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Life Beyond Diabetes with Teresa Owens, ARNP - Part 2


Medications, and sometimes surgery, can play an important part of controlling or even possibly eliminating your diabetes. Learn what you need to know to start on a bath to improve your health.

Some of this weeks episode highlights are:
19:02 It's really empowering that instead of me saying, “you need to do this”, YOU coming to the realization (with coaching) to make better decisions.
48:59 If you've got a diagnosis of diabetes, don't be afraid of medications, don't be afraid of surgery. Do whatever the heck it takes to get this under control and keep it under control as quickly you can.
50:56 Don't be afraid to talk to your provider, but if you talk to your provider and your provider isn't receptive and doesn't want it, it's okay to shop for a different provider! You need to work as a team!

--- Full Raw Transcription of Podcast Below ---

Dr. Angela Zechmann (00:00):
You are listening to the, keep the weight off podcast with Dr. Angela episode number 25.

Introduction (00:07):
Welcome to The Keep The Weight Off podcast, where we bust all the dieting myths and discover not just how to lose weight, but more importantly, how to keep it off. We go way beyond the food and we use science and psychology to give you strategies that work. And now your host, Dr. Angela Zechmann.. Well, hello again,

Dr. Angela Zechmann (00:27):
Well, hello again and welcome back everybody. Today's podcast is part two of our discussion with Theresa Owens on diabetes. So she's back with us again this week. So glad to have you here Teresa.

Teresa Owens (00:43):

Dr. Angela Zechmann (00:43):
I think, you know if you have not heard part one of what we did, what we talked about last week, I'd recommend that you go back and listen to that one first so that you can get a good idea of Theresa story. She told us all about how it was that she was diagnosed with diabetes and everything that she went through from both a mental and a physical standpoint in terms of getting her diabetes under control. And I think that will really help to inform this discussion that we're going to have today about managing diabetes and about the new medications that are out there and about CGMs a little bit about that. That's a continuous glucose monitor, if you've never heard of that.

Dr. Angela Zechmann (01:30):
And we just want you to, to know that since most people who are diagnosed with diabetes are managed with medications and not with insulin, we're not going to talk so much about insulin pumps or anything like that, but we are going to have a really nice discussion about the medications that are out there. But before we even start talking about that, I want to point out that your most important treatment is going to be your nutrition. Would you agree with that, Theresa?

Teresa Owens (02:03):
Yes, plus.

Dr. Angela Zechmann (02:05):
Yes, plus! Okay. Yes. Okay, great. So tell me what kind of nutrition recommendations you give your diabetes patients and why you give them those recommendations.

Teresa Owens (02:17):
So just like what you talk about a lot when we're talking about obesity medicine and what you talk about elsewhere on the podcast. I talk a lot about insulin resistance and carbohydrates and sugar in my practice, I generally call it carbohydrates instead of sugar. So we use the words interchangeably though. One of the things to remember is that diabetes is a disease of carbohydrate intolerance. So insulin resistance and carbohydrate intolerance go hand in hand. And, you know, we talk a lot in our culture about intolerances, you know, we've got gluten intolerance, we might have somebody who's gotten intolerance to eggs or, you know, whatever other kind of dietary and tolerance they have. But for some reason we don't talk about carbohydrate intolerance and a lot of us are carbohydrate intolerant. And that's what insulin resistant is, is that our bodies don't tolerate carbohydrates.

Dr. Angela Zechmann (03:26):
They don't know what to do with them. They just don't have that process.

Teresa Owens (03:29):
Because they're this influence that has made it dysfunctional in the same way that somebody who has celiac disease is truly intolerant of gluten.

Dr. Angela Zechmann (03:41):
Or Lactose Intolerance.

Teresa Owens (03:41):
Exactly body doesn't have the right ability to process that. Those of us who are insulin resistant are intolerance or carbohydrates. So we, I talk about that a lot. So that's one of the first things I talk about when I'm talking to somebody with diabetes origins, or is the reason that we are limiting carbohydrates is because our bodies don't tolerate them. So it's a disease of carbohydrate intolerance. And so then we start looking at well, what, how to carbohydrates work in our body. I talk about what influence system looks like. And then I take a really individualized approach with my clients, how, you know, we look at what they're eating. Now, we look at what they're willing to, to change. And some of them go full on sugar detox, like you've talked about in your podcast. And some of them maybe are going to just give up a soda a day.

