Introduction: Okay ladies, this is an episode you asked for. And I’ve wanted to do for so, so long. Today we’re finally tackling what I’m calling the prediabetes epidemic. Currently, more than a third of Americans have prediabetes, which is the precursor to type two diabetes. And most of the people who have it, don’t even know it. And for many women, especially those with a family history, prediabetes seems to crop up suddenly in midlife, especially around menopause. On the show today, we’re going to talk about what prediabetes is, and what it does to your body, how to find out if you have it, how to prevent it, or if you’ve already been diagnosed, how you can reverse it, or at least stop it from evolving into type two diabetes. And later in the show, we’re going to talk about Ozempic and all those other diabetes drugs that are being used for both on- and off-label purposes. This is some important health talk you don’t want to miss.
Welcome to More Beautiful, the podcast for women rewriting the midlife playbook. I’m Maryann LoRusso, and I invite you to join me and a guest each week, as we strive for a life that’s more adventurous, more fulfilling and more beautiful than ever before.
I am here today with Dr. Parveen Verma, a doctor of osteopathic medicine and a fellow of the American College of Endocrinology. Board certified in endocrinology and metabolism, Dr. Verma is currently a lead physician at Virtua Endocrinology in South Jersey and chief of endocrinology and metabolism at Virtua Our Lady of Lourdes Medical Center in Camden, NJ. Dr. Verma practices general endocrinology with a special interest in the care and management of patients with diabetes. Dr. Verma, welcome to the More Beautiful Podcast. It’s so good to have you here.
Dr. Verma: Well, thank you so much for having me today.
Maryann: I have been looking forward to this discussion for weeks and so have a lot of my listeners. Because prediabetes seems to be affecting so many midlife women, and it often kicks in sometime near the menopause transition. First, I would love to present our listeners with some startling facts. Diabetes is the most common chronic disease after obesity, afflicting 84 million Americans and more than 1 billion people worldwide. Currently, about 98 million American adults, which is more than one in three, are considered prediabetic. More than 80% of these people are unaware that they are prediabetic, which isn’t good because prediabetes puts you at increased risk of progressing to type two diabetes, as well as developing heart disease, stroke, and a myriad of other conditions. In the United States. diabetes is the number six killer of women ages 45 to 54, and the number four killer of women ages 55 to 64. It would be so great if you could start us out by defining in layman’s terms, both diabetes and prediabetes, and tell us what’s going on in our bodies when these conditions develop.
Dr. Verma: Sure. Diabetes is a chronic disease where the body has difficulty metabolizing glucose or sugar. So the deficit really is in the pancreas where the body is not producing enough insulin. Insulin is a hormone made by the body and it helps your body to metabolize glucose and send it to the cells where it gives cells energy. I think of it as like a lock and key mechanism. Insulin is the key that opens the door to cells to let glucose in. And when you’re not making enough insulin, which is the deficit and type two diabetes, this can occur where blood sugars will increase. Prediabetes is kind of that precursor. It’s a condition also that occurs when blood sugars are borderline elevated. And just to define some some numbers, we measure blood sugar by milligram per deciliter. And when we think of doing monitoring blood sugars, there are some values that are important to know. So with type two diabetes, blood sugars, typically in the morning, you haven’t eaten anything, you’re waking up, you’re checking a sugar. When you have diabetes, it runs between one 126 and above. If you eat something, your blood sugar normally stays below 140. And when you have diabetes, it stays much higher than that after you eat so it might run higher than 180. Prediabetes kind of falls in that in-between category where your fasting blood sugars fall between 100 to 125. And after you eat, it typically will go higher than normal between 140 to 180. So we get concerned about prediabetes, because it can obviously increase your risk of developing overt diabetes down the line.
Maryann: Thank you. So just to recap, pre-diabetes is a state of insulin resistance when blood sugar levels are higher than normal, but not yet high enough to be diagnosed as type two diabetes, what triggers it into becoming full blown diabetes?
Dr. Verma: So a number of things actually. First of all, most individuals who progress to type two diabetes, they have a genetic risk. So maybe they have a family history where other family members have the condition. And then there may be other influences. Obesity is one of the leading causes or contributing factors to diabetes. So maybe they also have a sedentary life, or they’re on medications that might increase that risk. So usually, there’s a genetic risk, complicated by lack of activity, obesity, poor dietary habits. Maybe there are other influences like other medications, such as steroids. So usually, it’s a combination of factors that will unmask underlying type two diabetes.
