In part 1 of this Exclusive Interview, Dr. Yehuda Handelsman talks with Diabetes in Control Publisher Steve Freed during the AACE 2018 convention in Boston, MA about his work as an endocrinologist, and about why contemporary approach to diabetes is that it is a cardiovascular disease.
Yehuda Handelsman, MD, FACP, FNLA, MACE is a past president of the American College of Endocrinology and Medical Director of the Metabolic Institute of America in Tarzana, CA.
Transcript of this video segment:
Freed: This is Steve Freed and we are here at AACE in Boston. We have the luxury of having some great endocrinologists to talk to. One of my favorite to talk to is Yehuda Handelsman. [Freed to Handelsman] I was going to read all the stuff about you –
Handelsman: (Laughs) Don’t!
Freed: – but, that was going to take too long.
Freed: Can you give us a 30 second overview of what you do?
Handelsman: Yes. I am an endocrinologist in a solo private practice – I am one of 17 percent of soloists still left around. I take care of endocrine-related diseases with a big focus on the metabolic aspect and cardiovascular disease. I am involved in the Metabolic Institute of America where we are doing educational activities as well as research – I am involved in quite a bit of clinical research on a different level. In my professional life, I am also the Chair of the Diabetes and Lipid Scientific Committees for the American Association of Clinical Endocrinologists. I publish quite a bit and I do education for a couple important conferences that I am involved in. One is the Heart in Diabetes physician [conference] in July in Philadelphia; we’re looking at everything heart in people with diabetes and how we incorporate a lot of the new information we have today in diabetes and cardiovascular disease. The other meeting that we’ve done for about 15 to 16 years is called the World Congress on Insulin Resistance – Diabetes and Cardiovascular Disease. We are looking at everything from basic signs to clinical signs of obesity, fatty liver, and diabetes; again, looking at everything which we call Tomorrow’s Clinical Science Today. So, kind of two educational laboratories were made where I can take the expertise of my people and see how we can apply it to medicine. I think that is plenty on myself.
Freed: (Laughs) That’s great! You have already done a presentation here and I believe the title was, “A Contemporary Approach to the Management of Diabetes as a Cardiovascular Disease.” If we go back 50 years, we had one drug for diabetes – it was Sulfonylurea which we do not even recommend anymore. It took us 50 years just to get one other drug. But now, we have so many other possible alternatives, especially in the cardiovascular area. We never had a drug before that could prevent cardiovascular disease, which most people with diabetes die from, and now, we have that. So, when you look at a patient, what do you look at? Blood sugar levels? Cardiovascular risk?
Handelsman: We think that a person with diabetes, specifically coming from the insulin resistance background, has too much fat in the body and free fatty acid, already has changes in their vascular bed and already has changes in target organ such as the kidney and heart. And so, they are already at the very high risk even before they get diabetes – higher risk for cardiovascular disease. Once a person has diabetes, they typically also have hypertension. So, the rate of people with diabetes and hypertension is about 85-90 percent. So, the majority of people with hypertension have diabetes and the majority of people with diabetes have hypertension. Not all, but the majority. Also, lipid disorders. We have the dyslipidemia of diabetes which is dyslipidemia of insulin resistance – it’s high triglycerides, low HDL, and many particles of low-dense LDL. So, the number may not look very high for the LDL but they have issues with cholesterol that we need to treat. We have blood pressure to deal with, cholesterol to deal with, high glucose – there’s an increased coagulation in people who have diabetes. Due to that increase of coagulation, we are then seeing that we may need to give [patients] medication to reduce Pi 1 (which is one of the coagulation) or reduce platelet aggregation so that they don’t get blood clot(s) or heart attacks and, of course, lifestyle and exercise and smoking – all of these factors are part of it.
In 1998, I created, for the first time, a slide to one of my first lectures and I said, “Diabetes is a cardiovascular disease; treat all risk factors.” And that was actually done in Denmark in a small clinic called Steno, it’s in the Steno village, where they took 160 people and they just said we’ll treat you to three goals: blood pressure less than 150/80, LDL less than 100, and A1C less than 7. So, simple goals, not crazy goals. They showed that when they controlled all three, there was reduction in events of near 50 percent by 8 years and by 13 years, reduction in mortality by 53 percent. So, what you were seeing in addressing all of this was that it was working. Even though many of them did not even get to the goals, just addressing that [worked]. From that moment on, we were promoting this combination approach. So, when you ask me how to treat, and since I oversee the guidelines, I changed the name from “Diabetes Guidelines” into “Creating a Comprehensive Healthcare Plan for People with Diabetes.” I made this change in 2012. We also have an algorithm, a comprehensive approach to that management of people with diabetes. And so, what does that mean? Treat the obesity, treat the blood pressure, treat the lipid, and treat the glucose. We had a session this morning and I was asked about that. I was asked in which of these areas do I treat the patient and I said I treat them in all of those areas. This is my responsibility for “John,” who is my patient. I do not treat my patients’ glucose and send them somewhere else to treat their blood pressure. I do not know if someone is able to treat those things for my patient, so for me, I believe you need to treat the whole patient.