Shireen: In this episode, we will be discussing the relationship between obesity and diabetes with Dr. Ivania Rizo. We will be talking about the disparities in diabetes and how it affects communities of color. 

Podcasting from Dallas, Texas, I am Shireen and this is the Yumlish podcast. Yumlish Is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.

Dr. Ivania Rizo is Director of Obesity Medicine at Boston Medical Center and Assistant Professor of Medicine in endocrinology, diabetes, nutrition, and weight management at Boston University School of Medicine. She is triple board certified in internal medicine, endocrinology and obesity medicine. Her clinical interests are obesity, diabetes, and metabolic disorders.

Welcome Dr. Rizo. 

Rizo: Thank you so much for having me on your podcast. It's a pleasure to be here.

Shireen: An absolute pleasure having you. So Dr. Rizzo jumping right into it. Can you tell our listeners a little bit about yourself and your medical background and why the specific interest in this, in this field? 

Rizo: So I attended Georgetown University School of Medicine and then followed up with an interest in internal medicine and did my internal medicine residency at Georgetown University.

I then went on to complete my endocrinology fellowship at University of Alabama in Birmingham, Alabama. And stayed on faculty there at University of Alabama Birmingham for approximately three years. The obesity and diabetes epidemic is actually much greater in some areas in the south. And when I was trying to treat patients with diabetes, I found that I really needed all the arsenal or all my armamentarium possible to be able to treat patients with obesity.

Therefore I went on and pursued To get board certified obesity medicine, and really practice diabetes and obesity as one whole disease. And so then I moved on to Boston Medical Center where I've further applied diabetes, you know, treated people with obesity and diabetes in my practice. 

Shireen: Will you explain to our listeners the relationship between obesity and diabetes?

Rizo: Of course. Obesity and diabetes are both very closely correlated. Diabetes is really one of the main metabolic complications of obesity. And there are really multiple similar studies that show that men with obesity have a sevenfold higher risk of diabetes and women with obesity have twelvefold higher risk of diabetes than without obesity.

So we know that people who suffer from metabolic complications of obesity, such as diabetes have abnormal or abnormal adipose tissue. And that means fat tissue essentially. And obesity is not just a greater number of adiposity or greater number of fat cells, but it really is in addition to that, we know that, that the adipose tissue actually has hypertrophy it enlarges. And also we have in a, in, in patients with higher risk have obesity and higher risk of diabetes. There's also increased visceral adiposity. And that means that there's increased fat, that wraps around the organs in their abdomen. And also we see increased ectopic fat, which means that there's fat Where it normally is not as present such as the liver and this abnormal fat tissue really leads to what we call systemic inflammation, which contributes to metabolic dysfunction. And what I mean by that is that you have in, for instance of diabetes, you have too much sugar in your blood. So this, if, so the systemic inflammation that's associated with obesity that I was talking about can lead to what we call insulin resistance.

Which means that cells resist letting insulin move glucose into them and more insulin is really needed to do the job. So insulin resistance is a cornerstone of type two diabetes. And the pancreas, which makes insulin can make more insulin in the setting of insulin resistance, trying to move that sugar out of the blood.

But over time, unfortunately with type two diabetes, there's a combination of insulin resistance and the inability of the pancreas to keep up with the insulin needs and you get elevated blood glucose. So, and with obesity too, it's important to think. When I see patients we, the distribution of the fat  adiposity is also important in terms of the risk of obesity.

I mean, I'm sorry, the risk of diabetes. So upper body at adiposity or, increased adipose tissue has really much greater risk with insulin resistance than lower body at obesity. So obesity is very heterogeneous and the risk of diabetes can also be different based on sort of where the adiposity is located.

So, but in general, by addressing obesity, we can intervene really upstream of type two diabetes and try to prevent the progression or even treat their even lead to remission of type two diabetes. 

Shireen: Mm-hmm  what would be some approaches for obesity and weight management that lead to diabetes prevention and even treatment?

Rizo: Yeah, so we, we know that weight loss can reverse these underlying metabolic abnormalities that we talk about such as, you know, increased glucose that we see in type two diabetes and that weight loss can improve blood glucose. It can lead to remission of prediabetes. It can lead to type two diabetes remission.

It can also lead to reversal of common microvascular complications that are associated with diabetes, such as chronic kidney disease. So, one pivotal trial called the direct trial showed that losing 15% of body weight can lead to remission of type two diabetes. In most people in that specific trial, 70% of the people who lost at least 15 kilograms with intensive lifestyle interventions had diabetes remission.

The numbers were somewhat low, cuz 70% was 14 outta 20. And when I say diabetes, remission, I mean that they had a hemoglobin A1C, which is an average blood sugar over three months, less than 6.5. And they were off of any medications that lower blood glucose. So 70% of those who lost 15 kilograms were able to have that views remission in a larger trial called the look ahead that had approximately,

think it was 5,000 patients that looked at the effect of intense lifestyle modifications on weight loss and cardiovascular events, meaning heart attacks, strokes. It showed that 10 years after patients had lost at least 10% of weight in that first year of intervention. That those patients who had lost at least 10% in that first year had a 21% reduced risk of cardiovascular events.