Maryann: As I mentioned earlier, insulin resistance can lead to a whole bunch of conditions that we do not want—from heart disease and stroke to kidney disease, nerve damage, even Alzheimer’s. Tell us why we want to get insulin resistance under control, what are some of the risks involved if we don’t.
Dr. Verma: So all the things you just mentioned…It’s sort of this behind-the-scenes damaging disease that if it goes untreated, it is one of the leading causes of heart disease. It also can increase the risk of kidney damage and the need for dialysis. And part of the reason it’s important to identify even prediabetes is that there is some relationship between that entity and eye disease. And we know that when you don’t treat diabetes, effectively, you can also develop blindness or other complications related to vision. Neuropathy is also a common condition where people can develop painful burning lower extremities, upper extremities, and it can be very, very debilitating for individuals.
Maryann: Insulin resistance is a complex process, right? And it’s spurred on and exacerbated by so many factors including our changing hormones during lovely perimenopause and menopause, as both estrogen and progesterone can affect the way insulin works in the body. And I’m personally hearing so many stories of women over 45 or 50, who had always been healthy, who are suddenly diagnosed with prediabetes once they hit menopause. For the first time, maybe their numbers are in the prediabetic range, or they’re creeping up. And this can be confusing. Are women more at risk for getting prediabetes or diabetes post menopause? And if so, what role do our declining hormone levels play in that?
Dr. Verma: There is definitely an interaction of hormones and insulin resistance. And actually, it can even predate menopause, where women who are younger can have an insulin resistance state called polycystic ovarian syndrome. And that is also an insulin resistance state where there’s an interesting kind of an interplay between estrogen, progesterone, testosterone, as well as insulin and the more insulin resistant you are, you can get kind of a disequilibrium between testosterone, estrogen and progesterone. So when you go through menopause, and those estrogen levels are falling, it can contribute to a redistribution of fat. So we all get concerned about that belly (visceral) fat. And part of that is related to these declining levels of hormones. And when you have insulin resistance, fat settles more in that central part of our body and can increase that risk of the development of overt type two diabetes. Women who have that earlier entity may have fertility issues, may have weight management issues even earlier in life, and then it can progress and get worse as you go through menopause, increasing the risk of developing into type two diabetes.
Maryann: So does visceral fat affect your insulin? Or does the insulin affect how your body distributes the weight?
Dr. Verma: When fat deposits [in your body], you can have subcutaneous fat, like under the skin, under arms and legs. Visceral fat (which is the fat that surrounds your organs) can increase your cardiovascular risk and the risk of complications. And the more insulin resistant you are, the more likely that when you gain weight, you’ll gain visceral obesity. And that’s the interplay that can further increase the risk. So in terms of which comes first, one sort of aggravates the other really.
Maryann: It’s a chicken or egg scenario. Wow. Good times. Can sleep issues, which are common during menopause, also affect our blood sugar?
Dr. Verma: Yes. Because if you have poor sleep, hygiene or difficulty sleeping because of hot flushes or other menopausal symptoms, that can slow your metabolism and affect weight management, and it sort of compounds all of these issues. So so getting good sleep, making sure you’re paying attention to your sleep hygiene can certainly help with having enough energy to motivate you to exercise and maintain your weight, so that you’re not continuing to develop further insulin resistance.
Maryann: And this is what I find scary: Insulin resistance can play a role in the development of Alzheimer’s. Can you tell us how that happens.
Dr. Verma: So there are numerous studies that are connecting diabetes and Alzheimer’s. Insulin resistance can increase these proteins called amyloid, which can deposit in parts of the brain. And there’s an association with amyloids and the development of Alzheimer’s. But not only Alzheimer’s, but other forms of dementia can also be related to diabetes. Just like we think of hardening of the arteries or the contribution to heart disease, you can get vascular dementia, where the effects of high blood sugars can can affect small blood vessels in the brain contributing to dementia, as well as low blood sugars, we talk a lot about high blood sugars. But when you’re being treated for diabetes, if you have low blood sugars, that can also affect a part of the brain called the hippocampus, which is a memory center. So both the variability and the disequilibrium of blood sugar management can contribute and aggravate multiple forms of dementia.
Maryann: You know, I just thought of a random question that I wanted to ask you, because endocrinologists are the hormone experts, right? What exactly is a hormone? Is it a liquid, a gas? [Laughs] What is it?
