Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And we have a panel for you today with Gwendolyne Jack. She's an Assistant Attending Physician at New York Presbyterian Hospital, Weill Cornell Medical Center, and an Assistant Professor of Clinical Medicine at Weill Cornell Medical College Cornell University; and Rachel Stahl Salzman, she's a registered dietitian and a lecturer in Medicine at Weill Cornell Medical College Cornell University. And they're here to highlight advancements in obesity care and diabetes management for us today.

Thank you both so much for being with us. And Dr. Jack, I'd like to start with you. I'd like you to talk about the prevalence and the current state of obesity today. It's really an epidemic, and how has that prevalence that we're seeing and the rise in obesity contributed to the rise in diabetes? Connect those dots for us.

Anyanate Gwendolyne Jack, MD: So, thank you for the question. What we can see from the data is that, over the past several decades, the rates of obesity as well as diabetes have increased. So, for example, it is estimated that the obesity prevalence is approximately 42%, and this is an increase from about a decade ago when it was 30.5%. Similarly, the rates of diabetes have also increased quite significantly over the past few decades, and it's estimated that approximately 38 million adults in the United States have type 2 diabetes, and really stark because approximately one in every 10 people has diabetes in the United States. And glaring to that is that one in 5 people are not aware that they have diabetes. And then, when we also think about the precursor to type 2 diabetes, prediabetes, it's estimated that 90 million adults in the United States have prediabetes. And more than eight in 10 people with prediabetes are not aware that they have it. So, more than 80 percent of people with prediabetes are not aware.

And so, it's really important to understand that there are so many different factors that play a role. There can be a role of genetics. There can also be a role of the environment that we live in and having access to healthy food options, having access to physical activity and also understanding the stressors that play a role in increasing the risk for diabetes and obesity.

Melanie Cole, MS: Those are some startling statistics. And yes, we're seeing this rise, and it is really very interesting to connect those dots. And I thank you, Dr. Jack, for doing that. Rachel, where in the spectrum now of diabetes diagnosis is obesity a factor? As we're looking at this increase in diabetes, there are also other risk factors for diabetes as well, so where in the spectrum is obesity considered a major risk factor?

Rachel Stahl Salzman: Obesity is a major risk factor for the development of type 2 diabetes. And this risk factor has, been a really crucial component for helping to address both the prevention and management of type 2 diabetes. And our leading organizations that we look to for guidance, the American Diabetes Association, the American Association of Clinical Endocrinology, all highlight in their treatment guidelines and algorithms that the treatment of obesity and weight management needs to be front and center. So, that really goes to emphasize the importance of that.

But like you said, Melanie, and as Dr. Jack alluded to, there are other risk factors that we need to consider when we work with the people that we care for. Genetics, family history of type 2 diabetes, certain racial and ethnic groups who are at higher risk for developing type 2 diabetes, being physically inactive. And certainly, the food, you know the type of food that people are eating in our country.

Melanie Cole, MS: That's true. All those things. That's so interesting. So, Dr. Jack, the most significant challenges that clinicians face in managing patients with both obesity and diabetes, and as someone who's worked in that field as well, these challenges are so not unsurmountable, but they are certainly a challenge. Speak about that and how that impacts patient outcomes.

Anyanate Gwendolyne Jack, MD: Yeah. So, I think just underlining the point that obesity is actually linked to estimated to more than even 50% of new cases of type 2 diabetes, right? So, underscoring the importance of addressing both at the same time. Part of the challenge is that there are a lot of systemic issues that need to be addressed in terms of access to healthy food options that are also cost effective or affordable. Also, access to medications that have been shown to be beneficial for not only lowering the glucose or blood sugar, but also helping with weight management as well. And then, having access to healthy green spaces to allow for increased walkability; having access to, again, optimizing or increasing physical activity. So, really being able to have adequate resources and making sure that those resources are distributed in an equal manner to everyone.

Rachel Stahl Salzman: And I would add here, just taking it a little bit more in a specific example is when people that have obesity or diabetes present to us, they often might have other comorbidities that we know having obesity and type 2 diabetes can increase their risk for, things like cardiovascular disease, kidney disease. So from a dietician standpoint, it can become very challenging for the person to know what to eat to manage all of these conditions, and to put it together into one individualized plan does take a lot of effort and work, and many people don't know where to go. So, it's so important that we focus on a multidisciplinary team in our approach to helping these people with access to dieticians, diabetes care and education specialists, nurse practitioner, and endocrinologists to bring that whole care team together to support them.