Teresa Owens (04:39):
And one of the things that's, I think a little bit different with diabetes than with weight loss is that there's, you know, there's a lot of emotion tied up in the in, in weight loss and, and everything. With diabetes, there's, I think another, another layer of that in that now there's a chronic life-threatening disease that's associated with it. And I think a little bit more gentle than saying we're going to culture key everything, because already they're looking at, oh my goodness, am I going to have my feet amputated? And now I have to give up my soda. Okay, well, you might have to give up your soda probably eventually you're going to want to give up your soda, but we don't have to do that today. So I think that's probably the one place where I have a little bit of a different approach than in a standard obesity medicine appointment.

Dr. Angela Zechmann (05:39):
Does that make sense?

Dr. Angela Zechmann (05:40):
Yep. Yep.

Teresa Owens (05:42):
But the other thing that, and I think part of the reason why this works also is that then I'm giving them a a glucometer. So they're either getting something where they're testing their glucose multiple times a day. I'm encouraging to test after they eat things so that they can see how, what they eat affects their blood sugar.

Dr. Angela Zechmann (06:01):
Okay. Wait. Yeah. Cause I just want to make sure, because we might have podcasts listeners who don't know what a glucometer is.

Teresa Owens (06:06):
Yes. So the glucometer or the glucose meter is basically the standard. One is the one where you poke your finger and you get an instant reading of what your glucose is.

Dr. Angela Zechmann (06:18):
Glucose is blood sugar, the blood sugar.

Teresa Owens (06:21):
So you can get, you can get, you can know exactly what your blood sugar is at any given time when with a finger poke.

Dr. Angela Zechmann (06:28):
Yes. So what should it be?

Teresa Owens (06:32):
So somebody who's not diabetic is going to have a blood sugar that's less than a hundred, pretty much all the time most people are going to be. So the fasting blood sugar, which is the one that would be first thing in the morning after not having anything to eat or drink in eight hours, you know, diagnostic of healthy according to the algorithms is, or according to the, the lab values is 99 or less. Prediabetes starts at a hundred, right? Diabetes starts at 126. That's that first one in the morning. And then for random ones, even somebody who you know, somebody who doesn't have diabetes, a random one still is going to be probably less than a hundred.

Teresa Owens (07:30):
It's pretty remarkable that they give allowances for it to be higher, but it generally isn't, if somebody is healthy and they have you know, they're, they're not insulin resistant, their blood sugar is not going to fluctuate much beyond maybe 110. They're going to stay right in that really lower range, somebody with diabetes you know, we're looking to have after, you know, two hours after a meal, we're looking for it to be, I think, gosh, it's been a long time since I've looked at those exact numbers. Well, I think it's like 140 to 180. Right. And you know, the fasting, we still want it to be, if we can get it below a hundred, that's, that's fantastic.

Dr. Angela Zechmann (08:15):
But it can be hard though, when you have diabetes.

Teresa Owens (08:16):
It can, and particularly for people with type two diabetes it's easier to get - it's interesting. And there's a lot of physiological reasons for this, for why, but it's for people with type two diabetes in particular, it's really hard to get that, that fasting blood sugar, that tends to be the highest one of the day. It's a crazy, crazy thing. Anyway, okay,

Dr. Angela Zechmann (08:40):
Sorry. Sorry. I interrupted you.

Teresa Owens (08:42):
No worries. After that little digression. So when I've got somebody that is even before they change their diet, sometimes I'll have them just take their blood sugar bunch of times throughout the day and can kind of see...

Dr. Angela Zechmann (08:57):
See where they're at.

Teresa Owens (08:58):
Just to see where they're at and to compare it to what they're eating so that they can see how, when they do drink that soda, how does that affect them? Yeah. When they have some French fries, how does that affect them when they have a salad? How does that affect them?

Teresa Owens (09:15):
When they have some chicken, how does that affect them? The various - how the various foods affect their blood sugar. It's an amazing way to learn. And a lot of times... And so then we start talking about cutting things out and you see how, okay. So if I'm not drinking that soda, that's pure sugar, my blood sugar is not going to go crazy high. And I will tell you, I don't know what my blood sugar does when I have a soda, because it's been so long since I've had one, but I know that it's going to, that it would go up by at least a hundred points. If I had a soda, my blood sugar would go up by at least a hundred points, probably more. And in a healthy person, it would, it might rise 30 points, but it certainly wouldn't go up a hundred points.