Dr. Verma: That’s a great question. So a hormone is a protein that’s made by a gland in the body. And it has a role where it has an effect on another part of the body. So for example, the thyroid gland is a butterfly shaped gland located in the base of your neck, and it makes thyroid hormone. And that hormone has an effect on every cell in the body, just like insulin is made by a gland called the pancreas, located in your abdomen, and acts on other cells, like I mentioned earlier, to let that glucose into those cells to do its job. So there are many, many, many different hormones, and they all have a different role on another part of the body to influence it to do its job, basically.
Maryann: Thank you for answering that. And now that we’ve outlined some of the causes and the complications of diabetes, we’re going to tackle what we can do about all of this. But first, what tests can we ask our doctor to order to figure all this out, and to see whether we even have prediabetes?
Dr. Verma: It’s very simple, actually, and really stresses the importance even if we’re feeling great to see your doctor annually, especially if you have risk, because they’ll do bloodwork and there are two simple blood tests. One is a fasting glucose. So that’s done after approximately an eight-hour fast and looking at your actual blood sugar at that moment in time. And like I had mentioned earlier, if your blood sugar is above 126, that meets the criteria for diabetes. But there’s another blood test called the hemoglobin A1c, and that’s a test that looks at an average of all of your blood sugars over approximately a three-month period of time. And that comes back as a percentage. So it represents kind of all the peaks and valleys in blood sugars throughout that time span. And we know that there are certain ranges that equate to prediabetes or diabetes….A hemoglobin A1c between 5.7 and 6.4 falls in that prediabetes category. And typically that correlates with a fasting sugar between 101 and 125. If it’s below that range or below 100, that’s considered normal for a fasting sugar.
Maryann: Is one test the gold standard? Or should we be asking for both tests? Do they work together?
Dr. Verma: So they do work together to better define [blood sugar levels]. Historically, before the blood test for hemoglobin A1c, we originally just used a fasting sugar. But now that combination also helps to show where that abnormality is…and it becomes really important when you are treating a patient to have both values because fasting sugar could be normalized because you’re on medication, for example, but the A1c might be high. And that is important for patients to recognize, because you might say, Well, my meds are working because I checked my blood sugar every morning, and it’s 95. But the A1c is still high at say 8.2. Well, that tells us that fine things might be under control in the morning, but throughout the day, there might be variability and. So it’s important to have both of those bits of information, both in defining whether or not you have the disease as well as treatment.
Maryann: I cannot tell you how many women in their early 50s that I know have recently told me that. And these are women who are a normal weight and exercise. They have told me that their a A1c is now around 5.7 or 5.8 Just at that brink. Which brings me to my next question, because I recently read an article that claimed that there is now this war on prediabetes that may have been taken too far. Apparently, the American Diabetes Association in 2019 lowered the A1c threshold from 6.1 to 5.7. So that more people are now finding themselves in this prediabetes category. Now on one hand, I see this as a good thing in terms of prevention. But on the other hand, it’s making people worried. What’s your take on this?
Dr. Verma: Yes, I think there’s different ways to look at it. And definitely there was some controversy when that story came out, about whether or not this was the influence of the pharmaceutical industry and medication [use] that may not be warranted. But my take is that you have to take that bit of information in context with your individual risks. So if you’re someone with with a family history of diabetes, and you have weight management issues, and your A1c is creeping up, that is really your wake up call that you have to do what you can to control this, so it doesn’t progress. There have also been some studies showing that by identifying that population, we can actually influence the progression by more aggressively recommending lifestyle modifications. So what do I mean by that? It’s combination of both exercising at least 30 minutes, five days a week in combination with nutrition to help delay progression. So yes, it’s becoming more apparent, or more people are becoming more aware, or their A1c number is creeping up. But I look at it more as as an eye opener, in that it’s better to know that you may have risk and factor in all of your other risk factors, and implement some strategies to lower that risk, than for it to not be identified and find out later that your A1c is 7.2 or higher, or that you’re [already] in that diabetes range. So I think it’s a point of education, and a point of education and a really good point where you can make an intervention that can delay progression.
Maryann: In a little while we’re going to get into all of the lifestyle changes that can help prevent or reverse prediabetes. And we’re also going to talk about Ozempic and other medications that are being used to treat diabetes (and are being used to off label as well). But first, I’d like to point out that even if you live like a very clean life, and you do everything right, if you have a great diet, if you exercise, if you avoid smoking and stress, there’s still a chance you can develop these conditions, right? Because there’s a hereditary component, like you just mentioned. How strong is that component? And how much should you pay attention to your genetics?
