Diabetes Care in 2016
Falk: John, you have had a storied and wonderful career as the face at one point of diabetes in the United States when you were the President of the American Diabetes Association, the ADA. Where is diabetes as a field going now?
Buse: You know, I’m not that old. I’m 57. When I first started in the diabetes field, every minute of every day, in our lobby of the clinic, we had patients with seeing eye dogs, white canes, amputations, lots of misery and disability. My interest in diabetes started because my father was the first endocrinologist in the state of South Carolina. He told me that his interest came from the fact that people with diabetes were by far the most miserable people that he cared for in the 1950’s. Miserable from disability, basically. And he was so impressed with the progress that had been made in his lifetime.
What I can say in my 25 years or so in the diabetes field, basically we have the tools to stop the disability and early death in diabetes. It can be done. People going blind or having amputations is basically a failure of the health care system. It’s not a failure of the ability to prevent it.
From my perspective today, we can stop the misery in diabetes.
Falk: How? What’s changed? What are the tools?
Buse: We have better drugs for treating diabetes. Basically diabetes is a complex metabolic disease. It’s more than just high blood sugar. We’ve discovered that blood pressure management, lipid management, cholesterol management, is essential. By doing these things together, we can prevent a lot of the basic underlying process that leads to blindness, kidney failure, amputations, early heart attacks, and strokes.
And we have better technology from all of the affiliated specialties. The kidney doctors are much better at managing kidney disease. The eye doctors are much better at managing eye disease, etc. It’s basically a process of providing the drug treatments to control diabetes, blood pressure and cholesterol, and making sure that the screening evaluations done to catch complications early in the natural history and basically with that process, patients really should have essentially zero risk of blindness, kidney failure, or amputations.
Falk: There are two different types of diabetes. They are generally classified as type 1 or type 2. Help me understand whether what you just said is true for both of those.
Buse: So type 1 diabetes, is the result of the destruction of the cells in the body that make insulin. The treatment is just very precise administration of insulin. The new technologies that we have are better insulins that allow us to provide insulin by injection and have it behave as if it was made by the body.
Falk: Insulin pump?
Buse: Insulin pumps, but we also have better insulins as well, even without a pump. The newest development is the availability of what are called continuous glucose monitors. So it allows us to know the blood sugar every 5 minutes, 24 hours a day, 7 days a week for the rest of your life. That allows us to catch the blood sugar that’s getting too low, to catch the blood sugar that’s getting too high. Not everybody needs that technology but we can apply it for those people that do.
For type 1 diabetes we pretty much can control the blood sugar very, very accurately. We have emerging technologies that we’re working on here at UNC called bionic pancreas technologies. Where, in the future, the patient will get cut out of the loop. Right now the patient has to decide how much insulin do I take? How do I reduce my dose because I’m going to be more physically active today? How do I increased my dose because I’ve got the flu, or I’m stressed? In the future that won’t be necessary. In the preliminary studies that we’ve done with this bionic pancreas technology is truly amazing. We took 10 patients that were masters at controlling their type 1 diabetes. And the bionic pancreas did a better job in every one of these 10 people.
Falk: That’s exciting.
Buse: That’s very exciting. In type 2 diabetes we have much better drugs. The old drugs when I started, was just insulin and a class of pills called sulfonylureas. They caused hypoglycemia, or low blood sugar as a side effect. They were associated with weight gain. In type 2 diabetes, which is generally asymptomatic, no “feeling bad,” until the blood sugars are way out of balance. To give drugs that caused symptoms like low blood sugar is just a hard way to manage a disease. Imagine if we treated hypertension with something that made you feel sick. It would be hard to get people to manage their blood sugar with drugs that made them feel sick. So we have drugs that are not associated with low blood sugar and promote weight loss instead of weight gain, and type 2 diabetes is a disease associated with obesity. So that’s another huge advance. The biggest thing we’ve done in type 2 diabetes is understanding the role of cholesterol and blood pressure as well. It’s just a completely different mindset in managing diabetes today than when I arrived at UNC 20 years ago. So I think the prognosis for people with diabetes is excellent, but they need expert care, and assistance.
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Falk: In today’s news, it suggested that the number of patients who are developing diabetes may have started to plateau and in some populations has plateaued. The inference there, at least in the news, was that this was a consequence of better control of weight, and that the obesity epidemic, that is important in the development of type 2 diabetes, may be starting to dissipate, at least in some populations. Where is obesity research? Where is obesity care going?
