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Israel Hartman Transcript

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Steve Freed: This is Steve Freed with Diabetes in Control and we’re here at the American Association of Clinical Endocrinologists 2016. And with us we have a special guest: Dr. Hartman. Dr. Hartman, I’d like to start off with maybe you telling us a little about yourself, your practice, maybe even where you went to school?

Dr. Hartman: Well, I’m an endocrinologist coming from Texas. I’m an Assistant Professor of Medicine at the University of Texas Southwest Medical School. I also have my private practice in Arlington, Texas which is right next to Dallas. I did my residency training at Indiana University and my Fellowship in Endocrinology at UT-Southwestern in Dallas.

Steve Freed: Maybe you can start off with tell us what are you doing here?

Dr. Hartman: I have been a member of AACE for many, many years. I believe that AACE brings value to the clinician, the practicing endocrinologist. I’m giving a presentation tomorrow for the Allied Health Professionals and we’re going to discuss practical points in the approach of the patient with diabetes, hyperlipidemia and obesity.

Steve Freed: That’s big.

Dr. Hartman: I know, it’s an impossible task. I have 30 minutes to tell you everything you need to know about it. But I think that it’s important. I condense one of the most important key points. We’re going to conduct it in the format of clinical cases in order to make this huge amount of information more palatable. Of course, you’re not going to learn everything you need to learn in that short period of time. But at least it’s going to give you an introduction and it’s going to stimulate these Allied Health Professional’s minds to go and read some more about it. I’m also going to leave an open line for them to contact me if they have any further questions or any concerns.

Steve Freed: So maybe you can go over some of the high points that you want medical professionals, not just endocrinologists, to walk away with from your presentation, if it were pharmacists, nurses, dietitians, family practitioners. What do you want them to walk away with?

Dr. Hartman: Well, when it comes to obesity management, it’s very important for them to understand that obesity is a clinical condition, it’s a disease. As an organization, we’re a little bit late in describing it as a clinical condition. I have been saying this for many, many years. The problem with the approach to managing the patient with obesity has been that in the eyes of some physicians it’s not a true clinical condition. It’s a willpower problem. They tend to stigmatize the patient, they tend to blame the patient. If somebody walks into your office with diabetes and asthma, you don’t blame the patient for having that. Obesity has a genetic component, it has an environmental component.  We’re just beginning to understand the importance of managing obesity. It’s very important for us to convey that message to the primary care physician and the nurse practitioner community because it needs to be treated as such. It’s a chronic condition. Same as diabetes, same as hypertension or any other chronic condition that we treat. When it comes to diabetes management, the most important message is that diabetes is a progressive illness. We need to make an early diagnosis and institute early aggressive treatments in order to prevent complications from happening. When it comes to hyperlipidemia, I’m going to just very briefly mention the current AACE guidelines when it comes to the management of a patient with hyperlipidemia. There has been a lot of confusion in this regard and the importance of early management and aggressive management early on.

Steve Freed: You mentioned hyperlipidemia, my question would be, for somebody with Type 2 diabetes that may have some risk factors for cardiovascular disease, how low is too low for LDL?

Dr. Hartman: That is a very good question and I’m glad you’re asking that question, because not until recently have physicians changed the guidelines to include LDL goals. We at AACE, we have been of the opinion that goals are very important. We differ in this regard with other organizations where they just promote the treatment without goal specific achievement. In my view, if the evidence based medicine points out to the fact that if you’re at high risk the LDL needs to be below 70, if you’re at medium risk, the LDL needs to be below 100. That’s where I try to get my patients towards. I have also a very specific triglyceride goal. I think it’s very important to treat triglycerides, especially hypertriglyceridemia in a patient with Type 2 diabetes. I try to aim for a triglyceride level of less than 150.

Steve Freed: What about raising HDL? Is that just as important?

Dr. Hartman: It is important. Raising HDL is a little bit more difficult than lowering LDL. In most instances the pharmacotherapy that we institute will raise HDL to some degree. The goal is a little bit more difficult to achieve because we don’t have a good understanding of how to do so in a safe manner. Ideally, the LDL goal ought to be over 50, but again the tools we have to achieve that are very limited. Of course, the cessation of smoking, exercise, and weight loss are essential to achieve that goal.

Steve Freed: One of the other questions I have confuses me to this day. Two completely separate but related organizations: one is the American Diabetes Association and certainly the Endocrinology Association. They both have different criteria. The ADA says that an A1C should be 7 or below. AACE says 6.5. Why can’t we agree on one number? I know it’s all related to studies but the studies are available to both organizations.