Dr. Verma: I think it’s really important to pay attention to genetics, but that is not the only thing that’s going to result in diabetes overall. All of these things, you know, it’s sort of that two-hit hypotheses where you may have a genetic risk, but there’s something else that unmasks it, so It’s important to have that information. And really, for those people who live that healthy lifestyle, what they’re really doing is delaying that progression to the actual diagnosis. So all these lifestyle habits that we try to put into play are helping to maybe in some ways, you know, delay the inevitable because of that genetic risk.
Maryann: Should we panic if we’re diagnosed with it? Can pre-diabetes be reversed? If we do all the things, can we get our levels back to normal?
Dr. Verma: In many situations, yes. So if you have those modifiable risk factors that are influencing it, absolutely. I’ve had a number of patients who have said, “There’s no way I’m not going to be on medications,” and they really do the things that we recommend, and we see those numbers come down back into the normal range.
Maryann: That’s so exciting. OK, so let’s go over some of those lifestyle choices you can make. Let’s start with diet and the foods we can be eating to support healthy glucose levels.
Dr. Verma: When it comes to diabetes in general, is there really is no one-size-fits-all diet. And the term “diet” even is a little bit bothersome to me, because it means you’re restricting something. So the whole goal of meal planning for diabetes is implementing strategies that are going to keep your glucose stable. So when you mentioned paleo, or there’s you know, anti-inflammatory diets, really what they’re doing is focusing on that balanced plate, no processed foods, focusing on nuts, healthy vegetables, fruits, lean proteins. That’s an excellent approach to to your meal plan. Similar to the Mediterranean diet, these are all diets that have been advocated as long as you can adhere to it. Because no diet is a great diet unless you can stick to it long term, right?
Maryann: Good point. OK, let’s talk about sugar, because we’ve all heard sugar—particularly added sugar—is the devil. Is it going to kill you to eat a handful of blueberries or grapes? [Laughs}
Dr. Verma: Not at all. There are healthy sugars. What we lean away from are those refined sugars, those processed sugars, but everybody needs some form of carbohydrates. So carbohydrates break down in the body to sugars, whether it’s a starchy, savory type of product, like a potato breaks down into simple sugars, or sugar itself. So fruit is a very healthy form of sugar. But eating a ton of fruit at one time, may not be. So part of it comes down to just understanding portions. What is a healthy serving size of grapes, for example?Maybe 16 grapes that are average size, maybe not those giant ones, is one serving of grapes. And so that’s a healthy amount, or there are certain types of fruits that have a lower glycemic index, so they tend to not have rapid absorption, raising blood sugar, and those are the ones like berries that you would want to lean towards. But all fruit can, within the right amount, can be healthy for you.
Maryann: I’ve read that fiber can help to slow down the release of glucose in the small intestine. Is that true? And what type of fiber would you recommend—and how much?
Dr. Verma: Absolutely. You want there to be some type of fiber in your diet because it delays that absorption. So certain cruciferous vegetables like broccoli. You know, when we when we talk about whole grain foods that are higher in fiber, those can actually help in managing your blood sugars when they’re part of your entire meal. So when you look at a label on on a product, it’ll usually list total carbohydrates. And you want products that are higher in fiber, at least five grams of fiber per serving, to know that that’s a healthy amount of fiber in that particular product.
Maryann: A lot of women I know are taking fiber powders. How do you feel about powder versus food?
Dr. Verma: It’s always better to get nutrients from food itself. But fiber can go both ways. If you take in too much fiber, it can be constipating. So it’s finding that balance in your body, where it’s keeping your digestive system intact, and also helping with the metabolism of food. Like we mentioned earlier, that fiber helps to delay that absorption and decrease the fluctuation in blood sugars.
Maryann: Is it helpful to be strategic about how you eat foods together, how you combine foods? For instance, like eating fat and protein along with the carbs in order to reduce that glycemic load?
Dr. Verma: Absolutely. There are some some advocates of the order of food makes a difference, that eating your carbs last can be helpful. But most important, just as you mentioned, is really having that plate with a diverse array of food types. So you are you trying to avoid unopposed carbs. So even though we think, for example, that oatmeal is healthy for breakfast, for someone with diabetes, or someone who has insulin resistance, oatmeal alone may not be the best option; you may want to have that with a hard boiled egg or some sort of protein, so you’re delaying that absorption. Now certain oatmeals may be higher in fiber, so they’re helping in that way. But having that combination of protein, healthy fats and carbohydrates will help with that overall variability in your blood sugars.
