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Advancing Access and Treatment for Obesity, Diabetes, and More

At the 17th annual Diabetes Forum at ADA 2023, the diaTribe Foundation and TCOYD moderated an expert panel that discussed access and equity issues, breakthrough treatments in weight reduction, fatty liver disease, type 1 therapies, and more.

The 17th annual Diabetes Forum at ADA 2023 convened the top minds for a discussion on the latest updates in the field and what’s to come down the road. While the panel touched on a broad range of diabetes-related topics, there was particular focus on new research of weight loss drugs, as well as the importance of equity and access when thinking how to properly distribute these medications.

The panel, co-moderated by diaTribe and Close Concerns founder Kelly Close and Taking Control of Your Diabetes (TCOYD) founder Steve Edelman, MD, included five speakers:

  • John B. Buse, MD, PhD, endocrinologist at University of North Carolina (UNC) Hospitals and director of UNC Diabetes Care Center
  • Juan Pablo Frias, MD, principal investigator at Velocity Clinical Research
  • Jeremy Pettus, MD, endocrinologist and associate professor of medicine at the University of California San Diego
  • Athena Philis-Tsimikas, MD, endocrinologist at Scripps Health in San Diego and vice president of the Scripps Whittier Diabetes Institute at Scripps Health
  • Eugene Wright, MD, consulting associate in the department of medicine at Duke University

Even more powerful weight loss drugs

Many clinical trial results released in the past year have demonstrated the effectiveness of weight-loss medications. In regard to what impressed him the most about ADA’s 2023 Scientific Sessions, Frias noted the greater focus on weight loss and its associated effects “not only on glycemia, but all of the other complications of overweight and obesity” among people with type 1 and type 2 diabetes.

Much of the forum discussion centered around the promise of the new and exciting weight loss drugs like tirzepatide (Mounjaro), semaglutide (Ozempic and Wegovy), CagriSema, and the even more recent drug retatrutide. The SURMOUNT-2 trial, which evaluated tirzepatide for overweight and obesity among people with type 2 diabetes, has shown a greater body weight reduction than the SURPASS trials

“With a drug this potent, lifestyle intervention may not be as important for weight reduction,” Frias said.

CagriSema has led to 15-18% weight reduction in 26 weeks, and semaglutide led to a 16% reduction in body weight after 32 weeks. In addition, according to Frias, 100% of people with fatty liver disease who took retatrutide experienced a 30% reduction in liver fat. These results are especially promising considering there is currently no medication for fatty liver disease.

While these drugs are largely used for people with type 2 diabetes, Pettus and Frias advocated for the use of SGLT-2s and GLP-1s in people with type 1 diabetes. 

“The type 1s are inappropriately left out,” Pettus said. “There’s reasons to treat type 1s with these agents to address insulin sensitivity, weight loss, and cardiovascular disease.”

Improving equity and accessibility of costly medications

The panelists highlighted the need for greater access to these expensive treatments. Without insurance, tirzepatide can cost up to $1,200 per refill and semaglutide can cost up to $915.

Buse shared two strategies for making healthcare work for more people: First, making drugs easier to prescribe and second, creating government programs to help subsidize the cost. “We need payment reform. It’s practically a moral peril that we’re not able to provide these drugs in an equitable way,” Buse said. 

In addition to cost, healthcare provider bias is a significant barrier to effective diabetes treatments. A healthcare provider might not prescribe someone a certain drug because of their race or even if they’re on public insurance as opposed to commercial insurance. As a consequence, people of color and low-income individuals do not receive the same quality care as people who are white and high-income.

“Sometimes people are excluded not because of their access but because of their zip code or what they look like. We have to treat bias like we did patient safety,” Wright said. “I think we have to set up systems that would trap the bias before it reaches the patient.”

Philis-Tsimikas shared a recent roadblock she encountered with federal government officials when training primary care physicians at federally qualified health centers on diabetes care: “We would prescribe CGMs to everyone that truly needed one, and it resulted in an investigation from the government.”

“Insurance was paying for them because they were being appropriately prescribed, but they didn’t understand why there was such a large number,” she said. “They didn’t even know what it was, to tell you the truth.”

Delaying the onset of type 1 diabetes

“For the first time, we have a drug that addresses that underlying condition of type 1 diabetes,” Pettus remarked, referencing the FDA approval of teplizumab late last year.

Teplizumab, the first and only treatment to delay the onset of stage 3 type 1 diabetes, works to interrupt the beta cell (which produces insulin) destruction process that happens in the pancreas for people with type 1.

Teplizumab could potentially help people already diagnosed with type 1 diabetes maintain any insulin production that they have left. The PROTECT trial is currently investigating teplizumab in people with newly diagnosed type 1 diabetes. Pettus said he hopes that by next ADA meeting, the standard of care will recommend everyone diagnosed with type 1 to undergo infusion of teplizumab to preserve further loss of beta cells.

Social determinants of health

Buse discussed the importance of social determinants of health – social and environmental factors that can impact people’s ability to manage their well-being – in delivering quality healthcare for everyone with diabetes. The care that people receive is often determined by factors beyond their control, including their race, income, and even more specific factors like how far they live from the closest grocery store and whether they live in a walkable neighborhood.

“A lot of times when people talk about social determinants of health, people think about zip codes, race, ethnicity, or educational level, but what we’re really talking about is access to food, transportation, and housing,” Buse said. 

“Turns out that many of us are just uncomfortable asking the patient: Do you have problems getting food? Transportation? We should feel comfortable asking that question, but it’s a question that doesn’t get asked often.”

A rebroadcast of the 17th annual Diabetes Forum with live commentary by Drs. Steve Edelman and Jeremy Pettus, will take place on July 26, 2023 at 7:00pm ET / 4:00pm PT.