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Some 30 million U.S. adults today have diabetes — but many of them might not yet know they have it. Endocrinologist Bartolome Burguera, MD, explains the factors that play into diabetes and the first signs to watch for, as well as the important components of a medical weight loss management program.

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Diabetes: Understanding Weight, Sugar and Insulin with Dr. Bartolome Burguera

Podcast Transcript

Nada Youssef:  Hi, thank you for joining us. I'm your host, Nada Youssef. And today we're here to discuss diabetes. We will cover causes, risks and treatments. And based on the American Diabetes Association, there are some statistics about this disease that I wanted to share.

1.5 million Americans are diagnosed with diabetes every year. Diabetes remains the seventh leading cause of death in the US, and according to the Centers For Disease and Control, the CDC, the number of people with diabetes has more than tripled in the last couple of decades, reaching 30 million today.

Today, our featured expert is Dr. Bartolome Burguera, endocrinologist here at Cleveland Clinic, and the Director of Obesity Programs in the Endocrinology and Metabolism Institute. And one of his main efforts is to integrate the different medical weight loss initiatives currently being developed at this institute, and to coordinate any evidence-based lifestyle weight loss program based on nutritional advice, physical activity, and use of appetite-control medications, which is being offered both to patients and caregivers here at Cleveland Clinic.

And please remember, this is for informational purposes only, and it's not intended to replace your own physician's advice. Thank you so much for being here.

Dr. Burguera:  Thank you, Nada. Thank you for inviting me.

Nada Youssef:   Sure thing. Let's just talk about diabetes. What is it? What is diabetes?

Dr. Burguera:    Diabetes is when the blood sugar goes too high. In general, there are different ways that your physician can make a diagnosis, when your fasting blood sugar, in the morning, before you eat, if it's over 126 mg/deciliter, that usually is concerning, and that suggests type 2 diabetes.

And sometimes also we do a measure in the blood called hemoglobin A1C. That is a marker that can be done with a blood test. And if that's over 6.5, it's also consistent with type 2 diabetes.

So that's a way that we have to make a diagnosis, but in general, type 2 diabetes occurs mainly because people they usually develop weight, weight gain.

Nada Youssef:   Weight. Okay. Let's talk about what is the difference between type 1 and type 2 diabetes.

Dr. Burguera:    There's a big difference. That one is when the pancreas does not produce insulin. That usually occurs in younger individuals. Type 2 occurs when your pancreas, even though it produces insulin, finds resistance in the periphery, in the tissues, to work. And that resistance is mainly because problems associated to overweight. We produce enough insulin, within type 2 diabetes, however it is not working properly in reducing the amount of sugar, because it cannot reach the target. It cannot work properly, the insulin. So it cannot lower the blood sugar.

Nada Youssef:   Correct me if I'm wrong, is it type 2 diabetes you can develop from weight gain?

Dr. Burguera:    Yes.

Nada Youssef:   Or develop later in life. Type 1, you're born with it? Is that correct?

Dr. Burguera:    No, you develop ... we really don't know 100% what is the cause of type 1. But in general, there is a destruction of your pancreas. The pancreas is an organ that we have in the belly, and produces insulin. And you stop producing insulin.

With type 1, when we check the insulin level in the blood, it's very, very low. So that's the reason why patients with type 1 do not have insulin. Therefore, the blood sugar goes up significantly.

They really need insulin to survive, because if not, they get into a condition called ketoacidosis, the blood sugar is too high. And that's very critical. So insulin is a must for type 1 diabetes.

For type 2 diabetes, we produce enough insulin from our pancreas. However, it's not working properly. It's not able to do the work, because it finds a problem when it reaches the target. The receptor. So it cannot do its work.

And it's because problems associated to overweight, to obesity. Those hormones, those problems, because of the obesity interact in the target, insulin cannot work properly, so therefore insulin cannot lower the blood sugar, and the blood sugar is also elevated in patients with type 2 diabetes.

Nada Youssef:   So the risk factors and causes for type 2 diabetes is that, the number one is obesity?

Dr. Burguera:    Absolutely. Absolutely.

Nada Youssef:   Okay. And that can cause a lot of other diseases.

Dr. Burguera:    Absolutely. We see that patients who develop type 2 diabetes, more than 90% of the cases, before they have accomplished weight gain. The weight gain causes problems, mainly in the fat tissue, there are hormones and substances produced by the fat tissue, by the adipocyte, that impedes or preclude the effect of insulin, that's not allow the insulin to work properly. So you develop insulin resistance, as a first step, and subsequently the insulin is not doing its work, and the blood sugar increases, and you are diagnosed with type 2 diabetes.

Nada Youssef:   Oh, I see. How do you know if you are developing diabetes? Are there early signs?

Dr. Burguera:    Absolutely. There are very clear signs. Some of them are not too specific. One is you develop some fatigue. Some increased appetite. You develop polyuria, that means that people urinate a lot. Polydipsia, that means that they become very thirsty. And also they are hungrier, they eat more, because they are losing a lot of sugar in the urine. So when they lose sugar, they are hungrier.

And also, because of the waste of sugar in the urine, there is weight loss. So when people develop fatigue, increased thirst, increased urination, hunger, they have to urinate during the night, and that's two or three times during the night, and all those conditions, all those characteristics, suggest that there is the presence of type 2 diabetes.

Nada Youssef:   Are there testing kits available for this, if you think you may have it?

Dr. Burguera:    Absolutely.

Nada Youssef:   Is there a certain age that you're supposed to go get tested?

Dr. Burguera:    Well, when people who feels that those symptoms are presence in their life, they should check with their doctor and make sure. They will have a blood test, and the blood test will check how high is the blood sugar. And if it's over 200 in non-fasting conditions, or if it's over 126 fasting, that would be consistent with type 2 diabetes. In the presence of all those symptoms, too.

Nada Youssef:   Our diet is really full of a lot of sugar, right? Is there a certain age that people should go get tested? Even if they're not feeling the thirst or ...