Melanie Cole, MS: Well, it certainly is true that a multidisciplinary approach is crucial for patients and people living with diabetes and obesity, and it's such a complex topic. This is such a bigger topic, Dr. Jack, as you alluded to, with rural and urban deserts, with food insecurity, with gym and recess and walkability in parks. I mean, we could go on just about that part of it, because that is so complex and really compounds on the situation. But Dr. Jack, I'd like you to pay a little bit of extra attention here in this podcast and speak about the prevalence and management in different demographic groups, how these disparities can be addressed. Because I think we're seeing such a rise in diverse populations and underserved communities, speak just a little bit about that and any outreach that you want to let people know about.

Anyanate Gwendolyne Jack, MD: Yeah. So, I think it's important to increase awareness, first and foremost, and then, of course, increase access to resources. It's also important, as we think about a team-based approach, is also thinking about a tailored approach. So, meaning that we are tailoring our approach to the person in front of us. So, we're thinking about not just applying general rules for everyone. But for example, when we're working with someone and we advise for them to walk in their neighborhood, assessing whether or not that's actually a barrier. Are there concerns about violence in the neighborhood or walkable space in the neighborhood? So, it's really about getting to know the person and tailoring what our counseling and our advice is for that particular person. So, I think it requires an individualized approach in addition to a team-based approach. So, I think that's one of the ways that we can tackle it on a more interpersonal basis.

Similarly, when we talk about food insecurity, it's about really making sure that we're having increased access to affordable and nutritious food options. When people have to think about whether or not they're going to be able to pay rent or pay their bills and thinking about healthy food options, we really want to be able to remove that out of the equation and allow for people to have access to these nutritious items as well.

Rachel Stahl Salzman: And I would add, I completely agree with Dr. Jack's points, and it's been a big challenge to help overcome some of these disparities. One thing that has been really exciting to follow in this space, and Melanie, you might be familiar with hearing about this, is the Food as Medicine programs, especially around medically tailored meals. So, I'm really hopeful that strategies like this to provide, you know, meals delivered to individuals, especially in areas where they wouldn't have access to it, or maybe they have disabilities that limit them to go to the grocery store to get these important healthy ingredients could really help improve these disparities.

We've also done a lot of programming. Dr. Jack and I, we call us the Dynamic Diabetes Duo. We've gone around in reaching to community centers across the boroughs. You know, we're based in Manhattan and really making efforts to touch different communities and tailor our content to meet their specific needs. And since COVID, we've done a lot of virtual. We've connected to senior centers across different boroughs who might not have access to meet with specialists in this space. So, we've really found that to be a great community-based intervention to help with some of these disparities and ultimately help educate people on what they can do to support their health.

Anyanate Gwendolyne Jack, MD: And I will just add to that that by interacting with the community members, we also learn as well. I think it's a bi-directional process, because they teach us so much in terms of how they're able to navigate some of these challenges and these barriers. So, for example, you know, if lack of access to healthy food options in the form of fresh fruits and vegetables, well, I have some people who buy frozen fruits and vegetables to be able to get the nutrients even though they don't have the access readily available for the fresh fruits and vegetables. So, I think it's important that we also listen to the community at large as well.

Melanie Cole, MS: What important points both of you just made. Now, Rachel, talk about some of the exciting advancements in treatments. as we're talking about awareness and outreach and Food is Medicine and even exercise is medicine. Tell us a little bit about some of the things that you're doing with patients to help get them to understand the conditions and the way they go together and those comorbid conditions, as you mentioned, high blood pressure and all the rest that go with it.

Rachel Stahl Salzman: This is such an exciting time in obesity and diabetes care that I think, you know, it's like a whole conversation in itself. We're constantly seeing new FDA approvals, new products, new options out for patients, increased access. So, it's been a really exciting time for us. I would kind of highlight a couple key areas that definitely excite me in this space, in the treatment of obesity and diabetes.

The first would be on the medication side, as I'm sure many of the listeners here are hearing a lot about the GLP-1 receptor agonists and the dual GIP/GLP-1 receptor agonists as helping to support both treatment of obesity and diabetes. And I would say this is just the beginning of where we have yet to go with these medications. There are clinical studies underway of Triple, they call them the triple agonists. So, really interested to see where the space goes to help support the people.