Dr. Hartman: The reason for the confusion is that when we deal with the A1C goals in the patient with Type 2 diabetes, we’re dealing with a very heterogeneous group of patients. I’m in agreement and disagreement with those schools of thought. I’m in agreement that we need to get the patient as close to normal as possible with the minimum amount of complications. In order to do so we need to realize that we need to individualize the treatment and individualize the goal. Not every patient ought to be at 6.5, in the same token, not every patient ought to be at 7%. So when you set those goals it needs to come with a caveat that these are not written in stone and we need to determine the pros and cons of achieving that goal for each specific patient. Let me give you an example, if you have comorbid conditions such as unstable angina, recent stroke, severe renal insufficiency, your goals are going to be totally different than if you’re otherwise complication-free, because achieving those goals can lead to more complications than what you’re going to prevent in the long term. Recently, every time I give a presentation like this, I like to bring real life cases. I recently saw a patient whose family read on the internet that the A1C goal ought to be 6.5% or less, the patient was brought over to me. He was a nursing home patient, 92 years old, stroke dementia, severe cardiovascular disease, I had to explain to the family: listen, your father is going to do just as well if not better if we increase that goal a little bit, actually a lot. That’s the problem with trying to put everybody, this heterogeneous group of patients, into just one number, one rigid number. On the other hand, if I have a patient regardless of age, who is otherwise healthy, I’m going to try to get him as close to normal as possible, as long as I’m not causing complications. And if you think about it, you mentioned the ADA, you mentioned other organizations, not so long ago the goals were 8 to 9% for the A1C. So why is it that we have these lower goals today? Well number one, we have the clinical evidence that if we get the patient down to these numbers we can potentially prevent complications from happening. We also have the tools to do so with minimal complications, the main one being hypoglycemia. When I started practicing in endocrinology, if you would have told me that the goal was 6%-6.5%, I would have told you that that is impossible. All we had was sulfonylureas and pork insulin. Nowadays we can do so, because we have the tools to do it and do it safely.

Steve Freed: So, you mentioned the word normal three times. A person comes in just for a physical, they’re 25 years of age, they’re in perfect health, they’re not overweight, cholesterol’s great, their blood pressure’s great, they are just there for a physical. What would you like to see their A1C result be?

Dr. Hartman: I would like to see it 5.5 or less. We know if you look at the data from the A1C, patients with elevated risk factors and an A1C over 5.8, a lot of them already had diabetes, if not prediabetes. 5.5 or less will be considered normal. Again, we need to individualize every single case. It’s very, very difficult to get someone to 5.5, but at least less than 6, less than 5.8 will be my goal, if I can get them there with no complications.

Steve Freed: Individualization is really the key factor, especially from AACE and even from the ADA, there’s no specific number for every single person. Everybody’s different. It’s kind of like a puzzle, a patient walks in and you got 50 pieces and you have to put it all together. That’s what makes diabetes a little bit more difficult because there used to be, like you said, one or two options, but now, I think there’s 11 possible combinations. Now you have to decide trial-and-error. Obviously it’s very important now. So how often will you change? Usually I think for most visitors a patient comes in every 3 months if you’re on new medications and changing. So what’s the time frame before you feel comfortable in saying “You know what? We need to make a change.”?

Dr. Hartman: It depends. We need to recognize what the A1C is telling us and the limitations of the A1C. The reason why we ask the patient to come every three months, if you know how the A1C is obtained, the hemoglobin is passed through a resin, this resin extracts the glycation of that hemoglobin, and it’s expressed as a percentage. The half-life of a red blood cell is 3 to 4 months, so we say that the A1C is giving us a mean for the past three months. It doesn’t work exactly like that and we know that not all A1Cs are the same and the lower the A1C the more postprandial component that it has. If the patient has an urgency to lower the blood sugars, such as a patient who is pregnant for example, a patient who’s going for surgery, I’m not going to wait three months to ask the patient to come back, I’m going to ask the patient to self-monitor the blood sugars and I’m going to see that patient every week, every two weeks, every three weeks as necessary. If on the other hand, we have time such as in the majority of the patients with Type 2 diabetes, perhaps I’m going to wait those three months, see what the A1C is and then make adjustments. So again we are dealing with a very heterogeneous group of patients. We tend to generalize and say diabetes as if everybody was the same. Not even all the A1Cs are the same. Let me give you an example, a clinical example. I saw a patient for the first time at my clinic, A1C of 8.3 the patient is a truck driver, he’s morbidly obese, he doesn’t exercise at all and he eats very poorly. Another patient, A1C presentation 8.3. She was a nurse at the hospital, she exercises every day, she eats very healthy, and she takes supplements and tries to eat very healthy. Same A1C, same number, you want to tell me that the approach is the same on both cases? Absolutely not! This is the danger of just looking at the number and not looking at the patient. In the case of the truck driver, a little bit of diet advice, a little bit of increase of activity level, it’s going to lower that A1C significantly. In the case of the nurse, she needs a very aggressive approach from the beginning, because how much more exercise is she going to do? How much more dieting? She’s already doing that. So we need to individualize, we need to look at the clinical presentation. We need to quit calling the patient with diabetes as if everybody had the same condition, because they don’t. We have a very heterogeneous group of patients that we are dealing with.