Even 10 years later. So these studies really show that the benefits of losing at least 10 to 15% of body weight on type two diabetes and the complications in the long term, including micro cardiovascular disease are really reduced. But I do wanna point out that like such studies really also show that in the long term, only two outta 10 people can really respond to lifestyle interventions alone, even with intensive support.

And so 8 out of 10 people will require more interventions to lose a significant weight loss and maintenance. And this is really not surprising because we know obesity is a complex chronic disease. And so it's not simply just a result of people having poor lifestyle choices. So it's important to try to, it's important for.

Physicians to consider pharmacotherapy and bariatric surgery such as gastric bypass, and sleep gastrectomy as really part of the medical interventions for people with diabetes and obesity you know, weight loss through dieting can really actually we know that it can cause multiple physiological changes that really that include an intense drive to eat.

After weight loss and also reduction in energy expenditure. And so this can really precipitate weight regain, especially in environments that really have easy access to low quality, high calorie, fast food and decreased physical activity. So it's important to think about anti obesity medications, or medications for diabetes.

That can really promote weight loss, such as the glucagon, like peptide one receptor agonist, like semaglutide is one example. Although other ones exist, like dulaglutide that can really reduce appetite and make people feel fuller and can really assist in making them in a in allowing them to make the lifestyle interventions that we're trying to help them do.

And so I think, so for example, Semaglutide . We call a GLP one receptor agonist with the greatest reduction in blood glucose and weight that's currently available in the GLP one class and it was approved for diabetes back in 2017. And and now it was approved for obesity alone in June, 2021.

But, you know, I think, like I mentioned earlier, people with diabetes meet criteria for various… so pharmacotherapy is very important. Either anti pharmacotherapy or anti pharmacotherapy and medications for diabetes that are proof for diabetes that help with weight loss. But people with diabetes also meet criteria for bariatric surgery.

If they have what's called a body mass index greater than, or equal to 35 kilograms per meter squared.  and the most common procedures we see are roux-en-Y gastric bypass or a sleeve gastrectomy laparoscopic sleeve gastrectomy. And the average weight loss with surgeries can be ranged from 19 to 37% which is higher than potentially one to 20% with pharmacotherapy.

And also we know that bariatric surgery, for example, the roux-en-Y  gastric bypass. After roux-en-Y gas, after roux-en-Y, gastric bypass, 75% of people can achieve diabetes remission for up to five years after surgery and then potentially 37 to 71% up to 20 years after surgery. So geriatric surgery when appropriate it can lead to remission of early, also chronic kidney disease in patients with diabetes improvements in blood pressure, cholesterol.

Significant reduction in microvascular disease and macrovascular disease, meaning strokes and heart attacks. So it's really important to consider all the available therapies. We have to treat diabetes and obesity and to discuss them with people with these two chronic disease processes.

Shireen: I see. And, you know, you, you mentioned the sometimes that diet and exercise can do well, but sometimes it also fails people. But we do know that it has some role to play in reversing type two diabetes. Would this apply to someone who has a high risk of serious complications? So we're talking amputations, blindness, even kidney failure.

Rizo: Absolutely. I mean, in terms of lifestyle, interventions are cornerstone and to all our interventions for obesity and diabetes, and they can be applied to anybody that can be applied with potential specific caveats to chronic patients with chronic kidney disease. We may be a little bit we may want to calculate how much protein specifically we ask them to take in versus someone without chronic kidney disease. Sometimes people with chronic kidney on dialysis, you know, there's potassium and phosphate that need to be considered in their diets. So in terms of being able to consider caveats, but they can all, but we can always, especially with.

Medical nutrition therapy that is done by registered dietician can very much tailor it to any chronic disease, despite the severity. 

Shireen: What is the main reason why diabetes is, is more common in communities of color?

Rizo: I think, you know, We do know that racial and ethnic communities of color have a higher burden of diabetes and they also have worse diabetes control and more likely to experience complications from diabetes.

So for example Hispanics or Latinx community, the death rate from diabetes is 50% higher than for non-Hispanic rates. And the reason for. Is multifactorial and includes a combination of risk factors. I think it's important to know that the conditions in which people live learn, work, play also referred to a social determinants of health really affect a wide range of health.

So for example, poverty, lack of quality, quality education, and lack of healthcare, significantly impact diabetes, risk, diagnosis, and outcomes. Diabetes is more common in those with less than a high school education and income, less than 25,000 a year. So. And we also know that years of systemic discriminatory policies led to many of these social economic disparities that now we know increase the risk of diabetes.

So it's really key to also address these social determinants of health. To decrease the disparities that exist between communities of color. 

Shireen: It, it's interesting that you mentioned that what are, what are the noticeable, usually significant disparities in inequalities that exist in communities of color?

You mentioned a lot to do with SDOH but these specific groups that are, that have higher risk for obesity and diabetes in part. What other risk factors, what, what are some other compelling factors here that, that puts them at high risk? 

Rizo: So I think in terms of when we look at potentially areas you know, there could be some relationship between areas of poverty having or increase.

So areas that have increased rates of poverty. And having less access to healthy and nutritious food. And sometimes we don't even think about not necessarily where there is healthy food deserts, but some people can refer to them as food swamps, where there is actually excess. There is food such as you can see lots of fast food restaurants available but the quality of food can.

Mostly in terms of obesity and diabetes, it can be food that in, in very small amounts is very dense in calories and therefore people are gonna take in a lot of food with high saturated, fat, and not necessarily being as healthy or sometimes not even having access. So it could be help food swamps and also decrease access to even supermarkets that allow them to shop for foods that

we want to increase such as healthy grains and fruits and vegetables.

Shireen: You talked earlier Dr. Rizo in particular about Semaglutide and can you help us understand some of the success in using Semaglutide with patients who have obesity and then also speak to some of the downsides of using it? Are there any negative effects?

Rizo: Yeah. I have found great success with using in general, the class of medication semaglutide is in, which is a GLP one receptor agonist. So the GLP one receptor agonist have really, truly changed the landscape of diabetes medications to allow more significant weight loss and glucose lowering effects.

In addition semaglutide. Has been Associated and other GLP one receptor agonists, such as dulaglutide and liraglutide have also been associated with significant decreases in major cardiovascular events, like heart attacks and strokes in people with type two diabetes, either have cardiovascular disease or at high risk of cardiovascular disease.

So, Semaglutide and other GLP one receptor Agonists, increased insulin when blood glucose is elevated, but it's in a glucose dependent manner. So I also find it helpful that they don't cause hypoglycemia in general and very low risk of low blood sugars. And at higher doses, it also, they also act on centers of the brain to suppress appetite and increase fullness, which helps with the weight loss.

Semaglutide specifically. Was evaluated in the sustained clinical trial program that looked at over 8,000 patients who had type two diabetes and they found greater reductions in weight and hemoglobin A1C and than other relevant diabetic type medications for diabetes. So semaglutide one milligram per week,

decreased A1C between 1.5 to 1.8. And I find that range to be what I also see in clinics sometimes maybe slightly lower, but the 1.4 to 1.8 and also a 10 to 14 pound weight loss and a higher dose of semaglutide was actually just approved for diabetes, in March 2022. It's two milligrams per week.

And it also showed a decrease of hemoglobin A1C of 2.2 and 25% of people who took semaglutide 2.0, had at least 15% weight loss compared to 3% with placebo. So I have found it to be very effective. There's a, the one difficulty we've had with Semaglutide, which, you know, the brand name is Ozempic is actually accessing it.

So there's been some trouble in terms of back orders with semaglutide and sometimes having some difficulty, being able to get it for patients. There is a new medication, actually. That's a combination of a GLP, one receptor agonist and another. What we call incretin hormone. G I P, which is called, which is a glucose dependent insulin Tropic peptide.

So it's a combination of a GLP one receptor agonist, and G I P called Trizepatide. And it was actually approved for type two diabetes in May 2022. And approximately in the trial. And one of the Sentinel trial that, that showed the success Trizepatide, up to 92% of people with type two diabetes with an A1C of eight were able to reach an A1C less than seven and 52% were able to reach an A1C less than 5.7.

And the weight loss scene ranged from eight to 11%. But I think we're just starting to prescribe the medication. So in terms of. What I see in clinic and what I see with my patients, I'll have to see. 

Shireen: That's really helpful. Thank you so much for breaking down a lot of these different medications with that Dr. Rizo, we are toward the end of this episode, unfortunately. How can our listeners just connect with you and learn more about your work?

Rizo: So you can connect with me through the Boston University website. Under my name also, I am not a heavy Twitter user, but I am @rizo_ivania. And as, and I will give you the website for Boston University.

Shireen: Lovely. And we'll, we'll add all of this in our show notes. So folks wanna access it. They can quickly get to the link and access that. So with that, Dr. Rizzo, thank you so much for, for coming on this episode for sharing your time with us and sharing all of this information with us. To all our listeners head over to our social media, our Facebook on Instagram and answer this quick question under the podcast post, what is the most challenging part of diabetes for you.

Get over to our Instagram @Yumlish_ or at our Facebook, which is @Yumlish. And go answer this question. What is the most challenging part of your diabetes? We will see you there and continue this conversation after this episode there. So we will see you there. And Dr. Rizo, thank you so much again.

Rizo: Thank you so much for having me. Was a pleasure.

Shireen:   Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media @Yumlish_ on Instagram and Twitter and @Yumlish on Facebook and LinkedIn. For tips about managing your diabetes and other chronic conditions and to chat and connect with us about your journey and perspectives. You can also visit our website Yumlish.com for more recipes advice and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week's show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we'll see you next time. Remember your health always comes first. Stay well.

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