Dr. Burguera:    Yes, in general, we should have a blood test on a yearly basis, at least. So usually, if ... obviously sooner if people who develop some of those symptoms. And I repeat, increased thirst, increased urination, hungrier, they eat more, they are losing weight, they are fatigued, they are urinating during the night. All those are ... especially if you develop nausea or vomiting, that would be obviously a big reason to go to the emergency department to be evaluated.

Nada Youssef:   Do genetics play a role in this at all? If my mom has it ...?

Dr. Burguera:    Well, to a certain degree. Overweight, obesity, also is genetic. People who have more prone to develop weight gain and to have overweight within their family, yes, that may preclude or direct them to develop type 2 diabetes.

There is a component of genetics, but I think the environment is what we're dealing with. We're in an environment that more and more, we are less active, we are having foods that have high caloric content, the stress in our lives. All those factors are playing a role in us as a society gaining weight.

Nada Youssef:   Now, with gaining weight, I want to ask this before we get into this, but tell me if this is right or wrong. If someone likes a lot of sweets, and they eat a lot of sugar, drink a lot of sugar, but they are not obese, they're not in any way big, does that mean that they are definitely away from ... they're not diabetic? Or it could be ... you could still have diabetes, even though you're not ...

Dr. Burguera:    Well, if you eat a lot of sweets, yes, you increase to a certain degree your risk of developing type 2 diabetes, but at the same time, if you like sweets, but at the same time you exercise significantly, and you eat that in moderation ... Eating a lot of sugar is not good, but eating a lot of anything is probably not good.

I'm not saying that you cannot have a piece of cake once in a while, but if you eat a cake on a daily basis, that pushes your pancreas to really produce a lot of insulin, and could get to a point that you gain weight, and then the insulin is stop being effective.

Watching what we eat is extremely helpful. A dietary program high in sugar is not a good idea, in general.

Nada Youssef:   How does diabetes affect other body parts like eyes or kidneys? And why do they affect other body parts?

Dr. Burguera:    Well, yes, elevated blood sugar causes a problem with what we call retinopathy. That's people develop problems in their eyes, also in the kidneys. The kidneys is start seeing a lot of blood sugar, when they filter the blood, the kidney sees a lot of sugar.

There's something neuropathy, when people start developing some numbness, tingling, in their arms, in their hands, feet. So that's consistent with type 2 diabetes. And if nothing happens, if we don't really take care of it, sometimes people present with eye trouble, and the ophthalmologist, the eye doctor, makes the diagnosis of type 2 diabetes.

So that's very unfortunate that nobody has been able to make that diagnosis before already a complication, and important complication, and severe complication like eye problems have occur.

The recommendation, really, is to see your doctor at least on a yearly basis so you have a blood test. If you develop those symptoms that I was describing, you seek medical attention. And with those symptoms, especially if you develop some nausea or vomiting, you really need to go to the emergency department, so they address that right away.

Nada Youssef:   Let's talk a little bit about treatments and management. What can you do to avoid type 2 diabetes? Check your weight.

Dr. Burguera:    Yes.

Nada Youssef:   It's what you're eating, correct?

Dr. Burguera:    Yes. I think that's number one. It's very difficult to develop type 2 diabetes if before you have not gained weight. It's very, very difficult. Yes, some people, from Asia, or from India or from China, they may develop those type 2 diabetes at a lower body mass index than a person like me from Spain.

We see in people from Europe, we see that, in general, we start developing type 2 diabetes with BMIs of 27, 28, 29. People from China, they may develop type 2 diabetes at BMI 22, 23, so at a lower weight.

We cannot say that, oh, no, it's not that they have developed obesity. No, they have developed weight gain, and the weight gain plays a role, impacts the pancreas in the production of insulin, so it's a risk factor.

So, number one, prevent weight gain. And how you can prevent weight gain? Eating healthy, for sure. Small portions. Drinking water and avoiding maybe too many pops and juice and-

Nada Youssef:   Temptations.

Dr. Burguera:    Yes. We need to enjoy life, but at the same time, in a way that is healthy. Talking to your providers and make sure that you have a good understanding of a healthy diet. That's very important. Mediterranean diet is very healthy. So that's number one, healthy nutrition.

Number two, physical activity. We have become a very sedentary society. We can have a very successful life burning very little calories along the day. Very little.

Number three, sometimes we use medications to control appetite. Some people really develop an increased set point in the brain for appetite, so that needs to be addressed. And we have FDA approved medications.

Nada Youssef:   So it controls appetite?

Dr. Burguera:    Yes.

Nada Youssef:   It's not working on insulin, it's not working on sugar, it's just literally just appetite suppressant.

Dr. Burguera:    That's right, yeah. It works in the brain, in the hypothalamus, and it helps people to be less hungry. Basically, they don't eat, to eat as much, to get to the same level of fullness.

Nada Youssef:   Oh, very, very interesting.

Dr. Burguera:    So they can be very useful. Number four is sleep.

Nada Youssef:   Sleep?

Dr. Burguera:    People who don't sleep more than six, seven hours could have increased appetite. In our clinic we have plenty of people who works third shift, and they gain weight. As soon as they start working in the night shift, there is usually associated weight gain.

When we are on call, the day after, and that has been fully documented, you are hungrier the day after you are on call.

And number five is anxiety, depression, stress. Those are big factors, also, that cause overeating.

Nada Youssef:   Is this a part of the medical weight management program?

Dr. Burguera:    Yes. We pay a lot of attention to those five areas that I was mentioning. We make sure that we work with our nutrition team. We have a group of dietitians who are very knowledgeable and help us to identify what is the best dietary program for our patients.

There is not really the best one. The best one is the one that you follow, the one that you feel comfortable, and hopefully that's healthy. The best program is the one that you are able to adhere to, and you are able to follow.

Our team helps our patients to really identify healthier eating. We pay a lot of attention to Mediterranean diet. The Mediterranean diet basically consists of more fish and poultry and vegetables, nuts, olive oil. Much less red meat. And olive oil is a very important component, plus nuts and chicken, fish.

Nada Youssef:   Cut down carbs, cut down sugar.

Dr. Burguera:    Cut down carbs. Absolutely. Yeah, fruits are also part of it, but yes, reduces carbohydrates. And we also have another type of diet that is the ketogenic diet. It's a diet that-

Nada Youssef:   Perfect. I was going to ask you.