Maryann: Speaking of oatmeal, and oats, I feel like we’re in the middle of this oat milk craze right now. Everybody I know is ordering their lattes with oat milk and eating oat milk ice cream. But looking at some of these labels, that stuff can be high in sugar.
Dr. Verma: They are. And a lot of these things are fads. Really, much of the benefit from milk in general is as a calcium source. So whether you’re substituting oat milk or other forms of milk, it is important to look at, is it sweetened or unsweetened, because you may actually be adding other things that you really don’t need. So it’s really important to factor that in. Because some of those options are much higher in sugar,
Maryann: In terms of dairy, what do you recommend to someone with prediabetes?
Dr. Verma: For something with prediabetes, nothing really is off limits; it all depends on portion. So if you want that milk in your coffee, have that milk in your coffee, but don’t add as much sugar or don’t have that coffee with a doughnut. Think about what you’re having with that coffee. We can even tie in the use of artificial sweeteners for a minute. Some may substitute an artificial sweetener but have their coffee with a muffin. I would recommend you put that teaspoon of real sugar, or honey, in your coffee, but whatever else you’re having it with, make a healthier choice. And it’ll create the same balance.
Maryann: Yeah, I think I think [omitting] doughnuts and muffins is the first line of defense.
Dr. Verma: We all have our vices in moderation. But you know, these are things that are sort of simple changes that you can implement and you find you don’t miss…because you’re really feeling better and you’re putting healthier things into your body.
Maryann: How do you feel about supplements? I’ve heard of people using Berberine.
Dr. Verma: There are a number of different supplements. Now the FDA that regulates our medications and does not put supplements through the same rigorous studies to prove benefits. So although there seems to be so me help you can get from things like cinnamon Berberine, chromium, curcumin, bitter melon (as far as a vegetable), we don’t know how much and what quantities actually help. So there’s no harm in using those. I don’t recommend that patients who are on diabetes medicines use them as a substitute. But there’s certainly no harm in adding those and sort of seeing what happens. But they’re no going to be a substitute if your body actually needs medication to keep this under control. But in the prediabetic patient who’s implementing healthier lifestyle habits, adding extra cinnamon or taking a cinnamon capsule may help.
Maryann: What role does drinking more water and staying hydrated play in controlling blood sugar…as a clutch my 60-ounce, ginormous water bottle? [Laughs]
Dr. Verma: [Laughs] Hydration in general helps the body and the cells just function more efficiently. When someone has blood sugar variability, just diluting some of that, by maintaining hydration can be helpful. You know, for someone with diabetes, if their blood sugar’s running high, we always recommend that they hydrate because again, that can help to bring blood sugars down.
Maryann: Any other types of foods you would recommend for helping to keep blood sugar at a good level?
Dr. Verma: I think really, the focus is on portions and, like we talked about earlier, combinations of foods. There’s no one food that’s going to make or break this, but how much you eat could be a defining factor.
Maryann: Fabulous. Let’s move along to exercise. It can help reduce visceral fat associated with inflammation. What else can it help with? And what are some of the best activities we could be doing right now to keep our blood sugar in check?
Dr. Verma: If we just focus on prediabetes, exercise is one of the key components to delaying progression. It’s been recommended that we get at least 30 minutes of a combination of cardiovascular exercise—walking on a treadmill or getting outside getting fresh air at a pace that’s not overexerting yourself, but getting a good increase in heart rate—and light weight training. We want to do that for at least 30 minutes, five days a week in some form. And that could be carried through as well if you have diabetes, or you’re trying to prevent diabetes. The combination of weight training—not looking to bulk up but to tone and redistribute that muscle mass and fat mass—is really important. So going on a great run a couple times a week or getting on that treadmill…but also integrating like light weights and thinking about core exercises. I do recommend to patients exercises like Pilates, where you’re really engaging your core; those exercises help to try to [convert] some of that belly fat to muscle.
Maryann: I know, strength training is so important. I haven’t had one expert on the show who has not mentioned strength training. We should all be doing some form of it in midlife.
