DR. KALYANI: Thanks so much, Paige. I'm glad to be here.
MS. WINFIELD CUNNINGHAM: I'm looking forward to our conversation because, of course, this is a hugely important topic. You know, every time we talk about chronic health conditions, massive health spending in the U.S., diabetes is a central part of this.
But to just kind of lay things out for our audience, first, when we talk about diabetes, the vast majority have Type 2 diabetes, and then a small subset have Type 1. Can you just kind of briefly lay out the two types and what the differences are between them?
DR. KALYANI: Sure. So, as you mentioned, Type 2 diabetes accounts for 90 to 95 percent of the diabetes both worldwide and in the United States. Type 1 diabetes accounts for about 3 to 5 percent, and then there are other [audio distortion] types and special subtypes of diabetes, as well, including [audio distortion] diabetes that round out the number.
So, when we talk about diabetes in America, the vast majority, if not almost all have Type 2, but also, Type 1 diabetes is particularly important [audio distortion], as well.
MS. WINFIELD CUNNINGHAM: Well, and we know that Type 2 is typically found in adults, and Type 1 typically diagnosed in children; although, sometimes Type 1 is found in adults. I'm actually one of them. I was diagnosed with Type 1 diabetes about five years ago, around the age of 30.
Can you talk a little bit about how common Type 1 is in adults and do we know what causes it?
DR. KALYANI: Yeah, that's a really great question. So, as you noted, Type 2 diabetes used to be called adult onset diabetes, and it was more commonly noted in adults. And now, as we see the rise of paediatric obesity, particularly in adolescents and ethnic minorities, in particular, we're seeing Type 2 diabetes in our younger population, as well.
Conversely, Type 1 diabetes, which used to be called juvenile-onset diabetes, was more commonly seen in children, but we are seeing diabetes in adulthood, as you shared, as well, your story. And it's not as common, but we're increasingly recognizing that some people who had been diagnosed with Type 2 diabetes may in fact have Type 1 diabetes as we do further testing.
MS. WINFIELD CUNNINGHAM: Well, and I know, of course, one of the biggest differences between Type 2 and Type 1 is that Type 2s typically don't require insulin; although, I know some do use it. Type 1s always require insulin. And I know there's been a growing awareness in recent years over the high cost of insulin, some patients even rationing it. Do you see that among your own patients, and how big of a concern is the cost of insulin to you?
DR. KALYANI: The cost of insulin is a big concern. And as you mentioned, Type 1 diabetes, usually patients have to be on insulin from the get-go. This is a disease where there is autoimmune destruction of the cells in the pancreas, the beta cells that produce insulin.
And so, usually people with Type 1 diabetes require insulin from diagnosis; whereas, patients with Type 2 diabetes where the underlying physiology is what we call insulin resistance. The body doesn't respond to the insulin that the pancreas produces as well as it should. And therefore, insulin is not as effective at lowering blood glucose. Usually, we can start off with oral medications or pills, or even some non-insulin injectable medications, too. But about a third of patients, throughout the course of their disease, will require insulin, and this is different for each patient.
Given that high numbers of people with both Type 1 and Type 2 diabetes that use insulin, clearly insulin cost is a big focus. And over the past decade, we've seen a tremendous rise in the cost of insulin that far outpaces inflation, almost 300 percent for some of the synthetic or analogue insulins, if you look at their current list price, compared to where they were ten years ago. And especially during the pandemic, these increasing costs, burdened with the economic hardships that many people in the United States are facing, makes it increasingly difficult to afford and to use insulin as prescribed.
MS. WINFIELD CUNNINGHAM: Do you ever personally experience this, where a patient comes to you and says, "Hey, I'm having trouble affording my insulin. What do I do?" And as a doctor, if you hear that from a patient, what's your response to that? What can you do?
DR. KALYANI: It's really difficult to hear when you have a patient in your clinic and you really want to do the best you can for them, prescribe them medications based on the latest evidence, prescribe them medications that you know will reduce their complications from diabetes in the long term, and then not have the financial resources to afford it.
And these social determinants of health, these other factors are just as important to address, because we can only prescribe the medications, but if the patients can't afford them, that's really where we need to be focusing our efforts. And yes, I definitely have had patients in my clinic come and say that, at times, they've had to delay the refill of their insulin because they're waiting for their next paycheck. And this is particularly disturbing when we're trying to reduce the burden of this widely prevalent disease and its complications.
MS. WINFIELD CUNNINGHAM: So, let's focus on Type 2 for a minute because, as we noted, millions and millions of Americans with Type 2. As a health policy reporter, I tend to think about this disease a lot just from a cost perspective. One dollar out of every four dollars spent on health care in the U.S. goes to diabetes care. Can you talk a little bit about the impact if we found a way to dramatically reduce the number of Type 2 cases in this country?
DR. KALYANI: That's an interesting question. You know, what we've seen demographically is that the number of cases of diabetes, if anything, has increased. And currently, we have more than 30 million people in the United States with diabetes; another 88 million with pre-diabetes who, if they don't get the appropriate interventions, which is usually lifestyle and weight loss, may progress to diabetes.
So, we are anticipating or projecting that the number of people with diabetes will continue to grow, particularly as the population ages and people are living with diabetes longer. We have new treatments and people are maintaining a longer lifespan. So, if we could reduce the number of cases of diabetes through preventive efforts to address pre-diabetes earlier on through weight loss, through weight loss, through education, through dietary changes, through healthier neighbourhoods, this would dramatically impact not only the societal and personal burden of this disease, but the economic burden, as well. And that would be fantastic to focus our efforts on ways that we can reduce diabetes in particular, and then reduce the cost of the disease.
MS. WINFIELD CUNNINGHAM: Who's most at risk at developing Type 2? And then, out of those who do develop Type 2, what types of patients are at most risk for developing long-term complications from the disease?
DR. KALYANI: So, those who are most at risk of developing Type 2 diabetes are people who are overweight or obese. And when we say overweight or obese, we usually use a metric called a body mass index, which is a ratio of the weight to height. And usually, a BMI greater than 25 is considered overweight for the general population; and greater than 30 is considered obese.
Now, in Asians, those cut-offs are a little bit different, because we know with the same body weight, Asians carry more percentage body fat than other ethnicities. And so, in Asians, overweight is considered a body mass index of 23; and obese is considered a body mass index of 27.5.
And so, clearly, overweight and obese are two factors that are main drivers and main risk factors for Type 2 diabetes, and perhaps not surprising, what we use to screen, when we're screening for people with diabetes.
Other major risk factors include age. Age over 35, 40, 45, older age in general is a risk factor for diabetes, type 2, in particular because the body becomes more resistant to insulin as part of the process of aging in general. We also know that ethnic minorities are at a high risk of Type 2 diabetes. This includes Hispanics, African Americans, Asians, and Pacific Islanders, as well. We additionally know that women with a history of gestational diabetes have a 50 percent lifetime risk of developing diabetes, and they also need to be carefully monitored. And then, other risk factors include having a known diagnosis of pre-diabetes, a history of heart disease, high blood pressure, cholesterol and, in women, a history of polycystic ovarian syndrome.
MS. WINFIELD CUNNINGHAM: Well, and of course, as we all know, if diabetes, whether Type 1 or Type 2, isn't managed well, it can lead to a whole host of extremely scary outcomes and very serious conditions. Can you talk a little bit about those consequences?
And then, what are some medical advancements that you think have helped reduce the risk of those complications?
DR. KALYANI: Yeah, Paige, that's a great question. So, we think of compilations from diabetes really in two major categories: What we call the microvascular complications and the macrovascular complications.
All of the complications from diabetes that we traditionally describe are due to damage of the blood vessels in the body. Microvascular complications are due to damage in the small blood vessels of the body, and this includes damage to the eyes, what we call retinopathy; damage to blood vessels in the kidneys, what we call nephropathy; and damage to blood vessels in the nerve, what we call neuropathy.
And then, macrovascular complications are damage to the larger blood vessels in the bodies, those that are in the brain that can lead to stroke; those that are in the heart that can lead to heart disease or heart attack; and those that are in the legs that can lead to peripheral vascular disease.
And so, based on results of large trials that were done in the 1990s, specifically the United Kingdom Prospective Diabetes Study in Type 2 diabetes, and the Diabetes Control and Complication Trial in Type 1 diabetes, both those hallmark trials demonstrated, by lowering blood glucose, as measured by A1C, which reflects average blood glucose over three months--by lowering A1C to below 7 percent, people with diabetes, Type 1 or 2, the results were consistent in both of these trials, could reduce the risk of microvascular complications over time. And these studies were done over ten years, and then people were observed for an additional ten years after the trial was over.
The evidence for macrovascular reductions, or reduction in heart disease, has been a little bit more difficult to demonstrate. In both these trials, benefits for reducing heart disease and stroke were only seen in the long-term follow-up and not in the initial trial period. And so, we've sought other ways to reduce cardiovascular disease through modification of cardiovascular risk factors and the use of some of the newer glucose therapies that we have, as well.
MS. WINFIELD CUNNINGHAM: I want to turn to the coronavirus and talk a little bit about the link between diabetes and COVID-19. And of course, you know, diabetics have been disproportionately represented among those hospitalized and who have died from COVID-19. But I think sometimes it's easy to get sort of tangled up in what the actual causes--you know, whether it's correlation or causation. When you're thinking about this risk, the risk for serious COVID-19 illness, do you think it's more related to diabetes or is it more related to obesity often being a factor in these cases? Can you kind of untangle that for us a little bit?
DR. KALYANI: Yeah, that's also a really great question. So, there's been multiple hypotheses proposed for why people who have COVID-19 are more likely to develop diabetes. In fact, in one meta-analysis which synthesized results from multiple studies that was done last year, it was reported that up to 14 percent of hospitalized patients with COVID-19 had new onset diabetes.
And so, we know that when people undergo a stress response or a tremendous inflammatory response as occurs with COVID-19, this can put the body under stress and, in those who may already have risk factors for diabetes, push them over the edge to rising blood glucose, particularly in the setting of steroid use, which is often used pretty early on with COVID-19--severe COVID-19 infection, and to the development of diabetes, as well.
And so, whether this is related to a direct effect on the cells that produce insulin, the beta cells--and there have been some theories proposed that COVID-19 may bind to receptors on the beta cells, and then enter the beta cells and disrupt insulin production, or whether it's due to inflammation in the pancreas, the organ where the beta cells live that then disrupts the insulin production, as well. It's not clear. But we know that people with diabetes are at greater risk of severe complications from COVID-19.
And as you mentioned, obesity is also an important coexisting illness for many of our patients with Type 2 diabetes, and that further exacerbates the risk of severe complications.
MS. WINFIELD CUNNINGHAM: It's been an interesting question to me because I've had lots of people come to me and say, "Aren't you at greater risk for complications, because you're Type 1?" And I'm never quite sure what to say because, as you know, Type 1 and Type 2 are such different diseases and sort of get lumped together.
Do you have any thoughts on that? Are Type 1s also at higher risk, as well as Type 2s?
DR. KALYANI: Yeah, you know, it's interesting, when the high-risk conditions were first listed by the CDC, it only listed Type 2 initially and not Type 1. And that really was primarily due to not having enough information at that time. And now, we have Type 1 and Type 2 both listed under those high-risk conditions to consider at high risk for complication.
So, yes, you know, and whether it's related to the greater risk of hyperglycaemia, having higher blood glucose during COVID-19 infection that can then predispose to complications. That's likely the unifying mechanism by which any type of diabetes really can put an individual at increased risk for complications from COVID-19.
MS. WINFIELD CUNNINGHAM: Well, and you referred to that really, really interesting finding that 14 percent of patients with severe or rare cases had developed some sort of diabetes. And I know we had a story in The Post in that. Do we know whether these cases are temporary or permanent, of these patients who've developed it seemingly as a result of COVID-19?
DR. KALYANI: That's another great question, and I think we're learning more as more people are recovering from COVID-19 and we're following them long term. There is an ongoing registry of patients who have developed diabetes during COVID-19 infection that is in the process of gathering this information. And I think this will give us further insights into whether this was a temporary condition that occurred or whether this is something that is more long term and people live with this disease after COVID-19 for many years. And that will be something interesting to see in the months to come.
MS. WINFIELD CUNNINGHAM: What do you think the overall impact of the pandemic has been on diabetes in the U.S.? I know I've read a lot of stories about how we've all been gaining weight during lockdown, maybe less active. And I know, overall, it has seemed to have a negative effect on people's health. Are you concerned that this is kind of feeding into this increase in cases, or what has the effect been?
DR. KALYANI: There have been far-ranging effects, I think all the way from--as we've already talked about, the hospitalization and severity of complications to even for those who have not developed COVID-19 a fear, a fear of [audio distortion] seeing their health provider and we know from surveys that are done, in patients with diabetes up to half of them report that they are reluctant to seek their routine preventive care during the pandemic.
And as an endocrinologist and a clinician that [audio distortion] for patients with diabetes, this is concerning, because we rely on routine preventive care to detect complications early, to manage the complications [audio distortion] before they become severe. And what's happening is, as patients are coming back into the clinic, we're finding that they may have had complications that could have been detected much earlier on.
And we know that patients are not getting the same access to healthy foods. They've reported this in the same questionnaire, about one in four report that they don't have same access to healthy foods during the pandemic as they did before, largely due to financial hardship. And many of them are substituting food for medication, like we talked about, given limited resources. And so, we are seeing far-ranging effects of the pandemic, both in those who develop COVID-19 and have diabetes, but also those that have diabetes and don't have the infection but may not be having the same preventive care or access to care for multiple reasons. And I know we'll be talking about telehealth in the next segment, but this has forced us to think a little bit more about our care models and how we can best reach our patients with diabetes during the pandemic to get them the care that they need.
MS. WINFIELD CUNNINGHAM: Well, and we're almost out of time, but want to throw one more question at you. Even if we take COVID out of the equation, we're still seeing cases of diabetes go up. What are the top things you think we need to be doing in the U.S. to really take this seriously and try to counter it?
DR. KALYANI: So, clearly, prevention is a big theme. As we talked about earlier, if we can prevent diabetes, if we can target those with pre-diabetes or other risk factors early, this can lower the societal and economic burden of the disease.
I think we need to better understand our unique populations that may be more vulnerable to complications, such as the elderly, which will represent a greater proportion of the population with diabetes in the future. Women, gestational diabetes, this is a high-risk population, as well, where we need to have increasing efforts for education and follow-up. And then, paediatric obesity and diabetes is a big area, as well.
And then, clearly, the cost of insulin, this has been at the forefront, but we really need concrete efforts to address this going forward.
MS. WINFIELD CUNNINGHAM: Well, we're out of time, so we'll have to leave things there, but thank you so much for joining me, Dr. Rita Kalyani. Thank you, it was a great conversation and I appreciate it.
DR. KALYANI: Thanks so much, Paige.
https://www.washingtonpost.com/washington-post-live/2021/05/04/transcript-diabetes-america/
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