Dr. Burguera:    Yeah, the ketogenic diet is quite common. The way it works is that people consume very little amount of carbohydrates. When you eat less carbohydrates, your body starts breaking down the fat. We need energy, so sugar is energy. When you don't eat too much sugar in your diet, you need to look for alternative energy, so the fat in our belly becomes the energy, and it gets burned.

When our body starts breaking the triglycerides, the fat, the consequence of that is the production of something called fatty acids. It’s a metabolite, it's a breakdown product of fat. Those fatty acids work in the brain, reducing appetite. It's what we call anorexigenic mechanism, reduction of appetite.

When people get into ketosis, that is those ketone bodies are being produced, they really are not too hungry. Basically, they are not hungry. They start breaking their own fat, and it's a great way to get into a situation where you are not hungry.

Sometimes a difficult diet to follow, because you eat very little carbohydrates, and your diet consists of mainly of protein. Eggs, chicken and fish.

Nada Youssef:   You can eat meat on the ketogenic diet, right?

Dr. Burguera:    Oh, plenty. Plenty of it.

Nada Youssef:   Plenty of meat. Okay. Okay.

Dr. Burguera:    Plenty. For meat, we mean chicken, and we mean turkey, and we mean red meat, and we mean fish. A lot of protein. Very little sweets. And very little potatoes and carbs.

Nada Youssef:   Even some fruits, and for those who don't know about the ketogenic diet, it's more protein, a lot of healthy fat, and really, really small amounts of carbs and sugar, including fruits. A lot of fruits that if you're on a strict ketogenic diet-

Dr. Burguera:    You cannot, no.

Nada Youssef:   ... you're not allowed to eat a lot of fruit. Just berries, right?

Dr. Burguera:    Yes, that's right. That's right. Mainly berries. It can be very effective. Sometimes we use it as a jumpstart, so people who are able to follow loses a few pounds, feel more motivated, and get more engaged. And slowly we have to make a decision to a more balanced diet, like Mediterranean diet.

Nada Youssef:   How long on the keto diet do you think someone should follow it strictly before they jump ship to Mediterranean?

Dr. Burguera:    It really varies. I think some people will have three months. Some people six. We have people who have been following more than a year. We check labs, we make sure your uric acid, your kidney function-

Nada Youssef:   Everything's functioning.

Dr. Burguera:    ... is okay. But it's a fairly safe diet. We make sure we follow people closely. Some of our patients really like this diet, and they are doing extremely well. But we have to understand that, once you stop that diet, your appetite comes back.

There is a lot of weight regain when you stop this diet, if you don't do anything else about it. That's why we are very aggressive, using medications to reduce appetite. So you get onto a ketogenic diet, you start producing your ketone bodies, your appetite gets down, you start losing weight. You can be extremely successful, losing 30, 40 ... we have people losing 80 pounds. But the moment they transition to a more balanced diet, their weight goes-

Nada Youssef:   They gain. Even if it's balanced diet?

Dr. Burguera:    Yes, because in general, their appetite comes back. So you are trying to meet what your brain is asking you to eat.

Nada Youssef:   So the ketosis is what's making them not hungry?

Dr. Burguera:    That's right.

Nada Youssef:   It's just not the fat in the brain, or the stuff that we're eating.

Dr. Burguera:    That's right, yes.

Nada Youssef:   Speaking of ketosis, how about fasting? Intermittent fasting-

Dr. Burguera:    Yes.

Nada Youssef:   I hear that you can also get ketosis through that.

Dr. Burguera:    Yeah, there is some data to suggest that intermittent fasting could be helpful, and some data suggest that when you skip one day, you may lower your insulin resistance, and maybe you are more effective, and your appetite is better controlled.

I am not sure that that's useful long-term. But at the same time, yes, short-term, there is some data to suggest that intermittent fast could be a good way to lose a little bit of, a few pounds, and after, try to go back to, again, a more balanced diet.

Nada Youssef:   Sure. Now, how long do you need to be fasting to get on ketosis? And how long do you need to be on the keto diet to get on ketosis?

Dr. Burguera:    Yes. Interestingly, when you start following the advice from our nutrition team, within 48 hours, 24, 48, you are in ketosis. Meaning you are producing your own ketone bodies, and your appetite is under control.

Nada Youssef:   And you're burning glucose-

Dr. Burguera:    Fat.

Nada Youssef:   Oh, you're-

Dr. Burguera:    You're burning fat, mainly.

Nada Youssef:   ... burning fat instead of glucose.

Dr. Burguera:    Yes. It usually occurs within 48 hours or so. And we have people who are in ketosis, on and off, during a year. So today we have a party here, today we have celebration, and maybe we have some sweets, and sometimes you get off ketosis. But within 48, 24-

Nada Youssef:   You can get right back on it.

Dr. Burguera:    ... you can get back.

Nada Youssef:   Okay, good.

Dr. Burguera:    We have people who are doing that. Obviously enjoying life is part, is very important. But you can have a very nutritious diet with a high-protein diet, but you have to be willing not to use carbohydrates.

Nada Youssef:   How much sugar should we allow in our daily diets?

Dr. Burguera:    That's a good question, and it varies, depending where your sugar comes from. Because sugar is very ... it's present in vegetables, it's present in fruit. It's present in many of the drinks that-

Nada Youssef:   Cupcakes.

Dr. Burguera:    ... sometimes we eat. So it's difficult to answer that question. I think fruit has to be part of our diet. No question of this, two pieces of fruit, sometimes even three pieces, depending what fruit you are eating. Vegetables, and lettuce and greens are also a very important part of our dietary plan.

There are plenty of good advice in the Internet about what a good Mediterranean diet should look like, but at the same time, really talking to an expert, talking to a dietitian, touch bases with your primary care provider, probably will be a good way.

But the nutrition is just a small component of improving our lifestyle. The nutrition is one of the five areas that we get under control. It is impossible to maintain weight loss long-term if exercise or physical activity is not part of our life.

So we can lose a few pounds eating less carbohydrates, but our brain is always trying to bring us back to our previous state. We have a set point in our brain. Some people's set point is 250 pounds, some people is 230, or 195.

