The Nonpharmacological Treatment of Diabetes

Peter Salgo, MD: OK, so you find—because now we’re going to screen everybody—you find millions of folks with type 2 diabetes. Are there [nonpharmacological] approaches that you try first? Is that where you go first?

Om P. Ganda, MD: There is no denying the fact that even if you need pharmacological agents, you’ve still got to think about lifestyle. It’s all about lifestyle when it comes to type 2 diabetes, with rare exceptions. I mean, there are people whose beta cells are failing faster than the others, but the vast majority of people with type 2 diabetes would not require as many medications as we use right now if they follow the lifestyle. Which means modest rotation to diet and modest exercise on a daily basis at least 5 days a week.

Peter Salgo, MD: Given what you were telling me, [suppose] we get a very motivated patient and he or she goes to the gym 5 days a week [and] loses 7% to 10% body weight. What percent of all those people will stay off meds?

Helena W. Rodbard, MD: Well, if you look at the DPP, the Diabetes Prevention Program, that Om just mentioned, what happened in that study is that 58% of people were able to prevent the progression of diabetes. Not the 100%, but 58% is a huge number. So sooner or later people will, if they are genetically programmed and if they have all the other risk factors, …progress to diabetes. But what they’re trying to do is to forestall the development of diabetes. And if we can do it for 5 years, for a decade or longer, this is the time that’s actually very precious because it’s preventing people from going on to needing more and more therapy.

Peter Salgo, MD: I know when you talk to somebody and you give them that initial diagnosis: “You’ve got diabetes.” There’s a moment of panic, isn’t there? It’s “Oh my gosh. This is terrible.”

Om P. Ganda, MD: Sure, yeah. Many people get very concerned that they have to do something for the rest of their life.

Peter Salgo, MD: And it’s true; they do.

Om P. Ganda, MD: And then of course they need some encouragement. You need to sit down with them, spend a few minutes, talk to them [to] see if they need to meet with a nutritionist or [an] exercise physiologist. Not everybody has to do that at great length. But a dietitian, I would say yes—at the time of diagnosis of diabetes. And I think they need to understand that it’s not only going to help their diabetes control, but it’ll help further down [with] the complications, particularly cardiovascular complications, which play the most major havoc.

Peter Salgo, MD: All right, let’s go back to guidelines for now. You’ve got the ADA [American Diabetes Association], the AACE [American Association of Clinical Endocrinologists]—they’ve got guidelines. What do they recommend for optimal glycemic control?

Helena W. Rodbard, MD: Well, they have different recommendations.

Peter Salgo, MD: And what does that mean, by the way, because they’re different.

Helena W. Rodbard, MD: It means different things to different people.

Peter Salgo, MD: I knew that.

Helena W. Rodbard, MD: Of course, why make it easy, right? So AACE recommends as a goal a hemoglobin A1C [glycated hemoglobin] of less than 6.5%, and the ADA recommends a hemoglobin A1C of less than 7%. However, both those organizations have some caveats. That treatment has to be individualized, and the goals of therapy also need to be individualized.

Peter Salgo, MD: Let me stop you just for a minute because you said prediabetes with an A1C less than 5.5%, uh more than 5.5%. But here you’re telling me the recommendation for diabetics, that number is higher than 5.5.

Helena W. Rodbard, MD: That’s correct.

Peter Salgo, MD: So you never, if you follow these guidelines, get somebody with diabetes down to somebody who’s already diagnosed with prediabetes.

Helena W. Rodbard, MD: Well, if we can bring them down to the prediabetic range, so more power to us and more power to the patient. But it’s not appropriate for every patient. For instance, elderly people, people with limited life expectancy—we are not trying to bring down their levels to the 5s or even lower 6s. Why is that? Because of hypoglycemia. And hypoglycemia is a major, major concern for people with diabetes.

Peter Salgo, MD: There was a period in this country, I guess the Joslin [Diabetes Center] clinic was 1 of the leading advocators of this, where [we had] very tight glycemic control. And I don’t hear that from you. Is that because people were getting into trouble from hypoglycemia?

Helena W. Rodbard, MD: Exactly right. That’s 1 of the major concerns, and also the ADA and AACE have come to the conclusion that we don’t treat everybody to the same standards. So we are not going to treat this aggressively a 70- or 80-year-old person with limited life expectancy because they may have a malignancy, they may have—I’m not going to worry about 40 years hence in terms of complications, as opposed to somebody who is 40.

