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Cedars-Sinai

On Diabetes

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Driven by rising obesity levels, the type 2 diabetes epidemic is a ticking time bomb. We asked a variety of experts — from researchers and dietitians to surgeons and health educators — what changes they want to see in the care, management, or prevention of this pernicious disease. From big ideas to small steps anyone can take, here’s how they answered.

“If you could change or implement one thing to significantly improve diabetes treatment or reduce diabetes and obesity rates in the US, what would it be, and why?”

Mark O. Goodarzi, MD, PhD, endocrinologist, geneticist:

REGULATE SUGAR LIKE TOBACCO.

Obesity and diabetes arise from the interaction of our genes and our environment. “Because we can’t simply change our genes, we need to change the environmental factors in America that contribute to obesity,” says Dr. Goodarzi. “A major contributing factor of this environment is sugar. Up to 80 percent of foods sold in America have added sugar, and sugary beverages account for some 15 percent of daily caloric intake. The government needs to label sugar as unsafe and strictly limit its addition in food. Public campaigns against tobacco and trans fats have met with tremendous success. This can work with sugar, too.”

Mark O. Goodarzi, MD, PhD, is director of the Division of Endocrinology, Diabetes, and Metabolism at Cedars-Sinai. His research focuses on endocrine genetics and seeks the genetic determinants of insulin resistance and related conditions such as diabetes, cardiovascular disease, and polycystic ovary syndrome.

Josiane Broussard, PhD, postdoctoral research scientist:

GET SOME SLEEP.

Studies suggest that people who sleep fewer than five hours per night are at higher risk for developing obesity and Type 2 diabetes. “Researchers took healthy volunteers and compared their hunger and metabolism after one week of eight hours of sleep versus a week of four hours of sleep,” Dr. Broussard says. After one week of only four hours of sleep per night, volunteers developed insulin resistance and had an increase in appetite. Their hunger-regulating hormones were also disrupted. “We need to recognize that adequate sleep is a major component of health and may reduce the risk of developing metabolic diseases,” says Dr. Broussard.

Josiane Broussard, PhD, is a Society in Science–Branco Weiss Fellow at the Diabetes & Obesity Research Institute, where she is looking at how sleep restriction affects the metabolic organs of the body.

Ruchi Mathur, MD, endocrinologist:

AWAKEN YOUR INNER CAVEMAN.

When our ancestors lived as hunter-gatherers, they evolved adaptive mechanisms such as insulin production and intestinal microbes that helped them harness and store calories in order to survive. “Our environment has changed faster than our genetics,” she says. “What once was adaptive is now maladaptive. We rarely go without food for three hours, let alone three days.” To combat obesity — and resulting diseases — Dr. Mathur recommends awakening your inner caveman. “Treat your body like it was meant to be treated: Fill up on vegetables, lean meats, and whole grains. Stop when you’re full, and keep your body moving.” Dr. Mathur thinks we have the power to reduce our individual burden of disease by honestly answering this simple question: How do you want to fuel your body?

Ruchi Mathur, MD, is director of the Anna and Max Webb & Family Diabetes Outpatient Treatment and Education Center at Cedars-Sinai. Her primary clinical interests are in pre-diabetes, diabetes, and obesity, and her research focuses on the effects of gastrointestinal microbes on metabolic diseases.

Carolyn Buenaflor, MPH, health educator:

SHOW PEOPLE THE TRUE COST OF “BIG VALUE” MEALS.

People in underserved communities are disproportionately affected by obesity and Type 2 diabetes. “There is a lot of appeal to buying and consuming cheap, high-calorie food,” says Buenaflor. “One of the things we teach is that, over the long run, that ‘big value’ meal is going to cost you a fortune in medical bills and lost productivity. We show families changes they can realistically make. There are no forbidden foods, only forbidden portion sizes. Enjoy your food. Just eat less of it.”

Carolyn Buenaflor, MPH, is associate director of Cedars-Sinai’s Healthy Habits program. Healthy Habits helps children and families learn about healthy eating and physical activity with programs reaching elementary and middle school students, parents of preschool children, and families in underserved communities.

David Geller, MD, PhD, pediatric endocrinologist:

DESIGN A SMARTER IMPLANTABLE INSULIN PUMP.

Diabetic children need a better way to receive insulin and modulate blood sugars, according to pediatric endocrinologist Dr. Geller. “For them, insulin shots are especially scary, and compliance is a problem.” Pumps that continuously infuse insulin under the skin are major advancements. However, current models depend on preset instructions, receive blood glucose information from separate sensors, and cannot act independently on this data. “Fortunately, I believe we are fewer than 10 years away from a smarter pump that measures blood sugar minute-by-minute and uses personalized algorithms to deliver insulin and glucagon through separate ports,” Dr. Geller says. “Patients will only need an Internet connection to verify the accuracy of the algorithms and integrity of the pump.”

