WELCOME TO OUR THIRD ANNUAL MEDICINE FOR THE PUBLIC PRESENTATION WITH OUR PARTNERS AT NIH. MEDICINE FOR THE PUBLIC IS A VERY LONG TRADITION FOR THE NIH AS A GREAT WAY TO INFORM OUR COMMUNITY AND WE ARE SO DELIGHTED TO CONTINUE THIS AMAZING EDUCATION OPPORTUNITY HERE AT SUBURBAN HOSPITAL. IN PARTNERSHIP WITH NIH AND IN THIS OUR THIRD MAY CONDUCTING THIS PROGRAM SO THANKS TO ALL THE AMAZING FAMILIAR FACES. I SEE MANY IN THE AUDIENCE AND THANK YOU FOR TAKING TIME OUT ON A LOVELY EVENING TO LEARN. WE'RE VERY HAPPY YOU HAVE CHOSEN TO BE HERE. I WOULD LIKE TO TAKE A MOMENT TO INTRODUCE MYSELF, MY NIEM IS MONIQUE FUENTES, DIRECTOR OF COMMUNITY HEALTH AND WELLNESS HERE AT SUBURBAN HOSPITAL. I WOULD ALSO LIKE TO TAKE A MOMENT FOR THOSE WHO HAVE PAGERS OR PHONES IF YOU CAN PLEASE CHANGE THOSE TO VIBRATE OR SILENT SO WE CAN GIVE ALL OF OUR SPEAKERS THE THIS EVENING OUR FULL ATTENTION AND RESPECT THAT THEY DESERVE. ALSO I HOPE MANY OF YOU ARE ENJOYING THE DELECTABLE AND MOSTLY HEALTHY TREATS WE HAVE. IF YOU WILL KINDLY TAKE ALL OF YOUR REACCEPTTY CLS BACK WITH YOU AS YOU EXIT THIS EVENING WE HAVE TRASH CANS AN RECYCLE BINS FOR YOUR WATER AT THE EXIT OF THE AUDITORIUM. ALSO RESTROOMS ARE LOCATED JUST OUTSIDE THE DOOR TO YOUR LEFT. ONE OF US WILL BE THERE TO DIRECT YOU IF YOU NEED ASSISTANCE. ALSO WE HAVE APPROXIMATE IMPORTANT ANNOUNCEMENT ABOUT PARKING. PARKING AT SUBURBAN IS ALWAYS FREE AFTER 5 P.M. SO AS LONG AS YOU ARRIVED AFTER 5 EVEN THOUGH YOU RECEIVED A TICKET, PARKING IS FREE. IT'S ALSO FREE P OPT WEEKENDS IN CASE YOU'RE EVER VISITING A LOVED ONE SO JUST TO REMEMBER WE DON'T WANT YOU TO WORRY ABOUT HAVING TO TAKE CARE OF THAT UPON YOUR EXIT. I HOPE EVERYONE RECEIVED A VERY DETAILED PACKET AS YOU CHECKED IN. YOU SHOULD HAVE SEVERAL PRESENTATIONS THAT ARE ON DIFFERENT COLORS TO FOLLOW ALONG AND TAKE NOTES. MOST IMPORTANTLY, YOU HAVE THIS EVALUATION ON THIS LOVELY I THINK KIND OF YELLOW LIME GREENSHEET OF PAPER. WHAT I ALWAYS SAY AND IT CONTINUES TODAY, YOUR FEEDBACK IS THE MOST IMPORTANT GIFT THAT YOU CAN GIVE BACK TO US THIS EVENING. LET US KNOW HOW WE DID, WE WANT TO KNOW ABOUT OUR SPEAKERS, WE ALWAYS GIVE THAT FEEDBACK TO EVERYONE WHO IS A PART OF OUR PRESENTATION. AND LET US KNOW ABOUT OTHER P TOPICS YOU WOULD LIKE TO HEAR ABOUT IN THE FUTURE REALLY THIS IS WHAT GUIDES US TO CHOOSING WHAT KIND OF HEALTH PROGRAMS WE WILL PUT TOGETHER. SO YOUR INFORMATION, YOUR IMPORTANT COMMENTS COUNTS. WE WANT TO KNOW THE GOOD AND THE BAD. WE ALWAYS WANT TO BE BETTER FOR YOU. SO WITHOUT FURTHER ADIEU, I HAVE THE PLEASURE AND HONOR OF INTRODUCING A GOOD FRIEND NOW AFTER THREE YEARS, MS. WENDY SCHUBERT WITH THE OFFICE OF COMMUNICATIONS AT THAT TIME NIH CLINICAL CENTER AND WENDY WILL GET OUR SHOW UP AND RUNNING UNTIL YOU -- AND TELL YOU GREAT INFORMATION ABOUT THE EXPERTS HERE TO SPEAK WITH YOU THIS EVENING. THANK YOU AND ENJOY THE NIGHT. [APPLAUSE] >> WELL, GOOD EVENING. AS MONIQUE SAID, MY NAME IS WENDY SCHUBERT. ON BEHALF OF DR. JOHN GALLIN DIRECTOR OF THE NIH MEDICAL CENTER WELCOME TO THE 2012 MEDICINE FOR THE PUBLIC LECTURE SERIESCH OUR PARTNERSHIP IS WITH THE COLLABORATION OF THE NATIONAL INSTITUTES OF HEALTH CLINICAL CENTER, JOHNS HOPKINS MEDICINE AND SUBURBAN HOSPITAL. THIS LECTURE IS BEING RECORDED FOR VIDEOCAST AND WILL BE AVAILABLE ON THE CLINICAL CENTER'S WEBSITE IN A FEW DAYS. PLEASE PLAN TO VISIT THE WEBSITE AT CLINICALCENTER.NIH.GOV AND FEEL FREE TO SHARE IT WITH YOUR FAMILY AND FRIENDS. TONIGHT'S LECTURE COMES IN THE MID-st OF -- MADDIST OF THE MASHLY AIRED DOCUMENTARY ENTITLED WEIGHT OF THE NATION PRODUCED BY CABLE NETWORK HO. NIH IS A PROUD PARTNER THAT LOOKS AT A KEY FACTOR OF TYPE 2 DEE BETEASE. THIS IS A FOUR-PART SERIES AIRING MAY 14th AND MAY 15th. YOU CAN VIEW THE FILM ON THE HBO WEBSITE AT HBO.COM. TODAY'S LECTURE LOOKS AT TYPE 2 DIABETES. DIABETES AFFECTS NEARLY 26 MILLION AMERICANS AND UP TO 95% OF THEM HAVE TYPE 2 DIABETES. WHICH IS THE MAIN CAUSE OF KIDNEY FAILURE, LIMB AMPUTATIONSND NEW ONSET BLINDNESS IN ADULTS. TYPE 2 DIABETES IS ALSO THE MAJOR CAUSE OF HEART DISEASE AND STROKE. INTERESTINGLY ABOUT 7 MILLION PEOPLE HAVE TYPE 2 DIABETES BUT DON'T KNOW IT. 79 MILLION ADULTS HAVE PRE-DIABETES WHICH SUBSTANTIALLY RAISES THEIR RISK FOR DEVELOPING TYPE 2 DIABETES. THERE IS GOOD NEWS IN RESEARCH, HOWEVER. RECENT STUDIES OF TYPE 2 DIABETES HAVE SHOWN BEHAVIORAL LIFESTYLE CHANGES INCLUDING MODEST WEIGH LOSS OF 5 OR 7% CAN PREVENT OR DELAY DEVELOPMENT OF THIS DISEASE IN PEOPLE AT HIGH RISK. NEW DEVELOPMENTS IN TREATMENT RESEARCH ALSO SHOW PROMISE AS WELL. DURING TODAY'S LECTURE OR PRESENTERS WILL PROVIDE A FRAMEWORK FOR PREVENTING AND MANAGING TYPE 2 DEE BY TEASE THROUGH CLINICAL PRACTICE AND EMERGING RESEARCH. OUR EXPERTS WILL EXPLORE THE MECHANISM OF DIABETES, WHAT CAUSES IT, HOW TO PREVENT IT THROUGH MEASURES OF LIFESTYLE BEHAVIOR CHANGE, AND LAST BUT NOT AT LEAST, STANDARD AND NOVEL TREATMENT OPTIONS INCLUDING BARIATRIC SURGERY WHICH MAY SHOW PROMISE AS BOTH TREATMENT AND PREVENTION. INFORMATION ABOUT THE EXPERIENCE OUR SPEAKERS BRING TO THIS TOPIC IS AVAILABLE ON THE MEDICINE FOR THE PUBLIC WEBSITE LOCATED ON THE CLINICAL CENTER WEBSITE AT CLINICALCENTER.NIH.GOV. WE HAVE TWO PRESENTERS TONIGHT. DR. JOHN MERINDINO IS CHAIRMAN OF ENDOCRINOLOGY AT SUBURBAN HOSPITAL, CLINICAL PROFESSOR OF MEDICINE AT GEORGE WASHINGTON UNIVERSITY SCHOOL OF MEDICINE, AND INSTRUCTOR AT THE JOHNS HOPKINS DIABETES EDUCATION PROGRAM AT SUBURBAN HOSPITAL. DR. KRISTINA ROTHER IS CLINICAL INVESTIGATOR IN THEM  DIABETES END CRIOLOGY AND -- ENDOCRINOLOGY AND OBESITY BRANCH AT NATIONAL INSTITUTE OF DIABETES DIGESTIVE AND KIDNEY DISEASES AND PRINCIPLE INVESTIGATOR FOR AN NIH BENCH TO BEDSIDE STUDY ON TYPE 2 DIABETES. TO KEEP OUR PROGRAM RUNNING SMOOTHLY, OUR PRESENTERS WILL FIRST GIVE THEIR SPEECHES, AND PRESENTATIONS AND THEN WE WILL OPEN THE FLOOR FOR QUESTIONS FROM THE AUDIENCE WITH A CASE SESSION. WE'LL BE-- A YEAH SESSION. WE'LL -- A Q AN A SESSION. WE'LL BEGIN WITH DR. JOHN MERINDINO FROM SUBURBAN HOSPITAL. [APPLAUSE] DOSIMETRY >> LET ME GET ORGANIZED HERE. WE HAVE A POINTER I GATHER? OKAY. GOOD. ALL RIGHT. WELL, I NO SMALL TASK HERE WHAT IS DIABETES, HOW TO PREVENT IT AND HOW TO TREAT IT IN 30 MINUTES. A LOT OF MATERIAL TO COVER. I MIGHT END UP SOUNDING A LITTLE BIT LIKE A I'M RUNNING AN AUCTION UP HERE IF I SPEAK TOO QUICKLY. I JUST WANT BEFORE I GE BEGIN I WANT TO SAY WHAT A PLEASURE THIS IS BECAUSE I'M A NAYSIVE OF THE AREA BUT AFTER MY MEDICAL TRAINING I CAME BACK TO DO MY ENDOCRINE FELLOWSHIP AT THE NIH AND I STAYED AT THE NIH FOR A NUMBER OF YEARS AFTER THAT, ALL TOLD I WORKED THERE FOR TEN YEARS. SO I'M IN PRIVATE PRACTICE AT SUBURBAN AND GW BUT I SPENT A LONG TIME AT THE NIH AND I REMEMBER GOING TO THESE LECTURES WHEN I WAS IN TRAINING SO THIS IS A BIG PLEASURE FOR ME. WE'RE GOING TO START WITH BASICS ABOUT WHAT DIABETES IS. DIABETES IN THE END, LET ME GET THE -- IS THERE A LASER POINTER THING HERE. OKAY. IN THE END DIABETES WAS THE RESULT OF INADEQUATE INSULIN ACTION IN THE BODY. INSULIN NOT DOING ITS JOB. THERE ARE A COUPLE OF REASONS WHY THAT MIGHT HAPPEN BUT LET'S START BY TALKING ABOUT INSULIN. INSULIN IS MADE IN THE PANCREAS, THE PANCREAS IS A FAIRLY LARGE ORGAN THAT SITS IN THE MIDDLE OF THE ABDOMEN HERE, IN THE LIVER F YOU REMOVE THE LIVER YOU CAN SEE THE PANCREAS HERE IN THIS CURVE MADE BY THE UPPER SMALL INTESTIN. THE PANCREAS IS A MIXED ORGAN THAT'S INVOLVED IN FOOD DIGESTION BUT ALSO INVOLVED IN HORMONE PRODUCTION AND ONE KEY HORMONES THAT'S MADE IS INSULIN. AND IF YOU LOOK AT THE CYCLE OF ENERGY BALANCE IN THE BODY, IT'S VERY COMPLEX BUT IF WE BREAK IT DOWN TO ONE ARM, WHAT HAPPENS IS IF YOUR BLOOD GLUCOSE LEVEL GOES UP SAY BECAUSE YOU HAVE EATEN SOMETHING WITH CARBOHYDRATES SUGAR OR STARCH IN IT, THAT TRIGGER THE PANCREAS TO MAKE INSULIN, IT'S RELEASED INTO THE BODY. IT HAS A NUMBER OF EFFECTS, IT SUPPRESSES PREEFLY STORED GLUCOSE FROM THE LIVER AND INCREASES THE AMOUNT OF GLUCOSE TAKEN UP INTO THE TISSUES IN THE BODY, INCLUDING THE SKELETAL MUSCLE. LOOK AT WHAT HAPPENS TO BLOOD SUGAR AND ISLE USE THE WORDS SUGAR AND GLUCOSE MORE OR LESS INTERCHANGEABLY IN THE NEXT FEW MINUTES, THIS IS A GRAPH, THIS IS TIME DOWN IN THIS AXIS AN THIS IS OVER 24 HOURS. LOOK AT WHAT HAPPENS TO GLUCOSE IN SOMEBODY WHO IS EATING THREE MEALS A DAY, EACH TIME SOMEBODY'S IT GOES UP, THEN DOWN THEN UP AND BACK DOWN. BREAKFAST LUNCH, DINNER GOES UP AND COMING BACK DOWN EACH TIME. WHY? IT COMES BACK DOWN BECAUSE INSULIN IS RELEASED BY THE PANCREAS. THE ACTION OF INSULIN IS PRINCIPALLY IN THIS SITUATION TO ALLOW GLUCOSE TO MOVE INTO CELLS IN THE BODY WHERE IT IS USED AS A SOURCE OF FUEL. THE SYSTEM IS KIND OF EXTRAORDINARY IN THAT GLUCOSE IS THE PRIMARY FUEL SOURCE FOR VIRTUALLY EVERY CELL TYPE IN THE BODY AND YET FOR MOST CELLS GLUCOSE WILL NOT GET INSIDE THE CELL UNTIL INSULIN IS AROUND TO HELP IT DO SO. I SOMETIMES -- I THINK FOR EXAMPLE IF YOU'RE IN THE EMERGENCY ROOM AND SEE SOMEBODY COME IN WHO HAS DIABETES OUT OF CONTROL, THE EXTRAORDINARY THING IS A NORMAL GLUCOSE LEVEL AROUND 100, SOMEONE WHO HAS DIABETES OUT OF CONTROL MAY COME IN WITH A GLUCOSE LEVEL OF 5, 6, 800 OR