Dr. Verma: Absolutely. And it’s not it’s not a matter of joining an expensive gym or anything like that. You can take some soup cans, you can get three or five pound weights from the dollar store. I mean, it’s not expensive to live a fit life and to integrate exercise. It’s about carving out a little bit of time each day to do it. It’s really important.
Maryann: Also, like you mentioned earlier, cardio is no longer very effective [in midlife] if you’re doing nothing else. But there are different types of cardio, such as prolonged zone 2 cardio, that’s performed at more medium intensity, rather than HIIT.
Dr. Verma: As long as you’re able to do something consistently, that’s the exercise that’s going to work for you. Because you’re getting your heart rate up when you’re doing HIIT or similar exercises, those may be more beneficial. But when it comes to delaying progression, it’s really just that consistency that’s important.
Maryann: What’s your take on exercising on an empty stomach versus having a little something before working out?
Dr. Verma: You definitely need to have healthy something in your body to really get your muscles to perform. It’s important to not eat too close to exercising, because you you may feel full and it may backfire on you, but having healthy sources of carbs to give you that energy. And then also having enough some kind of post-workout combination of protein and carbs to help rebuild that muscle. So flanking both sides is really important. There are some groups that recommend exercising on an empty stomach. But as an endocrinologist, I’m usually managing people with diabetes who may be on medication. So you have to balance. If you’re exercising on an empty stomach, you may actually cause hypoglycemia depending on how your other medications work.
Maryann: I’d to touch on menopause. You and I spoke a few weeks ago about this and we talked about how everything overlaps: our menopause symptoms can be going on at the same time as these prediabetes symptoms. And if we’re having a particularly rough perimenopause or menopause, we need to manage those hormones. So how do we manage the menopause stuff if we’ve got prediabetes going on? Because they play into one another. So what do you do, because you’re like, “What do I do first?”
Dr. Verma: That’s definitely a difficult question to answer, because the symptoms of menopause may take away your motivation to exercise. So that sort of aggravates that insulin resistance. So I think it really dials back—and I know it sounds easier said than done—to getting into those habits even before you reach menopause. So it’s part of who you are, that you are already engaging in an exercise routine, so as your body transitions through menopause, you’re sort of already in that. It’s hard to balance, there’s no quick answer. How do we keep our body in the right place as we’re watching our body change as we transition through menopause. But it’s recognizing that we are just one body evolving that how we looked or felt 10 years ago, 15 years ago…or the exercises that worked for us 10 years ago, 15 years ago are not going to work now. And being able to change what you’re doing to respond to partly the symptoms and partly what your body can do as you’re experiencing certain symptoms of menopause.
Dr. Verma: It’s a very difficult question…
Maryann:I know it is very difficult. But how about this question: If a patient is being treated with hormone therapy for menopause, can that treatment also help with the prediabetes?
Dr. Verma: It can. Because you’re going to remove some of those symptoms and the influence of that dropping estrogen. So you may not get that weight redistribution as rapidly as you would if you were not under the influence of hormones. I mean, the whole goal of hormone replacement therapy is to more gradually transition you through menopause, so you’re not experiencing everything all at once. So it may actually allow you to change your habits and kind of get used to your body’s transitioning through that phase,
Maryann: It’s important to mention, we should also find ways to manage our stress and get more high quality sleep right during this time.
Dr. Verma: All of that’s important. So stress and sleep can affect another hormone we haven’t had an opportunity to talk about yet, which is cortisol. And cortisol is our stress hormone. And there’s normal levels of cortisol. But if your body’s not resting, if you are not exercising, you can get another disequilibrium in cortisol levels. If that’s not regulated appropriately, it can aggravate blood sugars, it can aggravate blood pressure, it can affect mood and sleep. So having that balance of proper sleep hygiene and all of that works together.
Maryann: I love my Oura ring that tracks my sleep. It really does a good job. And it’s it teaches you a lot about your sleep patterns.
Dr. Verma: Sure.
Maryann: OK, let’s talk about those diabetes drugs. Because you have to be living under a rock these days to not know that a lot of women—some of whom have had longtime difficulty keeping their weight at a healthy level—are suddenly dropping weight very rapidly. Oprah, for example, has slimmed down very recently and admitted that she’s taking one of those drugs. And there are other brands such as Manjaro. Tell us about this class of drugs, what they were originally designed for and how they work to control diabetes. You told me in a previous conversation that they’ve been around since like 2004, which surprised me.