David H. Geller, MD, PhD, is a pediatric endocrinologist in the Department of Pediatrics at Cedars-Sinai. He has given more than 30 lectures, seminars, and presentations on endocrinology-related issues at national and international conferences and is highly active in community service, alongside his clinical practice.

Richard Bergman, PhD, biomedical science specialist:

MAKE THE PHARMACEUTICAL INDUSTRY PAY ITS SHARE.

In the U.S., most biomedical research is funded by the National Institutes of Health (NIH) and the majority of medical breakthroughs are born in the public sector. But private companies are allowed to mine this research and use it to develop drugs and treatments while rarely having to pay for it. Unfortunately, the NIH is in financial trouble. Less than 10 percent of proposals are now funded, so researchers are forsaking the public sector in favor of industry, where their projects won’t struggle for money. Dr. Bergman has a solution: “Some of the proceeds from the sale of any prescription drug made by a pharmaceutical company should go directly to the NIH. The NIH would have a guaranteed source of income, and it would be fair.”

Richard Bergman, PhD, the Alfred Jay Firestein Chair in Diabetes Research at Cedars-Sinai, is director of the Diabetes and Obesity Research Institute and the Sports Spectacular Diabetes and Obesity Wellness and Research Center. The Bergman lab is elucidating why resistance to insulin predisposes people to diabetes and is developing new treatments and procedures that might reduce obesity or suppress the link between excess weight, insulin resistance, and Type 2 diabetes.

Deborah Clegg, PhD, metabolic disease specialist:

CELEBRATE EXPANDING FAT CELLS!

Most people know that extra calories can be stored as fat. “That’s actually not a bad thing,” says Dr. Clegg. “It means your fat cells are healthy, expanding enough to absorb the fat and prevent it from circulating in your bloodstream. Premenopausal women have lower rates of diabetes than men, and research suggests it’s because they have healthier fat cells — in men, extra calories turn into lipid droplets that course through the body. After menopause, women’s fat cells shrink and their risk of diabetes becomes equal to men’s. “We need to identify what makes fat cells healthy in younger women so we can create therapies to help women as they age — as well as men in all stages of life.”

Deborah Clegg, PhD, is an associate professor and biomedical science researcher at Cedars-Sinai. She is former associate professor of Clinical Nutrition and Internal Medicine at the University of Texas Southwestern Medical Center. Her research examines sex differences in the behavior of adipose tissue and their link to Type 2 diabetes.

Alexander Ljubimov, PhD, ophthalmology and stem cell researcher:

TREAT DIABETES AS MORE THAN A BLOOD-SUGAR DISEASE.

Bariatric surgery can normalize blood sugar for some obese patients who suffer from Type 2 diabetes. However, it does not always reverse the risk of future complications, such as blindness and neuropathy. “It’s like the body has a metabolic memory — in some ways, the body continues to behave as if it had diabetes even after the blood sugar is normalized, because blood-sugar problems caused lasting genetic changes in the patient,” explains Dr. Ljubimov. It has become clear that diabetes is not just about insulin and glucose. “It should be treated with a combination of interventions, just like other complex diseases, such as AIDS or cancer. We need medications that prevent or treat the neuropathies that can contribute to blindness or amputation. Ultimately, we need drugs that can destroy that metabolic memory once and for all.”

Alexander Ljubimov, PhD, is an internationally recognized eye researcher and the director of the Eye Program at Cedars-Sinai’s Board of Governors Regenerative Medicine Institute. His research includes studies of inhibitors of a key enzyme to block abnormal retinal vessel growth, gene therapy to restore corneal function in patients with diabetic retinopathy, the use of stem cells for corneal regeneration, and targeted nanomedicines for cancer.

Jan Perry, city official, diabetic:

MAKE GOVERNMENT AND INDUSTRY WORK TOGETHER.

“It starts with teaching children healthy habits,” says Perry. A lifelong public servant and Type 2 diabetic, she thinks government and the private sector should work together to slow the epidemic of obesity and Type 2 diabetes. “One major goal must be to improve the food in public schools. The government simply can’t provide all the funding, although the public sector needs to do its part.” Perry notes that several Los Angeles Unified School District schools have launched healthy lunch programs, even growing their own vegetable gardens. At the same time, some private companies are voluntarily removing their sugary products from school vending machines, an essential and encouraging development. “That trend needs to accelerate: government making public health a priority, and industry showing real leadership,” says Perry.

Jan Perry is the manager of the Economic and Workforce Development Department in Los Angeles. She served as a Los Angeles city councilmember from 2001 to 2013, helping enact restrictions on fast-food restaurants, promoting a campaign to combat obesity by helping fund public parks, and encouraging better grocery stores.

Miguel Burch, MD, bariatric surgeon:

TRAILBLAZE WITH BARIATRICS.