HIGHER, THEY HAVE AN ENORMOUS AMOUNT OF GLUCOSE AND FUEL IN THEIR BLOODSTREAM YET THEIR PHYSIOLOGY AT THAT POINT IS ONE OF STARVATION. IF YOU LOOK AT THE OTHER MED BOLLIC CHANGES GOING ON IT'S A PHYSIOLOGY OF STARVATION BECAUSE ALTHOUGH THERE'S PLENTY OF SUGAR THERE, KIT NOT GET INTO THE CELLS WHERE IT WOULD BE USED AS A FUEL. I LIKE THN TO BEING STUCK ON A DESERT ISLAND WITH CASES OF CANNED FOOD BUT NO CAN OPENER. SO IN A CERTAIN EXTENT INSULIN IS LIKE THE CAN OPENER HERE, IT WILL ALLOW GLUCOSE TO GET INTO THE CELLS WHERE IT CAN BE USED AS A FUEL. WHEN GLUCOSE LEVELS ARE HIGH THAT'S WHEN WE DIAGNOSE DIABETES. THERE ARE SEVERAL MEANS BY WHICH WE CAN DIAGNOSE DIABETES. THE MOST COMMON ONE IS TO LOOK AT FASTING BLOOD SUGAR LEVELS, BLOOD SUGAR WHEN YOU GET UP IN THE MORNING AFTER YOU HAVEN'T HAD ANYTHING TO EAT OR DRINK FOR 8, 10 HOURS. AND YOU CAN SEE THE ANGLE IS POOR FOR ME BUT FOR A FASTING GLUCOSE HERE, NORMAL BLOOD SUGAR IS UNDER 100. BLOOD SUGAR THAT EXCEEDS 126 AND IF THAT'S TRUE ON A SECOND DAY, THAT'S ONE OF THE MAJOR CRITERIA FOR DIABETES. IF YOU HAVE A BLOOD SUGAR IN THE INTERMEDIATE RANGE BETWEEN 100 AND 125, THAT CONSTITUTES PRE-DIABETES IN ESSENCE. THE TECHNICAL TERM IS IMPAIRED FASTING GLUCOSE CONTROL. BUT IT'S ENTIRELY REASONABLE TO THINK OF THAT AS PRE-DIABETES. IF YOU HAVE EATEN OR GIVEN GLUCOSE AS PART OF A GLUCOSE TOLERANCE TEST, DOESN'T MATTER WHAT ARE OR HOW MUCH YOU HAVE EATEN YOUR BLOOD SUGAR SHOULDN'T RISE ABOVE 200. YOU CAN'T SAY I SHOULD HAVE STOPPED AT THE 7TH PIECE OF KEY LIME PIE, BLOOD SUGAR SMOWN BE OVER 200. IF YOU DO YOU WILL BE DIAGNOSED WITH DIABETES. IN THE ENTERMEETIATE RANGE YOU HAVE IMPAIRED GLUCOSE TOLERANCE. ANY WHO HAVE DIABETES WOULD KNOW ABOUT THE HEMOGLOBIN A 1C BUT THOSE WHO DON'T, THIS IS ANOTHER MEASURE OF NOT ONLY USE FOR DIAGNOSIS BUT ONGOING MANAGEMENT OF DIABETES. HEMOGLOBIN AS YOU REMEMBER, IS THE MAJOR PROTEIN INSIDE RED BLOOD CELLS, IT'S THE OXYGEN CARRYING PROTEIN, THE THING THAT CONFERS THE RED COLOR TO RED BLOOD CELLS, SO THESE ARE RED BLOOD CELLS FULL OF HEMOGLOBIN, THE HEMOGLOBIN MOLL ACTUAL CHEMICALLY ATTACHES TO GLUCOSE TO FORM HEMOGLOBIN A-C OR GLYCO HEMOGLOBIN. THE MORE GLUCOSE AROUND THE MORE HEMOGLOBIN A-1C ACCUMULATES INSIDE THE RED BLOOL CELLS. THE CELLS SURVIVE THREE OR FOUR MONTHS AND AS A CONSEQUENCE IF YOU LOOK AT AMOUNT OF MATERIAL ACCUMULATED CELLS, IT GIVES YOU A WINDOW INTO THE PAST OF WHAT THE GLUCOSE LEVELS HAVE BEEN LIKE FOR THE PROCEEDING SEVERAL WEEKS. A NORMAL LEVEL IS UNDER ABOUT 6, IF YOU HAVE 6 1/2 OR OVER, YOUR DIAGNOSED TO HAVE DIABETES. ONCE DIAGNOSED TO HAVE DIABETES THIS TEST IS USED AS A MONITORING TEST TO KNOW HOW WELL CONTROLLED YOU ARE AND YOU SHOULD HAVE LEVELS IDEALLY THAT ARE UNDER 7 OR UNDER 6 AND A HALF. THE HIGHER YOU GO, THE HIGHER YOUR AVERAGE GLUCOSES ARE. AS WE'LL SEE AT THE END OF THE LECTURE HERE, THE HIGHER THE A-1C IS MORE POORLY YOU'RE LIKELY TO DO WITH YOUR DIABETES. NOW, WHY DO WE WORRY ABOUT HIGH SUGAR? OBVIOUSLY WE DON'T WORRY BECAUSE WE'RE WORRIED A FUNNY LOOKING NUMBER WILL END UP ON A LAB REPORT. WE WORRY BECAUSE OF THE THINGS IT CAUSES. IN THE INTRODUCTION WE HEARD IT'S THE CAUSE -- ONE MAJOR CAUSE OF HEART DISEASE, IN FACT, IT'S PROBABLY THE LEADING CAUSE OF HEART DISEASE NOW IN THE COUNTRY. IT'S AT LEAST AS POWERFUL CAUSE OF HEART DISEASE AS SMOKING, HIGH CHOLESTEROL, HIGH BLOOD PRESSURE FAMILY HISTORY OF DIABETES AND THOSE THING, A MAJOR CAUSE OF STROKE AND IT'S ONE OF THE MAJOR CAUSES OF OF A VARIETY OF SMALL VESSEL OR MICROSCOPIC CHANGE RELATED DISORDERS WE HEARD ABOUT INCLUDING THE LEADING CAUSE OF BLINDNESS FOR PEOPLE UNDER AGE 70. WHEN YOU LOOK AT HOW HEART DISEASE AND STROKE, IT'S CAUSING ACCUMULATION OF CHOLESTEROL RICH MATERIAL ON THE INSIDE OF ARTERIES TO PLUG THEM UP SO WE CALL THAT ATHEROSCLEROSIS. ONCE AN ARTERY NARROWED SUBSTANTIALLY A BLOOD CLOT WILL FORM ON THE INSIDE, BLOCK OFF BLOOD FLOW TO THE TISSUE. IF THAT HAPPENS IN THE HEART AND THE BLOOD FLOW IS BLOCKED OFF MORE THAN ABOUT 7, 8 MINUTES A BIT OF HEART TISSUE BEGINS TO DIE AND WE CALL THAT A HEART ATTACK. IF THE SAME THING SHAPING IN THE BRAIN AND EVEN A LITTLE MORE QUICKLY A LIT OF BRAIN IT SHALL SHOE DIES WE CALL THAT A STROKE. SO OBVIOUSLY A CATASTROPHIC PROBLEM. EVEN AT A MICROSCOPIC LEVEL WHERE VESSELS ARE NOT BIG ENOUGH TO BE AAMENABLE TO ANGIOPLASTY, THESE CHANGES TAKE PLACE ALONG WITH A NUMBER OF OTHER CHANGES THAT CAUSE TISSUE DAMAGE. IF WE TALK ABOUT BLINDNESS, BLINDNESS IS THE EXAMPLE I ALWAYS BRING UP BECAUSE IF YOU POLE PEOPLE ABOUT THEIR NUMBER ONE MEDICAL FEAR, THE ANSWER IS BLIENNESS. IF YOU SAY WHAT YOU MORE AFRAID OF, THE NUMBER ONE ANSWER THAT COMES UP IS I'M AFRIDAY OF GOING BLIND. TWO TO ONE MORE LIKELY THAN THE SECOND LEADING ANSWER IS I'M AFRAID OF KAREN. SO PEOPLE ARE AFRAID OF GOING BLIND WITH GOOD REASON. THIS IS THE BACK OF THE EYE OR THE RETINA, THIS IS THE VIEW THAT YOUR RETINA DOCTOR WOULD SEE OR OPHTHALMOLOGIST WOULD SEE AFTER DILATING YOUR EYE. YOU DON'T HAVE TO BE AN OPHTHALMOLOGIST YOU CAN SEE HEALTHY LOOKING VESSELS CARRYING A RICH SUPPLY TO THE TISSUE. IF WE CONTRAST THAT WITH SOMEBODY WHETHER HAS ADVANCED DIABETIC EYE DISEASE, YOU CAN SEE THAT THE VESSELS ARE IN MANY CASES BLOCKED UP WITH CHOLESTEROL PLAQUE SO HERE IS A VESSEL BARELY GETTING ANY BLOOD FLOW THROUGH IT, HERE IS ANOTHER ONE. THEN ANEURYSM IN THE EYE THAT'S RUPTURED AND LED TO BLEEDING, YOU CAN SEE THIS, IT JUST DOESN'T LOOK ANYTHING, IF I FLIP BACK, IT DOESN'T LOOK ANYTHING LIKE A NORMAL HEALTHY RETINA. THIS IS A PERSON WITH ADVANCED DEE BETTIC EYE DISEASE. A PERSON BLIND OR ON THEIR WAY TO GOING BLIND. HUNDREDS OF THOUSANDS OF PEOPLE IN THIS COUNTRY HAVE SEVERE VISION LOSS AS A CONSEQUENCE OF DIABETES. WHAT ARE THE CAUSE? WHY DOES THE BLOOD SUGAR GO UP AND NOT DO ITS JOB IN THERE ARE BASICALLY TWO REASONS FOR THAT. I WANT YOU TO KEEP THESE TWO THINGS IN MIND. AS WE GO THROUGH A COUPLE OF THINGS THAT I WANT YOU TO KEEP IN MIND AS WE TIE TOGETHER AT THE END, REMEMBER THAT HEMOGLOBIN A-1C AND GOOD NUMBERS DOWN NEAR 6, BAD NUMBERS THE HIGHER YOU GO. THE TWO MAJOR THINGS THAT GIVE RISE TO DIABETES ARE EVERYTHING TIES BACK TO INSULIN NOT BEING ABLE TO DO ITS JOB. IN A LOT OF CASES THERE ISN'T ENOUGH INSULIN THERE. WE'RE HERE TO TALK ABOUT TYPE 2 DIABETES BUT FUNDAMENTALLY TYPE 1 DIABETES OR WHAT IS JUVENILE DIABETES IN THE PAST IS ALL TOGETHER A DISEASE OF NOT HAVING ENOUGH INSULIN PRODUCTION. THE INSULIN PRODUCING CELLS IN THE PANCREAS ARE DESTROYED BY IMMUNE MEDIATED PHENOMENON. BUT MANY PEOPLE WHO HAVE ADULT TYPE DIABETES OR TYPE 2 DIABETES ARE PART OF THE PROBLEM IS PANCREAS IS NOT MAKING AS MUCH INSULIN AS IT SHOULD. IN FACT, AS PEOPLE GET OLDER THEIR PANCREAS ISN'T MAKING QUITE AS MUCH INSULIN AS WHEN THEY WERE YOUNG AND ONE REASON DIABETES BECOME AS MORE COMMON PROBLEM AS PEOPLE GET OLDER T. OTHER MAJOR ISSUE IS WHAT'S TERMEDDED INSULIN RESISTANCE. BACK MORE THAN TEN YEARS YOU WOULD HAVE ONLY HEARD AN ENDOCRINOLOGIST UTTER THAT PHRASE. IT'S PART OF THE LEXICON AND OUTSIDE MEDICINE I HEARD PUBLIC ANNOUNCEMENTS REFERENCE INSULIN RESISTANCE. IT CAN SOUND LIKE A CONCEPT THAT'S COMPLEX BUT IT'S NOT. RESISTANCE SIMPLY MEANS A RESISTANCE TO THE ACTION OF INSULIN. IN ORDER EVEN IF THERE'S INSULIN THERE THE BODY ISN'T RESPONDING TO IT IN THE WAY THAT IT SHOULD AND IT TAKES MORE INSULIN TO ACHIEVE THE SAME EFFECT. LOOK ACT THE NATURAL HISTORY OF DIEP 2 DIABETES, THE DEVELOPMENT OFEN LINS RESISTANCE STARTS YEARS BEFORE BLOOD SUGAR GOES UP. THE INITIAL THING THAT HAPPENS INTERESTINGLY AS SOMEBODY IS PROGRESSING ALONG THE ROAD TO DIABETES IS IT NOT THEIR INSULIN LEVEL FALLS BUT IT ACTUALLY GOES UP. IT GOES UP BECAUSE THE BODY IS BECOMING RESISTANT TO INSULIN BUT ON THE OTHER HAND THE BODY KNOWS THAT IT WANTS TO KEEP THE SUGAR LEVEL NORMAL SO IT INCREASES THE AMOUNT OF INSULIN THAT IT MAKES IN AN EFFORT TO OVERCOME THAT INSULIN RESISTANCE. OVER TIME THE HIGHER INSULIN LEVELS INITIALLY ARE ENOUGH TO KEEP SUGARS NORMAL BUT EVENTUALLY AMOUNT OF INSULIN MADE STARTS TO DECLINE, AS HA THANKED THE BLOOD SUGAR GOES UP T FASTING SUGAR AND I SHOULD SAY THE MEAL RELATED SUGAR GOES UP AND FASTING SUGAR GOES UP THAT'S WHEN YOU CROSS THE THRESHOLD INTO DIABETES. WE ALL KNOW DIABETES IS TIED TO OBESITY. ONE OF THE MAY JR. AREAS OF RESEARCH AROUND OVER AT THE NIH AND THE WORLD IS WHY IS THAT? WE KNOW INSULIN RESISTANCE IS CAUSED BY A NUMBER OF THING, DRUGS AND HORMONES AN CHEMICALSCH MOST THINGS THAT LEAD TO TYPE 2 DIABETES IN THE USUAL PATIENT WHO COMES IN ARE RELATED TO AB NO, MA'AM MALL OBESITY, THE AMOUNT OF FAT INSIDE YOUR AB NOMINAL CAVITY, PARTICULARLY AROUND YOUR LUNG AND LIVER. IT'S THE WORST KEPT SECRETE IN THE WORLD OBESITY HAS BECOME AN ENORMOUS EPIDEMIC IN THIS COUNTRY AND OBESITY PREVALENCE HAS RISEN OVER THE PAST 30 YEARS. IF YOU LOOK AT THE SLIDES COMMONLY SHOWN FROM CENTERS FROM DISEASE CONTROL WHAT'S HAPPENED THE LAST 15 YEARS T LIGHTER COLORS ARE LOWER PREVALENCES OF OBESITY, LOWER PREVALENCE OF DIABETES AND AS TIME HAS GONE ON, 6 YEARS LATER, 15 YEARS LATER AND LOOK AT THE INCREDIBLE PREVALENCE OF OBESITY NOW, 30% OF THE POPULATION BEING OBESE, THREE QUARTERS OF THE POPULATION