Expanded Coverage of Weight Loss Drugs? Diabetes Advocates Say Yes

Mark Masselli (00:04)
Historians say diabetes was one of the first diseases ever described, going back to ancient Egyptian times since
then, why haven't we been able to make progress in preventing diabetes? Now it's an epidemic with over 38
million American children and adults diagnosed with diabetes.

Dr. Robert Gabbay (00:22)
It, it really is important that we, try to get upstream of diseases. we know that obesity is a disease, but it's a, it's a
big driver to the increasing numbers of people developing diabetes. and, and it's important that people have
access to treatments that are effective. And at least at this point, Medicare is not covering those treatments. And
that's something we've been advocating for.

Margaret Flinter (00:48)
Dr. Robert Gabbay is the Chief Scientific and Medical Officer for the American Diabetes Association. It aims to
educate, advocate, and support research into these endocrine diseases characterized by sustained high blood
sugar levels.

Dr. Gabbay (01:02)
We started with, really a call for health equity now, and as part of that, a, bill of rights that, really speak to
everybody having access, to, the things to help them live healthy with their diabetes, whether that is
medications, technology, screening tests, and, and healthy food.

Margaret (01:25)
This is Conversations on Healthcare.

Mark (01:36)
Well, Dr. Gabbay, welcome to Conversations on Healthcare.

Dr. Gabbay (01:39)
Thank you so much.

Mark (01:41)
Oh, it's great to have you. We have a lot to talk with you about, but I wanted to start off with some facts that I
don't think many Americans know that the cost of diabetes to the US healthcare system is over 400 billion a
year, and that one in seven American adults have type two diabetes now up from one in 20 in the 1970s. I wanna
start off though, with the cost of insulin, there's a Medicare cap on the cost of insulin, and 25 states in the
Washington DC have cost limits on insulin. But what about the rest of the country? What can and should be
done to make sure that all Americans have equal access to these reduced prices?

Dr. Gabbay (02:22)
Well, you know, Mark, the, the American Diabetes Association has really been engaged over the last several
years in ensuring that all people that, need insulin have access to insulin. And, and, and so that, that battle has
taken us a lot of different places. As you mentioned, we've been successful in many states, and from the
Medicare perspective, but we still need, more work to be done to extend it to all states, and ultimately, for all
payers. And we continue to engage in efforts to ensure people have access to insulin.

Margaret (02:58)
Well, Dr. Gabbay, let's talk about, some of your recent updates. Your association has updates on cardiovascular
health for people living with diabetes, including some new screening recommendations for heart failure. Tell us
about these changes. How are they going to help with the overall wellness of this population?

Dr. Gabbay (03:16)
Yep. Well, you know, one of the things that we know is that people with diabetes are at greater risk for heart
failure, and we now have new treatments that can, prevent any progression of the earliest form of disease. And
so as a result of that, we've made recommendations for those individuals that are at high risk for developing
heart failure. in other words, they might have type two diabetes, high blood pressure, obesity, lipid, cholesterol
issues. those individuals should get screened with a, blood test. it's a relatively simple blood test, BNP. And
based on that, you can tell whether somebody may actually have heart failure and evaluate them further.

Mark (04:02)
You know, there are a lot of new words that get added to the English language each year. I think Ozempic, falls
into that category, new words, and, and it's really, one of the biggest pieces of recent, diabetes news has
obviously been the approval of injectable weight loss drugs such as Ozempic. they're leading to a reduction in
blood sugar levels. I wonder if you could share with our audience what the latest research on these drugs is, and
what's your view on their use?

Dr. Gabbay (04:31)
Well, there really have been a very exciting, new entry into the ways of managing individuals with diabetes and
helping them achieve their goals. And we know that weight is so critical for most people with type two diabetes.
but honestly, even for people with Type one diabetes, about, a quarter of them, live with obesity as well. And
obesity leads to all sorts of, potential complications. Not only worsening, diabetes, but increasing the risk of
heart disease, sleep apnea, a whole series of other, issues. You know, up until recently, the only, medical
treatments that we've had, you know, we've certainly had lifestyle and that continues to be important. And, and
the only medical treatments we've had have maybe resulted in, you know, five, 7% weight loss. And then these
newer medications, come on the market and they, result in any, you know, from like 15% weight loss or higher,
something almost, what we, previously had seen with surgical options. And so they've really been a, an
important tool in helping to manage diabetes.

