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Dr. Buse:
The prevalence of obesity continues to rise in the United States, affecting up to 37 percent of adults with type 1 diabetes. How can we manage these conditions in our patients? Today we are joined by an expert in the field who will share some of the keys to doing this successfully. 

Welcome to Diabetes Discourse on ReachMD. I’m Dr. John Buse. And joining us for a discussion on obesity in people with type 1 diabetes is Dr. Elizabeth Selvin. Dr. Selvin is a Professor of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. 

Dr. Selvin, thanks for speaking with me today. 

Dr. Selvin:
Thanks so much for having me. I’m glad to be here, John. 

Dr. Buse: 
Can you tell me why you were initially interested in the issue of obesity in type 1 diabetes? 

Dr. Selvin:
Yeah, definitely. I mean, as you know, there have been phenomenal improvements in treatment and management of type 1 diabetes over the past two decades, so there are people with type 1 diabetes who are living into their 70s and 80s, even their 90s, and that’s really something that doctors didn’t think was possible decades ago. And now that people with type 1 diabetes are living to much older ages, the health profile of this population has shifted. It was once thought that obesity was rare in type 1 diabetes, and as you described, obesity has grown to epidemic proportions in the general population, and so now it’s starting to be very common in people with type 1 diabetes. So we undertook this study to estimate the national prevalence of obesity in adults with type 1 diabetes. 

Dr. Buse:
What were some of the strategies you used to tackle this challenge? 

Dr. Selvin:
So this was a collaboration with my colleague at Johns Hopkins: Dr. Mike Fang. And Mike and I do a lot of work together with national survey data. So, for this particular study, we used data from the National Health Interview Survey. And in the National Health Interview Survey, they interviewed almost 130,000 people across the entire nation and included questions about height, about weight and about medical history on topics like diabetes. 

Dr. Buse:
With that in mind, what were some of your key findings? 

Dr. Selvin:
We found that among adults who had type 1 diabetes, 62 percent were overweight or had obesity, so this was really similar to the overall population without diabetes. So in the overall population without diabetes in this sample, the prevalence of overweight or obesity was 64 percent, so obesity, overweight, much, much higher in people with type 2 diabetes, around 86 percent. So, what we’re seeing is that people with type 1 diabetes had a prevalence of overweight or obesity that was really quite similar to the general population, and that really throws the paradigm of type 1 diabetes being a thin person’s disease on its head. And as part of the study, we also looked at who had received recommendations from a healthcare provider about lifestyle modification, so things like ‘Has a healthcare provider told you to increase your exercise or reduce your calories?’  because of being overweight or obese, and we found that most people with type 2 diabetes who were overweight or obese had received lifestyle recommendations from their providers, whereas adults with type 1 diabetes who were similarly overweight or obese were less likely to receive lifestyle recommendations from their doctor. 

Dr. Buse:
And how about lifestyle change? 

Dr. Selvin:
Similar to dietary recommendations, people with type 1 diabetes were really—even if they were overweight or obese were less likely to have received recommendations from their doctor about lifestyle changes. 

We sort of interrogated two areas: whether you had received advice from a doctor or healthcare professional on increasing physical activity or exercise, and then whether you were now increasing your exercise or reducing fat or calories in your diet or making lifestyle changes. So, similar to what we found for healthcare provider recommendations is those people with type 1 diabetes who were similarly overweight or obese compared to people with type 2 diabetes were less likely to be engaging in physical activity or increasing exercise or making dietary changes to address obesity or overweight. 

Dr. Buse:
Yeah. And the thing that I found interesting is that, even though it was more than half of people could recollect being told by their provider to increase their physical activity or reduce their fat or caloric intake, it was just over half, and so there is this missing opportunity to counsel everyone, and only about half were actually engaged in physical activity or fat calorie reduction.

Dr. Selvin:
Absolutely. It’s a huge gap. I mean, I think one thing that is really clear is there is a lot of things where we know what works, and we’re not doing those things that we know work. 