Teresa Owens (10:09):
And it would come down really quick. My hundred points would stay there for a few hours. Yeah.

Dr. Angela Zechmann (10:16):
So whats big deal about that. Like why does it matter if your blood sugar goes up a hundred points and stays up a hundred points for a few hours? Like, what's wrong with that?

Teresa Owens (10:26):
So you've got sugar that's hanging out in your blood that doesn't belong there. Yeah. And that's causing, so that's one of the problems and that is causing, gonna filter down into all the little tiny places where there's not room for it to be. And all of the things, all of the nasty, horrible things that we hear about which we call the microvascular complications, which are the things that cause blindness and kidney failure and amputations.

Dr. Angela Zechmann (10:59):
Those tiny, tiny little blood vessels. Yeah.

Teresa Owens (11:02):
Tiny little blood vessels when they get full of sugar, they die. So we want to keep you from having really high blood sugar because they get, those are the things that causes bad, those bad complications. So interestingly that those high blood sugars are not the things that cause the heart complications. Those are it's a whole different podcast, but those, but those, all those things that when we think about diabetes and we think about, you know, my friend's cousin's uncle that had a double amputation, those, those are all caused by long-term high blood sugar. We do not want high blood sugar. So that's why we want to avoid those high blood sugars. So back to the nutrition so we start talking about talking about cutting out carbs and we, and I have people compare what's going on with their blood sugar versus what's going on with what they're eating.

Dr. Angela Zechmann (12:07):
I think that's brilliant.

Teresa Owens (12:08):
And it's self-reinforcing yeah. It's and, and I also kind of have them, I encourage them to gamify it, like how, you know, what happens when you do this, how, you know, show and I say, make a chart, show me what happens. You know, whatever is a fun way. And I try to talk to people you know, my practice is set up in a way that I have time to do this, that we, that we really, we talk to people. I kind of figured out what it, what it is about, what part motivates them. Cause if it's just imputations that motivate them, okay. We can work on that. But for most people, you know, for a lot of people it's today, not 30 years from now that motivates them. So well today it might be getting the number to be less than 120, most of the day.

Teresa Owens (12:59):
So that's where, and you mentioned continuous glucose monitor and that's where if I can get it covered by insurance, I like people to be on a continuous glucose monitor. And what a continuous glucose monitor is, is there is a, and I have a continuous glucose monitor. I briefly mentioned it in the last podcast. It's it goes either on your, a sensor goes either on your belly or on the back of your arm. And it just lives there all the time and gives you a reading all the time. It shows up on your phone. And I can look at my phone at any given time and know exactly what my blood sugar is.

Dr. Angela Zechmann (13:41):
Oh, that's so cool.

New Speaker (13:42):
It is so amazing. And you know, I, and when I first got it, I used to play with it a lot, like to say, okay, so what happens now? Like, and now I actually kind of, I don't think I could tolerate it cause I think I would really hate it. But part of me is like, I wonder what would happen now that we're talking. I'm like, maybe I don't want to go drink a soda, see I'd probably throw up. I think it'd be really gross, but I'm curious. But part of me was like, huh. And I would be able to watch in real time as my blood sugar climbed on the ground. So again, a continuous glucose monitor is a really excellent way to help people learn and there's in, and they weren't built to gamify to gamify it with blood sugars, but you can set up goals. And I've even seen some things because I on Facebook or because, you know, I have things on my internet that I follow that are about diabetes.

Teresa Owens (14:40):
I get the Facebook ads that are about diabetes or about blood sugars. I've even seen ads come across Facebook now where, where there are companies that are using continuous glucose monitors, help people do low carb diets. Yeah. Which I think is partly brilliant and partly sketchy. But, but anyway, it's for somebody who has diabetes, I even have, I have a few of my clients who have pre-diabetes who use them to, you know, that are monitoring. It's very difficult to get them covered for pre-diabetes. So some of them are paying out of pocket for their, for their monitors because they want the information.

Dr. Angela Zechmann (15:26):
What do they cost?