BEING EET OBESE OR OVERWEIGHT AND COMMENSURATELY A TREMENDOUS INCREASE IN THE RATE OF DIABETES. DIABETES IS NOW DESCRIBED BY THE WORLD HEALTH ORGANIZATION AS THE MAJOR CHRONIC MEDICAL PROBLEM GOING INTO THE 21st CENTURY AND FOR THE FIRST TIME EVER ABOUT 7 OR 8 YEARS AGO THE WORLD HEALTH ORGANIZATION ANNOUNCED ALL OTHER THINGS BEING EQUAL THE CURRENT GENERATION OF CHILDREN WOULD BE THE FIRST TO NOT LIVE AS LONG AS THEIR PARENTS BECAUSE OBESITY CAUSING AN INCREASED PREVALENCE OF DIABETES AN RELATED COMPLICATIONS. SO NOT ONLY IN THE UNITED STATES BUT IN MOST OF THE DEVELOPED WORLD, EVEN TO A CERTAIN EXTENT IN THE DEVELOPING WORLD NOW. LEADING THE ECONOMIST MAGAZINE TO SUGGEST MUCH LIKE NATIONAL GEOGRAPHIC WHEN I WAS A KID THIS THING EVOLUTIONARY THINGS WERE UP ON THE BLACK BOARD SO HOMORECTUS HOMOSAPIEN AND UNFORTUNATELY HOMOGIGANTIS AS WE GO ON. INSULIN RESISTANCE SYNDROME OR METABOLIC SYNDROME IS A WHOLE CONSTELLATION OF THINGS GIVING RISE TO INCREASED HEART DISEASE RISK AND THE LIKE AND IT'S COMPRISED OF DOCUMENTNAL OBESITY, ELEVATED TRIGLIS RIDES AND LOW HDL CHOLESTEROL OR GOOD CHOLESTEROL, HIGH BLOOD PRESSURE AND ELEVATED FASTING GLUCOSE. WEIGHT LOSS, GOOD DIET, EXERCISE, THE IS KEY TO REVERSING ALL THESE THINGS THAT'S WHY WE EMPHASIZE IT. SO WE'LL MOVE TO PREVENTION AN TREATMENT OF DIABETES. BUT THE FIRST POINT IS PREVENTION. OF COURSE NO SECRET WHY WE ARE WHERE WE ARE. THESE KIND OF LOUSY DIETARY HABITS THAT WE HAVE AND THIS SORT OF EXERCISE HABIT WHERE THE ONLY THING THAT'S EXERCISED IS YOUR THUMB MUSCLE AS YOU SURF THROUGH CHANNELS. AND IN THE INTRODUCTION WE HEARD ABOUT SOME POWERFUL DATA SUGGESTING THAT YOU COULD PREVENT DIABETES EVEN THROUGH MODEST DEGREES OF WEIGHT LOSS AND SO FORTH. REFERENCE THERE WAS BEING MADE TO SOMETHING CALLED THE DIABETES PREVENTION PROGRAM OR THE DPP, A LARGE MULTIPLE CENTER TRIAL THAT WAS FUNDED BY THE NIH BEGINNING 12, 13 YEARS AGO, RESULTS WHICH WERE PUBLISHED IN THE EARLY -- MID 1990s OR THEREABOUTS. IN THAT STUDY 3,300 GIVE OR TAKE PEOPLE WERE IDENTIFIED HAVING PRE-DIABETES THROUGH GLUCOSE TOLERANCE TEST IN PAIRED FASTING GLUCOSE OR IMPAIRED POST GLUCOSE IN TOLERANCE THEY WERE RANDOMIZED. EVERYBODY WAS TOLL ABOUT THE IMPORTANCE OF DIET AND EXERCISE. MODERATE LEVEL COUNSELING, ONE GROUP BECAME THE CONTROL GROUP, NO REAL FOLLOW-UP EXCEPT COME IN AND GET YOUR BLOOD DRAWN THAT, KIND OF THING. ANOTHER ACTIVE DRUG METAPHORMAN WE'LL TALK ABOUT IN THE MEDICATION SECTION IN A FEW MINUTES, METAPHOR MAN, MAIN STAIN DRUG FOR MANAGEMENT OF DIABETES. THEN A THIRD GROUP SUBJECTED TO NOT SUBJECTED TO IS A BAD WORD BUT SHALL WE SAY ASSISTED IN MORE MAJOR LIFESTYLE CHANGE. ALSO OF DIETARY COUNSELING, REGULAR FOLLOW-UP WITH DIETITIAN, AND SO FORTH EITHER IN PERSON OR ON TELEPHONE. SO THIS IS NOW THE CONTROL GROUP AND YOU LOOK TO SEE WHAT HAPPENS WITH MEDICATION. AND WHAT HAPPENS WITH SUBSTANTIAL LIFESTYLE CHANGE. THESE ARE THE RESULTS. SO IF YOU'RE USING THE CONTROL GROUP AND YOU ASK HOW MUCH BENEFIT DO YOU GET FROM EITHER DRUG OR LIFESTYLE CHANGE, THE ANSWER IS, IF YOU WERE ABLE TO CHANGE YOUR LIFE AND THIS IS WHERE WE HEARD IN THE INTRODUCTION ABOUT A 5% WEIGHT LOSS, SO IF YOU'RE 200 POUNDS, ABOUT TEN POUNDS, NOT ENORMOUS WEIGH ON AVERAGE BUT THAT RESULTED IN NEARLY A 60% FALL IN THE LIKELIHOOD THAT YOU WOULD PROGRESS TO DIABETES OVER THE DURATION OF THIS STUDY. AND NOTABLY, NEARLY TWICE AS GOOD AS THE MAIN STAIN DRUG. THAT'S THE FIRST LINE DRUG. SO WE SHOULD NOT FORGET AS WE MOVE TO DRUG TREATMENT, THAT CHANGING YOUR LIFEK CHANGING YOUR DIET AND EXERCISE HABITS IS AN EXTREMELY POWERFUL TOOL IN THE BATTLE AGAINST DIABETES. SO WHAT WE WANT IS THIS, WE A PLATE OF FOOD WHERE MORE THAN HALF IS MADE UP WITH LOW GLYCEMIC FRUITS AND VEGETABLES, MAINLY VEGETABLES AN HIGH FIBER FOODS, LEGUMES AN COMPLEX CARBOHYDRATES AND A MODERATE PORTION OF MEAT, PARTICULARLY RED MEAT W A PREPONDERANCE OF FISH AND POULTRY AS OUR PROTEIN SOURCE, ET CETERA AND REGULAR EXERCISE. BOTH AEROBIC EXERCISE AND WEIGHT TRAINING EXERCISE. I'M A BIG ONE FOR ENCOURAGING WOMEN IN PARTICULAR TO UNDERTAKE WEIGHT BEARING EXERCISE BECAUSE AS YOU GET OLDER THAT HAS ENORMOUS BENEFIT IN TERMS OF MAINTAINING BONE DENSITY AND ALSO THE GREATER MUSCLE MASS AT REST THE MORE GLUCOSE YOU ARE UTILIZING AS FUEL AND THE MORE YOU CAN KEEP YOUR GLUCOSE DOWN. AFTER YOU EXERCISE THERE'S A BENEFIT THE TO METABOLISM FOR A COUPLE OF DAYS EVEN DEPENDING HOW HEAVILY YOU EXERCISE SO SO MAJOR BENEFITS TO BLOOD GLUCOSE MANAGEMENT. THE NEXT TEN MINUTES AS I WRAP UP WE'LL SHIFT TO DRUG TREATMENT. I HAVE THIS COMPLEX SLIDE UP HERE, THE NEXT SLIDE IS MORE COMPLEX. AND THIS IS NOT BECAUSE I WANT YOU TO FURIOUSLY WRITE NOTES ABOUT THIS OR THAT DRUG OR HOW YOU TREAT. I WANT TO SHOW YOU THAT IN CONTRAST TO WHEN I STARTED MY ENDOCRINE TRAINING 20 PLUS YEARS AGO, JUST INSULIN IN ONE CLASS ORAL MEDICATIONS FOR THE TREATMENT OF DIABETES, WE NOW HAVE A LOT OF OPTIONS. YOU CERTAINLY KNOW THAT IF YOU PAY ATTENTION TO THE MARKETING OUT THERE FOR DIABETES DRUGS. SO THIS PARADIGM FROM THE AMERICAN DIABETES ASSOCIATION AND ITS COUNTER PART ORGANIZATION IN EUROPE SHOWS FIRST STEP AND THEN SECOND STEPS AND MOVING TO THIRD STEPS, ET CETERA. AND A SIMILAR PROTOCOL FROM THE AMERICAN ASSOCIATION OF CLINICAL END ENDOCRINOLOGISTS HERE A LOT OF STEPS, A LOT OF DRUGS, BEGINS TO LOOK LIKE A NEW YORK SUBWAY MAP AT A CERTAIN POINT. NOT FOR YOU TO REMEMBER OKAY I GO A TO B AND B SUB PRIME, ET CETERA BUT JUST BE AWARE THERE'S A LOT OF OPTIONS FOR THE TREATMENT OF DIABETES. IT DOES NO GOOD TO A MEDICAL STUDENTS OR PHYSICIAN YOU'RE TRYING TO EDUCATE MUCH LESS THE PUBLIC AT LARGE TO SAY OKAY, CLASS ONE, THIS IS WHAT THEY DO. CLASS 2, THIS IS WHAT THEY DO. REALLY, THIS IS WHERE I WANT YOU TO GET BACK TO WHAT WE MENTIONED EARLIER ABOUT THE MAJOR CAUSES OF DIABETES. WHAT ARE THEY? INADEQUATE INSULIN PRODUCTION, RESISTANCE TO THE ACTION OF INSULIN. MOST PART DRUG TREATMENT OF DIABETES IS GOING TO ATTACK ONE OR THE OTHER OF THOSE TWO PROBLEMS. THOSE ARE WHAT GIVE RISE TO DIABETES, THE TREATMENT OF DIABETES, IS GOING TO TARGET ONE OR THE OTHER OF THOSE TWO THINGS. SO EVEN THIS DIAGRAM IS MORE COMPLEX THAN MAYBE I WOULD WANT IT TO BE BUT BASICALLY MAKING THE POINT INADEQUATE PRODUCTION OF INSULIN BY PANCREAS IS A MAJOR CAUSE OF DIABETES. INSULIN RESISTANCE ON THE PART OF TISSUES THAT ARE RESPONDING TO INSULIN IS THE OTHER MAJOR THING. YOU OVERCOME DIABETES IF YOU CAN'T ACCOMPLISH IT BY DIET AND EXERCISE AND YOU HAVE TO TURN TO DRUG, THE DRUGS ARE ATTACKING ONE OR THE OTHER OF THOSE TWO THINGS. FOR THE MOST PART. NOW, YOU CAN ALWAYS OVERCOME HIGH SUE DIABETES WITH INSULIN. THE FOUR LETTER WORD WITH DIABETES IS INSULIN, HOW FAR MANY LETTERS IT IS BUT IT EVOKES A LOT OF ANXIETY ON THE PART OF PEOPLE AND I'M GOING TO SAY A FEW THINGS ABOUT INSULIN. I WANT TO START REALLY FROM THE PREMISE THAT WHEN I TEACH IN THE DIABETES EDUCATION PROGRAM HERE, ONE OF MY MAJOR POINTS IS NOT TO THINK ABOUT INSULIN AS A DRUG. THINK ABOUT INSULIN AS A NATURALLY OCCURRING HORMONE FOR THE BODY UTTERLY ESSENTIAL FOR LIFE. YOU SIMPLY WILL NOT SURVIVE WITHOUT INSULIN, END OF STORY. NO POINT TRYING TO NEGOTIATE THAT. IF YOU DON'T HAVE INSULIN YOU WON'T SURVIVE. SO WHEN YOU THINK INSULIN DON'T THINK HORRENDOUS THING, THINK ABOUT GETTING SOMETHING BACK INTO YOUR BODY THAT'S NATURAL AND NECESSARY AND HAS GONE AWRY IN DIABETES. A LOT OF DIFFERENT FORMS OF INSULIN DIFFER PRIMARILY IN TERMS OF HOW RAPIDLY THEY ACT, SIMPLY GOING TO SAY YOU HAVE SEEN THIS SLIDE EARLIER, BRINGING IT BACK HERE TO SAY THIS IS WHAT HAPPENS NATURALLY AND THE INLYNN IS BEING MADE BY THE BODY BUT IF THERE'S NOT ENOUGH INSULIN AROUND YOU AS A PRESCRIBING PHYSICIAN WANT TO BASICALLY GET BACK TO THE ACQUISITION WHERE INSULIN SMACHED TO SUGAR. THAT CAN BE WITH INJECTABLE INSULIN OR ORAL MEDICATIONS OR OTHER INJECTABLE MEDICATIONS OR WITH A COMBINATION. WE THINK ABOUT THIS INSULIN SOME INSULIN IN THE BACKGROUND ALL THE TIME INCLUDING OVERNIGHT FASTING AND RAPID ACTING INLYNN WHEN EATING SO THERE'S FAST ACTING FORMS OF INSULIN, SLOW ACTING FORMS OF INSULIN. THE BULL WELCOME TYPE 2 DIABETES T PRIMARY WAY WE USE INSULIN IS LONG ACTING FORM TO CONTROL HIGH GLUCOSE LEVELS IN THE MORNING. YOU WOULD BE SURPRISED SOME OF YOU TO KNOW THAT FOR A LOT OF PEOPLE WITH DIABETES, A LOT OF SUGAR IS IN THE MORNING, MOST OTHER MEDICATIONS DON'T DO A GOOD JOB ADDRESSING THAT PROBLEM. THE HIGH SUGAR ISN'T FROM WHAT YOU HAVE EATEN BECAUSE YOU HAVE GONE THROUGH 8, 10 HOURS NOT EAT BUG GLUCOSE PUT OUT BY YOUR LIVER THERE. NEEDS TO BE AN APPROPRIATE AMOUNT TO MATCH THAT DESPITE THE FACT THAT IT'S NOT FROM YOUR FOOD. OFTEN TIMES GIVING INSULIN IN LONG ACTING FORM IS THE BEST WAY TO GET SAW GARS DOWN IN THE MORNING. MOST OF WHAT PEOPLE THINK THEY KNOW ABOUT INSULIN IS MISCONCEPTION, THEY THINK THE SHOTS HURT THAT'S HARDLY THE CASE, TWO TIMES OUT THREE PEOPLE TAKE AN INSULIN SHOT THEY DON'T EVEN FEEL IT. THE OTHER THINGS YOU CAN REALLY KIND OF LUMP THEM TOGETHER IN OH, MY GOD, INSULIN. IT'S SOME BADGE. IT'S -- IF YOU'RE ON E I THINK I WOULD SUM UP THIS WAY. THE AVERAGE PERSON THINKING THAT IF THEY'RE ON ORAL MEDICATIONS THEIR DIABETES