Dr. Buse:
For those just tuning in, you’re listening to Diabetes Discourse on ReachMD. I’m Dr. John Buse, and today I’m speaking with Dr. Elizabeth Selvin about obesity in patients with type 1 diabetes. 

Liz, as we’ve been discussing, patients with type 1 diabetes are often less likely to get advice on their lifestyle choices. Do you think that helps or hurts when it comes to managing obesity? 

Dr. Selvin:
Yeah. So it’s a really important question. As you know, changes in exercise and diet can be particularly tricky for people who have type 1 diabetes. People with type 1 diabetes are going to need to adjust their insulin dose to keep their blood sugar at a safe level and avoid hypoglycemia. In type 2 diabetes, we had a really strong evidence base for what works, and we know that even modest weight loss or just preventing weight gain is incredibly important. And as you also know, there have been a big focus on new drug therapies for weight loss that can help as well. In type 1 diabetes, we just don’t have that evidence base, and as we described, weight management in type 1 diabetes can be quite complicated and people with type 1 diabetes may be very concerned about avoiding hypoglycemia because an important acute complication of exercise. So, it may also be that providers are simply not exactly sure what to say for their patients with type 1 diabetes, and I think also, this could end up being a very long conversation, which may not fit into a typical doctor’s visit. 

Dr. Buse:
On the other hand, everybody with type 1 diabetes in the United States has access to diabetes self-management education and support; longer visits often with dietitians and other people with special training in lifestyle management. I do think it’s really critical that people get that kind of access if they have type 1 diabetes in general, but then particularly, if they are overweight or obese, because if they do pursue lifestyle change based on what they see on the internet, they’re more likely to get into trouble. 

Dr. Selvin:
Absolutely. I cannot agree more. 

Dr. Buse:
We’re constantly battling for people with type 1 diabetes to have access to the same therapies for hyperglycemia and obesity that patients with type 2 diabetes have. What are your thoughts on this? 

Dr. Selvin:
Yeah. So, I mean, I think the real issue is we just don’t have the evidence base, right? I think, as you’re saying, there’s lots of people with type 1 diabetes, and our research really shows that there are a lot of people out there who need access to these therapies, and also, we need an evidence base for even lifestyle interventions. What works for weight loss? What works for weight management in type 1 diabetes? And this has just not traditionally been a focus of type 1 diabetes treatment, and we don’t have the randomized clinical trials, just don’t have the evidence base that we need to inform care. So I think it’s going to be an uphill battle in terms of even getting approval for these medications for those indications in people with type 1 diabetes, which is going to make access to these new therapies even more difficult. 

Dr. Buse:
Before we close, do you have any final thoughts you’d like to share with our audience? 

Dr. Selvin:
Yeah, sure. I mean, I think for me and for what I’d like to convey to your audience is that I think this study really should be a wakeup call. We found that among US adults with type 1 diabetes, the burden of overweight and obesity is substantial, and it’s clearly not adequately managed. And I just really think going forward, we’re going to need randomized clinical trials and really clear clinical guidance and patient education that directly addresses this gap and tells us how to best tackle obesity in type 1 diabetes. 

Dr. Buse:
I think another lovely thing about this story is it really reflects the essence of what epidemiology can do for us: identify a problem and now tackle it with clinical trials and better patient and provider education. 

Dr. Selvin:
Absolutely. 

Dr. Buse:
With obesity rates on the rise, this information can really help us provide better care for our patients. So, as we come to the end of our discussion, I’d like to thank my guest, Dr. Elizabeth Selvin, for being here and sharing her insights on combating obesity in patients with type 1 diabetes. 

Liz, thank you so much for joining us. 

Dr. Selvin:
Thank you. This was a lot of fun. 

Dr. Buse: 
For ReachMD, I’m Dr. John Buse. To access this episode and others from our series, visit ReachMD.com/DiabetesDiscourse where you can be Part of the Knowledge. Thanks for listening.