Buse: 2015 was a banner year in obesity. For the first time, we actually have multiple drugs approved by the FDA for the long-term management of overweight and obesity. That was not true until this last year. We have had advances in bariatric surgery. We understand now that it’s not a one-size fits all approach to weight management from a lifestyle perspective. It used to be that the American Heart Association had a diet and the American Diabetes Association had a diet, and the process was one of having a doctor or a dietician say “This should be your diet.” We understand that that doesn’t work. What you have to do is develop a tailored approach. You have to have the patient engaged to help understand what they’re willing to do, what they’re able to do. We understand the role of family, friends, employers, etc in the process. I think the obesity epidemic has started to peak, mostly because of the advances in our understanding of what it takes to help people lose weight or not gain weight. I think that the future in obesity likewise is very bright. That as we understand these processes better, as we know to apply these drugs more effectively, we will get on top of obesity. That’s very much an emerging area of clinical medicine.
The other interesting thing that happened in 2015 is for the first time obesity was declared a disease. Before then, it was like a social problem. It was a matter of will, and slothfulness, and a lot of sort of negative connotations about people with obesity, now it’s recognized as a disease, we have treatments, we understand the lifestyle therapy much better.
The big advances will be coming from societal change. Pressure on the food industry not to provide 2,000 calories to people as a meal when you go to a restaurant or a fast-food establishment. Making it easier for people to walk in their neighborhood or ride a bicycle to work. Those kinds of things will take years to come. Now we understand it is a major threat to the solvency and productivity of the United States, this obesity epidemic.
Falk: So what’s the role then of bariatric surgery, gastric sleeves, or other sorts of things that would surgically alter one’s ability to take in a large amount of food?
Buse: That’s an area of some controversy. There are people who are desperate to have bariatric surgery and frankly, their insurance companies resist them on it. There are people who desperately need bariatric surgery who are fearful of either the side effects of the procedure or the fact that eating is a big part of their lives and they just can’t imagine going through the rest of their life without having the 12 oz ribeye or the Thanksgiving feast. It’s a very complicated issue that needs very open discussion between patients and their providers to determine whether the procedure is right for them, and whether they’re right for the procedure. Applied with expertise, it’s remarkably effective. People lose 50-75% of their excess body weight. They go from being very heavy to being generally, at worst, modestly overweight. They have a reversal of the metabolic consequences, the diabetes, in more than 50% of cases.
Falk: The University of North Carolina Endocrine Division that you lead is really an outstanding group of trained physicians who think about all these various diseases. Tell me about your division.
Buse: It’s been a wonderful group to be associated with. Over the last 5-10 years we’ve recruited a number of faculty members and we’ve looked for a very specific type. Or 2 very specific types. One is the promising young investigator who is going to discover the next great thing in the treatment of endocrine disorders. And the other is the well-trained clinician who went to a top-notch school, got excellent training at a top-notch university, went into private practice because they were particularly interested in clinical care, and then recognized that being in the academic center allows you to have a more robust intellectual existence in thinking about clinical medicine, and have applied for positions here. The ideal candidate for us is someone who is well-trained, interested in clinical medicine, and came to academia to participate in the process of better teaching, better care.
We now have the amazing situation where every one of our doctors is listed in Best Doctors in America. Every single one.
Falk: That’s remarkable, that’s just fantastic.
Buse: It is, particularly since many of these people have come to the area in the last 5 years. To get on these lists, people have to know who you are. It’s truly remarkable. Our clinic is extremely busy. And thanks to the support of the Department of Medicine, we’ll be hiring more doctors of this type, so we’re looking forward to even more robust programs. Our major focus today are diabetes, obesity, bone disease, pituitary disease, thyroid cancer, and we’re looking to increase our depth and expertise in those areas, as well as providing general endocrine care.
Falk: There are many examples at UNC where specialists from a number of areas gather to consider an individual patient and that individual patient’s disease. In endocrinology, can you give me an example of that kind of care?
Buse: You know, fundamentally that’s what endocrinologists do. As an example, with pituitary disease, our pituitary clinic works very closely with the folks from neurosurgery because neurosurgical approaches is the way we rid the body of these pituitary tumors in most cases. We also work with radiation therapists, because we have very specialized technologists, a gamma knife, which is an x-ray technique for destroying these tumors in the brain.
In diabetes, it’s all about the integration of doctors, dietitians, behavioral therapists, etc. In thyroid cancer, the endocrinologists are the experts at the thyroid, but the oncologists are the experts at the chemotherapy drugs and the use of radiation therapy is done with the radiation oncologists. So almost every area of endocrinology involves multi-disciplinary care, and frankly it’s what makes it exciting as a physician to work at UNC because we get to do this all the time. It’s one of the reasons why we’re successful at recruiting some of the best young doctors in America, because in private practice, it’s much harder to do that.