New Speaker (15:29):
You know, the there's two that are there's the Freestyle Libre (, and it does not actually do a full, continuous, not truly full continuous monitor because you actually have to wave your phone across the sensor in order for it to give you the readings. And I think that that one is maybe $100 to $200 a month. Okay. Well, that's reasonable to that. Yeah, it is. And that's the one that your body handles different. Somebody has to pay out of pocket. That's the one that they get. The one that hooks up with the it's really used by people that have that are taking insulin. So need it to know whether or not they're going to low is called the Dexcom ( and that one hooks up with the insulin pumps. So so I have mentioned in the last podcast, I have my insulin pump and it talks to my continuous monitor there and makes the micro adjustments. And that one, I have no idea how much it costs. I'm just really glad I have insurance coverage.

Dr. Angela Zechmann (16:39):
Yeah. It's gotta be way more expensive.

Teresa Owens (16:41):
It is. And it, and it does it. And the reason that I got it initially is that I have what's called hypoglycemic unawareness, which means that when my blood sugar goes low, I don't know. Oh. And that can be very dangerous. So I got it initially because I was taking insulin and I didn't know when my blood sugar was going low. Was it dangerously low? People around me might have noticed, but I didn't notice that I wasn't functioning normally. And so the Dexcom gives you an alarm when you're going low.

Dr. Angela Zechmann (17:18):
So for our podcast listeners who might not actually have diabetes, but they're concerned about their blood sugars and they wanted to get a continuous glucose monitor and they knew that their insurance company wasn't going to cover it. You would recommend the Freestyle Libre. Do they need to get a prescription for that?

Teresa Owens (17:34):
You know, I don't know. I, I honestly, I just, I don't know the answer to that because if any of my clients want them, I prescribed them. Oh, okay. It's, it's as easy as that. It's and I have a couple of clients that when I've prescribed it, it's worked and they've gotten insurance coverage and some of them, they haven't and they just pay out of pocket.

Dr. Angela Zechmann (17:56):
So but I think that's a brilliant idea because you can just eat, you can eat foods and just see how your body manages your blood sugar. It is, you make it decisions that way. I'm all about teaching people to make empowered decisions. Like when you understand the science of what's going on in your body, it is so much easier to make the right decision.

Teresa Owens (18:19):
Well, and even honestly, even if you're going to make an educated, bad decision, like it's like, okay, you own your decision.

Dr. Angela Zechmann (18:28):
Yeah. I'm making this choice. And I know as opposed to, I'm just drinking sodas all day because, you know, that's what I do - I have no idea what it's doing to me.

Teresa Owens (18:39):
Which is, which is why I, you know, I don't like to tell people, don't drink your soda, but drink a soda and see what it does, your blood sugar. And then we'll talk next time about soda. And oh, if they drink a soda and see what it does, as well as your group, when they come back, they're probably not drinking soda or if they are, they've given up every single other carbon their life, because they really want to keep their soda. I mean, so, you know, it's anyway. So that's basically, that's where I fall in nutrition is like, let's get the carbs as low as we can.

Dr. Angela Zechmann (19:13):
And generally it's about teaching your patients, what it does to their body to make informed decisions. Yeah. Okay. That's cool.

Teresa Owens (19:21):
And I think it's also, it's really empowering that instead of me saying, you need to do this, them coming to the realization and me coaching them along along that, that, you know, this is probably gonna be a better decision, but why don't you see for yourself what it looks like?

Dr. Angela Zechmann (19:37):
Yeah. That it's, it's more collaborative. It feels, it feels better for everybody. And then if there's rebellion, it's not against me. It's about it's against themselves. Like I said, I think I mentioned last time that sometimes I have little toddler tantrums because it's helpful to have little toddler tantrums for me to get my anger out. And then they're over, you know, if I'm making, if I'm making a rebellious decision, it's against my own self. It's not against what my endocrinologist told me because she and I work in collaboration when we're deciding what my next, what my treatment plan is. I want the same thing with my clients. I want them, you know, we're working together. If you make a decision, that's different than that. It's not because I told you to do something and you're mad at me. It's because you want to figure that out yourself.

Teresa Owens (20:26):
And we'll, we'll work that through. Yeah. So that's where I fall on nutrition. Awesome.

Dr. Angela Zechmann (20:35):
So, and you generally try to, you, you don't use, usually recommend a keto diet in somebody with diabetes, because we talked about this last time you need to be making insulin.

Teresa Owens (20:48):
So it, again, it depends. And first of all, I don't generally recommend a keto diet unless it's something that somebody comes to me and says, I really want to do a keto diet.

Dr. Angela Zechmann (20:56):
Yeah. And I always say, you know, you need to, you need to be willing to live a keto lifestyle, not just do the keto diet.