But I would also say at the core of it is always lifestyle foundation as a key factor in helping with these advancements and use of digital health tools to help empower people, keep them engaged with their nutrition, keep them engaged with their exercise. We're seeing a lot with wearables. And with all this data, then as the clinician, we could now see it. A lot of these apps and tools integrate into a healthcare provider side, so we can actually see the data all together, their glucose data, their food diary, their steps that they're tracking to put together a whole plan.

And I would say the last piece in the space too that we're seeing is the growth of artificial intelligence. I think we could all understand and acknowledge that in all arenas of the world today. And so, I'm really excited about the role of that for obesity and diabetes Care.

Melanie Cole, MS: I'd love to give you each a final thought here. And Dr. Jack, I'd like you to speak about patient education, empowerment, how they all play a role together, and any exciting technology that you would like to bring into this episode or discuss future thoughts about this epidemic that we're seeing and this combination of obesity and diabetes. I'd like you to give us your best advice and wrap up.

Anyanate Gwendolyne Jack, MD: Yeah. So just adding on to what Rachel mentioned, I think what we have currently on the market as well as what is in the horizon in terms of medications, I just want to highlight that obesity is a medical condition. And really, it's important for us to really de stigmatize obesity. So when we talk about medications, there are several medications that have, for example, an indication for diabetes, but they have a similar base medication. So, for example, tirzepatide is a medication that many may know of as Mounjaro. That is FDA approved for diabetes. But now, we have actually the indication for obesity or weight management that's called Zepbound. And so, it's really important that we understand that the same way that we would treat diabetes as a medical condition, it's really important that we also treat obesity as a medical condition and to really destigmatize obesity and to really understand that we don't define people by their medical conditions. So, really staying away from using terms like obese patient and really sticking to person with obesity and really humanizing the person. So, I think that just changing the way that we talk about obesity and diabetes is integral whenever we're having discussions and conversations with people.

And in terms of treatment, also using diabetes technology, highlighting continuous glucose monitors, it's always fascinating when someone is able to see their data and see really the impact of eating certain foods, and also the impact of physical activity. And having that data in and of itself can be so empowering for people especially as they're making these lifestyle changes or taking medications, or after they have weight loss surgery. It's so important to see this data available and seeing that there's such a huge impact that nutrition makes, physical activity, and medications.

And so, I think I'm so optimistic about the technological advances that we have and also the medication advances that we have and really highlighting the importance, again, of the team-based model. So, seeing the primary care doctors, seeing your endocrinologist, seeing the dietician, nutritionist, these are all important, especially when there's significant weight loss. We want to make sure that there isn't significant protein or muscle mass loss as well.

So, in summary, I would say having the team-based approach, integrating technology to be able to see the data and see the impact of these interventions, and then also individualizing our approach to the person in front of us, and really utilizing lifestyle changes as well as potentially medications and other options as well to holistically optimize diabetes care and weight management.

Melanie Cole, MS: You said that so beautifully, Dr. Jack. And really it's true, individualizing that patient care for the patient in front of you. Rachel, I'd like to give you the last word. I'd like you to speak about your team and your approach to that patient-centered care because it is a sensitive thing and it is difficult for some people to hear from you both, you're experts. And so, I'd like you to speak just from the patient's perspective and from your team and how you work with compassion to help people that are living with diabetes and obesity.

Rachel Stahl Salzman: Absolutely. This has been such a really great discussion. And I would echo Dr. Jack, our work as a multidisciplinary team, practicing really person-centered care, which really uses inclusive and non-judgmental language, and really just leading with empathy. I think one of the biggest things that we have seen so much is we always want to share the latest and educate others. But we need to listen, understand their biggest pain points in managing their obesity or their diabetes. What bothers them at that particular time at that visit and understanding that that can change over time as well.

So, I think the importance of getting everyone on board to support them in all the different avenues for their medications, for their behavior change, for their lifestyle, and using both motivational interviewing, shared decision-making to help empower them to really be educated and understanding of how to manage their conditions. Because as the reality is, a lot of that management is when they're not in the office, right? The amount of times they actually meet with us per year, you know, if we're lucky, is so much less than we would want, so how we can really help support them between visits to be empowered for their health.

Melanie Cole, MS: Thank you both so much for joining us today. And that was an excellent discussion. And you're both very good educators. Thank you so much for sharing your expertise. And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcasts, Spotify, Pandora, and Google Podcasts. For more health tips, go to weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. So many great podcasts there. I'm Melanie Cole. Thanks so much for joining us today.

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