Dr. Verma: They have. There are many different classes of diabetes medications, but this particular class is called GLP receptor agonist glucose like peptide. And they have been around in managing patients with diabetes since the early 2000s. But it’s only recently that a few of them, as they’ve evolved over the years, have really shown a good effect on weight management. So the most common ones that we use, that you mentioned are used for treating diabetes, Ozempic and Manjaro, are actually sort of derivatives and an evolution of other medications that we’ve used in the past to treat diabetes. One was called Victoza, others were Byetta and Bydureon. And they all kind of work in the same way. They have appetite suppressing effects, they affect central neurotransmitters to help reduce your appetite. They work on satiety centers, so people who are on them feel like they don’t have those cravings that they used to have. So for someone with diabetes, that can help to prevent those spikes in blood sugar. So from that standpoint, it’s beneficial. They also delay gastric emptying, so how rapidly food goes through the stomach. That can also help in keeping people feeling full. And there’s an interplay of the effect of that hormone on other hormones that help with weight management. So one of the positive side effects that evolved with these meds being on the market was weight loss.
Maryann: Yes.
Dr. Verma: So the companies that manufacture them went back to the FDA, and basically rebranded them under different names for weight loss. So the ones that should be used solely for weight loss in people who meet the criteria and suffer from obesity (there are three) are called Saxenda, Wegovy and a newer one that just was approved in early December called Zepbound. And they all work similarly to the ones that I mentioned earlier for diabetes, because they really are the same product.
Maryann: Do you ever suggest these meds for women who are diagnosed with prediabetes? Or would lifestyle interventions come first?
Dr. Verma: I do. So in women or men with prediabetes who are also obese, these are excellent meds to delay progression and really work on reducing one of the risk factors, which is obesity. So absolutely, I do use them and I use them successfully, where you can actually follow those parameters, meaning the fasting sugar that we talked about earlier and the hemoglobin A1c, and actually see them improve.
Maryann: What about women who are at a healthy weight already, but have prediabetes?
Dr. Verma: I wouldn’t use it. Well, [those drugs are] not approved for [that use]. If you’re at a healthy weight, then really those medications may not be appropriate for you. Are they being prescribed for those reasons? Possibly, but they really are meant for people suffering from obesity, where their BMI (body mass index) is above 30, possibly with other comorbidities, meaning other health issues that that could be impacted by obesity. We really don’t recommend them in those leaner people, where you just want to lose a few pounds, for a number of reasons. They’re possibly not covered by insurance. They’re very expensive. And these medications do have side effects. So you have to be mindful that they could actually cause a problem.
Maryann: That was my next question. What are the side effects? I was reading about something called Ozempic face?
Dr. Verma: Sure, so that term came about because people were really showing rapid weight loss. And so there was sort of this sagging of the face or an appearance that individuals would have, really because you’re losing fat from all different pockets of the body, and the face is most visible. But other common side effects are GI, because the medication delays gastric emptying, so food is not really traveling through the stomach as rapidly. You could experience nausea, some people experience vomiting, queasiness, some people experience significant constipation. So those are those are common side effects. But as long as we start the medication at a low dose, communicate with our patients, make sure our patients are communicating with us, and we aren’t increasing the dose too rapidly, we can usually avoid a lot of those side effects. There are some rare side effects that can happen and some some studies that were precursors to these medications coming to the market, there was some association with rare thyroid cancers. So we do take a very good history of our patients to make sure they’re not at risk or that they don’t have family members with underlying thyroid cancers that may be a contraindication to the medication. There can be an increased risk, possibly, of pancreatitis. Although, you know, we don’t see that often. If you read that package insert there are a lot of potential side effects, but I would say the GI side effects are the most common.
Maryann: So it sounds like these drugs, ideally,, should be prescribed only for women who have prediabetes and some weight management issues, or women with severe weight management issues. Is that correct?
Dr. Verma: You can say that, yes. So women who are suffering from obesity, they certainly can be used without any diabetes relationship, because they have been proven to be safe and effective to treat obesity, which is a disease with or without pre diabetes.
Maryann: In terms of preventing prediabetes, are there any other things we can do? What would you say to a woman who’s been diagnosed and is confused about all this?