Teresa Owens (21:02):
Yeah, exactly. And, and there's, you know, and not just because you read about it on the internet and because it's what the bodybuilders are doing you know, I think you and I pretty much eat keto most of the time, but that's because that's the food we like. And that's because that's how the people we hang out with eat. And that's, you know, it's, it comes easy, but it comes easy because that's how we live. Not because, you know, we, it's not hard to make. I think you should only eat keto if it's easy for you, I guess is my thing on that. So as far as the ketogenic diet goes, if you know, for sure that you make plenty of insulin, I have no problem with somebody doing a ketogenic diet. The one caveat to that is a medication that we're going to talk about a little bit later that nobody should be doing a ketogenic diet on that medication unless they are being, unless they're closely monitoring their ketones. Okay. yeah. So and then again, I, then I also, I would say I would want them talking with their medical provider about that.

Teresa Owens (22:05):
I would not. You know, I have a couple patients that do take that medication do ketogenic diet, but they're really closely monitored by me. I would never recommend to somebody else that they do that diet and that medication without being closely monitored by their own medical provider. Got it. So that's, I would never say you should do this without talking with your own provider and having them monitor. You're not just talking about it, but like, know what's going on with you.

Dr. Angela Zechmann (22:33):
Yeah. So what medications do we use in diabetes these days? There's so much going on to keep up. Sometimes.

Teresa Owens (22:44):
it is. So the first line medication has been for the last 25 years, probably 20 years, at least actually I wouldn't say 25 years. I want to say about 20 years has been Metformin and it's still is. And it's it's cheap. Everybody knows how to use it. Most people tolerate it really well when it's prescribed in the right manner. So people talk about horror stories with Metformin. But generally those come with it not being prescribed in a way that is tolerated very easily. And I'm going to talk about I'm going to say how it, how it's easily, how it's better tolerated in just a minute. And I want people to pay close attention to this, because if it's prescribed differently than that, I want you to feel to talk to your provider about this other way that you heard it prescribed. I'm not saying that I'm, again, I'm not your medical provider.

Dr. Angela Zechmann (23:49):
Yes. We're not giving medical advice here.

Teresa Owens (23:51):
But I don't want you to change the way they're doing it. I want you to talk to them and ask them if this might be tolerated better for you.

Teresa Owens (24:01):
Because a lot of times, first of all, providers don't believe it when patients tell them that it's not well tolerated. And I will tell you that when I first took Metformin, I do not tolerate Metformin well at all. I took Metformin. I don't take it anymore, but I used to take Metformin because the benefits were so astounding that to me, they were worth the horrible side effects. And the side effects for me were truly disastrous. And it was, and so when people say, oh, I don't believe the side effects are that bad. I'm like, well, that's because either you haven't tried it or you did, if you did try it, you did not have the disaster side effects because they can be very severe stomach upset and severe diarrhea. And having said that, that doesn't happen to most people. So it doesn't happen to most people, particularly when it's prescribed appropriately.

Teresa Owens (24:57):
So when I say prescribed appropriately the best way to take it is generally through the extended release version. So there's, there is an extended release version and an immediate release version on the market. A lot of providers don't prescribe the extended release version because it used to be that the extended release version was very, very expensive. Yeah, it is no longer, very expensive, but a lot of providers don't realize that it's not expensive anymore. And so they're still prescribing the same one that they used to prescribe. And so I never prescribed the immediate release version.

Dr. Angela Zechmann (25:38):
Neither do I.

Teresa Owens (25:39):
The one exception to that is somebody who's, who's had weight loss surgery and that's because they can't take extended release versions of anything. But other than that, there's no reason to give anybody the, the, the, the regular release version of it.

Teresa Owens (25:56):
But again, a lot of providers don't because they, they used to have, if they prescribed the extended release version, they had to go through insurance companies, or patients would say, I can't do it because it's so expensive. They don't realize it's not expensive anymore. It's still under $10. If not like a lot of insurance covers it completely, you don't have to pay anything for it. So that's one thing. The other thing is a lot of times providers will say, I want you to, you know, they want you at, at a specific dose eventually. And they'll just say, here's the dose I want you at go start taking this dose and suddenly your body whose that's never seen this medication before is taking this medication that can be really hard on your stomach without having to adjust to it. And so we call that titrating.