Mark (05:49)
Is there any shortage of Ozempic and those, that type of drug right now? Maybe you could talk about that, and I
know it's also, you know, off-label being used in different parts of the parts of the world.

Dr. Gabbay (06:01)
Well, you know, we're, we are been monitoring the, the supply chain and the availability of these medications,
because there has been a big demand for them. this seems to be getting better, as time goes on. And, and the
hope is that, anyone who needs and would benefit from these medications would have access to them.

Margaret (06:23)
Well, Dr. Gabbay, you've written, and I think I'm quoting here, that obesity is included in the litany of chronic
diseases that plague six in 10 Americans, except by Medicare, which consistently refuses to cover treatment for
obesity until it causes significant health problems like diabetes or heart disease. I have a feeling you've given a
lot of thought to this issue. So take a moment and fill us in on your perspective, and do you see this changing as
Medicare seems to be committed to continuing to work towards a more preventive oriented agenda?

Dr. Gabbay (06:58)
It, it really is important that we, try to get upstream of diseases. we know that obesity is a disease, but it's a, it's a
big driver to the increasing numbers of people developing diabetes. and, and it's important that people have
access to treatments that are effective. And at least at this point, Medicare is not covering those treatments. And
that's something we've been advocating for.

Margaret (07:25)
And it would seem that we would have the same issue with Medicaid and hopefully at a much younger age,
since Medicaid is the primary public insurance for, children, and certainly the issues of obesity and children are,
are very paramount in our prevention agenda. Anything that you're doing in that area to focus on the, on school
aged children, for instance?

Dr. Gabbay (07:45)
Well, school aged children are, are another group to be considering. there's really an opportunity with them to,
do a, a number of lifestyle interventions that can really be beneficial, and we'd like to see more of that spread
across the country.

Mark (08:01)
Well, I wanna pick up on your theme of access to treatment, and certainly, you understand that. And here, in the
Community Health Center Movement school-based health services, access to care is very important and also for
racial and ethnic groups, but some very troubling, data points that black Americans are 60% more likely to be
diagnosed, with diabetes by their provider than white adults. and blacks with diabetes are three to four times
more likely to have a limb amputated than a white person with the same conditions. And unfortunately, the rate
of amputation seems to be getting worse. I wonder if you could just describe what initiatives are underway to
address these disparities?

Dr. Gabbay (08:44)
It's an incredibly important issue that the American Diabetes Association has really leaned in and over the last
several years. we started with, really a call for health equity now. And as part of that, a, bill of rights that, really
speak to everybody having access, to, the things to help them live healthy with their diabetes, whether that is
medications, technology, screening tests and, and healthy food. And, you know, many of these statistics that you
describe are, are driven in part by the, the zip code people live in and the availability of, care, healthy foods, safe
exercise. And so all of those things have been areas where, we've been working a great deal on, on the, issue of
amputation. I'm glad that you brought that up because most people don't realize that that's one of the few,
complications of diabetes. It's actually getting worse. we've made progress on many others, but not, around
amputation. And so in our standards of care, the global, guidelines for diabetes, we've also, in included
information about early screening for peripheral arterial disease, one of the reasons why people may get
amputations and working, effectively in that area to really, identify people early, to prevent amputations.

Margaret (10:20)
Dr. Gabbay, I have to say, you're just making a great case for people need access to really excellent primary
care. It's screening for the, peripheral arterial disease, for the retinopathy, for the kidney disease, for nutrition
education and counseling. thanks for, for making that so clear. We have just got to do something about those
increasing rates of, amputation, but tied into, all these concerns. And I think it's another, area where we see a
real disparity between people based on, as you say, the zip code, perhaps as a marker, for economics and
education and access to resources. But it's the need for access to the best diabetes technology that we have
today. Certainly. an example of that that many people are familiar with is, continuous glucose monitoring and
being able to maybe do that remotely. With your results, being channeled to your primary care provider, I know
you and others are involved, in this initiative to make it more widespread, where appropriate. How is this
working? Again, particularly from a, racial equity viewpoint?