And there are different signals that set that set point. How many hours you sleep, what do you eat, your level of physical activity, the stress, how many hours of light, your levels of vitamins, the flora in your gut, your microbial, all those factors modulate your set point.

Yes, you start losing weight, but your brain is trying to bring you back to where you were before.

Nada Youssef:   It's hard work.

Dr. Burguera:    It's the set point. So unless you move to Florida, or you change jobs, or you divorce, or you get rid of your kids, your life, your set point, will continue to be the same.

We need to understand that. It's not that you lose weight, that's it, I'm done. No. You lose weight, but you need to keep doing long-term what caused you to lose weight. Because the moment you stop doing that, you will regain the weight. And we see plenty of people who come to 150 pounds, they are successful, they lose 30 pounds, they stop coming or they do something else, and a year later, two years later they come back, and they are back again, 250 pounds. That's their set point.

Nada Youssef:   So it should be a lifestyle change.

Dr. Burguera:    Absolutely.

Nada Youssef:   Not just a diet, right?

Dr. Burguera:    Absolutely. So, whatever we do has to be done in a way that is easy to do long-term. I cannot ... oh, I'm going to start going to gym every day. That's not going to happen.

Nada Youssef:   Not realistic.

Dr. Burguera:    Not realistic. Realistic expectations are very important. Yes, exercise is a big part of it, but exercising three times per week, that's usually realistic.

Nada Youssef:   For how long? 30 minutes?

Dr. Burguera:    Yes, I think make sure that you are up to 10,000 steps, maybe, depending on your physical ... We have plenty of patients that come to see us in wheelchairs. So we need to develop a personalized exercise program so they can integrate that on their lives.

I have a patient that goes to the swimming pool with a bottle of oxygen. And we're very proud of her because she's doing that. Exercise, there is no reason why people cannot increase their level of physical activity. Unless they are intubated in the ICU. And we could still discuss that. There is no reason why people could not be more physically active.

And that's very important to guarantee success long-term. We know that physically is the best predictor for success long-term to keep people's weight down.

Nada Youssef:   Do you have any tips or tricks for people that are going to be joining big dinners during the holidays, and a lot of temptations?

Dr. Burguera:    Yes. I think, first of all, when you go to a party, you should have eaten something at home before you go.

Nada Youssef:   Don't go full. Don't go so hungry.

Dr. Burguera:    That's right. Don't go so hungry, because most likely what you're going to find there is not very healthy. So make sure that you already ate something before you go so you can be selective of what you are going to be eating.

Yes, of course, try to enjoy the party. Try to eat the healthier component. Yes, if you are going to drink alcohol, be cautious. I think with a drink probably is plenty. And drink, especially eat, slowly. Make right choices more on the green stuff. Some of the almonds, less peanuts, and more on the fish and turkey and chicken than compared to the red meat, maybe.

Seafood is very healthy, but make sure you don't fill it up with mayonnaise, and all these sauces.

Make the right choices, and don't let you get to a point that you are too hungry that you will just be non-selective on what you eat.

Nada Youssef:   You'll see a lot of people, if they're trying to stay away from sugar, when they go for drinks, my coffee or my tea, they go for sweeteners instead. Is that a good idea? Because we heard a lot of things about sweeteners. Are they healthy? Are they better than sugar? What's the good sweetener?

Dr. Burguera:    I don't think they are ... I think if you like your coffee a little bit sweeter, the best thing is to add a little bit of sugar.

Nada Youssef:   Sugar? Better than sweetener?

Dr. Burguera:    Yes. I think a little bit, because we really don't know the side-effects of these artificial sugars.

Nada Youssef:   Yes, the long-term, yeah.

Dr. Burguera:    We start having to see some data to suggest that play a role changing the flora in the gut, the microbial. We know that people who develop obesity have some type of microbia that is different that the people who have not developed obesity. So we don't know to what degree our microbiota in the gut is playing a big role in the development of obesity.

Yes, so if you have type 2 diabetes, maybe you don't want to add a ton of sugar, but a tiny bit of sugar, if that's what you like your coffee, I personally do that. If you like sugar, if you like coffee, I think without sugar is the best way to take it, but obviously that's a personal decision.

Nada Youssef:   Yeah, you have to get used to it, to the black coffee.

Dr. Burguera:    Yes. But the exercise helps to counterbalance everything. If you have a party today, you have a couple of drinks or maybe just one, and you have eaten a little bit too much, if the day after, the gym will be open and waiting for you. Or the street, and you can walk, or physical activity has to be planned. It's very important that ... it's very difficult to say, "Oh, I'm going to go for a run." That usually doesn't happen.

Unless you have planned the day before, yes, tomorrow is my day to run, it's not going to happen. Physical activity has to plan in our daily routine, the same way that meeting with other people, or-

Nada Youssef:   Put it in a calendar, just like you would everything else.

Dr. Burguera:    Yes.

Nada Youssef:   Okay, that's perfect. With your program, the medical weight management program, how is it different? What do patients expect when they first go to a program like that? Is it a lot of people? A lot of support? Is it one-on-one?

Dr. Burguera:    Yes.

Nada Youssef:   What is it?

Dr. Burguera:    Our program, we have a lot of people with type 2 diabetes. But we center mainly on the weight. We know that if we help people to lose weight, their type 2 diabetes gets under control.

There are two ways to take care of diabetes. One will be the glucocentric approach, meaning we care about your blood sugar, we make sure we control your blood sugar, and we use medications to control your blood sugar. That's the way that diabetes is treating many where.

We treat diabetes in a different way. We treat diabetes in a way that we make sure that we help you to lose weight. Yes, we pay attention to your blood sugar, but the main goal is to help you to lose weight. When patients lose weight, the blood sugar, the cholesterol, the blood pressure, the sense of wellbeing, improves.

Nada Youssef:   Everything, yeah.

Dr. Burguera:    If we follow more the blood sugar approach, yes, you start with metformin, and after they give you maybe another pill like glitazones, so they give you another pill that usually end up taking insulin and causes weight gain.