IS SORT OF NO BIG DEAL. LITTLE TOUCH OF SUGAR. IF THEY'RE ON INSULIN, MUST BE A SERIOUS DISEASE. I GET THAT ALL THE TIME. OF COURSE, NOTHING COULD BE FURTHER FROM THE TRUTH. THE TRUTH IS THAT IF THE BLOOD SUGARS ARE WELL CONTROLLED BY WHATEVER MEANS THAT'S WHAT CONSTITUTES SOMEBODY WHO IS IN GOOD HEALTH. THAT F THAT REQUIRES INSULIN IT'S NOT SOMETHING TO PROVOKE ANXIETY F. YOU DON'T USE INSULIN YOU CAN USE MEDICATIONS THAT HELP THE BODY MAKE MORE OF ITS OWN INSULIN COMMON ONES LISTED HERE (INDISCERNIBLE) AND GLIBERIDE ARE MEDICINES REASONABLE TO USE. LESS COMMONLY USED THE GENERIC NAMES HERE BUT THESE ARE DRUGS THAT HELP THE BODY MAKE ITS OWN INSULIN SO AS LONG AS THERE'S SOME INSULIN YOU CAN TAKE MEDICATIONS AND BOLSTER THE AMOUNT YOU CAN MAKE. DR. ROTH eWILL -- ROTHER WILL TOUCH MORE ON OTHER INSULINS THAT MODULATE GLUCOSE IN THE BODY. ONE OF THE MOST IMPORTANT ONES IN TERMS OF MEDICAL THERAPY RIGHT NOW IS SOMETHING THAT'S CALLED GRKSLUCOGON TYPE PEPTIDE 1. GLP-1. IT HAS A LOT OF PHYSIOLOGIC EFFECTS BUT BASICALLY IF YOU LOOK AT THIS SIMPLIFIED SLIDE GLP-1 IN THE INTESTIN IS RELEASED TO THE BLOODSTREAM AND THE ACTIVE GLP-1 ACTS ON THE PANCREAS TO INCREASE INSULIN BEING MADE. ENZYME IN THE BLAD STREAM CALLED DPP-4, BREAKS THE GLP-1 DOWN SO IT'S INACTIVE. YOU CAN GET THE BENEFITS OF GLP-1 EITHER BY GIVING A DRUG THAT IS BASICALLY MIMICKING GLP-1 ACTION OR BY GIVING A DRUG THAT IS INHIBITING THAT DPP-4 ENZYME. THERE ARE DRUGS IN BOTH CATEGORIES HERE. WE HAVE THE DRUGS THAT BASICALLY MIMIC GLP-1 ACTION, A LONG ACTING FORM THAT DR. ROTHER WILL TALK ABOUT A LITTLE BIT AND VICTOZA, APOLOGETICCABLE DRUGS AND -- INJECTABLE DRUGS AND THINGS THAT INHIBIT DPP-4 MEDICATIONS SOME NAMES FROM TAKING THE DRUG OR SEEING ADVERTISEMENTS. SO I'M GOING TO TELL YOU I'M A BIGGER FAN OF THESE THINGS, IS THAT BECAUSE I'M A SADIST AND I WANT PEOPLE TO STICK THEMSELVES? NO. BECAUSE ON BALANCE THESE DRUGS GET GLP-1 LEVELS IN T BLOOD HIGHER THAN THESE AND AT HIGH LEVELS YOU HAVE A VERY DESIRABLE EFFECT WHICH IS YOU OFTEN LOSE WEIGHT. I CAN'T TELL YOU THE NUMBER OF TIMES I HAVE TRIED TO GET SOMEBODY TO TAKE INSULIN AND IT'S OH, NEEDLE CAN'T DO IT. THEN I SAY WHAT ABOUT THESE THINGS, THESE ARE INJECTABLE AND MIGHT HELP YOU LOSE WEIGHT. LOSE WEIGH, I'M THERE, NO PROBLEM. NO DIFFICULTY DOING THAT. SO SOMETIMES I END UP, SOMETIMES THIS IS THE ENTRYWAY TO GETTING PEOPLE TO OVERCOME THEIR ANXIETY. NOW, SO THOSE ARE ALL THINGS THAT INCREASE THE AMOUNT OF INSULIN IN THE BLOOD. IF YOU TURN THEN TO THE THINGS THAT HELP THE BODY MAKE OR I'M SORRY, RESPOND TO INSULIN BETTER, THESE ARE DRUGS THAT ARE OVERCOMING INSULIN RESISTANCE, THERE ARE A COUPLE OF DRUGS OUT THERE, MET FOR MAN THE ONE USED IN THE DIABETES PREVENTION PROGRAM IS TYPICALLY THE FIRST LINE DRUG THAT'S USED TO TREAT DIABETES, IT'S BEEN AROUND FOR 40 PLUS YEARS, WE KNOW ITS SIDE EFFECT PROFILE, IT'S AVAILABLE GENERICALLY, IT'S CHEAP, IT TENDS TO FACILITATE WEIGHT LOSS IN PEOPLE, WE KNOW IT'S SAFE. THE ONLY TIME IT'S A PROBLEM IS IN PEEP WHEN WILL HAVE KIDNEY FAILURE. IN EXPERIMENTAL ANIMALS INTEREST LIG IF YOU USE THIS DRUG IT HELPS THEM LIVE LONGER. IF YOU HAVE RATS LITTER MATES AND YOU SPLIT TWO GROUPS AND GIVE A GROUP PLACEBO AND THE OTHER METAPHORMAN. FROM THE TIME OF BIRTH THE METAPHORMAN RATS LIVE 20% LONGER THAN THE RATS THAT DON'T GET METAPHORMAN. PROBABLY BETTER DATA THAN FOR RESVERTROL THOUGH IT GETS ALSO OF PRESS. ANOTHER DRUG PROBLEMATIC IN THE EYES OF MOST THAT'S ANSWER INSULIN SENSITIZER, ACTOSE. AVANDIA WAS REMOVED FROM THE MARKET BUT IN THE SAME CLASS. ANOTHER DRUG TEN YEARS AGO REDULIN CAUSED PROBLEMS SO IT'S NOT I'M IN THE A BIG FAN BECAUSE IT CAUSES WEIGHT GAIN AND OTHER PROBLEMS BUT FRANKLY IN YOU COMPARE THE PROBLEMS THAT IT HAS AS A DRUG AGAINST THE CATASTROPHIC OUTCOMES THAT COME FROM POORLY CONTROLLED DIABETES, UNQUESTIONABLY IT'S A VALUE IN THE RIGHT KIND OF PATIENT. SO METAPHORMAN AND ACTOSE ARE DRUGS THAT IMPROVE INSULIN RESPONSIVENESS. TWO OR THREE MORE SLIDES. I SAID DRUGS EITHER ATTACK INSULIN RESISTANCE OR INCREASE THE AMOUNT OF INSULIN IN THE BODY. ONE EXCEPTION TO THAT, A VERY INTERESTING CLASS OF DRUGS, THE GENERIC NAMES, MEGLATOL, BRAND NAMES (INDISCERNIBLE), THESE ARE DRUGS THAT WORK BY SLOWING THE DIGESTION OF STARCH. IF YOU EAT A POTATO, RICE, SOMETHING LIKE THAT, IT'S -- IT HAS TO BE BROKEN DOWN INTO GLUCOSE IN YOUR GASTROINTESTINAL TRACT BEFORE ABSORBED AS GLUCOSE INTO YOUR BLOODSTREAM. THESE DRUGS ACTUALLY SLOW DOWN THE PROCESS. THEY INHIBIT THE ENZYME ALPHA GLUCO SIGH DAYS THAT BREAKS DOWN THE STARCH INTO THE COMPONENT GLUCOSE, THEY SLOW DOWN, SO IF YOU ARE EATING A POTATO, YOUR BLOOD SUGAR WILL RISE AND FALL LIKE THAT. IF YOU EAT A POTATO AND YOU HAVE -- WITH IT YOUR BLOOD SUGAR WILL RISE AND FALL MORE SLOWLY OVER A PERIOD OF TIME. IN THE END HERE IS THE IMPORTANT POINT. HAVING DIABETES IS BAD NEWS, CAUSES ALL THESE THINGS THAT WE TALKED ABOUT. THE GOOD NEWS HERE, THE GOOD NEWS IS IF YOU CONTROL YOUR BLOOD SUGARS, YOU CAN DERIVE ENORMOUS BENEFIT. AND PULLING DATA FROM LOTS OF STUDIES WE CAN SAY ON BALANCE IF YOU CAN GET YOUR BLOOD SUGAR DOWN BY ONE POINT YOUR A-1C THAT THING THAT SHOULD BE UNDER 6 OR UNDER 7 IS BETTER. EVERY POINT YOU GET IT DOWN ON AVERAGE YOU CAN LOWER YOUR ALL CAUSE MORTALITY BY ABOUT 20%. IMAGINE FROM A 9 TO A 7 THE BENEFIT THAT YOU HAVE DONE FOR YOURSELF. REMEMBER, WE SHOWED EARLIER THAT THE RIGHT KIND OF LIFESTYLE MODIFICATION CAN BE MORE POWERFUL THAN DRUGS SO YOU CAN LITERALLY SAVE YOUR LIFE IF YOU EAT RIGHT AND EXERCISE REGULARLY. I THINK THE VERY LAST SLIDE, LOOK AT LOTS OF THE DIFFERENT COMPLICATIONS OF DIABETES AN RELATE THEM TO THIS HEMOGLOBIN A-1C LEVEL YOU CAN SEE THE LIKELIHOOD RELATIVE RISK OF THESE THINGS HAPPENING FALLS AS THE HEMOGLOBIN A 1C FALLS SUCH THAT WHEN YOU'RE DOWN AROUND 7 OR UNDER YOU'RE NOT TERRIBLY MUCH MORE LIKELY TO HAVE THESE TERRIBLE THINGS HAPPENING TO YOU, THAN YOU ARE IF YOU'RE SOMEBODY WHO DOESN'T HAVE DIABETES. THAT'S THE END OF MY SECTION. I'LL LET DR. ROTHER TALK THEN WE'LL TAKE QUESTIONS. [APPLAUSE] IN CONTRAST TO DR. MERINDINO I'M NOT A LOCAL, YOU CAN HEAR THAT BY THE ACCENT. BUT I FEEL LIKE A LOCAL. I GREW UP IN SOUTHWEST GERMANY THEN CAME TO THE UNITED STATES TO TRAIN AND HAVE BEEN HERE AT THE NIH ALMOST 20 YEARS. SO THAT'S WHERE THE LOCAL COMES FROM. DR. MERINDINO HAS COVERED SO MANY TOPICS ALREADY THAT I CAN NOW FOCUS ON NOVEL TREATMENT OPTIONS AND ESPECIALLY BARIATRIC SURGERY. BEFORE I START I WANT TO TELL YOU THAT I WILL DIVIDE THE TALK INTO THESE THREE PARTS FIRST COMMENT A LITTLE BIT THAT'S KIND OF MY HOBBY ON THINKING WHY WE HAVE SO MUCH DIABETES THESE DAYS. ESPECIALLY TYPE 2 DIABETES BUT ALSO TYPE 1 DIABETES IS ON THE RISE. THEN I'LL FOCUS ON BARIATRIC SURGERY, AND IN THE LAST PART I WILL TALK MEDICATIONS THAT ARE SO CALLED IN THE PIPELINES. THEY'RE IN DEVELOPMENT AND NOT YET AVAILABLE. SO MY THOUGHTS ARE THAT IN GENERAL WE OVERSIMPLIFY THE CAUSES LEADING TO TYPE 2 DIABETES. WE CALL IT THE BIG 2. THE BIG 2 ARE TOO MUCH FOOD, TOO LITTLE EXERCISE. THAT'S TRUE. THEN THERE ARE MANY OTHER FACTORS. ONE OF THEM IS WE ALL KNOW GENETICS PLAYS A ROLE. YOU SAY MY PARENTS HAD IT AND MY SISTER HAS IT, HERE I AM, I HAVE IT TOO. BUT WE ALSO KNOW GENETICS HASN'T CHANGED. GENES HAVEN'T CHANGED IN THE LAST 20, 30 YEARS. STILL WE HAVE THIS MASSIVE RISE SO MUST BE SOMETHING IN OUR ENVIRONMENT. SO WHAT IS IT? I AGREE THE BIG ONES ARE TOO MUCH FAST FOOD, TOO LITTLE EXERCISE AND TOO MUCH TELEVISION BUT THERE ARE OTHER FACTORS. BY THE WAY, I AM TRAINED AS A PEDIATRICIAN, I SEE ADULT PATIENTS AT THE NIH TOO. BUT THIS PICTURE HERE INDICATES THAT TYPE 2 DIABETES HAS NOW REACHED SUCH A YOUNG AGE AS THIS CI HERE SO WE SEE CHILDREN NOT TYPICALLY BELOW THE AGE OF 10 BUT AS OF AGE 10 THEY MAY DEVELOP TYPE 2 DIABETES AND IT'S ALWAYS RELATED TO OBESITY. SO ONE OF THE FACTORS THAT SURELY PLAY AS ROLE IS SO-CALLED EPIGENETICS. BASICALLY WHAT THAT MEANS IS IT'S THE ENVIRONMENT TO WHICH A BABY IS EXPOSED TO IN THE UTERUS. THAT MEANS THAT WOMAN WHO IS OBESE AND MAYBE SHE HAS DIABETES DURING PREGNANCY, SHE EXPOSES THE CHILD TO HIGHER BLOOD SUGAR LEVELS, HIGHER GLUCOSE LEVELS AND TO AN ENVIRONMENT THAT SETS THE STAGE FOR EARLIER DEVELOPMENT IN THIS CHILD. SO WE'RE PASSING ON DIABETES NOT ONLY VIA OUR GENES BUT ALSO PASSING IT ON BY THE ENVIRONMENT THAT WE'RE PROVIDING FOR OUR CHILDREN. IT STARTS AS EARLY AS IN THE WOMB. THIS THREE LEGGED FROG IS THERE TO THE REMIND ME THERE ARE CHEMICALS IN THE ENVIRONMENT THAT CAN CAUSE SUCH THINGS AS THREE LEGGED FROGS BUT YOU MAY HAVE HEARD ABOUT FISH WE FIND IN THE POTOMAC THAT ARE SUPPOSED TO BE MALE BUT THEY LOOK FEMALE. THERE ARE CHEMICALS IN OUR ENVIRONMENT THAT ARE THEY ACT LIKE ENDOCRINE HORMONES. SOME OF THEM ACTUALLY ARE THESE CHEMICALS THAT WE FIND IN PLASTIC BOTTLES. THESE DAYS WHEN YOU BUY YOURSELF A WATER BOTTLE IT PROBABLY SAYS BPA FREE, SO IT DOESN'T CONTAIN THESE -- THIS TYPE OF CHEMICAL ANY MORE. BUT THERE ARE SO MANY IN THE ENVIRONMENT AND SOME OF THEM PROMOTE DEVELOPMENT OF FAT CELLS AND SOME ARE NOT HEALTHY FOR INSULIN PRODUCING CELLS IN THE PANCREAS. THEN WE HAVE VIRAL INFECTIONS. DON'T THINK IT'S