Dr. Gabbay (11:27)
We've had some success, but we honestly have more to do. one of the, the first steps, you know, in, in coverage
for, technology is really derives out of our standards of care and providing the evidence. And so last year, we
made the, unequivocal statement that, anybody, with diabetes on insulin, whether they're, a child, an adult or an
older adult, should have access, and, and availability of a continuous glucose monitor. As a result of that, we
were successful in getting Medicare coverage, and we were really pleased about that for, those populations and
now have been working state by state with Medicaid. which to your point are, are, is really the, the, the
mechanism that we can address the, inequities in terms of, access to treatment. The other thing I'll, I'll sort of
point out is we've been doing a lot of educational efforts, targeting primary care, in particular to, ensure that
they're comfortable, with the technology, with interpreting the results and be able to guide their, patients to
manage their diabetes effectively.

Mark (12:48)
You know, I wanna pick up on your theme earlier about complications with diabetes. And while Americans
wish that COVID was in our rear view mirror, it is here still with us, and, quite prevalent, but there are serious
complications that can arise if one gets COVID and has diabetes. Maybe talk a little bit about that, also, about
the research that's needed in this area, particularly around the issues around long COVID and the others, sort of
a waterfront of issues to handle there. But I think for most Americans, COVID is still very present somewhere in
their community or within their families.

Dr. Gabbay (13:24)
Yeah, we, we've been fortunate that, that things are better than they were, but, but at its peak, you know, the
COVID pandemic really, devastated the diabetes community as, at one point, as many as 40% of the deaths
were with people, living with diabetes. And so, really, really staggering. you know, individuals with diabetes,
when they develop COVID, tend to do much worse, much more likely to be hospitalized, increased mortality, all
of that. And then the other interesting piece that has been evolving is whether COVID itself may lead to the
development of diabetes, and there have been some studies seeing, an increase in type one diabetes and also in
type two diabetes. So that's an area that needs to be further studied, how the virus itself may be causing diabetes.
And again, as, as you started this program with, the rising numbers of individuals developing diabetes, the last
thing we need is anything fueling that further.

Mark (14:30)
And would you, and not that you're, treating anybody, but is Paxlovid sort of, the drug of choice at that point, if,
somebody with diabetes gets it? And are you looking at any, any of these, maybe talk a little bit about long-

term, COVID and its, its potential treatment, metformin, other things that are, might be being used in treating
this?
Dr. Gabbay (14:58)
Well, Paxlovid certainly is something indicated for people with diabetes developing COVID because they're at
much higher risk for, more dangerous complications of, of, COVID infection. So that, that is very much a
recommendation. long COVID is something that we're still, honestly defining, and in many ways, really trying
to understand how, how common it is. But early studies suggest that people with diabetes are once again, more
likely to develop long COVID, all the more reason, to avoid infection and then treat that infection with
Paxlovid.

Margaret (15:39)
Dr. Gabbay, I wanna pick up my theme again around the importance of the routine screenings, in diabetes care
that we know are so important, often pose, access barriers for many people. And one of them is certainly in the
prevention of blindness. I think, people perhaps in years past thought it was inevitable that there might be loss of
vision in diabetes, but we know that with early detection, we can actually remedy that. And of course, we need
to talk about artificial intelligence and its role, in all of this. So, tell us about the emerging artificial intelligence
technology and the role it might play in eye screenings, which is so important. And can this eye screening take
place in routine primary care?

Dr. Gabbay (16:24)
Very, very important issue. You know, diabetes continues to be a leading cause of blindness, and it is largely
preventable. And, and how do you prevent it? It's, it's really catching it early and how do you catch it early,
yearly eye exam. And despite that, that being very clear, only about 60% of, people living with diabetes get a
yearly eye exam. So we, everything we can do to make that more accessible and more available is really
important. having that done in primary care with retinal cameras, is one way to be able to do that. The
technology is really advanced to be able to take a picture of the eye and be able to diagnose early disease and
then refer somebody to ensure that, they don't lose their sight. and the technology is now advanced with artificial
intelligence to be able to read those retinal images effectively, and be able to tell significant, disease versus, you,
you sort of have it all clear and just come back next year for that eye exam. The FDA has now approved, several
technologies that use AI to interpret those, those retinal photographs. And, and our hope is, and, and our
recommendations and our standards of care were that those are, an effective tool to be able to use, to increase
the number of people that get eye exams done, particularly to your point in primary care, where most people
with diabetes get their care.

Mark (17:57)
Yeah. And we're, we're so excited about that opportunity and, and have been working with people around the
country around that, initiative. you know, the intervention for diabetes is really sort of being re-framed in a
much broader context. And the Federal Commission on Diabetes recently delivered a national report to
Congress on diabetes. And the, it was really the first of its kind in 50 years. And what was interesting that, as I
said, it re-frames the diabetes epidemic as social, economic and environmental problems and not just health
issues. and really the experts suggest improving access to healthy foods and rethinking transportation networks
are part of the answer. I'm wondering how the a DA feels about this larger re-framing and maybe any initiatives
that you have going on that might address some of these areas outside of the four walls of the medical office,
which are very important, come on in for your primary care, but also, where you live, breathe, pray and, and,
enjoy life is also important.

Dr. Gabbay (18:58)
Very much so. And, you know, diabetes, probably more than any other disease is, is so dependent on, what the
individual living with diabetes does in terms of their self-management. And, and, and helping them to do that is,
is really the role of the healthcare system. And at the same time, they're only seeing their healthcare
professional, you know, once every two or three months. So what's happens during all that time in between, it's
all the decisions that they need to make on, on their health. And, and part of that, really falls onto this broader,
area that is often referred to as the social determinants of health. And it turns out that those social determinants,
where you live, poverty, access to healthy foods, safe places to exercise, transportation, to go to your
appointments, all of those things to turn out to be as important as what the healthcare system delivers. And so
there's been interesting work where, healthcare systems have engaged in community interventions and, and with
the American Diabetes Association have been doing that in a number of communities, in Chicago, working to,
in, ensure access to healthy foods for many of these individuals that we've been, partnering with. It's the first
time they're really having access to fresh vegetables, and, and then teaching them what to do with them. 'cause
sadly, this is not something that they've access for. So real, really important issue.

Margaret (20:37)
Dr. Gabbay, I'd like to, give you a chance to maybe shine a spotlight on an annual, research report of the A DA,
that highlighted efforts to improve outcomes, specifically for the deaf community living with diabetes through
some specially designed programs. Tell us about that.

Margaret (20:55)
Well, we, we fund a great deal of research, and have, I think 171 active grants that we are managing right now.
And one of them, is a really exciting one, by an investigator, Michelle Litchman, who, is solving the problem of,
individuals, with hearing loss and how did they learn about diabetes. and, and it turns out there's a huge gap
there. They tend to do far worse with their diabetes than, individuals that have normal hearing. and because of
the communication, because of the understanding, they may or may not, no sign language, there really needs to
be better ways to reach out to them. And, this research project has been developing those tools to help that
community.

Mark (21:50)
Oh, such, such an important issue. You know, you were talking earlier about social determinants of health and
really wanna talk a little bit about the mind body relationship with diabetes. And, people with diabetes are 20%
more likely to experience anxiety than people without diabetes. And, 40% of people with diabetes have said
they have struggled with their psychological well-being since being diagnosed. I'm wondering how the a DA is,
addressing these psychological issues, to go along with the physical ones.

Dr. Gabbay (22:24)
Well, one of the important ways we've been doing that, just from Margaret's last question is, is around
supporting research. each year we target, different areas to make our investments. And one of the big areas, over
the last year has really been about mental health. so those statistics are really concerning. it also turns out that
about a third of people, with, type two diabetes are at risk for depression as well. And we know that individuals
with diabetes that have any of these mental health issues tend to do a lot worse. So thinking through the
interventions that can be done, to help, we've also established a mental health directory to help, healthcare
professionals as well as people living with diabetes find a mental health person, that they can work with to be
able to address their issues.

Margaret (23:19)
Well, Dr. Gabbay, we've, had a chance to talk about, the very important work, that a DA is doing around,
prevention around helping people live better lives with diabetes, about preventing the complications. But I'm,
I'm thinking, you know, this year brought us the, the big news around sickle cell disease, and the hope of a cure,
right, through, CRISPR technology and, and some of the things that we look forward to playing a, a greater role
in the future. Would you like to take a moment to tell us, is there anything on the horizon undergoing research
that looks at a cure for diabetes at this point?

Dr. Gabbay (23:58)
Very exciting period, right now, and you know, the, probably the most promising, and something that's been,
active, research for a number of years is the idea of, being able to replace the cells that are, either destroyed in
type one diabetes or not functioning appropriately in type two diabetes, the insulin producing cells, there is now
the ability to take, a, a blood sample, isolate those blood cells and devolve them into stem cells, and then grow
them into, insulin producing cells, and, then, potentially transplanting them into individuals. And, and, and that's
happened, with some early success. And, and the next level of, sort of, problem to solve is, dealing with the
immune system, that these cells do not, would not get destroyed. And, to your point, one of the, technologies
that's being used is actually CRISPR technology, identifying what it is on those insulin producing cells that
attracts the immune system. and can you alter that, that cell surface so that it won't be recognized as something
to destroy, and allow these cells to, to thrive, continue to produce insulin, and not be, not require people to take
immunosuppressive drugs that have the downsides of, of just broadly suppressing the immune system.

Mark (25:39)
Tell us a little bit about yourself. How did, how did you get to where you are today? Tell us what, you're
passionate about, in this field, and maybe also tell us a little bit about the a DA, how do people interact with it?
Is there a way that people can support and participate in the work that you're doing?

Dr. Gabbay (25:58)
Yeah. Well, thank you for that. so really for me, professionally, I've been in the, diabetes world, my entire
professional career. And I, I started as a basic scientist working in the laboratory trying to understand how
insulin signaled at the cell level. and, finishing my PhD I realized that I wanted to be, have a greater impact in a
more applied and direct way. And so I went to medical school and became an endocrinologist, over time and
treating patients. And, and, and I, I still see patients at my former institution, the Jocelyn Diabetes Center, that I,
I led, before coming to the American Diabetes Association. And, and for me, it's really about how to have an
impact on as many people as possible. And that's the, the wonderful thing that the American Diabetes
Association does. we, we fund research towards a cure towards solutions to help people in the here and now. we
advocate, for people living with diabetes, and we engage the healthcare professionals to guide them on how to
deliver the best possible care and lots of programs from establishing what those benchmarks and clinical
guidelines are, our standards of care to educating and working directly with clinicians, to help them change their
practice to delivery care better. you know, one of the ways that, your audience can engage with the American
Diabetes Association is through our website, diabetes.org, where there's a wealth of information on a lot of what
we've talked about, how to live healthy with diabetes and a, and a and a, the kind of research we're doing and all
of the things that we've been talking about in addition and opportunity, if they want to support this important
mission so we can do even more to help people living with diabetes and those at risk.

Mark (27:59)
Well, Well, speaking of support, and you're, you're down in the, Washington DC area. Congress is still, haven't,
hasn't passed a, a budget. What are the implications, for diabetes research and treatment, and where should
people be looking to focus in on, in addition to the monies that come to the a DA, where is the bolus of dollars,
in the federal budget?

Dr. Gabbay (28:23)
One area that we've been advocating and we continue to, is really around research funding. and that is largely
through the National Institute of Health, that has the, the sort of largest opportunity to fund, diabetes, research,
tends to be more at the basic level, and then there's a Center for Disease Control that has many programs, to,
help people with diabetes and also to prevent the development of diabetes. And so advocate for increased
funding in, to those agencies that can really make a difference.

Margaret (28:58)
Dr. Gabbay, with the American Diabetes Association, thank you for joining us, and thanks to our audience for
being here. Be sure to subscribe to our videos on YouTube, find us on Facebook and X with our account names,
CHC Radio. As always, you can go online to chcradio.com, sign up for our email updates and share your
thoughts and comments about this program. Dr. Gabbay, thank you again for your contributions to health and
healthcare, and thank you for joining us.

Dr. Gabbay (29:24)
Thank you so much for the opportunity to speak with you.

Margaret (29:30)
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