Sulfonylureas, sulfonylureas and insulin are associated with weight gain.

Nada Youssef:   So that's the medications for diabetes, can cause weight gain?

Dr. Burguera:    Yes. So that perpetuates the disease. We use medications and an approach to treat type 2 diabetes that we help people to lose weight. When they lose weight, the diabetes gets into remission. So that's extremely important.

And I think if we agree, and I think that's being shown, that people develop type 2 diabetes because, first, they have gained weight. I think it's really counterintuitive to treat a disease like type 2 diabetes with medications that cause weight gain, when the weight gain was the reason why you development type 2 diabetes to start with.

Nada Youssef:   That's a good point.

Dr. Burguera:    So we don't agree with that. We are more eager to treat the obesity, help people to lose weight, help people to lower their insulin resistance. And get the blood sugar under control. And we have plenty of data, and we publish that data to show that, when that happens, people do better.

We have plenty of information with bariatric surgery.

Nada Youssef:   I was just going to ask you that question.

Dr. Burguera:    People with bariatric surgery, what happens is that their set point in the brain, their appetite set point, gets lower. We have our colleagues in the bariatric institute, they do more than 700 surgeries per year.

When we see these patients after bariatric surgery, they tell us, "I am not hungry." And you ask patients, "So, you lost 30 pounds. Why is this gone?" "Doc, I am not hungry."

That's a new feeling for many people. So not being hungry is because their set point is lower. So the bariatric surgery, what it does is that your set point was before 280 pounds, and you needed to eat so your-

Nada Youssef:   To get up to that.

Dr. Burguera:    ... to be there. Now your set point is 220. So there is 60 or 70 or 80 pounds difference, and you just eat less.

Nada Youssef:   That's the appetite suppressor that you were talking about.

Dr. Burguera:    That's right.

Nada Youssef:   So bariatric surgery is a good option for people with diabetes, to lose weight.

Dr. Burguera:    Absolutely.

Nada Youssef:   Absolutely. And diabetes type 2 is completely reversible with diet?

Dr. Burguera:    Diabetes type 2 gets into remission in many circumstances after bariatric surgery, because of the weight loss. The weight loss causes less insulin resistance, so the pancreas starts working better. And the blood sugar gets under better control, so the diabetes gets what we call into remission. We don't like to say that it's cured. We like to say it's getting into remission.

Nada Youssef:   I see. It's gone for now.

Dr. Burguera:    But for that, we understand that sometimes people who came to see us, taking insulin, and taking medications, they have bariatric surgery, and they leave the hospital with no insulin and maybe just with a medication called metformin.

So they can have a tremendous improvement in their blood sugar after undergoing bariatric surgery. The surgery changes some of the hormones in our gut. Those changes in the hormones cause the appetite to be lower. And also may play a role in improving insulin sensitivity, meaning, allowing the insulin that the pancreas produces, to work better.

All those factors help to get the diabetes into remission. People who had diabetes less than five years, usually do much better getting into remission than people who had diabetes more than 10, 15 years.

Nada Youssef:   Okay, it's a shorter term. We have a lot of live questions coming in, so I was-

Dr. Burguera:    Yes. Let me emphasize one thing about our program. We see patients in the context of groups. We give lot of attention to the group support. That works very well. When we see the patients we check blood pressure and we check the weight. And after we review everything that I was telling you, in the context of groups.

And we have already shown that when we compare that to a standard of care, meaning seeing them individually, the groups are more efficacious. The data looks better. Why? Because the group offers an extra support. You see, from the other members in the group. You become more comfortable, you get a lot of knowledge from them. And we see them frequently. We see them every month. So we can make changes and motivate, and make sure that things go in the right direction.

And if they are not going the right direction, we try to identify why is that happening, and try to make corrections.

Nada Youssef:   It's a shared medical appointment.

Dr. Burguera:    It's what we call a shared medical appointment, yes.

Nada Youssef:   Okay. Great. Great. And we'll put the website on the comments section here below as well, for our viewers. But let me go ahead and go to some questions.

Dr. Burguera:    Please.

Nada Youssef:   I have Barb. What number do you consider pre-diabetic? For example, an A1C of 5.7.

Dr. Burguera:    Well, that's in the cutoff, yes. We start getting concerned about that. 5.6, 5.7.

A number ... I think a number is just an orientation. If you have been noticing that you are gaining weight, it's going to be a moment that, unless you do something about it, that will continue to increase.

Sometimes, we have numbers just to start the diagnoses, but the point is, if you have been gaining weight, and you're seeing that your fasting blood sugar is slowly getting higher, and you don't do anything about it, yes, today you are pre, and tomorrow you are full. It's just ... the number is important, but it's just an indication. We need to make sure that when you see things going up, you start making corrections.

Nada Youssef:   With the prevention. Sure thing. And then Suzette. Great information. So, do you think a glucose of 109 is pushing it? A1C is 5.7. She's the same one as ...

Dr. Burguera:    Well, yes, I would like to know how it was six months ago. But yes, that suggests that it's in the pre-diabetes. Over 100, over 101, we are just getting concerned. So yes, we want to be having a fasting blood sugar less than 100-

Nada Youssef:   So 109's a little bit high.

Dr. Burguera:    Yes, it is. Yes, it is.

Nada Youssef:   Okay. Okay. And then Donald. What is a normal sugar count to see if you're diabetic?

Dr. Burguera:    Well, it depends if you are fasting, if you are postprandial, if you have already eaten. And one blood sugar number really doesn't say much. If you already have type 2 diabetes, we are looking at the hemoglobin A1C, that's the average blood sugar over the previous three months. So we want to make sure that you keep that, hopefully, less than 6.5.

The closer to 6 the better. But at the same time we want to make sure that you don't develop hypoglycemia, see if you're being treated with other medications, like sulfonylureas, which will cause low blood sugars, or weight gain.

That's the problem that I was saying before. If we are aggressive treating the hemoglobin A1C with medications like sulfonylureas of insulin, yes, we may get the hemoglobin A1C to 6.0, but maybe from 180 you go to 220 with your weight. So we're trying to make sure that, from 180, you went to 170 or 165, and at the same time we keep your hemoglobin A1C under control.

