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Joy: Hello, I’m Joy Pape, Medical Editor for Diabetes in Control, and we are here at the American Diabetes Association 77th scientific session 2017 and I am delighted to be able to speak with Dr. Leigh Perreault from the University of Colorado. I’ve heard you speak before and I know our audience will not be disappointed. I don’t mean to set you up, but what is your specialty?
Dr. Perreault: I specialize in diabetes prevention and the treatment of people with prediabetes.
Joy: I’ve heard you speak more on the subject of obesity. What do you think the causes of obesity are?
Dr. Perreault: The causes of obesity as we know it are either genetic or environmental. It is very clear that people’s adolescent height and weight is genetically set. After that, it’s really a matter of environment. The environment incorporates biological, psychological, and social components. Of the biological components, we usually think of things like, “diet in and energy out.” But what we have learned about diet in and energy out that is extensive and definitely not as simple as we think. Of course, there is psychology around feeding behaviors, hedonistic behaviors, and I think we are all constantly inundated by the social aspects of food. So, it’s really a very complex combination of all those things, that ultimately lead to weight gain in people.
Joy: I’ve also heard you talk about plastics, hormones, medications, things in the water, can you talk more about that?
Dr. Perreault: Absolutely. We talk to people about their dietary intake and we have learned so much. It’s not just about the total number of calories that we put in our bodies, but where those calories come from. Every time we drink a Starbucks, take look at what is floating on top of that! That cup is paper and it would leak if the inside wasn’t covered inside with plastic and so when you drink that you are drinking plastic. Whether it’s plastic or pesticides from foods that we are ingesting, ultimately, we are creating the bugs that live in our gut known as the human microbiome. We are also learning that depending on the type of bugs that live in your gut, some of them can also pull calories out of foods that we thought didn’t have any calories! So, things like lettuce. So by definition fiber is indigestible starches. Imagine if you had a bug in your body that could take calories out of that piece of lettuce and now suddenly you are eating more calories. So ultimately it’s a combination of all these strange things in our diets that aren’t just things that we think of as having calories, but that dictate our microbiome that then decides how many calories are really in our food.
Joy: Sometimes people say, “I didn’t eat anything that was high in carbs or even has carbs and my glucose still went up!”
Dr. Perreault: I hear that all the time, I think most of us think “is that really happening?” But as we are starting do more and more studies that show that certain types of bugs can get more calories out of food, you start wondering if it’s true. There are research centers around the country that are doing proven concept studies where they actually are doing fecal transplants…can you even imagine? Who would sign up for such a study. But it’s amazing! You can have someone put an NGT down their nose and into their stomach and give them the feces of a lean person and it can actually reverse diabetes, treat obesity. It’s very clear that the bugs that live in our guts can give us disease, and if we get rid of these bugs or replace them we can fix the diseases.
Joy: What do you teach your patients when it comes to some of these environmental things, and tips that you give them and teach us and teach our patients, that people can really do and live with?
Dr. Perreault: The first thing is eat real food. Oh my goodness, I think all of us go to the grocery store and when you look at the ingredients on it you think, “wow…all these funny chemicals!” Those are not really foods, they are chemicals or preservatives they are things that make them have a nice mouth feel but in my opinion not really food. So the first thing I tell patient is please, you don’t need supplements you just need to eat real food. Anything you can pick from a tree, a plant, get from the ground or get from an animal, that’s real food. Some people say if you see something in the grocery store that has more than 5 ingredients, maybe shy away from it. The other thing I tell people to get all white food out of their diet, that means pasta, bread, potatoes, sugar. Those are really high-carb foods and the irony is, even though there are calories in those foods, eating them makes us hungrier. By getting rid of them it makes us less hungry and eat less total calories. Those are two simple tips I give my patients in respect to what to eat.
Joy: What about if they go out and have a cup of coffee? What kind of cup do you tell them that they should use? (laughter)
Dr. Perreault: Right, so, I must admit. When I have a chance, I do use a re-usable mug or even if I’m in a hotel, I’ll try to use a ceramic mug more than a paper cup. It’s not always possible. I mean people have to live their lives and whatnot, but I tell them to just be careful; just know that there are things out there beyond the calorie. You read a food label, you see how many calories are in something, but there are foods that actually change where we get calories and how our body burns calories, and even processed foods….newer data coming from lots of interesting, major research labs showing that the processing of food can actually change insulin sensitivity in our bodies beyond the calories. So, when patients telling you they’re not necessarily eating that much, they might be right.