CRAZY BECAUSE THERE ARE SOMETIMES ARTICLES IN THE NEWSPAPER THAT SAY MAYBE THERE IS SOMETHING INFECTIOUS THAT CAUSES US TO BE OBESE AND MAYBE LOSE OUR BETA CELL INSULIN PROTECTION. IN TYPE 1 DIABETES THAT IS QUITE REAL. IN TYPE 2 DIABETES THERE'S ALSO EVIDENCE THAT SOME OF THE BETA CELLS PRODUCE INSULIN MIGHT BE ATTACKED BY SOME VIRUSES. THEN DR. MERINDINO ALREADY MENTIONED THAT HORMONE. GUT HORMONES PLAY A GAD ROLE IN THAT WE USE THEM AS SOMETHING THAT WE ACTUALLY GIVE AS A DRUG BUT ON THE OTHER HAND, WE ALSO KNOW THAT THE BACTERIA THAT GROW IN OUR -- WE HAVE GOOD ONES AND BAD ONES, THESE GOOD ONES CHANGE IN PEOPLE WHO ARE OBESE OR PEOPLE WHO HAVE DIABETES, DIFFERENT BACTERIA LIVE IN THE GUT AND MAYBE THEY'RE NOT THAT HELPFUL WITH DIGESTION OF FOOD. SO THAT'S WHY I SAY YES, THE BIG TWO BUT THERE'S SO MUCH MORE TO IT. AND THIS IS ONLY SOME OF THEM ARE MENTIONED HERE, THIS PLAYS A ROLE WHY WE HAVE SO MUCH MORE DIABETES THESE DAYS. HERE ARE SOME THINGS THAT ARE CLOSE TO MY HEART. FIRST WE'RE DOING RESEARCH ON IT, SECOND, I THINK THIS IS SOMETHING THAT EACH ONE OF YOU MAY WANT TO THINK ABOUT. LACK OF SLEEP, DEPRESSION, AND STRESS. WHO HERE ISN'T STRESSD? YOU ALL MADE IT THIS EVENING, YOU MIGHT HAVE BEEN ALMOST LATE. YOU GOT HERE AFTER A BUSY DAY, WE'RE ALL STRESSED. STRESS MAKES IT EASIER TO DEVELOP DIABETES. I'M NOT SAYING EVERYBODY WHO IS STRESSED OUT WILL DEVELOP DIABETES BUT ONCE YOU'RE STRESSED IT IS MORE LIKELY THAT YOU DEVELOP DIABETES AND IF YOU HAVE DIABETES AND YOU'RE STRESSED OUT YOU KNOW EXACTLY YOUR NUMBERS ARE WORSE. SO IT PLAYS A ROLE THESE THREE FACTORS PLAY A ROLE FOR THE IN THE ONSET OF DIABETES AS WELL AS CONTROL OF DIABETES. THIS IS HOW WE ALL WANT TO LOOK WHEN WE GET OLDER. YOU HAD A SIMILAR PICTURE ON THE BEACH. I LIKE THAT TOO. BUT IN EFFECT WE LOOK MORE LIKE. THIS BURDENED DOWN BY A LOT OF THINGS. SO I WANT STO ASK YOU TO THINK ABOUT HOW YOU COULD GET RID OF SOME OF THESE BOULDERS. BEFORE WE EVEN START THINKING ABOUT BARIATRIC SURGERY. CAN YOU IMPROVE YOUR SLEEP? IT'S VERY CLEAR THAT SLEEP APPROXIMATE PEEIA FOR EXAMPLE CAUSES GLUCOSE BLOOD SUGAR ABNORMALITIES. IF YOU HAVE SLEEP APNEA, YOU NEED TO TAKE CARE OF IT. IF YOU THINK YOU HAVE SLEEP APNEA, YOU NEED TOE B VALUE WAITED FOR IT. STRESS MANAGEMENT. SO THESE BOULDERS COULD BE EVEN LOOKED AT AS SOMETHING YOU WANT TO MEDITATE ABOUT. I'M NOT KIDDING BUT WE NEED TO LEARN HOW TO DEAL WITH STRESS BETTER AND MEDITATION MINDFULNESS ARE, THESE ARE SOME WAYS OF LEARNING TO DEAL WITH IT. IF YOU FEEL YOU ARE DEPRESSED, YOU NEED TREATMENT OR IF YOU DON'T GET EFFECTIVE TREATMENT FOR DEPRESSION, YOU NEED TO GET IT. IN THE LIFESTYLE CHANGES YOU MENTIONED EARLIER, EXERCISE AND DIET WE ALL KNOW WE PROBABLY DON'T DO A VERY GOOD JOB. THEN WITH REGARD TO MEDICATIONS. MANY OR SOME OF YOU MAY HEAR IN THE ROOM MAY ACTUALLY HAVE A PRESCRIPTION FOR A CERTAIN MEDICATION BUT EVEN HERE WHO STAND ON THE PODIUM, IF WE TAKE A MEDICATION ONLY ANTIBIOTIC FOR TWO WEEKS, EVERY DAY MORNING AN EVENING, HOW OFTEN DO WE FORGET? WE'RE SO STRESSED OUT, RIGHT? SO IF YOU HAVE A MEDICATION, TAKE IT. AS YOU'RE BEING TOLD THE TAKE IT, FIND OUT IF IT'S THE RIGHT DOSE AND MAYBE CHANGE AND ADD MEDICATIONS JUST AS YOU MENTIONED IN BASICALLY THESE DIAGRAMS. SO NOW WE WANT TO GET TO THE MEAT OF THE TALK, THIS IS BARIATRIC SURGERY. BEFORE WE GET INTO IT I WANT TO EXPLAIN, I ALWAYS WANT TO KNOW WHERE THE WORDS COME FROM, THEN I CAN REMEMBER THEM BETTER. ON THE RIGHT SIDE I HAVE A BAROMETER AND LEFT SIDE I HAVE THIS PEDIATRIC SCIENCE. SO WITH THE BAROMETER YOU MEASURE AIR PRESSURE TO PREDICT THE WEATHER. SO THIS IS PRESSURE OR WEIGHT T BAR IN IT. AND THE ATRICS IN PEDIATRICS IS TREATMENTMENT SO PUT THEM TOGETHER TO BARIATRIC SURGERY, SO THERE'S BAR, WEIGHT, TREATMENT, WITH SURGERY. THAT'S ALL IT IS. THERE ARE TWO TYPES OF BARIATRIC SURGERY, TWO MAIN TYPES. THE FIRST ONE ON THE RIGHT SIDE YOU SEE A STOMACH THAT IS KIND OF STRANGLED. THAT MEANS THAT LESS FOOD CAN GET INTO THE STOMACH AND THEREFORE YOU RESTRICT THE INTAKE AND THAT'S WHY IT'S CALLEDDED RESTRICTIVE BARIATRIC SURGERY. SO THIS IS BANDING. ON THE OTHER HAND, ON THE LEFT SIDE -- NO, THIS IS RIGHT SIDE. IM, THE RIGHT SIDE YOU SEE SOMETHING THAT'S CALLED A GASTRIC BYPASS. WHAT HAPPENS IN A GASTRIC BYPASS IS YOU SEE HERE AGAIN THAT'S THE ENTRANCE TO THE THE STOMACH, HERE IS THE WHOLE STOMACH. AND THIS HERE IS PART OF THE FIRST PART OF THE SMALL BOWEL GOING DOWN INTO -- FURTHER DOWN. IN GASTRIC BYPASS THE STOMACH IS NOT REMOVED BUT IT'S STAPLED SO YOU MAKE A VERY SMALL STOMACH UP HERE JUST A SMALL POUCH, ACTUALLY ABOUT THREE TABLESPOONS. AND THEN FOR EXAMPLE HERE, YOU CUT THE SMALL BOWEL HERE AND YOU TAKE THAT LOWER PART AND PULL IT UP INTO THE STOMACH. SO NOW FOOD GOES DIRECTLY FROM COMING IN TO THE STOMACH INTO THE SMALL INTESTIN. AND YOU DON'T LET IT TOUCH MOST OF THE STOMACH AND THIS UPPER PART OF THE SMALL ENTERTIN. THIS PART HERE IS -- INTESTINE. THIS PART HERE IS CALLED DUODENUM. WHEN DR. MERINDINO SHOWED YOU THIS AIR I CAN'T RECOLLECT THIS IS WHERE THE PANCREAS IS. BUT I'M TO CUTSING ON THE GUT AND THAT'S WHY I LEFT THE PANCREAS OUT. A GASTRIC BYPASS IS A BIT MORE OF A COMPLICATED PROCEDURE. IT HASyM TWO COMPONENTS, NAMELY NOW YOU HAVE A SMALL STOMACH, RESTRICTIVE. AND SINCE THE FOOD DOESN'T GO ALL THE WAY THROUGH ITS NORMAL PASSAGE, YOU ABSORB LESS OF WHAT YOU EAT. THAT'S WHY IT'S CALLED MAL ABSORBTIVE, BAD ABSORPTION. THESE ARE THE THREE MOST COMMON PROCEDURES BEING DONE IN THE UNITED STATES AT THE PRESENT TIME. AND THIS IS ACTUALLY A VERY MUCH MOVING TARGET. EVERY TIME WE HAVE A PROTOCOL, A TRIAL SET UP TO STUDY ONE PROCEDURE, THE SURGEONS MOVE ON AND SAY WE THINK THIS THIS IS NOW ACTUALLY BETTER. WE'RE MOVING ON TO THE NEXT ONE. WE ARE ALWAYS A LITTLE BIT BEHIND. PRINCIPALLY -- I'M SORRY. YOU SAW THE FIRST ONE WHICH WE CALLED THE LAP BAND, WHAT IT STANDS FOR IS LAP PROSCOPIC ADJUSTABLE GASTRIC BANDING. I WILL GET TO WHAT THE WORD LAPAROSCOPIC MEANS. IN THE MIDDLE WE HAVE GASTRIC BYPASS AND THE SURGEON WHO INVENTED THIS TYPE OF SURGERY HE HAS THE NAME SOMETIMES YOU HEAR SOMETHING THAT SAYS I HAD A JU WIDE PROCEDURE. SO DR. JU IS THE NAME YOU FIND HIS NAME IN THE PROCEDURE AND THEN THERE'S CALLED GASTRIC SLEEVE. WHY IS IT CALLED A SLEEVE? BECAUSE THERE'S NOT MUCH LEFT OF THE STOMACH ACTUALLY THAN JUST KIND OF THIS BAND HERE ORER THIS SLEEVE. THIS PART OF THE STOMACH IS IN EFFECT TAKEN OUT. SO IN THE GASTRIC BYPASS PROCEDURE YOU H LEAVE THE STOMACH AND DUE DUODENUM AND YOU TAKE THIS PART OF THE STOMACH OUT. IT'S VERY SURPRISING THAT YOU CAN TAKE SUCH A BIG PART AN ORGAN IN YOUR BELLY OUT OF A SMALL LITTLE HOLE CREATED SURGERY. -- SURGICALLY. THIS IS HOW A PATIENT LOOKS LIKE WHO UNDERGOES LAPAROSCOPIC PROCEDURE. I LIKE TO EXPLAIN HOW WE COME UP WITH THESE WORDS, THIS LAPRO IS SOFT PARTS OF THE BODY BETWEEN THE RIB MARGINS AND THE HIP AND MANY OF YOU USE THE WORD SCOPE, THE SCOPE OF THINGS, THIS COMES FROM SCOPING, TO SEE OR VIEW OR EXAMINE. SO WHAT HAPPENS INSTEAD OF MAYBEING A BIG CUT, 20 YEARS AGO WHEN SOMEBODY UNDERWENT BARIATRIC SURGERY, THE PATIENT WAS IN THE HOSPITAL FOR TWO WEEKS. NOW PATIENT UNDERGOES GASTRIC BYPASS, HAS ANYBODY HAD A BYPASS IN THE ROOM? YOU DON'T NEED TO SAY BUT MANY OF YOU KNOW YOU WILL LEAVE THE HOSPITAL TWO OR THREE DAYS AFTER THE PROCEDURE. IT'S REALLY FAST. IT'S REALLY FAST BECAUSE THIS IS HOW THE PROCEDURE IS DONE. YOU CAN ACTUALLY SEE, THESE ARE BASICALLY THE INLETS TWO HOLES MADE HERE INTO THE INNER PART OF THE ABDOMEN. AND IN THIS ONE HERE AND THAT ONE YOU CAN SEE THERE ARE SOME SCISSORS STICKING THERE AND LIEU THE OTHER ONES THE SURGEON PUTS A CAMERA, SO HE OR SHE CAN SEE WHAT'S GOING ON INSIDE. AND THROUGH ONE OF THEM THERE IS CO-2 PUMPED INTO THE ABDOMEN SO THE ABDOMEN GETS BIG AND ONE CAN OPERATE IN THERE. SO THROUGH ONE OF THESE HOLES YOU WOULD PULL OUT THIS PART OF THE STOMACH THAT YOUR CUTTING OFF. I ALWAYS THINK THAT SURPRISING BUT IT WORKS. THE PATIENTS LEAVE IT'S NOT A MAJOR PROCEDURE ANY MORE COMPARED TO THE BIG CUT THAT PEOPLE HAD TO HAVE EARLIER. NOW I WANT TO COME TO FREQUENTLY ASKED QUESTIONS. BEFORE I WANT TO MENTION WHY I PUT THIS PICTURE UP THERE, IF YOU UNDERGO BARIATRIC SURGERY YOU DO NEED A LOT SUPPORT AND YOU NEED SUPPORT FROM YOUR FAMILY, IN THIS CASE HERE IS SUPPORT OF COUPLES WHO HELP EACH OTHER AND WENT THROUGH THE PROCEDURE AND LOOKED VERY WELL AFTERWARDS. PRINCIPALLY YOU'RE PROBABLY ASKING IS THIS SOMETHING FOR ME? DO I QUALIFY FOR BARIATRIC SURGERY? WHAT ARE THE LONG AND THE SHORT TERM CONSEQUENCES OF BARIATRIC SURGERY? THEN IS THIS A PROCEDURE THAT HELPS ME KEEP OFF THE WEIGHT OR IS IT LIKE ANY DIET WHERE SOON I'M BACK UP OR EVEN HIGHER? FINALLY, WILL MY DIABETES GO AWAY IF I UNDERGO BARIATRIC SURGERY, AND WHEN OR DOES IT COME BACK. FIRST ONE DO I QUALIFY FOR SURGERY, FOR THIS ONE WE HAD HAND-OUTS LYING OUT THERE BECAUSE WE NEED TO TALK ABOUT ONE CONCEPT, THIS IS THE BODY MASS INDEX, MANY OF YOU KNOW WHAT THIS IS BUT—m BASICALLY YOU JUST LOOK AT HEIGHT AND WEIGHT AND PUT ANYTIME A FORMULA FOR MEN AND WOMEN, IT'S THE SAME. IF MY BMI IS 25, IT'S TES SAME IF I'M A MAN OR WOMAN. YOU CAN DETERMINE BMI BY EITHER LOOKING