Nada Youssef:   And you're literally going to the cause, which is-

Dr. Burguera:    The weight.

Nada Youssef:   Weight is one of the huge ones. Okay. And then Shannon. Can you get rid of type 2 diabetes with weight loss? And that's-

Dr. Burguera:    Absolutely.

Nada Youssef:   Absolutely can be done. And have Shada. Once diagnosed, do you always have diabetes, or can it be cured?

Dr. Burguera:    Well, that's a great ... in general, we say to our patients, "You have type 2 diabetes, and this is a chronic disease."

Yes, it's a chronic disease, but we know that if there is weight loss, as I said it, you will get into remission. Plenty of data already published showing that, yes, today your hemoglobin A1C is 6.6, you have type 2 diabetes. But we help you to lose 20, 10, whatever, and the next hemoglobin A1C is 6.2 or 6.3.

And if you are already taking medications, your diabetes is not there. So you have a normal fasting and a normal hemoglobin A1C, you cannot say that you have diabetes anymore. So, yes, you got into remission. Why? Because the weight loss.

Nada Youssef:   That's excellent. And then Amy wants to know, can diets like clean eating, or removing certain foods, reverse diabetes?

Dr. Burguera:    I don't think that a single food will do that. I think it's the weight loss associated to eating healthier that will cause you to improve your insulin sensitivity, and yes, get into remission.

Nada Youssef:   Sure. Sure. And Ryan. With all the new diets out there, and with so many choices, is there one that you would recommend over any others specifically targeted, the characteristics of diabetes, like keto, Atkins, paleo.

Dr. Burguera:    I think-

Nada Youssef:   Is there a more-

Dr. Burguera:    I would go with a Mediterranean diet, because it's the only one that have shown to improve cardiovascular risk, decrease our chance of having a heart attack, decrease our chances to have a stroke. Decrease the risk of developing Alzheimer's and dementia. So it's a very healthy diet, but at the same time, you need to try to follow it in a way that you reduce your number of calories. So you slowly lose weight.

But for that, to keep the weight off, you need to increase your level of physical activity. And if you are not successful improving your diet and becoming more physically active, the use of medications should be considered. We need to also talk about your stress. We need to talk about how many hours you are sleeping. All those factors need to be-

Nada Youssef:   There's a lot more factors than just the diet.

Dr. Burguera:    Yeah. Thinking that improving your diet, you're going to be successful long-term, is nonsense. That's not going to happen. The problem is that there is a tremendous business associated to every diet. You have somebody famous that is endorsing that diet, even more noise around a specific diet, but the reality is that usually doesn't happen long-term.

Nada Youssef:   Back to keto. Anna. Does keto diet increase your cholesterol?

Dr. Burguera:    At the beginning, it may, but usually with the weight loss, we see that getting better. But yes, if you follow a very high-fat diet, yes, your cholesterol may increase.

When you talk about eating protein, we talk about eating hopefully more turkey and fish, and more chicken. But yeah, some red meat could be that, associated to that. The risk of cholesterol increase is very ... I don't think that's a big concern, if you are cautious.

Nada Youssef:   Sure. Alright. And then Roy. How much weight do you need to lose to affect your blood sugar? I guess it depends.

Dr. Burguera:    Roy has a tough question there. It really depends. It really depends where you start. In general we see improvement of fasting blood sugar after a 3% weight loss.

Nada Youssef:   3%.

Dr. Burguera:    3% to 5%. But with 3%, you have already. If you lose 10 pounds, in general, that usually a good idea. It depends where you start from. And everybody is different, obviously.

Nada Youssef:   Of course. Right. Janine. I'm on concentrated insulin. It seems to take too long to work, and I'm gaining weight very fast. Any advice?

Dr. Burguera:    Yes. If she had type 2 diabetes, and I assume that's the situation, she needs to talk to her doctor about the possibility of using other medications, like what we call GLP-1 analogs, like peptide analogs.

They are working, or they can be administered daily or weekly. There are at least five, six in the market. That should be considered. There are other medications called SGLT2 inhibitors, GLUT2 inhibitors. They work in the kidney, also increasing the amount of sugar that we lose by the urine. So that's a way to consider also.

Insulin is associated with weight gain. So that's really the glucocentric approach for the treatment of type 2 diabetes. Sulfonylureas and insulin are associated with weight gain. She needs to talk with her provider about using GLP-1 analogs and SGLT2 inhibitors. Those two type of medications are associated with weight loss.

They can be associated after metformin, when people do not do well with metformin, those two medications could be considered-

Nada Youssef:   soon after-

Dr. Burguera:    ... and that's what the American Association of Clinical Endocrinologists, and the American Diabetes Association suggest as a possibility, instead of being more prone to using sulfonylureas and insulin.

But at the same time, I guess she may have also obesity. Maybe her BMI is over 30. So she goes to talk to her provider about the possibility of using some of the medications known to be responsible for lowering appetite, what we call anti-obesity medications, also approved by the FDA, for weight loss.

Nada Youssef:   Anti-obesity, that's the one that suppresses the appetite?

Dr. Burguera:    Yes.

Nada Youssef:   Is that given to every patient that is seen for diabetes, then?

Dr. Burguera:    No.

Nada Youssef:   That is struggling with weight?

Dr. Burguera:    No.

Nada Youssef:   Or is that a-

Dr. Burguera:    But in many circumstances should be considered. And that's what I am suggesting. We are suggesting that, instead of treating diabetes with medications that cause weight gain, and considering that you have development type 2 diabetes before you gain weight, you should consider, your physician and provider should consider treating your diabetes in a way that they help you to lose weight. There are medications, FDA approved, for the treatment of diabetes, that are associated with weight loss, number one.

And number two, there are all medications approved for obesity therapy also by the FDA. That could be considered also, in addition to those medications that are using to control your type 2 diabetes.

My point is that we need to control the weight. If the weight gets under control, type 2 diabetes, cholesterol, depression, blood pressure-

Nada Youssef:   Yeah, everything comes with that, yeah.