Dr. Verma: I wish there was the one right pill to prescribe. But it really goes back to basics: lifestyle, diet, exercise, staying consistent, finding that meal plan that you can stick to. Now there is a medication that can be used for prediabetes, called Metformin. Metformin is a medication that we use very regularly to treat type 2 diabetes, it’s been around for well over 30 to 40 years. And the same study that advocates lifestyle modification, with 30 minutes of exercise five days a week and nutritional counseling, also showed that using Metformin can delay progression to overt diabetes. But we try to lean more toward the lifestyle modification, because one, it’s not a medication, and all medications can have a side effect. But that is also an option that that can be used when someone feels like they’re doing everything, but they are still struggling and their labs are in that borderline range. That may be an appropriate discussion to have with your doctor.
Maryann: My mother was on Metformin [for diabetes]. And as I understand it, the drug stops being as effective over the years, so you have to [increase] your dosage.
Dr. Verma: So it’s interesting, it’s oftentimes that sort of the understanding that the medication stops working, it’s probably not that the medication stops working. But we have to think of prediabetes and diabetes along a spectrum, that diabetes is a chronic progressive disease. So when a medication stops working, it could just be that that prediabetes is now progressing. And so if you’ve crossed that threshold and now have developed diabetes, you may need add-on therapy. The whole idea of prediabetes and diabetes is that there’s this slow destruction of the cells that make insulin in the pancreas. And the whole goal of managing prediabetes is to delay that progression. So we know that by the time someone is diagnosed with type 2 diabetes, the abnormalities in their blood sugar, sort of behind the scenes, really have been going on for about five to seven years. So that prediabetic state probably has been going on; maybe you don’t know because you hadn’t gone to get your bloodwork done every year. But those things are happening. And by the time you’re actually diagnosed with diabetes, you’ve lost about 50% of those cells that make insulin. So one thing to clarify in the definition that we started with: Diabetes is a combination of insulin resistance where your body’s not using insulin effectively, but also a state of insulin deficiency, where your body’s not making enough. So you have two different things going on, causing those blood sugars to go up.
Maryann: In terms of women with prediabetes, what percentage of them will be able to stay in that range? Or to reverse the pre-diabetes?
Dr. Verma: It’s hard to put a number on it. But if you are doing those things we’ve already talked about with lifestyle modification…a large percentage of those patients can can at least delay progression. You never know what influences come later, whether it’s inability to exercise or have that genetic risk that doesn’t go away—you can’t change what’s been passed down. But if something else influences your ability to maintain those healthy lifestyles, those are the factors that can increase that risk. So you can delay progression by doing those things that can help you.
Maryann: This is what amazes me: I know people who have been diagnosed with prediabetes and their doctors say, this is what you have. And either are like, “Don’t worry about it, it’s not diabetes yet,” or “Do you want to consider medication?” But there’s not this lovely sit-down like we just had with, where we break it down and talk about all the lifestyle tweaks you can make. Which is a shame.
Dr. Verma: It is very unfortunate. And there are many different reasons why that might be happening, as we try to fit everything into a well visit with a patient.
Maryann: It’s hard.
Dr. Verma: It is hard. But I think it is so important for health care providers to take that minute and not just say, like you had mentioned that, “oh, it’s not diabetes yet. You don’t have to worry about it.” No, I think that’s the point where we can actively influence the behaviors of our patients by stressing the importance of how their own actions can actually change that prediabetes or stabilize that prediabetes. I don’t think it’s solely the patient’s responsibility, I think it is the [responsibility of] the healthcare environment and physicians or whoever is managing that patient to take a minute to look at those labs and really explain what this means to a patient, to empower the patient so they really can do things to to delay this from getting worse and becoming overt type 2 diabetes.
Maryann: Do you think our culture will ever get a grip on this epidemic? And what kind of change would you like to see happen on a wider scale?
Dr. Verma: More education. I think we can definitely manage diabetes without the need for medications in many cases. And I think we need to spread the awareness of prevention. Even when you’re feeling OK, visit your doctor, get bloodwork done, have that conversation. I definitely think that we have modalities that are out there to help convey information—social media, for instance. There’s so much out there that we can use to provide the education so that people are aware of their own risk factors and how to modify them.
Maryann: Thank you. I’m personally hopeful that women listening to this now feel empowered to take charge of their health and make the lifestyle changes to stay healthy and diabetes free. And thank you so much for sharing your wisdom with us. And please tell everybody out there where they can find you [online].
Dr. Verma: So I’m here in South Jersey and am part of the Virtua healthcare system. If you go to Virtua.org and look up Dr. Parveen Verma, you’ll be able to find me.
Maryann: Thank you so much. This was amazing.
Dr. Verma: You’re welcome.
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