AT ONE OF OUR ARTICLES THERE AND YOU CAN GET IT AFTERWARDS AND LOOK IT UP WHAT YOUR BMI IS, ALSO WE'LL GIVE YOU SOME HELP IN THE NEXT SLIDE AND SHOW YOU EXAMPLES. SO THERE IS ONE WAY TO LOOK IT UP IN A CHART OR YOU CAN CALCULATE IT OR JUST GO ONLINE, THERE ARE MANY, MANY SOURCES, JUST PLUG IN YOUR NUMBERS, HEIGHT, WEIGHT, YOU KNOW YOUR BMI. BODY MASS INDEX. A NORMAL BODY MASS INDEX IS BETWEEN 18 1/2 AND 25. BETWEEN 25 AND 30 IS WHAT WE CALL OVERWEIGHT AND ABOVE 30 IS OBESE. A FEW EXAMPLES HERE. IF YOU ARE 5, 4 AND YOU WEIGH 205 POUNDS, YOUR BMI IS 35. IT'S CLEARLY IN THE OBESE RANGE. IF AT THE SAME HEIGHT YOU WEIGH 235 POUNDS YOUR BMI IS 40. I A FEW MORE EXAMPLES MAYBE YOU CAN FIND YOUR OWN HEIGHT AND COMPARE IT TO YOUR WEIGHT AND YOU KNOW ABOUT WHERE YOU ARE WITH YOUR BMI. I'M CONCENTRATING SO MUCH ON THE BMI BECAUSE YOU NEED TO KNOW IT TO KNOW WHETHER YOU QUALIFY FOR BARIATRIC SURGERY. SO IF YOU HAVE A BMI OF 40 OR GREATER, YOU QUALIFY FOR BARIATRIC SURGERY. DOESN'T MEAN YOU SHALL UNDERGO IT BUT YOU CAN AND THE INSURANCE COMPANY WILL PAY FOR IT. A BMI OF 35, IF YOUR LIGHTER BUT YOU HAVE ANOTHER DISEASE LIKE DIABETES OR HYPERTENSION, HIGH BLOOD PRESSURE OR LIPIDS, HIGH CHOLESTEROL OR WHAT WE MENTION BEFORE, OBSTRUCTIVE SLEEP APNEA, YOU CAN ALSO UNDERGO BARIATRIC SURGERY. WE'RE ALWAYS WARNING AND SCREENING PEOPLE FOR HAVING AN EATING DISORDER BECAUSE EATING DISORDERS DON'T GO AWAY WITH BARIATRIC SURGERY AND CAN MAKE IT COMPLICATED AFTERWARDS. ADDICTION TO ALCOHOL OR ANY OTHER ADDICTION, UNTREATED DEPRESSION OR ANY OTHER CONDITION THAT MAKES IT DIFFICULT FOR A PERSON TO FOLLOW THE INSTRUCTIONS AND THE TYPE OF EATING THAT IS REQUIRED AFTER SURGERY. WHAT COMPLICATIONS CAN ONE EXPECT? I THOUGHT THIS WAS INTERESTING BECAUSE ADVERSE EFFECTS DOESN'T SOUND AS BAD AS COMPLICATION BUT IF YOU HAVE VOMITING DIARRHEA, THESE OCCUR RELATIVELY COMMONLY IN THE BEGINNING AFTER SURGERY, YOU DON'T FEEL SO GOOD BUT IT'S NOT DANGEROUS. WHETHER IS MORE DANGEROUS IS DEVELOPING AN INTERNAL INSIDE HERNIA OR LEAKAGE FROM THE STAPLES, WOUND INFECTIONS, BLEEDING FROM THE STOMACH O WHERE YOU IN THE GASTRIC BYPASS ONE HAD TO CONNECT TWO PARTS OF THE INTESTINE. THERE'S THE POSSIBILITY THIS EITHER BECOMES TOO TIGHT OR IT BLEEDS. THESE THINGS OCCUR BUT THEY ARE RATHER RARE IN THE HANDS OF AN EXPERIENCED SURGEON. ALSO DEATH IS VERY RARE. THIS HAS BECOME A VERY SAFE PROCEDURE. MOST SURGEONS ARE HAPPY TO SHOW YOUR THEY WERE NUMBERS, YOU CAN ASK, WHAT ARE YOUR STATISTIC? AND THEY WILL TELL YOU. THERE ARE SOME THINGS WE DON'T QUITE UNDERSTAND WITH BARIATRIC SURGERY, ONE, WE'RE WORRIED ABOUT BONE HEALTH, YOU CAN IMAGINE WHEN YOU DON'T ABSORB FOOD VERY WELL YOU DON'T ABSORB VITAMIN D VERY WELL AND THAT'S VERY IMPORTANT FOR YOUR BONE HEALTH. NEUROLOGIC DISEASE, SOME ARE ALSO CAUSED BY VITAMIN DEFICIENCIES, VITAMIN B-12 BUT OTHERS WE DONE KNOW WHERE THIS IS COMING, IT STARTS WITH HEADACHES AFTER BARIATRIC SURGERY, WE DON'T KNOW WHY THEY OCCUR. THEN THERE'S SOMETHING THAT IS INCREASED RISK OF SUICIDE. THAT'S SOMETHING WE FOUND STATISTICALLY INCREASED. WE REALLY DON'T KNOW WHY. ONE REASON TOWB PEOPLE WHO UNDERGO BARIATRIC SURGERY, LOSE A LOT OF WEIGHT, THEY'RE DISAPPOINTED. IT DIDN'T CHANGE THEIR LIVES AS MUCH AS THEY WANTED TO. IT WASN'T TO WEIGHT. OR IT LEADS TO MORE ACTIVITY, YOU'RE MORE ACTIVE AND MAYBE THAT'S ONE OF THE REASONSCH THEN THERE'S ANOTHER COMPLICATION, SEVERE LOW BLOOD SUGARS AFTER BARIATRIC SURGERY. SO WE'RE INTENSELY TRYING TO FIGURE THIS ONE OUT. THAT QUESTION I CAN ANSWER WITH MUCH MORE CERTAINTY. THIS IS HOW LIKELY IS IT THAT I REGAIN ALL THE WEIGHT I LOST? THERE IS A BEAUTIFUL STUDY DONE AND IS STILL GOING ON IN SWEDEN. WHAT YOU SEE HERE IS ON THIS ACCESS HERE YOU SEE THE PERCENT OF WEIGHT LOSS. SO OVER TIME THIS IS UP TO 15 YEARS. SOMETIMES PEOPLE SAY BARIATRIC SURGERY IS NEW AND WE DON'T HAVE FOLLOW-UP. WE ACTUALLY DO KNOW QUITE A BIT. IN THIS STUDY PATIENTS UP TO 15 YEARS, NOW ACTUALLY LONGER. THERE ARE 2000 CONTROLS WHICH MEANS THESE ARE PEOPLE WHO ARE OBESE, AND THEY'RE GETTING TREATMENT, NAMELY DIET EXERCISE NO SURGERY, WHAT HAPPENS IS, UPPER LINE HERE, THESE PEOPLE ALSO LOSE WEIGHT, NOT MUCH BUT MOST PEOPLE IF THEY CONE GET HELP FROM PHYSICIANS IN THE TEAM THEY GAIN WEIGHT OVER TIME. THESE PEOPLE MAINTAIN THEIR WEIGH WHICH IS NICE. BUT WHAT YOU SEE IS IN THE GREEN LINE MAJOR DECREASE IN WEIGHT IN PEOPLE WHO UNDERWENT BARIATRIC SURGERY, GASTRIC BYPASS, MORE THAN 30%. MEANS YOU WEIGH 300 POUNDS, YOU LOSE 100. ARE YOU NOW NORMAL WEIGHT? NO. INDIVIDUALS AFTER BARIATRIC SURGERY VERY OFTEN ARE NOT OF NORMAL WEIGHT. BUT MUCH BETTER OFF. IF YOU UNDERGO THE BANDING -- THIS ONE HERE IS BANDING THE ORANGE LINE, YOU LOSE 20%, STILL A GOOD AMOUNT. 60 POUNDS P IF YOU WERE 300 POUNDS. DO YOU KEEP IT OFF? THERE IS AFTER ONE OR TWO YEARS YOU SEE THE CURVE CREEPS UP BUT IT DOES NOT REACH WHERE YOU CAME FROM. SO CLEAR, YES, YOU KEEP THE WEIGHT OFF DESPITE YOU NOT STAYING TT LOWEST POINT OF WEIGHT LOSS. WILL DIABETES DISAPPEAR AND WILL IT COME BACK? THIS IS ANOTHER ONE WITH GOOD NEWS. HERE ARE FIVE GROUPS, THESE ARE DIFFERENT SURGEONS GASTRIC BYPASS, HERE IS A STUDY THEY LOOK AT LAP BAND. THE FOLLOW-UP IS BETWEEN ONE YEAR AND NINE YEARS. WE HAVE DATA IN THESE STUDIES, THIS IS ALMOST 8, 9 YEARS, LOOK AT THE RESOLUTION OF DIABETES. THE RESOLUTION v OF DIABETES IS LESS, WITH THE BAND, MORE WITH GASTRIC BYPASS. BUT IT LASTS. SO THERE'S ONE SURPRISING OBSERVATION. THIS IS WE ARE ENDOCRINOLOGISTS SO WE LIKE TO GIVE MEDICATIONS AND TREAT OUR PATIENTS THE WAY WE CARE FOR THEM. IT WAS SURGEON WHOSE SAID YOU KNOW WHAT, I THINK WE'RE DOING SOMETHING THAT RESOLVES DIABETES QUICKLY. THIS WAS ALREADY OBSERVED IN THE 199 T 0s. AND PUBLISHED BY AN EXCELLENT BARIATRIC SURGEON WHO SAID LOOK, MY PATIENTS DON'T LOSE MUCH WEIGHT. THEY ALREADY DON'T TAKE THEIR MEDICATIONS ANY MORE. THERE ARE PATIENT WHOSE WALK OUT OF THE HOSPITAL THREE DAYS AFTER SURGERY AND THEY DO NOT TAKE MEDICATIONS. THE BLOOD SUGAR MAY NOT BE TOTALLY PERFECT BUT THEY DON'T NEED MEDICATIONS. IN THE BEGINNING THIS WAS, SURE HAPPENS IN A FEW BUT DOESN'T HAPPEN THAT OFTEN. NOW WE KNOW THAT THIS IS ACTUALLY SOMETHING THAT IS TRUE, WE'RE TRYING TO FIGURE OUT WHY IT HAPPENS. AND ONE OF THE ANSWERS BY MOST PEOPLE IS WELL, I MEAN, IF I ATE THIS AFTER SURGERY, THEN MY BLOOD SUGAR WOULD BE BETTER TOO, RIGHT? PEOPLE AFTER BARIATRIC SURGERY AFTER GASTRIC BYPASS EAT FOR THE FIRST WEEK, NOTHING. THEY DON'T EAT ACTUALLY. YOU GET LITTLE SIPS OF THIS PROTEIN SHAKE AND YOU CAN'T EVEN TAKE THE WHOLE SHAKE BECAUSE YOU'RE HUNGRY, YOU TAKE LITTLE SIPS HERE AND THERE BECAUSE IF YOU TAKE MORE YOU WILL START TO VOMIT. YOU CAN'T KEEP IT DOWN. IT MAKES YOU FEEL BAD. ONE GOOD THING IS AFTER BARIATRIC SURGERY PEOPLE SOME SAY IT WAS LIKE THAT, I WASN'T HUNGRY MY MORE. THAT MAKES IT EASIER BUT YOU GET 300-CALORIES PER DAY, AND MOST OF YOU KNOW 300-CALORIES IS LIKE A PIECE OF CHEESE, A HANDFUL OF ALMONDS ALL DAY. THAT'S IT. SO YES, FASTING MAKES BLOOD SUGAR BETTER BUT WE BELIEVE IT'S MORE THAN THAT. ONE REASON WE THINK SO IF YOU DO THE MORE INVASIVE PROCEDURE, THE REROUTING OF FOOD FROM THE STOMACH INTO THE SMALL INTESTINE WITH THE GASTRIC BYPASS YOU SEE EARLY RESOLUTION OF DIABETES MUCH MORE FREQUENTLY. IN ADDITION PEOPLE HAVE DONE SURGERY WHERE JUST THAT UPPER PART OF THE GUT WAS CIRCUMVENTED THE DUODENUM, IF YOU DON'T LET FOOD TOUCH THAT PART YOU CAN ALSO SEE RESOLUTION OF DIABETES. SO THERE MUST BE SOMETHING IN THAT PART OF THE GUT. WE'RE VERY INTERESTED IN FIGURING THIS OUT. SO THE ANSWER, IS IT JUST FAST SOMETHING WE SAY PROBABLY NOT. NOW I'M INVITING EVERYBODY INTERESTED WHETHER YOU HAVE DIABETES OR DON'T, YOU COULD HELP US FIGURE THIS OUT. I'M ALLOWED THE MAKE THAT LITTLE ADVERTISEMENT FOR OURSELVES, IT'S THE NATIONAL INSTITUTES OF HEALTH. RIGHT? SO WE'RE LOOKING FOR VOLUNTEERS WHO HELP US DO THIS STUDY, PEOPLE MUST HAVE DIABETES AND THEY MUST BE OBESE, AND WE ON ONE GROUP LOOK AT PEOPLE WHO UNDERGO BARIATRIC SURGERY AND THE OTHER GROUP WE FEED THEM JUST THE WAY YOU WOULD EAT AFTER BARIATRIC SURGERY, THAT WAY WE FIGURE OUT WHAT IS IT. ALSO OUTSIDE, I HAVE SOME CARDS AND ADVERTISEMENTS AND SOME INFORMATION ABOUT THE STUDY IF YOU'RE INTERESTEDDED YOU CAN GIVE US A CALL. MORE IMPORTANT FOR YOU PARTICIPATING IN A CLINICAL TRIAL IS PROBABLY THIS. YOU HAVE HERE IN THIS AREA EXCELLENT SOURCES OF INFORMATION. IF YOU'RE INTERESTED IN BARIATRIC SURGERY. YOUR OWN DOCTOR AND END CRENOLOGIST WILL HELP YOU VARIOUS INFORMATION EVENINGS THAT ARE BEING ORGANIZED BY THE BARIATRIC SURGERY CENTERS IN THE REGION ARE VERY HELPFUL. SUBURBAN HERE ASSOCIATED WITH JOHNS HOPKINS CENTER FOR BARE Y TRICK SURGERY, WE HAVE SIBLY IN DC, HOLY CROSS, MED STAR, HOWARD UNIVERSITY. WE HAVE A WHOLE ARRAY OF EXCELLENT CENTERS WHERE YOU CAN SEE WHETHER YOU CAN GET THE CARE YOU WANT. NOW ENOUGH OF BARIATRIC SURGERY, VERY BRIEFLY BEFORE I FINISH UP, NEW MEDICATIONS, DR. MERINDINO MENTIONED THIS ONE HERE BY (INDISCERNIBLE). I MENTION IT AGAIN. I'M GOING TO MAKE VERY CLEAR THAT'S SPECIALLY COMING FROM NIH WE DO NOT SUPPORT ANY SPECIFIC MEDICATION FROM ANY SPECIFIC COMPANY. BUT WHAT I WANT TO SAYrk– IS