Dr. Burguera:    ... osteoarthritis, sense of wellbeing, sexual function, everything gets better. If you're going to get all those things that I have just said, better, in the situation that I was talking about here, you have five medications. You need one for the cholesterol, one for the blood pressure, one or two for the diabetes, one or two for the depression.

Nada Youssef:   Well, for the side-effects, yeah.

Dr. Burguera:    So you are treating the consequences of weight gain, instead of treating the primary problem, that is the obesity, that if you treat that, everything else gets better.

Nada Youssef:   Will fall into place. Okay. Great to know. That's great, thank you. Let's see. So, Darlene. I'm a type 2 insulin-dependent diabetic. Explain to me why, when I quit my insulin, I lost 83 pounds. Then I had a stroke, so I went back on insulin, and now I've gained 61 of it back. I think insulin makes you gain weight.

Dr. Burguera:    I fully agree with her. I'm really sorry she developed a stroke. But I will guess that the stroke was not because of the weight loss.

Nada Youssef:   I was going to ask, yeah. Right.

Dr. Burguera:    She makes the point. She really has a cause and a consequence. She started insulin, gained weight, she stopped insulin, she lost weight. We know that. We know, we have plenty of information to suggest that when you start insulin or when you start sulfonylureas, yes, there is associated weight gain.

We need to talk with our providers. We need to make sure that we are in a situation, and being taken by a provider that really thinks that weight is a concern.

Nada Youssef:   Sure. Sure. You're being medicated for a problem, but it's creating even a bigger problem.

Dr. Burguera:    That's right. That's right.

Nada Youssef:   That's exactly what's happening. Juan. Is metformin safe to take? And what are the side-effects?

Dr. Burguera:    Juan, metformin is a very good medication.

Nada Youssef:   Okay, good.

Dr. Burguera:    metformin, what it does, is to reduce the amount of sugar that our liver produces. If you have type 2 diabetes, having your glucose, the one that is being produced by the liver, being reduced, that helps to get better control of the blood sugar.

Yes, metformin is the first line of therapy for people with type 2 diabetes, after or at the same time they improve their eating habits, and they become more physically active-

Nada Youssef:   Sleeping.

Dr. Burguera:    ... and everything. Importantly, metformin also reduces appetite. So people who start metformin usually lose a little bit of weight because of decreased appetite, and also better control of their blood sugar. Insulin gets lower, and they usually are less hungry too. metformin is a very good medication to treat type 2 diabetes.

Nada Youssef:   Great. And then I have a question from Ice. Can we use metformin for weight loss?

Dr. Burguera:    It's not FDA approved, but-

Nada Youssef:   Okay. It's not-

Dr. Burguera:    ... people who have type 2 diabetes or pre-diabetes or insulin resistance, we use  metformin to help them to improve their insulin sensitivity, and to lose a few pounds. In the context of everything that I was saying.

We need to understand, also, that metformin sometimes, if it's taken with an empty stomach, could be associated with some nausea, with some diarrhea, so it's recommended to start metformin after dinner, after we eat.

And yes, sometimes metformin ... We need to make sure the kidney function is appropriate. There is a condition called lactic acidosis, that is very rare, but patients could develop that if the kidney function is not working properly.

Obviously, you need to talk with your doctor about it, but it's the first line of therapy, we have thousands of people taking metformin.

Nada Youssef:   Excellent. So, "Can you take metformin and insulin?" Barbara asks.

Dr. Burguera:    Yes. But before adding insulin to metformin, in a situation of type 2 diabetes, that has been probably caused by weight gain, instead of adding insulin to metformin, I will add, as I suggested before, the medications, the glucagon, like peptide GLP-1 analogs, or the SGLT2 inhibitors.

One helps the GLP, helps the insulin to work better, and also reduces appetite. The SGLT2 works in the kidney, increasing the amount of sugar that we lose in the urine.

The first one reduces appetite and helps your insulin to work better. The second one helps you to get rid of more sugar in the urine. The consequence of both is that you lose weight and you get your blood sugar under control.

I will not be prone to add insulin after metformin. I will be prone to use any of those medications that I have just suggested, because I know that they are going to help you to lose weight, and also it's going to help you to get your blood sugar under control.

The moment I start you on insulin, most likely you are going to gain weight. Yes, we may get your hemoglobin A1C under control, but I think we can get your hemoglobin A1C under control with any of those two medications, plus the weight loss that is going to be associated to that.

Nada Youssef:   Great. So, check on these two other medications. And then, Jill. What is the name of the appetite suppressant you mentioned earlier?

Dr. Burguera:    Well, there are different appetite suppressants that have been approved by the FDA. There is a combination of phentermine and topiramate, that's a combination that can be used long-term. There is another medication that is a combination of Wellbutrin and naltrexone, that can also be used long-term.

There is another medication that is liraglutide, also, that could be used long-term. There is something that works in the gut, reducing the absorption of fat, that is called orlistat.

Phentermine has been in the market for many years.

Nada Youssef:   Phentermine?

Dr. Burguera:    Phentermine, yeah. There is different medications that work in the brain, and you need to talk to your provider to see which one is the best for you, based on your general history, and we try to make sure that we use one that is effective. And we discuss the pros and cons. Any medication, to treat any condition, has pros and cons.

There is a lot of bias against the use of medications to control appetite, mainly because of the history. Many medications used in the past were not FDA-approved. They had been used off-label to treat obesity. The ones that we have right now, yes, they are FDA-approved. They have-

Nada Youssef:   Okay. So all the ones you mentioned are FDA-approved.

Dr. Burguera:    Yes.

Nada Youssef:   Okay, good.

Dr. Burguera:    So I have not mentioned the actual name, but it's the combination of those two, those medications.

There is another one called lorcaserin. Lorcaserin also works in the brain, reducing appetite.

So those are ... any of ... FDA-approved medications to treat obesity, there is a list. You need to talk to your provider.

Nada Youssef:   Talk to your doctor about that.

Dr. Burguera:    They need to understand what is your history, whether or not you have a history of depression, whether or not your kidneys working properly, how is your blood sugar. There are more than one type of obesity. The same way that there is more than one type of cancer, and more than one kind of depression.

We cannot say people have obesity. No, you-

Nada Youssef:   You have to customize the program for-

Dr. Burguera:    That's right. You really saw detailed history, get a sense of what's going on in a patient's life to understand what has been ... if they see any predisposing factor, quitting smoking, going through change in jobs, move to somewhere else, a divorce, genetics, started some medications. Some of the medication that we have to treat anxiety, depression, bipolar disease, blood pressure ... Some of the medications that people uses, beta blockers, antipsychotics, they are associated with weight gain.

So we have to make sure that-

Nada Youssef:   Ah, so it could be a side-effect of something else.

Dr. Burguera:    ... first, your doctor reviews with you which medications you are taking to treat all the medical problems. Because sometimes, switching a medication is the first thing that we need to do to help people to lose the weight.

Nada Youssef:   Great. And then Jill ... well, no, that's the one I just asked. Roy. Can we get a prescription for appetite suppressant from our primary care physician? Or do we need to see a specialist?

Dr. Burguera:    No. In general, any licensed provider should be able to prescribe an appetite suppressant in the context of a visit where everything that I have been suggested, is being addressed.

Giving you a prescription for an appetite suppressant, if you don't do that in the context of everything that we are doing, it's not going to be that effective. We know that. So it's very important that you talk to your provider. They get a good sense of your general health. They know what have been the predisposing factors, what is going on in your life, what is going on with your health, which medications you are taking. And after, yes, if necessary, a lifestyle intervention with nutrition, with more physical activity, the appetite control, the sleep and stress, all those factors I was suggesting, are being addressed.

They are ... two of them are controlled substances. The meaning of that is that you need to see your physician on a monthly basis, they need to renew the prescription. A controlled substance means that the FDA potentially has concerns that you may be getting addiction.

In general, the addiction to appetite suppressants is not there. I really personally have not seen that. But patients need to be seen on a monthly basis. Make sure that we address the pros and cons, we evaluate the progress. And if ... I don't think there is a medication that people could abuse, to be honest. But we paid lot of attention to that. We made sure that we see patients on a monthly basis, we see whether or not they are responding. And we address any concerns that they may have.

Nada Youssef:   Are those medications that suppress your appetite, are they something that your body gets used to, and you will need a higher dosage the more you use it? Or is this kind of like a one-time deal?

Dr. Burguera:    No. In general we don't see that. In general we see that people start losing weight, and after there is a plateau. Your weight gets under control.

Nada Youssef:   Okay. There's a plateau. Okay.

Dr. Burguera:    The concern there, for many people, is that they are not being effective and not losing more weight. So it's not so much that. They are continue to be effective. If you regain, we could say maybe they are not effective. But if you keep your weight down, that's effective.

And usually, in general, the plateau is because what we call the basal metabolic rate, changes. So the basal metabolic rate is the amount of calories that we burn for being alive without moving. We burn calories through different ways, three different ways.

One is with physical activity. Two is having our body functioning. Your brain, your heart, your lungs. When that works, it burns calories.

Nada Youssef:   Just automatically.

Dr. Burguera:    Those calories that are being used to keep your body functioning, that's the basal metabolic rate. So, physical activity, basal metabolic rate, and the third way is what we call the thermic effect of food. Meaning, how much calories you burn, your gut, processing your food.

When you eat, your gut obviously has to process the food. We burn calories through that way. When we start losing weight, our body doesn't like that. Our body wants to keep the weight that has been there, because it feels that the extra weight that we have means reserves.

You have, if something goes wrong, if you break a leg, or if you don't have access to food, or if you develop an infection, or if women get pregnant, having an extra energy there is a guarantee of extra energy in case you need it for unexpected events.

Over the evolution, that kept you alive. If you had the extra energy. So your body's happy with the energy that you have accumulated. So when we start losing weight, the basal metabolic rate may change. So if now you need 1,500 calories to keep your body functioning, your lungs, your brain, your heart, your body's able to do that with 200 calories less. It's more efficient.

So instead of burning 1,500 to keep you alive, it just burning 1,300. So those 200 calories, whereas now they are not being burned. So that's the reason why before you were losing and now you are plateauing, because you don't end up the day with 200 calories less.

How to compensate that? Well, you need to probably burn 200 calories extra, or eat less 200 calories. Sometimes when people plateau, we add a medication, or we change the medication. Or, in ... sometimes that set point, that changes in metabolic rate, and this is a matter of controversy, it may come back, and you go back to the 1,500 instead of the 1,300.

That doesn't happen to everybody, and we could discuss this forever. But plateau means that your brain is feeling that you are being successful, so it's changing your basal metabolic rate. It's trying to prevent you from losing more weight. We have ways to counterbalance that. And it's very important.

But when people plateau, they should not be frustrated. They should keep doing what they're doing. They should-

Nada Youssef:   It means you're doing it right.

Dr. Burguera:    That's right. That's right.

Nada Youssef:   yeah, and as long as you're in a healthy BMI rate, then you're good. I'm going to ask you one more question, then we're running out of time. Ibrahim wants to know, are there new drugs for treatment for type 2 diabetes?

Dr. Burguera:    Not really. There is a tremendous armamentarium to treat patients with type 2 diabetes. There are more than seven, eight different categories to treat patients with type 2. Meanwhile, we just have five medications to treat people with obesity.

The ones that we have right now should be very effective to treat the type 2, and also to treat the obesity that caused the type 2. So it's just a question of having a conversation with your provider, so in addition to treat the blood sugar, they are also treating the weight. So you keep your weight down, and you get your diabetes under remission.

Nada Youssef:   Wow. Alright. Well, we are running out of time. Thank you so much for being here.

Dr. Burguera:    Thank you, Nada Youssef, thank you for inviting me, I really enjoyed talking with you.

Nada Youssef:   It's been a pleasure. And if you're ready to make a life-changing decision, and are interested in learning more about the medical weight management program here at Cleveland Clinic, you can call us at 216-444-3672 to schedule your consultation. Or simply go to ccf.org/freshstart for some powerful weight loss tools.

And thank you so much for watching us, and keep watching us on Facebook. Follow us on Twitter, Instagram and Snapchat, @clevelandclinic, one word, and we'll see you again next time.

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