For obese patients with Type 2 diabetes, bariatric surgery can lead to more than weight loss — it can also normalize blood sugar. “The welcome side effect is most reliable in patients who have had diabetes less than five years,” says Dr. Burch. “Patients with Type 2 diabetes who are at least 65 pounds overweight should probably be screened for bariatric surgery within a year or two of diagnosis, especially if their diabetes is uncontrolled and they’re gaining weight despite attempts at weight loss. Ultimately, we need to figure out why surgery normalizes glucose and develop a noninvasive way to trigger that same mechanism in diabetics who don’t need weight loss surgery.”

Miguel Burch, MD, is a surgeon at the Cedars-Sinai Weight Loss Center. He is associate director of Minimally Invasive Surgery and director of the Minimally Invasive and Bariatric Surgery Fellowship. His research includes endoscopic therapies for the management of obesity and the link between bariatric surgery and diabetes resolution.

Beth Moskowitz, philanthropist, entrepreneur:

CHANGE YOUR TRADITIONS.

When it comes to disease prevention, Moskowitz says people are getting an incomplete message. “It’s not about creating a new lifestyle — it’s about creating new traditions,” she says. For various reasons, including genetics and socioeconomic factors, Type 2 diabetes disproportionately affects certain groups, including Latinos and African-Americans. “You can’t change your genes, so change the traditions you follow and pass those on to your children,” she says. “Keep the family dinner — just change what’s on the table. Make health and a disease-free life your most important family tradition, whatever your culture.”

Beth Moskowitz is executive director of Sports Spectacular, a philanthropy that allies with elite athletes and medical professionals to promote wellness through advocacy and the support of research. A valued partner of Cedars-Sinai, Sports Spectacular’s fundraising efforts have benefited a variety of programs and projects, including the Sports Spectacular Medical Genetics Institute. In 2014, Sports Spectacular pledged $10 million to establish the Sports Spectacular Diabetes and Obesity Wellness and Research Center at Cedars-Sinai.


Donald Dafoe, MD, pancreas transplant specialist:

Use stem cells to treat Type 1 diabetes.

In Type 1 diabetes, islet cells — clusters of pancreatic cells that make insulin — are destroyed. “Transplanting islet cells from a healthy donor pancreas can reverse the diabetes,” says Dr. Dafoe. Unfortunately, the body can reject the foreign cells. In addition, there are too few organ donors.

Stem cells may be the answer. “We would take an ordinary skin cell from the patient, drive it back to a pluripotent state — where it essentially becomes a blank slate — and grow it back into a healthy, insulin-producing cell. If we can prove the procedure is safe for humans, we may have a revolutionary breakthrough for Type 1 diabetics.”

Donald Dafoe, MD, is director of Pancreas Transplantation in the Kidney and Pancreas Transplant Center and the Eris M. Field Chair in Diabetes Research at Cedars-Sinai. His primary research interests are pancreas and kidney transplantation and stem cell research.

Cindy Wu, PharmD, pharmacist:

Implement the “teach back” method.

Diabetics who do not need insulin injections are often prescribed oral medications such as a sulfonylurea. “I routinely encounter patients who don’t read the drug information,” says Dr. Wu. They don’t realize that if they skip a meal, for example, they must skip the pill, too, or their blood sugar may fall to dangerously low levels.

“Often, patients don’t listen carefully to the pharmacist’s instructions,” she says. “To change that, pharmacies should implement the ‘teach back’ method: Tell the patient how the medication should be taken, then ask them to ‘teach it back’ to the pharmacist. It could make a big difference. The method should be taught in all pharmacy programs and implemented universally.”

Cindy Wu, PharmD, is a pharmacist at Cedars-Sinai. She also runs the Employee Wellness Clinic.

Viorica Ionut, MD, PhD, research scientist:

Solve the bariatric surgery riddle.

Bariatric surgery, originally intended for weight loss, can reverse Type 2 diabetes in some patients, though it is not understood why. If researchers can solve that riddle, they may be able to develop a non-surgical treatment that harnesses the same mechanism. “Maybe the surgery triggers a change in a hormone or a microbe,” explains Dr. Ionut. Until recently, to qualify for the procedure, candidates had to have a BMI of more than 40 — or more than 35 if they suffered from a related condition such as heart disease or Type 2 diabetes. Today, patients can qualify with BMIs of 30 if they also have diabetes. “Surgery is still not recommended for diabetics who are not significantly overweight,” says Dr. Ionut. “And noninvasive treatments, if just as effective, are always preferable to invasive ones.”

Viorida Ionut, MD, PhD, is a research scientist at Cedars-Sinai’s Diabetes and Obesity Research Institute. Her current research includes using functional MRI to determine how gut hormones activate the brain in obese patients with Type 2 diabetes, and investigating the role of gut hormones and gut-brain communication in bariatric surgery-induced changes.

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