THIS TYPE OF MEDICATION, NOW THAT IT'S AVAILABLE AS A ONCE A WEEK SHOT INJECTION IS SOMETHING THAT SHOULD BE CONSIDERED AND especially you mention it before because it will help you with weight management. ONE OF THE FEW MEDICATIONS THAT IS PROVEN TO HELP WITH WEIGHT LOSS. THIS IS WHAT I POINTED OUT HERE. IT NOT ONLY IMPROVES BLOOD SUGAR BUT ALSO HELPS WITH WEIGHT LOSS AND YOU HAVE NOT DAILY INJECTIONS, YOU HAVE A WEEKLY INJECTION. THESE I WANT TO MAKE CLEAR ARE NOT AVAILABLE YET. THEY'RE SO CALLED IN THE PIPELINE WHICH MEANS DRUG COMPANIES ARE TRYING TO GET THEM TO MARKET BUT THEY'RE NOT QUITE THERE, THEY'RE BEING TESTED FOR SAFETY. WE ARE GETTING NEW INSULIN AND BETTER INSULIN WHICH REALLY -- IF YOU THINK ABOUT WE DON'T EVEN HAVE TO TALK ABOUT GLASS NEEDLES AND THE OLD INSULIN AND THEY CAME FROM COWS AN PIGS, NOW WE HAVE FANTASTIC HUMAN INSULIN. AND AS DR. MERINDINO SHOWED, IN ORDER TO KIND OF IMITATE WHAT THE BODY IS DOING WE GET BETTER TOOLS INSULIN. SO IT REALLY SHOULDN'T BE LOOKED AT AS MEDICATION OF THE LAST RESORT. BUT THEY ARE NOW FINE TOOLS FOR US TO HELP WITH BLOOD SUGAR REGULATION. THERE'S ALSO ONE IN THE PIPELINE THAT MAYBE INHALABLE INSULIN, IÖ% CAN'T TELL YOU MUCH MORE ABOUT IT. IN EFFECT I DON'T THINK THAT INJECTING INSULIN IS THE BIG PROBLEM FOR US IS TO KNOW HOW MUCH AND THAT DEPENDS ON BLOOD SUGAR, WE NEED TO MEASURE THE BLOOD SUGAR RIGHT. SO THESE ARE THINGS THAT ARE VERY IMPORTANT TO DEVELOP TOO, BLOOD SUGAR MEASUREMENTS. ANOTHER VERY SMART MEDICATION IS ONE WHERE YOU CAN SEE HERE, THE KIDNEYS THAT FILTER SUGAR OUT OF THE BLOODSTREAM WHEN THE SUGAR IS TOO HIGH AND YOU END UP WITH SUGAR IN THE URINE. THIS MEDICATION, THAT'S -- DOES EXACTLY THAT. IT BLOCKS REUPTAKE OF SUGAR, YOU SPILL IT, YOU FIND THE SUGAR HERE WHICH MEANS YOU'RE LOSING CALORIES ACTUALLY. SO THIS IS ON PURPOSE, THE BLOODSTREAM IS BEING CLEARED OF SUGAR VIA THE KID IDNIES. ONE THING THAT I WANT TO MENTION, THIS PLAIN LOOKS LIKE A GUT, RIGHT? THERE ARE NEW DEVICES. REMEMBER - THE PICTURE OF THE GASTRIC BYPASS. I POINTED OUT THAT IT SEEMS TO BE ESPECIALLY THIS PART OF THE GUT, THIS UPPER PART WHICH IS CALLED DUODENUM, WHICH PLAYS AN IMPORTANT ROLE IN RESOLUTION OF DIABETES. SMART PEOPLE SAID HOW ABOUT WE DON'T OPERATE, WE JUST PUT A STINT, A LINER, A PLASTIC TUBE INTO THIS PART SO FOOD GOES THROUGH THE MIDDLE AND DOESN'T TOUCH THE WALL OF THE INTESTINE. I THINK THIS IS A MARVELOUS IDEA BECAUSE YOU DON'T NEED SURGERY, YOU CAN TAKE THE TUBE OUT AGAIN. THE PROBLEM IS THERE ARE STILL SOME DIFFICULTIES WITH ANCHORING, YOU NEED TO -- THIS THING HERE, THIS IS BEING ANCHORED IN THE OUTLET OF THE STOMACH. YOU CAN IMAGINE WHEN YOU HAVE SOME CLAWS GETTING INTO THE OUTLET OF YOUR STOMACH CAN HURT, IT CAN LEAD TO BLEEDING. THEY STILL HAVE TO SOLVE THIS, ONCE IN A WHILE THE TUBE SLIPS. IF IT SLIPS ALL THE WAY OUT, THAT'S GREAT BUT IF IT GETS STUCK SOMEWHERE IN THE MIDDLE, NOT SO GREAT. SO THERE ARE STILL PROBLEMS WITH IT BUT PRINCIPALLY I THINK IT'S A GOOD IDEA BECAUSE YOU COULD INSERT THIS TUBE FOR THREE MONTHS, DIABETES GETS BETTER, WEIGHT IS BEING LOST, YOU TAKE IT OUT AGAIN, VERY OFTEN ONCE YOU HAVE STARTED LOSING WEIGHT, ONCE YOU START YOUR EXERCISE AND DIET AND SEE THE EFFECTS YOU CAN KEEP GOING WITHOUT A DEVICE. SO FIRST QUESTION, THAT WAS THE TITLE OF THE TALK, CAN CAN WE OUTSMART TYPE 2 DIABETES. AND WHEN I GOOGLED THAT, I WAS SHOCKED WHEN I LOOKED LIKE THIS, I DON'T THINK OUTSMARTING IS DIFFICULT BECAUSE WE HAVE NOTHING TO DO WITH THAT TYPE OF OUTSMARTING DIABETES. THIS IS SOMETHING ELSE. I THINK WE DIDN'T KNOW WHEN WE THOUGHT ABOUT THE TITLE THAT THERE'S SOMETHING AROUND -- THAT IS THE ONE, TWO, THREE, SO WE DON'T HAVE A ONE, TWO, THREE, WE HAVE SOMETHING MUCH MORE COMPLICATED. I THINK YOU HER THIS EVENING THAT THERE ARE SO MANY COMPONENTS TO TYPE 2 DIABETES. COMPONENTS THAT YOU MAY NOT HAVE EVEN THOUGHT ABOUT WHEN YOU CAME IN HERE AND AGAIN, I WANT TO BRING UP THE SLEEP, DEPRESSION, STRESS. IN ADDITION TO THE EFFECTIVE MANAGEMENT THAT ACTUALLY CAN BE PROVIDED IF YOU USE DRUGS THAT ARE AVAILABLE AND ULTIMATELY I DO THINK THAT WE REALLY HAVE TO ACKNOWLEDGE THAT THERE IS NO OTHER TREATMENT THAN BARIATRIC SURGERY AT THE PRESENT TIME THAT LEADS TO PERSISTENT WEIGHT LOSS AN PERSISTENT RESOLUTION OR TYPE 2 DIABETES. I'M NOT SAYING THAT EVERYBODY SHOULD CONSIDER THIS BUT I'M SAYING THAT WE AS RESEARCHERS SHOULD REALLY LEARN FROM THAT PROCEDURE AND LEARN HOW IT WORKS IN ORDER TO TRANSLATE THAT INTO A TREATMENT THAT DOESN'T REQUIRE SURGERY. WITH THAT, I WANT TO THANK YOU. [APPLAUSE] >> I THINK YOU'LL ALL AGREE THAT -- AND NOW WE'RE OPEN FOR THE QUESTIONS, THAT A PRUDENT QUESTION IS ONE-HALF OF WISDOM. DOES ANYBODY KNOW WHERE THIS CITATION COMES FROM? I GIVE YOU A HINT. I GIVE YOU ANOTHER P HIPT AND THEN BE COURAGEOUS. THAT'S IT. SIR FRANCIS BACON. WITH THAT, THANK YOU AGAIN.cvl I GUESS WE WOULD BOTH BE VERY HAPPY TO ANSWER QUESTIONS. >> WHO WANTS TO ASK THE FIRST QUESTION? OKAY. >> THANK YOU VERY MUCH. THAT WAS VERY HELPFUL. I JUST HAVE A QUESTION, YOU MENTIONED DR. MERINDINO, IN THE BEGINNING ABOUT SPIKING THE BLOOD SUGARS EVERY TIME YOU EAT. T I HEARD IT'S BETTER TO EAT EVERY TWO HOURS AS OPPOSED TO WAITING FOR THREE BIG MEALS. >> THAT'S A GREAT QUESTION. THE DEPICTION I SHOWED WAS FOR SOMEBODY WHO HAD TYPICALLY THREE MEALS DURING THE DAY. IF YOU HAVE DIABETES OR PRE-DIABETES, IT'S CHARACTERIZED BY AN INABILITY TO MATCH THE RISES IN SUGAR THAT OCCURS WITH YOUR MEALS. THE YOU HAVE SMALLER MEALS AN EAT MORE FREQUENTLY YOU'RE NOT CHALLENGING THE SYSTEM AS MUCH WITH EACH MEAL. IN SOME INSTANCES THIS IS A REASONABLE APPROACH TO THE MANAGEMENT OF DIABETES AND IN FACT IT'S THE MAIN STAY OF TREATMENT FROM A DIETARY STANDPOINT IN GESTATIONAL DIABETES. SO A LOT OF TIMES BEFORE SOMEBODY GETS PLACED ON MEDICATION THEY'RE TOLD TO EAT MULTIPLE SMALL MEALS THROUGH THE DAY. IF THAT WORKS WITH YOUR LIFESTYLE, IT'S A PERFECTLY REASONABLE THING TO DO. >> WE ACTUALLY MET A YOUNG MAN RECENTLY WHO IS BLIND NOW BECAUSE OF DIABETES SO THAT IS A GRAVE CONCERN BECAUSE WE HAVE ALWAYS KNOWN DIABETES CAN GO INTO BLINDNESS, AFFECTS YOUR EYES. BUT NOW IS GLAUCOMA HAND IN HAND WITH DIABETES? CAN YOU GET GLAUCOMA FROM DIABETES? >> WELL ACTUALLY IT TURNS OUT THAT A VARIETY OF OTHER OPTHALMALOGICAL PROBLEMS ARE MORE COMMON IF DIABETES, CAT RACS DEVELOP EARLIER AND MORE AGGRESSIVE AND SOMEWHAT INCREASED LIKELIHOOD OF DEVELOPING GLAUCOMA IF YOU HAVE DIABETES. THE MAIN DIABETES SPECIFIC PROBLEM IS IN THE RETINA. BUT OTHER OPTHALMALOGICAL PROBLEMS BECOME MORE LIKE IF YOU HAVE DIABETES. >> I HAVE HAD SURGERY FOR PANCREATIC CYSTS. WILL THAT MAKE ME MORE LIABLE TO DEVELOP TYPE 2 DIABETES? >> TYPICALLY, IF YOU STILL HAVE THE NORMAL AMOUNT OF THE TISSUE OF THE PANCREAS, YOU'RE PROBABLY NOT MORE LIKELY. AS I CAN SEE YOUR WEIGHT IS NORMAL. SO IT'S PROBABLY, GOOD THING TO BE CAUTIOUS AND HAVE YOUR BLOOD SUGAR CHECKED ON A REGULAR BASIS BUT IF THE TISSUE WASN'T EFFECTED THE THE ONLY QUESTION IS WHY DID YOU HAVE THEM, SO I CAN'T ANSWER THAT QUESTION OF COURSE. >> DR. MERINDINO, CAN YOU TELL US WHAT PARAMETERS YOU USE IN MAKING A DECISION WHEN SOMEONE USES A PUMP? VERSUS INJECTION? THANK YOU. >> THAT'S A LITTLE BIT OF A SPECIALIZED QUESTION SO I'LL START BY EXPLAINING WHAT YOU MEAN BY A PUMP. INSULIN PUMP IS A DEVICE THAT DELIVERS INSULIN CONTINUOUSLY UNDER THE SKIN RATHER THAN TAKING INJECTIONS THROUGH THE COURSE OF THE DAY. IT'S USUALLY USED IN SOMEBODY WHO HAS TYPE 1 DIABETES WHO DOES NOT MAKE ANY INSULIN AT ALL BECAUSE THE AVERAGE PERSON WITH TYPE 2 DIABETES DOESN'T NEED TO REPLACE THEIR INSULIN IN QUITE AS COMPLEX A MANNER. IT'S A LITTLE BIT OF A SPECIALIZED QUESTION IN SOMETHING THAT IS A HIGHLY INDIVIDUALIZED QUESTION OF COURSE. BUT I WILL SAY BASICALLY THIS. A NUMBER OF STUDIES HAVE ADDRESSED THIS QUESTION, I FACE THIS QUESTION IN MY OWN PRACTICE FREQUENTLY. BY AND LARGE PEOPLE CAN ACHIEVE ROUGHLY THE SAME DEGREE OF GLUCOSE CONTROL IF THEY'RE USING MULTIPLE INJECTIONS AS THEY CAN IF THEY'RE USING PUMP. I THINK THE KEY THING REALLY IS ADEQUATE FREQUENCY OF TESTING. I'M OF THE OPINION THAT PROBABLY THE KEY TECHNOLOGY TO EMPLOY ISN'T NECESSARILY IMMEDIATELY TO GO PUMP BUT A CONTINUOUS GLUCOSE MONITOR IS THE MOST VALUABLE THING. THE ONE -- THERE ARE -- IF YOU COMPARE PUMP TO SHOT, PARDON ME, THE KINDS OF PROBLEMS PEOPLE RUN INTO ARE A LITTLE BY DIFFERENT. PEOPLE WHO TAKE SHOTS ARE MORE PRONE TO HAVE LOW BLOOD SUGAR REACTIONS BECAUSE ONCE THE INSULIN IS IN IT'S IN. PEOPLE ON PUMP ARE A LITTLE BIT MORE LIKELY TO HAVE KILO ACIDOSIS BECAUSE IF THE PUMP CLOGS P YOU MAY NOT KNOW FOR A NUMBER OF HOURS. THE ONE SPECIFIC SITUATION IN WHICH IT'S MUCH MORE VALUABLE TO HAVE PUMP THAN SHOTS IF YOUR BACK GRUN OR BASELINE INSULIN PRODUCTION NEEDS TO BE DIFFERENT AT DIFFERENT TIMES OF THE DAY BECAUSE THAT'S QUITE DIFFICULT TO ACHIEVE WITH INJECTIONS WHEREAS YOU CAN PROGRAM THE PUMP TO DO THAT. OTHERWISE IT'S MOSTLY A LIFESTYLE DECISION. YOU'RE A PEDIATRICIAN SO YOU PROBABLY HAVE STRONG FEELINGS ABOUT THIS. >> I DO HAVE SPHRONG FEELINGS ABOUT IT. WE IN FACT PROMOTE INLYNN PUMPS, NOW WE'RE TALKING ABOUT CHILDREN WITH TYPE 1 DIABETES AS EARLY