Joy: Do you use probiotics in your practice?
Dr. Perreault: That’s a great question. People are super interested, again in that notion that you can change the microbiome either in by a prebiotic, a probiotic, a xenobiotic, gosh knows an antibiotic even. People are so interested in this and they’re trying all kinds of things. I think the answer is, we have so much learn, but I’m not really sure it’s ready for prime time yet. If you eat something your body is probably going to degrade it so how much of it is going to stick around to actually change the microbiome, I don’t think we don’t know yet. But I can say a lot of companies are very interested in this, whether it’s an over the counter or pharmaceutical grade probiotic, so I think we are going to see a lot over the next few years.
Joy: But there’s no one that you recommend at this time?
Dr. Perreault: I don’t. A lot of my patients will eat lactobacillus yogurts, things like that, and they are really confident that it’s helping them manage their weight or manage their appetite or other things like that. So I always say, if it works for you then I have nothing else to say except go with that!
Joy: For your patients who have prediabetes, do you teach “eat less, exercise more”? What else do you teach?
Dr. Perreault: I absolutely do talk to my patients about healthy eating and increased physical activity because I feel like I would be remiss if I didn’t talk to them about that. I truly believe that eating healthy and exercising more are the foundations of health for all people, regardless of where they are, what their blood sugars are, where their bone density is, all their other medical problems. But most of my patients, when they’re coming to me, they have already been told to eat less and exercise more, and if they knew how to do that and make it work, they would have done it. When they come to me I’m educating them about other potential possibilities for them. In prediabetes, there are consensus guidelines saying that you can use medications that have been historically used in diabetes, things like metformin, for the prevention of diabetes. There was a recent article in Diabetes Care that looked at the use of metformin in people with prediabetes and showing that only 0.7% of people with prediabetes in the United States are treated with metformin, so the uptake is very low. I also talk to my patients about weight loss medications or even weight loss surgery depending on where they are in life. If they have a large enough body mass index and a lot of health problems related to their weight, I think that everything is on the table for them, I put everything on the table because my job is to help them and so I don’t want to not give them options for that. Weight loss medications, absolutely key. I also talk to them about managing risk factors for both diabetes and cardiovascular disease. There are guidelines that have been put forth by the ADA, ACE and the endocrine society for multiple risk factor intervention to prevent cardiovascular disease in people with prediabetes by lowering blood pressure and cholesterol, as well as glucose and they have largely gone ignored. That’s putting those patients at risk for things beyond diabetes. So yes, I talk to my patients about what they eat and how physically active there are, but I but I also educate them on where they might be going and what we can do to prevent all those things.
Joy: You mentioned prevention of cardiovascular disease in prediabetes, although not indicated at this point for people with prediabetes, do you recommend SGLT2s? Do you recommend GLP1s? Do you use those in your practice for people who don’t have diabetes?
Dr. Perreault: The shorter answer is, I wish I could. Those drugs would be absolutely ideal for those patients because they lower glucose and body weight. But generally, insurance companies will not pay for those unless people have a very clear diagnosis of diabetes. Sometimes I try and diagnose people with diabetes based on a 2-hour oral glucose tolerance test, and/or fasting glucose and/or an A1c because if I can get a diagnosis of diabetes then those things are finally at my disposal. So that said, there was a recent publication in The Lancet showing that liraglutide accelerated weight gain in people with prediabetes but also, prevented diabetes in people with prediabetes. So, the SCALE Prediabetes and Obesity Study, and that is very clear that the weight loss and prevention of diabetes…that is what I am trying to do for my patients. Canagliflozin is also in clinical trials for the prevention of diabetes in people with prediabetes. In fact there is so much interest in the notion that we can not only prevent diabetes, but prevent the complications of diabetes in people with prediabetes that currently there are over 1,700 global trials registered for the prevention of complications of diabetes in people with prediabetes using a number of different things including GLP1, etc, analogs and SGLT2 inhibitors.
Joy: Well, I thank you for this interesting interview. We’d love to have so many other subjects to talk about, but I guess we’ll hold that for another time. Thank you.
Dr. Perreault: Thank you.