Peter Salgo, MD: I’m only smiling because if it’s 60.

Helena W. Rodbard, MD: I can see that. [laughter]

Om P. Ganda, MD: I think part of the problem was, in the past, you know when diet didn’t work, the only medications we had cause hypoglycemia. And now we have so many other choices, I’m sure you’ll come to that later on in our discussion.

Peter Salgo, MD: Sure.

Om P. Ganda, MD: But the point is that if I develop diabetes today, and if I could, I would like to be as close to normal A1C as possible. Why not?

Peter Salgo, MD: Sure. Why not?

Om P. Ganda, MD: Of course, the only exception is of course, as Helena said, older people. [And] by older I mean not chronologically but biologically.

Peter Salgo, MD: I like him so much. [laughter]

Om P. Ganda, MD: If you had advanced renal disease, let’s say, or a history of stroke, obviously I’m not going to show for A1C let alone 6.5%, not even 7%, and we have guidelines for that. Up to 7.5% is acceptable, even 8% in some people. It all depends. So I think now we’re becoming wiser in our approach because there are so many better tools than we used to have before.

Peter Salgo, MD: Let me, before we even leave this, ask [a] question. I was sort of skating around this, by saying it’s hard. What [percentage] of people follow your advice, lose that 7%, go to the gym 5 days a week?

Helena W. Rodbard, MD: I have to admit, I haven’t been very successful. I try my very best. I spend a lot of time. My dietitian spends a lot of time with our patients. There’s a lot of hand holding in my practice if you will. How successful am I? Well, if I’m successful half of the time, I consider myself ahead.

Peter Salgo, MD: But 50% is a lot actually. It’s 1 of their big numbers.

Helena W. Rodbard, MD: Yes, I consider myself ahead. I think it’s great.

Peter Salgo, MD: And let me [ask]—so that we don’t let doctors off the hook—what [percentage] of all doctors follow the guidelines? I mean, it’s 1 thing to say to the patient, “It’s your fault.” But are the docs doing what they’re supposed to do?

Om P. Ganda, MD: Well, I think you know people do look at guidelines. But I think, again, you’ve got to individualize patients. Even the guidelines say it, that you’ve got to individualize patients. Even the guidelines say it, that you’ve got to individualize the treatment. So I think the point is that we need to get our patients to at least meet us halfway. And I tell my patients that even if you don’t lose any weight, don’t worry about it initially. As long as you’re exercising, you’re making yourself more insulin sensitive, and you will need less medication.

Peter Salgo, MD: So you give them something to hold on to.

Om P. Ganda, MD: You’ve got to meet them halfway.

Peter Salgo, MD: OK.

Helena W. Rodbard, MD: But it seems it’s a negotiation.

Peter Salgo, MD: But you let the docs off the hook because in order to get to that point, the doc has to know the guidelines and at least try to implement it. And are docs doing a good job of this or not?

Om P. Ganda, MD: I think they try. I think there are two things. You’re alluding to 2 very important things. One is called clinical inertia, which basically means that, you know, you don’t want to keep adding medications. Patients come and plead to you, “Doc, give me a few more weeks, and I’ll show you I can do better.” And their next appointment is canceled because the patient doesn’t want to disappoint the doctor, right? So this is human. I think that’s 1 part of the problem.

The other part is the patients’ side, where there may be some adherence issues—cost of the drugs, not wanting to exercise all the time because they can’t find time or they need some more motivation. And you know it’s a lifelong process with diet, and there are too many opportunities to indulge oneself in our lifestyle. So this is all part of the equation. But adherence to treatment also includes taking your drugs properly every day. And a patient with type 2 diabetes in particular is a good example. And every patient takes, like, 8 or 9 drugs a day—something for blood cholesterol, something for hypertension, 2 or 3 drugs for diabetes, sometimes 2 drugs for lipids. So it adds up, and they need to be reminded and educated why these drugs are important.

Peter Salgo, MD: It’s tricky because as you get older, your ability to remember to take all these drugs gets impaired sometimes.

Om P. Ganda, MD: These issues are also important.

Peter Salgo, MD: And the diabetics are associated with cognitive deficiencies too. And we’re piling on stuff, right?