AS CAN BE WHICH IS SOON AFTER DIAGNOSIS. WHAT YOU JUST MENTION SECOND DEGREE YOU CAN IMAGINE IF YOU HAVE A 3-YEAR-OLD WHO SAYS I'M NOT GOING TO EAT THIS, COULD BE A SIX-YEAR-OLD I'M NOT GOING TO EAT THIS, COULD BE A 13-YEAR-OLD WHO SAYS MOM, FORGET IT. AND THIS KID HAD INJECTED INSULIN BEFOREHAND AND WOULD THEN BE PRONE TO HYPO-- TO A LOW BLOOD SUGAR. IF YOU HAVE A PUMP YOU JUST GIVE AT THE TIME OF THE MEAL AND KID IS EATING YOU CAN GIVE INSULIN. ESPECIALLY AT THE CHILDREN, UNPREDICTABLE LIFESTYLE, PUMPS ARE FANTASTIC. THIS IS A LITTLE BIT OF A DIFFERENT TOPIC BECAUSE WE TYPICALLY DON'T USE PUMPS FOR PATIENTS WITH TYPE 2 DIABETES. >> I WOULD LIKE NEW TREATMENT (INAUDIBLE) ESPECIALLY THOSE WHO HAVE A STRONG FAMILIES. IS THERE ANY GENETIC THERAPY OR STEM CELLS REFER TO SOMETHING LIKE THAT? THAT YOU CAN PREVENT IN THE FIRST PLACE, THANK YOU. >> YOU BRING UP SOMETHING VERY IMPORTANT, THAT IS FROM THE QUESTION I HEAR IS THERE ARE CERTAIN PEOPLE AND A CERTAIN ETHNICITIES FOR EXAMPLE, SOUTH ASIA, WHERE TYPE 2 OCCURS IN PEOPLE WHO CONOT FALL INTO THESE CATEGORIES WE MENTIONED BEFORE WITH SIGNIFICANT OVERWEIGHT OR OBESITY. YOU SAY FOR THESE PEOPLE WEIGHT MANAGEMENT IS NOT A BIG DEAL BECAUSE THERE'S NOT THAT MUCH OVERWEIGHT. SO WHAT OTHER THERAPIES ARE THERE, FOR EXAMPLE, CAN CAN WE MAKE NEW BETA CELLS THAT PRODUCE INSULIN? THERE'S A LOT OF RESEARCH GOING ON BUT IT IS VERY DIFFICULT. THERE'S NO QUESTION ABOUT IT. THERE ARE ATTEMPTS OF MAKING CELLS IN YOUR BODY, FOR EXAMPLE, LIVER CELLS TO TURN THEM INTO INSULIN PRODUCING CELLS. THERE ARE AS YOU MENTIONED, ATTEMPTS TO USE STEM CELLS AND TURN THEM AND MAKE THEM DEVELOP INTO INSULIN PRODUCING CELLS. SO THESE THINGS ARE UNDERWAY. THERE ARE ALSO SOME ATTEMPTS TO USE ANIMAL CELLS AND PUT THEM INTO HUMANS AND THEN LET THEM MAKE INSULIN. BUT I -- JUST SAY WE'RE NOT THERE YET. BUT YET. THIS IS DEFINITELY AN AREA, HOT TOPIC IN RESEARCH OF DIABETES. BOTH FOR TYPE 1 AND TYPE 2 DIABETES. >> DR. MAIRN DI KNOW, DR. ROTHER, EXCELLENT PRESENTATIONS. THANK YOU. >> I WANTED TO ASK YOU A QUESTION MORE FROM A PROVIDER SIDE OF THINGS. DR. MERINDINO, FOR YOUR PATIENTS THAT ARE DIABETICS OR PRE-DIABETICS, LET'S MAKE THAT DIABETICS, HOW OFTEN DO YOU RECOMMEND THEY GO SEE AN OPHTHALMOLOGIST FOR CHECK UP? AND THEN IS THERE ANY RECOMMENDATION WHETHER CARDIAC CATH OR A STRESS TEST YOU RECOMMEND TO KEEP CHECK ON THEIR CARDIAC STATUS? >> I THINK THAT THOSE ARE BREAD AND BUTTER QUESTIONS FOR ANYBODY WHO IS DOING ROUTINE CARE OF PEOPLE WITH DIABETES. OUR BASIC ANSWER ABOUT OPTHALMALOGICAL CARE IS ONCE A YEAR SCREENING FROM AN OPHTHALMOLOGIST AND YOU NEEDN'T SEE -- THOUGH THE LION'S SHARE OF SERIOUS PROBLEMS HAPPEN IN THE RETINA, YOU START OFF BY SEEING YOUR GENERAL OPHTHALMOLOGIST. IF THE GENERAL OPHTHALMOLOGIST SEES SOMETHING'S OF CONCERN HE OR SHE WILL REFER YOU TO A RETINA SPECIALIST. FROM THERE IF YOU HAVE GOT A PROBLEM YOUR FOLLOW-UP WILL BE DICTATED MORE FREQUENT AS NECESSARY. THE SECOND PART OF THIS WAS WHAT ABOUT SPECIALIZED TESTS FOR CARDIAC PROBLEMS? THAT'S A VERY, VERY IMPORTANT QUESTION BECAUSE NOT ONLY ARE PEOPLE WITH DIABETES SUBSTANTIALLY MORE LIKELY TO HAVE CARDIAC PROBLEMS BUT THERE'S SITUATIONS WHICH MANIFESTATIONS OF THE CARDIAC PROBLEM ARE A LITTLE UNUSUAL OR PERHAPS DIFFICULT TO IDENTIFY. SO WE DIDN'T REALLY TALK ABOUT IT IN DETAIL AS A COMPLICATION BUT ONE THING YOU OFTEN SEE IS NERVE DAMAGE OR NEUROPATHY. THAT MAY CAUSE A LOSS OF SENSATION. SOMETIMES LOSS OF SENSATION FROM INTERNAL NERVES AND THE LIKELIHOOD OF SOMEBODY HAVING A HEART TAI TACK AND NOT -- HEART ATTACK AND NOT PERCEIVING CHEST PAIN IF THEY HAVE DIABETES IS GREAT. SO FROM THE STANDPOINT OF PROVIDER I THINK REALLY THE GUIDANCE THERE IS ALWAYS KEEP IN YOUR MINE THE FACT PEOPLE WITH DIABETES ARE MUCH INCREASED RISK OF HEART DISEASE P AND TAKE HEED AND RECOGNIZE THEY COULD BE CARDIAC AND THE NEED TO EVALUATE FROM A CARDIAC STANDPOINT IS MUCH GREATER IN SOMEBODY WHO HAS DIABETES. >> FOR DR. ROTHER JUST ONE QUICK QUESTION. FOR SOMEBODY THAT DOES NOT FIT THE PROFILE FOR A BANDING OR ANYTHING, ARE THERE STUDIES ABOUT HYPOSUCTION, THE FAT REMOVAL, DOES THAT HELP? >> THAT'S A VERY GOOD QUESTION. THIS WAS A PROMISING FIELD, I PERSONALLY TALKED ABOUT THIS WITH A SURGEON ALSO A SURGEON IN THE FIELD VERY LONG TIME IN NASHVILLE VANDERBILT AND THE SURGEONS HAD HIGH HOPES THAT LIPO SUCTION WOULD HELP. SO IT WAS REALLY STUDIED, CHECK SUGARS BEFORE, DO LIPO SUCTION, CHECK SUGARS AFTER. DOESN'T HELP AT ALL. SO IT'S VERY DISAPPOINTING. LIPO SUCTION TAKE ACE WAY MOSTLY THE FAT THAT IS DIRECTLY UNDER THE SKIN IN THE BELLY AREA. IT'S THE FAT THAT IS INSIDE THE BELLY THAT IS REALLY THE FAT THAT BOTHERS THE LIVER AND BOTHERS THE BLOOD SUGAR, METABOLISM, IT'S NOT WHAT WE HAVE UNDER THE SKIN. IN FACT, THE FAT UNDER THE SKIN ESPECIALLY IN WOMEN, NOT SO BAD TO HAVE SOME FAT ON THE HIPS THIS IS GOOD FAT. IT'S WHAT WE HAVE INSIDE THE BELLY. THEREFORE UNFORTUNATELY BECAUSE THAT WOULD BE GREAT IF WE COULD DO A LITTLE LIPO SUCTION AND IMPROVE, BUT VERY GOOD QUESTION, IT WAS TESTED AND THE ANSWER IS PRETTY MUCH NO. >> MORE QUESTIONS? >> THANK YOU SO MUCH FOR YOUR PRESENTATION. WONDERFUL INFORMATION. I HAVE A QUESTION REGARDING INSURANCE COMPANIES AND ACCEPTING THE SURGERIES. IT'S VERY HARD YOU HAVE TO GO THROUGH QUITE A BIT IN ORDER TO QUALIFY FOR SURGERY. EVEN IF YOU DO QUALIFY AND YOU MEET THE BMI YOU'RE STILL HAVE TO GO WITH DIET AND EXERCISE FOR SIX MONTHS TO A YEAR BEFORE THEY EVEN THINK OF APPROVING YOU. ISN'T THAT -- DO YOU THINK THAT WILL IMPROVE WITH TIME AND NEW STUDIES? >> THAT'S ALSO A GREAT QUESTION. I DO THINK JUST LIKE I MENTIONED BEFORE, WE'RE MOVING TO NEW SURGERY TYPES, DIFFERENT TECHNIQUES, LESS INVASIVE, THE SAME THING IS TRUE FOR JUMPING THROUGH THE HOOPS IN ORDER TO GET BARIATRIC SURGERY. IN FACT, ONLY 1% OF PEOPLE WHO QUALIFY FOR BARIATRIC SURGERY GET BARIATRIC SURGERY IN THIS COUNTRY. AND STILL IF YOU THINK IT'S THE -- FASTEST GROWING TYPE OF SURGERY THAT IS BEING CONDUCTED, WE HAVE TO -- WE GUESS THIS YEAR UP TO 400,000 PROCEDURES. SO IT'S AN ENORMOUS AM OF SURGERY BEING DONE. SO THE POINT IS EARLIER SURGEONS INSISTED THAT YOU ALSO NEED TO GO ON A VERY STRICT 800-KILO CALORIE DIET BEFORE YOU UNDERGO SURGERY. RIGHT? THIS IS THE PAST, MOST SURGEONS DON'T REQUIRE THAT ANY MORE. SO THIS IS REALLY A MOVING TARGET AND I'M SURE WHEN PEOPLE ARE MORE CERTAIN ABOUT WHAT THEY'RE DOING THEY MAKE IT LESS DIFFICULT TO GET THERE. >> LAST QUESTION. >> EITHER ONE OF YOU CAN ANSWER THIS OR BPO. WHAT'S YOUR OPINION, I HEARD FROM DIFFERENT PUBLICATIONS, DIFFERENT DOCTORS ARTIFICIAL SWEETENERS AND THE AFFECT OF BLOOD SUGAR. I DRINK A DIET SODA EVERY DAY. I DON'T KNOW WHETHER ANY ONE PARTICULAR SWEETENER OR BETTER, NOT AS GOOD OR AVOID THEM ALL TOGETHER, IF IT'S STILL INCREASES BLOOD SUGARS OR WEIGHT. >> SO THE QUESTION WAS HOW ABOUT ARTIFICIAL SWEETENERS OR DIFFERENT TYPES OF SWEETENERS. HOW WILL THEY AFFECT YOUR METABOLISM. WE HAVE TO MAKE SURE AND TELL EVEN THIS IS NOT QUESTION THAT I ASKED YOU TO ASK ME. IT'S ONE OF MY FAVORITE TOPICS. AND WE'RE ALSO DOING RESEARCH ON THAT TOPIC BECAUSE THERE IS NO EVIDENCE IN ANIMALS THAT MAYBE THESE ARTIFICIAL SWEETENERS THAT HAVE NO CALORIES, DOESN'T MATTER H IT IS, SWEET AND LOW, SPLEN DA, IT DOESN'T MATTER AT ALL, THEY MAY NOT BE ENTIRELY INERT SUBSTANCES. BUT IN WHICH DIRECTION THEY GO, WHETHER GOOD OR BAD, THAT'S SOMETHING THAT'S COMPLETELY OPEN. SO WE'RE DOING RESEARCH ON PEOPLE WITH DIABETES WHO TAKE THESE SWEETNERS AND WE LOOK AT IT BUT WE DON'T HAVE AN ANSWER YET. THE POINT THOUGH? GENERAL. IF WE WERE ABLE TO EAT NATURAL FOOD AND JUST APPLES AND ALL THIS, WE'D BE BEST OFF AVOIDING PROBABLY SOME OF THE ARTIFICIAL INGREDIENTS. CAN WE DO THIS? NO, LIFE IS AS IT IS. IS IT BETTER TO EAT REAL SUGAR OR A SWEETENER? PROBABLY FOR THE BLOOD SUGAR AND THE MEASUREMENT DIRECTLY AFTER YOU EAT IT'S BETTER TO USE AN ARTIFICIAL SWEETENER. IS THERE A GREAT THING LONG RUN? THAT'S WHY WE DO THE RESEARCH WE DONE KNOW YET. BUT AMONG THE ARTIFICIAL SWEETENERS WHEN THEY ARE ZERO CALORIE ARTIFICIAL SWEETENERS, THERE'S PROBABLY NO DIFFERENCE. NOW, THE INTERESTING FACT IS WE HAVE JUST LOOKED AT DATA IN THE UNITED STATES B FOOD AND DRINK THE MOST RAPIDLY RISING IS NOT THE DIET SODA PER SE. MANY PEOPLE ESPECIALLY WELL EDUCATED PEOPLE SAY I SHOULDN'T HAVE MORE THAN FIVE SO DAYS -- SODAS A DAY, RIGHT? DIET OR REGULAR, DOESN'T MATTER. BUT IN FACT WHAT IS ON THE RISE ARE THE FOODS THAT HAVE SUGAR AND ARTIFICIAL SWEETENER. SO IT'S THE SO-CALLED NATURAL FRUITS DRINKS AND SO ON AND IN ORDER TO MAKE THEM TASTE GOOD THERE'S NO ADDED SUGAR, THERE'S NATURAL SUGAR IN THERE THEN THERE'S SWEETENER ADDED. SO YOU NOW EXPOSED TO TONS OF ARTIFICIAL SWEETENERS AND YOU DON'T KNOW ABOUT IT. LOOK IN ANY ICE CREAMS AND ANYTHING THAT'S SMOOTH AND SWEET, IN CECH UP, DOESN'T MATTER, LOOK AND READ THE LABEL AND YOU WILL PROBABLY FIND IT. SO WE ARE EXPOSED TO ARTIFICIAL SWEETENERS IN A LOT OF PLACES WHERE WE DON'T EVEN KNOW. AND WHAT THEY EXACTLY DO TO US WE DON'T KNOW. I WOULDN'T EVER SAY THEY'RE BAD. >> OKAY. GREAT. IF EVERYBODY COULD JOIN ME IN THANKING DR. ROTHER AND DR. MERINDINO AGAIN. [APPLAUSE]