Steve Freed: One of the other things that’s changed recently, that’s made the headlines in all the journals and everything is that the criteria for bariatric surgery has been lowered. You kind of get the feeling that if you have Type 2 diabetes and you’re obese, you go for the surgery. What is your feelings on that?

Dr. Hartman: The surgery is yet another tool that we have at our disposal to treat patients, but by no means is it personal therapy for everybody. We have a lot of recurrence on the obesity after the surgery and that’s something that needs to be investigated further and over the years, we’ll find out that unfortunately, since we have different types of obesity, some of these types they don’t respond as well to the surgery as others. By limiting, by anatomically limiting, the amount of food you can eat, you are not treating the core of the problem in a lot of the cases. It works really well for a lot of patients, it doesn’t work for all the patients. For the patients that it works really well, sometimes it’s not a long lasting solution. So we need more research in the field of obesity to see how we can treat the core of the problem and not just to try to fix it with an anatomical modification of the gastrointestinal tract.

Steve Freed: If you go back I think maybe 30 years ago, if you were treating obesity, you had all these diet pills available, and then we found that there were all these side effects. The government, the FDA pulled them from the marketplace. Then we had nothing for maybe 15 to 20 years and now all of the sudden, there’s a number of options, I think at least three, you can call diet pills. They haven’t found all the side effects yet, it’s obvious time tells the difference. As far as treating obesity, do these come into your practice? I know people probably ask for them, give me a pill. What are your feelings with the dangers, the possible dangers? Is this something you use on a regular basis with your patients? My personal feeling is, I haven’t seen that great of results. If you want to lose 40 pounds they’re not going to help you. If you want to lose 5 to 10 pounds, they may be able to help you. What are your feelings in your practice?

Dr. Hartman: You mention a very interesting point and that is that for the longest time we didn’t have any advances in obesity management. That is due to the fact that we didn’t recognize obesity as a true illness, as a true chronic condition.  Now we do. You also mentioned a very interesting point and that is that we have three or four agents that are approved for long term management of a patient with obesity. How many diabetic agents do we have? How many antihypertensive agents do we have? In the third part of your question that makes it very interesting is that when we talk about obesity we make the same mistake, if not worse, than when we talk about diabetes. There are so many different types of obesity out there that the key to success on all these pharmacological interventions in the future will be to identify who responds to what. Let me give you an example. If you go to the hospital and you take all the patients who have a fever in the hospital and you give them penicillin.  All of them. You’re going to find out that only a small percentage of them will respond to the penicillin. Does that mean that the penicillin didn’t work? Now, it means that you need to identify the patients who have fever that are responders to penicillin, those are the penicillin-sensitive bacteria. The other ones have resistance, or they have a virus, or they have cancer, or they have connective tissue. There are many factors that cause fever. So does penicillin work? It works for a patient that needs penicillin. So with obesity, we’re making the same mistake. We’re giving this drug or that drug to all the patients with obesity, but not all the patients with obesity are the same. Not all the pathophysiology of these patients is the same. So the future, for the success of this type of patient, will be to identify which drug works for which patient and give it just to that patient. That’s going to be when we’re going to see real results in the management of obesity.

Steve Freed: How far away is that?

Dr. Hartman: We’re in diapers. We just recognized that obesity is a disease. We’re 10 to 20 years from identifying all the different types and tailoring the treatment for that specific type. There are types of obesity that behave exactly like an addiction. We have a drug that treats that. We have other drugs that treat other forms of obesity. We have biochemical markers in the brain that stimulate the satiety center. We have a drug that does that. We don’t have the tools to identify which patient is going to respond to which drug and that’s what we need in the future. Not to mention that we need more research and we need more drugs.

Steve Freed: Well I don’t want to take much more of your time and I want to thank you for your time, I know you have a busy schedule. I wish you the best of luck in your presentation. It’s certainly very interesting and the people that get our newsletter will enjoy our conversation.