that is extremely difficult. They hear us but they hear it differently depending on how we say it. So it's important that we support them, that we tell them I'm with you. I understand. And try to cheer them up and empower them little gains a little bit at the time, and give them the tools. And I would say, out of everything out there, of course, medications are extremely helpful and important, losing weight nowadays.

But those new tools that we're developing that give people data are extremely helpful because people tend to try, if we give them the tools, they will do it. if we give them a tool, like a continuous glucose monitor that in a diabetic allows them to tell, Hey, what you ate probably was either too much or the wrong thing. It's extremely valuable. It's maybe not for everybody, but for most people it allows them to change their behavioral modification tools that are really powerful.

So I would say there's nothing else other than counseling, these new technology tools, we need to use them and giving to people just to make it easier for them. They're extremely helpful. They probably just, think that if we had a tool or a sensor like that would allow people to know how many calories they're eating. People will stop after, we tell them, Hey, this is how much you burning in a day. And you have a gage just like you having the gages in your car, for the gasoline, you know how far you can go and you're not gonna drive from Alabama to New York with just one gas tank.

You know, You know you're gonna have to stop and how far you can go before you have to stop for gas. And the same thing when you eat, how many calories you can eat per day. If we had those tools that will give people that type of data, that will be extremely valid. And of course we don't have that yet, but I'm analogizing this to make the point that data makes a huge difference. When you exercise, for example, it makes a big difference if you know, haven't done this before in a spinning class where you had data. Including your heart rate, including how much power you were generating.

How much, energy you were generating in watts and Not just calories, but watts energy, that, data driven approaches to, whether it's exercise, diet, or, glucose management are incredibly, helpful. We do it all the time with other things. We do it with blood pressure, we do it with, oxygen, we do it many other things that we do in life nowadays. Would emphasize the use of the technology nowadays.

Melanie Cole (Host): What great information, really up to date and you're so succinct about it. So thank you so much Dr. Ovalle. It's such an important topic, and thank you for joining us. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST, or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole.