How Losing Weight Can Impact Diabetes with Dr. Shirisha Avadhanula

Podcast Transcript

Cassandra Holloway:

Hi there, welcome to the Health Essentials Podcast brought to you by Cleveland Clinic. My name is Cassandra Holloway and I'll be your host for this episode. Today we'll be discussing diabetes and weight loss. We're joined by endocrinologist Dr. Shirisha Avadhanula. Welcome to the podcast.

Dr. Shirisha Avadhanula:

Thanks, Cassandra. I'm happy to be here.

Cassandra Holloway:

So losing weight can be a challenge and may be an uphill battle for the majority of us but it can be even more challenging for those struggling with diabetes. In this episode we'll chat about the benefits of weight loss when it comes to diabetes and we'll also discuss some strategies for how to actually go about it.

              Before we dive into this full episode we just want to take a moment to remind listeners that this podcast is for informational purposes only and is not intended to replace your own doctor's advice.

              So I want to start off by first asking you if you'll tell us a little bit about your practice at Cleveland Clinic and the types of patients you typically see.

Dr. Shirisha Avadhanula:

So at the Cleveland Clinic in endocrinology we see a wide spectrum of endocrine disorders, things like disorders of the adrenal, the pituitary. In my clinic, specifically I focus on weight management and diabetes management, thyroid disorders, as well as [inaudible 00:01:49] care.

Cassandra Holloway:

So can you start off by explaining a little bit to our listeners what's actually happening inside of the body when you have type 1 or even type 2 diabetes?

Dr. Shirisha Avadhanula:

Yeah, so diabetes is common and it's important to know what happens exactly when somebody develops diabetes and we're talking about diabetes mellitus here. So when we talk about diabetes broadly speaking there's two types of diabetes. There's type 1 diabetes, also known as autoimmune diabetes and type 2 diabetes.

              Let's go back here to the process of digestion. So if you were to eat a carbohydrate heavy meal, for example I had a bowl of pasta this afternoon. So when I am eating that through the process of digestion these carbohydrates they get broken down into sugars and the sugars sit in your bloodstream until they get taken up into cells and we use this as energy or as fuel and this whole process is mediated by a hormone called insulin, which is a really important hormone that's made by the pancreatic beta cells.

              What happens in diabetes is that there is a disruption in this entire process. So in type 1 diabetes you're not making any insulin at all so the sugar will sit in your bloodstream and we're not able to take this up into cells. In type 2 diabetes the most prevalent concern really is insulin resistance. The cell is not really able to be as sensitive to the effects of insulin so more and more sugar gets built up into your bloodstream and just can't take it up into the cells and use it [inaudible 00:03:33].

Cassandra Holloway:

I'm curious, if you have either type 1 or type 2 diabetes is it common to also be overweight? Do you often see that being a symptom of being diabetic?

Dr. Shirisha Avadhanula:

Yeah, that's a good question. So most often the patients that we see with type 2 diabetes are in fact overweight or they're obese. I do want to make the distinction though, not everybody who's obese or overweight has diabetes and I think that's an important distinction to make.

              Those patients with type 1 diabetes they actually present with weight loss instead of weight gain and that's a function of the insulin deficiency.

Cassandra Holloway:

If you have diabetes and you are overweight why is it important to lose that weight? What are some of the benefits and also some of the risks if you don't take some of that weight off?

Dr. Shirisha Avadhanula:

Losing weight is critical when it comes to diabetes. We have an eagle eye view when we treat our patients. We have a really individualized approach but for every patient we have this broad algorithm, if you will, when we start treating diabetes. The very first thing we ask people to do is we ask them to exercise and we ask them to diet so that they can lose weight.

              We identified being overweight and being obese as one of the major risk factors for the development of type 2 diabetes. We know through studies that patients that have a significant amount of weight loss, whether it's through metabolic surgery or whether it's through calorie restriction, there can be a remission of type 2 diabetes.

              There's factors that we can control and there's factors that we can't control. Other risk factors for diabetes are things like your genetics, things like your race, your age, past medical history, things like polycystic ovarian syndrome. These are things that you can't control but a major risk factor is being overweight or being obese and this is something that you can control. So we hugely focus in the management of diabetes on weight loss.

Cassandra Holloway:

I want to go back to what you said about the unexplained weight loss or the lower weight loss with someone with type 1 diabetes. That seems really interesting to me being on opposite ends of the spectrum. Why would type I diabetes sometimes cause you to lose weight actually?

Dr. Shirisha Avadhanula:

Yeah, so the answer to that really is insulin deficiency. So actually it's not just type 1 diabetics that tend to lose weight. What can happen in type 2 diabetes, I alluded to this point earlier, but during the process of insulin resistance just imagine this, your pancreatic cells are working overtime. They are working 24 hours in the day, seven days a week. Eventually they'll tire out, right? And that renders, that's when a patient with type 2 diabetes is rendered as "insulin deficient" so at that point because of the insulin deficiency patients will start to lose weight.

              I also do want to mention that we have a certain kidney threshold for sugar. So after a certain point sugar will enter into your kidneys and then you eventually urinate it out. Patients will present with things like increased thirst and increased urination because sugar is a really small molecule and it pulls water with it and so you'll have patients that complain often of thirst, of urination and of weight loss and this is usually when a type 2 diabetic or somebody with type 2 diabetes, excuse me, comes in pretty far along in the course of the disease.

Cassandra Holloway:

Yeah, it's interesting. I feel like that thirst is something you hear a lot about being one of those red flag. If you're always constantly thirsty of it being a symptom of diabetes.

Dr. Shirisha Avadhanula:

Yeah, absolutely and it's certainly for the reasons that I mentioned. It really is that kidney threshold and we tend to see that a lot, increased thirst, urination but I also do want to mention that the most common symptom when people present with diabetes really is no symptom at all.

              So these are a little more rare but it's definitely important to know. It's a red flag, somebody comes in with the weight loss, increased thirst and urination.

              The other thing I do want to mention though unintentional weight loss for diabetes associated reasons or not should always be looked at by the provider.

Cassandra Holloway:

Absolutely. So generally speaking is it safe to say that having diabetes makes weight loss more difficult?

Dr. Shirisha Avadhanula:

I think that's an interesting question. It's certainly difficult in some patients and I'll tell you why. It's because some patients get put on insulin and insulin is what we call anabolic so it'll make you gain weight. So in a certain subset of patients who are taking [inaudible 00:08:37] exogenous insulin it is a little bit more difficult to lose weight and that sort of reiterates the point that when somebody is on insulin and they still have a functioning pancreas we really work very hard to maximize medical therapy.

              So as many medications as possible so that we're able to put the patient on as little insulin as possible so that they won't gain weight because I think the point that you have is [inaudible 00:09:06]. It becomes this vicious cycle, right? You gain more weight, your blood sugars are out of control, you need more insulin. It's this vicious cycle. So that's why maximizing medical treatment before you're on insulin is so important.

Cassandra Holloway:

Yeah, it's just hearing you talk I can see how frustrating that would be. How do you stop and get off the hamster wheel if you have to take insulin to survive but it's contributing to your weight gain.

Dr. Shirisha Avadhanula:

Yeah, absolutely. I mean, diabetes, I always think of diabetes as a multifaceted, it's complicated and it takes a team of people to manage it. I mean, diabetes isn't just an endocrinological disorder. We have people seeing dieticians. We have people seeing exercise physiologists.

              We have people seeing psychologists because I think as we all know food is very emotional. When we're happy we tend to eat. When we're sad we tend to eat. So the study of diabetes and the study of weight management is profoundly complex and it involves multiple different providers. So definitely agree with what you're saying. It can be very frustrating.

Cassandra Holloway:

So oftentimes when we think about the standard diet advice we often hear eat less, exercise more but what you're saying and alluding to that sometimes it could be a lot more complicated than that for people with diabetes. So does that standard advice ring true with people with diabetes or what should they be thinking about?

Dr. Shirisha Avadhanula:

So there's been a paradigm shift when we're talking about weight management. We have come so far. It's important to note that obesity and being overweight is actually a new disease. It wasn't 30 or 40 years ago that our main nutritional focus was starvation and although food insecurity still remains a hugely prevalent problem our main focus is on the management and the treatment of obesity now.

              So it's relatively a new field. It's evolving. We're learning every day. We do have weight loss medications. We have a lot of great options but if you really step back there's really two main things that we focus on. The first thing is consistency and the second thing is calorie restriction. What you were alluding to earlier but the reason that I say consistency is because your body makes it incredibly difficult for you to maintain a weight loss.

              What happens when you lose weight is your body secretes counterregulatory hormones because it thinks that you're starving and it will make you hungry. It will essentially try to have you gain that weight back and that's an evolutionary mechanism. It will also become excellent at conserving energy more efficiently.

              So for example if you were to run on a treadmill for, I don't know, a half an hour and you burnt 120 calories, when you lose the weight that exact same run you may only burn 100 calories or 90 calories and it's because your body is becoming more efficient at conserving that energy. It doesn't want you to lose the weight.

              We are all at "a set point", a metabolic set point, and it takes a couple of years for that set point to actually change and for your body to accept this new weight. That's why consistency is key because you have to make sure that whatever you're doing you can do it for years to come. I always tell people, "Losing weight is a very serious commitment. It's more serious than a marriage so you really have to be committed to this."

              The second thing is calorie restriction, the basic principle if you really go back to it, weight loss occurs when there's a net negative between energy intake and energy expenditure but when you think about weight loss with a lens of diabetes you have to go a step further because in that respect we're not only telling, advising our patients that yes, they have to watch their calorie intake but now we're having them think about the quality of the foods that they're consuming because if I ask a patient to say consume 1400 calories in a day if they consume 1400 calories of Fun Dip then it would be detrimental to their blood sugar.

              Really it comes to the quality of the foods that they're consuming. So it's certainly more complicated and we're learning things every day but I think we're moving in the right direction.

Cassandra Holloway:

Yeah, I feel like you always hear about diet and nutrition and exercise, making it part of your lifestyle and it has no end date. You're always going to be something ... working toward that, being that consistency point that you're talking about. I'm curious though, do you have any diet recommendations? Are there any specific diets that you often recommend to your patients or is it more of that lifestyle overall message that you give?

Dr. Shirisha Avadhanula:

So there are, when a patient is diagnosed with diabetes, there are certain, I guess guidelines that we recommend for patients that were newly diagnosed with diabetes. The first is that they should limit simple sugars.

              The second is as much as possible limiting things like white rice, pasta, potatoes and white bread and also limiting carbohydrates as much as possible. So as long as they're adhering to those guidelines then with that scope the best diet is the diet that you can stay on.

Cassandra Holloway:

Do you ever recommend Keto, if someone can do that longer term?

Dr. Shirisha Avadhanula:

Yeah, people have asked me about the Keto diet. People have asked me about intermittent fasting. There have been studies on the Keto diet that show a reduction in body mass index as well as decrease in triglyceride levels. I will say though we find for Keto in the long term it's very difficult for patients to be compliant to that diet so it's not a great diet in the long term.

              We also did see studies where patients had emergency room visits for things like electrolyte disturbances, things like dehydration and also hypoglycemia, so low blood sugars. So Keto may not be the best diet.

              On the other hand, there's also a lot of people ask me, within your line of questioning, about intermittent fasting, just as an example and there was a really good article in the New England Journal of Medicine last year that highlighted the benefits of intermittent fasting and although there are a lot of benefits to intermittent fasting it could potentially be problematic in patients with diabetes because the antihyperglycemic agents that they're taking should very likely be reduced prior to starting this diet. Patients can end up with hypoglycemia.

              So really the bottom line in whatever diet you do is you should do it under a close monitoring of a healthcare provider to make sure that it's safe because in fact, I mean, these diets may not be the safest thing if you do them on your own but under the close monitoring of a healthcare provider, your healthcare team, you could potentially be successful.

Cassandra Holloway:

So when it comes to getting proper nutrition advice how often do you recommend these patients work with a dietician? I know there's lots of people involved, what you said of managing diabetes and treating it. How often are you recommending working with a dietician?

Dr. Shirisha Avadhanula:

Every time. So any time a patient comes to see me who has newly diagnosed either type 1 or type 2 diabetes I always recommend that they see a dietician. It really is a team based approach when we talk about diabetes and I think as many angles as possible that we can educate our patients, empower our patients, the better.

              So we're sending our patients to a dietician. We're sending our patients to diabetes educators. We're sending our patients to a pharmacist. We have an excellent endocrine pharmacist who really in depth goes through medications, side effects, medication interactions and really educates the patient on what exactly to expect with these medications and not to mention of course, an exercise physiologist. So it really is, as you mentioned correctly, it really is a team approach.

Cassandra Holloway:

And that exercise component, you mentioned working with an exercise physiologist, do you also recommend sometimes working with a trainer or is that ... just depends on where they fall in their journey, I guess?

Dr. Shirisha Avadhanula:

Not necessarily. I would say that if you have the resources and the means to do it then go for it. The major thing with a trainer, again, is really the consistency and the accountability. You're paying somebody to see you every day or every week or however often you have the trainer. If you have the means and the resources to do it then go for it but there's lots of other options.

              For example, we refer, as I mentioned, to the exercise physiologist. Now I'm seeing lots of great groups on social media. I've been seeing Facebook groups. I've been seeing Instagram groups where people are getting together. They're exercising together. They're keeping each other accountable and motivated and this is fantastic. So I don't really think that it's necessary to dish out the cash for a trainer by all means go for it but at the same time I think there is just as effective ways to exercise and to keep motivated.

Cassandra Holloway:

Absolutely, definitely. Finding out what works for you and then what you can do, again, long term and consistent.

Dr. Shirisha Avadhanula:

Exactly.

Cassandra Holloway:

Can you talk to me a little bit more about how the pandemic has made virtual care more accessible to these types of patients?

Dr. Shirisha Avadhanula:

Telemedicine has been around for a really long time but during the pandemic we were able to leverage telehealth systems to open up accessibility to care to the point where patients were safely seen and their visits ... they weren't falling off from their appointments.

              I think one of the most important things when we talk about weight management, when we talk about diabetes, is consistency with appointments. So following up with your care team and not missing appointments is hugely important because in your day-to-day life accountability is important but also accountability is also important with your providers.

              We're able to ask you prompting questions, make you think, empower you with the tools that you need for your day-to-day life and luckily during the pandemic we were able to use telehealth systems to really improve and expand the accessibility to care. So not only are we seeing patients within the Ohio area but we were actually able to see our patients nationally as well and this was a huge gain for us and we were very happy to leverage that system.

Cassandra Holloway:

So I want to switch gears and talk just a little bit about bariatric surgery and people with diabetes receiving this surgery. How often does this happen? Would you say, how many patients of yours end up needing bariatric surgery to reverse diabetes or work on their weight loss?

Dr. Shirisha Avadhanula:

Bariatric surgery has become a really important tool in our toolkit for management of diabetes. We have seen not only sustained weight loss but also sustained glycemic control. So bariatric surgery is a very good option for patients who actually qualify for the surgery and patients do achieve diabetic remission.

              Remember, I say remission and not cure because we look at glucose as if it's a continuum but we do see patients achieve diabetic remission with bariatric surgery. So it can be an excellent tool for patients who qualify. And by that I mean there's a certain BMI or body mass index cut off when we talk about bariatric surgery. Patients who have a BMI of over 40, they qualify but also patients with a BMI of over 35 with associated comorbid conditions and diabetes just happens to be one of them can pursue bariatric surgery.

Cassandra Holloway:

You said something really interesting about bariatric surgery allowing someone to be in remission from diabetes. I'm curious in general are you ever cured from diabetes or can you cure it?

Dr. Shirisha Avadhanula:

So when we talk about diabetes we talk about diabetic remission and not cure because we assume that glucose is in a continuum. So we talk about remission and remission is certainly possible. Patients who lose a significant amount of weight, like I mentioned either from bariatric surgery or from calorie restriction can certainly achieve remission.

Cassandra Holloway:

So we've talked about nutrition, exercise and movement, if patients are candidates for bariatric surgery but I wanted to ask about certain medications. Are there any medications out there that can help people with diabetes lose weight?

Dr. Shirisha Avadhanula:

When we have a patient with diabetes we have a bird's eye algorithm. We always start with lifestyle modifications and then we build in medications. It is always an individualized approach. So for example, if a patient has type 2 diabetes and they're struggling with their weight we're looking to choose medications that are generally either more weight control or are weight negative. So we want to stay away from the medications that could potentially cause weight gain.

              Like I mentioned earlier insulin is one such medication that can cause potential weight gains and there's other diabetic medications as well that can cause weight gain but really we build from an individualized approach. If a patient comes in and they have, for example, kidney dysfunction, we're going to stay away from certain medications and certain classes that may further disrupt that damage. So it always is an individualized approach and when we're talking about medications for weight loss now because we are ... we have great medications for weight loss that are good for weight loss alone.

              We're moving into a paradigm now where we're thinking about weight loss medications as long term treatment. So if somebody, for example has high blood pressure and you give them a high blood pressure medication you don't take them off the medication when their blood pressure goes back to normal right? You keep them on the medication. So we're starting to slowly think about weight loss medication in that same lens.

              So if somebody is to achieve their desired weight we generally tend to keep them on this medication long term and they've been approved in the long term because what we end up seeing is when patients come off this medication we tend to see a very slow increase of weight back to their original weight. So very slowly and in line with the American Board of Obesity Medicine we're shifting our thinking about weight loss medications.

Cassandra Holloway:

Can you tell me a little about newer medications, I believe they're injections and I feel like that's been in the news lately? Can you tell me a little bit about what patients should know about these injections for weight loss and being diabetic?

Dr. Shirisha Avadhanula:

There is a class of medication called GLP-1 analogs. These medications were originally approved for the treatment of type 2 diabetes and they're also weight negative so they help patients lose weight as well and there is a medication in this class that's solely approved for patients who are overweight or obese.

              There has been recently some more attention in the media a medication from that family that has not been approved by the FDA yet but maybe later on this year that is showing some very promising results, weight loss of up to 15%, which is a huge amount of weight loss. So we're looking forward to that approval. Like every other medication there are potential side effects. The most common side effect that you're likely looking at on this class of medication is gastrointestinal.

Cassandra Holloway:

So the last thing I want to ask you about here is for your general advice to listeners. So maybe someone is diabetic and they're listening to this podcast and maybe they're struggling to lose weight or struggling to find motivation or even where to start but they know it's important, what would you say to them? What would be your encouragement or general advice that you would give them?

Dr. Shirisha Avadhanula:

For anybody listening if you have ever tried to lose just one pound of weight you know how difficult it is. I would say I'll leave you with these three thoughts. The first is, take advantage of the resources that are available to you. See your care team and start the conversation.

              The second thing is align yourself with people that are like-minded so that you can keep yourself motivated. Like I was saying earlier there's tons of free groups you can join. The most important thing really is accountability and putting yourself in a group of like-minded people and allies will really keep you accountable.

              And the last thing that I'll leave you with is try your best to keep your motivation positive. If you're trying to lose weight do it for your health, do it for you and not to achieve an unrealistic body standard.

              Thanks so much for having me.

Cassandra Holloway:

Thank you for joining us. Wonderful advice to end on. We really appreciate you being here.

              To learn more about weight loss and diabetes visit clevelandclinic.org/endocrinology or call 216-444-6568. If you want to listen to more Health Essentials Podcasts featuring experts at Cleveland Clinic subscribe wherever you get your podcasts from or visit clevelandclinic.org/hepodcast.

              Also, don't forget to follow us on Facebook, Twitter and Instagram @clevelandclinic, all one word, to stay up-to-date on the latest health news and information. Thanks for listening.