Teresa Owens (26:46):
And so we want to start with a dose, what we call a titration dose, where we start with a low, you know, take one tablet a day, instead of four tablets a day. So if your, your doctor is prescribing Metformin and they're prescribing the standard release with a full say, 2000 milligram dose, and they say, just start it. Well, your stomach is going to be, you're going to be at worlds of hurt. This is not going to go well for anybody, even if you're going to tolerate it really well later, that is just a recipe for disaster. So if that happens, if first of all, say, you know what I read somewhere, or I heard on a podcast that there might be a better way to take it. I'm really afraid I'm not going to tolerate this. Can we talk about doing it differently? And if you explain to them it's not expensive, or, you know, I checked with my pharmacy, or I looked up on GoodRX, what the price is.

Teresa Owens (27:44):
It's not that expensive. I can afford this. I'd really like you to prescribe this one, check with them. And they'll probably prescribe the other one and they'll have learned something new too. And they probably will. It'll probably help them when they're talking to the next patient. Yup.

Dr. Angela Zechmann (27:58):
So so Metformin is the place to start.

Teresa Owens (28:03):
Yes. and then after that the next place that a lot of providers go is to a class of drugs that is actually not even on the algorithms anymore, which the algorithms, you know, the, the charts that recommend... And so there's two organizations that put out these charts. There's the American College of Clinical Endocrinologists and there's American Diabetes Association. Neither of them recommend as the second line, but many providers still prescribe as a second line, a class of drugs called Sulfonylureas. And those are the drugs that are known like Glyburide and Glipizide. So the ides is what I call them. And those are drugs that cause your pancreas to release more insulin.

Teresa Owens (29:02):
So the reason that people go to them is that they are covered by Medicare and they're covered by insurance and they are dirt cheap. So they're super cheap. They're easy to prescribe and nobody has to do any paperwork. The problem with them is that, and this is a reason why they're not on these charts anymore and not recommended anymore is that they can cause people to have low blood sugars, which is a problem. Because if you have low blood sugar, you can get dizzy, you can pass out, you can become disoriented. Plus, I mean, it just doesn't feel good and it's not healthy for your body to have low blood sugar so they can cause low blood sugar.

Teresa Owens (29:52):
And the other thing is that there's some evidence that they might wear out your pancreas cells that you want to keep going as long as possible. You want to keep them functioning as long as possible.

Dr. Angela Zechmann (30:01):
So they lower blood sugar by actually stimulating your pancreas to produce more insulin.

Teresa Owens (30:07):
Yes. So we don't want that. So again, there may be a reason that your doctor's prescribing that, that I don't know about and that again will be between you and your provider, but that those drugs aren't even showing up on the recommended medication charts, but the next, so there's three different classes of drugs that, that are pretty equal on the next class of medication that the second line medication. So it's always Metformin first. And then the recommendations for the next three are a drug called the class is called the DPP-4 inhibitors.

Teresa Owens (30:46):
DPP-4 inhibitors. And that, that drug, the one that's most commonly known as the brand named Januvia. Yep. So that drug works in a similar pathway to the next drug that I'm going to talk about. And I will say I've never prescribed this drug because I don't see that it has any benefit over the next drug that I'm going to talk about. And, but it is the one benefit that it has, it's an oral medication. It tends to be the one that a lot of people go to as the second line before the next two that I'm going to talk about because there's better insurance coverage for it usually. Okay. And Medicare covers it without as much of a, of a hassle. So, you know, again, a lot of, unfortunately a lot of these things are dictated by where, where insurance coverage comes from.

Dr. Angela Zechmann (31:44):
Exactly. Yeah.

Teresa Owens (31:46):
So there's there, there, aren't, there's not a problem with this drug. There's no reason to say this is a bad drug. I just don't think it does good as the other two that I'm going to talk about. And the reason, so the next class of drug that I'm going to talk about is called GLP 2 Receptor Agonist. Yes. So these are the drugs, the most common ones that you'll hear, you'll see advertised. It used to be that Victoza was the one that everybody knew about. And that was a once daily injection. The very first one on the market was Byetta. That was a twice daily injection. I took that one when it was brand new.

Teresa Owens (32:45):
I think I started taking it just three or four months after it came out. And it was remarkable and it was it was a big deal to be taking that drug. I was really excited about it. And and now there are long acting versions of those drugs that are once weekly. And so the one that you'll hear the most about that because it's advertised everywhere is Trulicity. But there's a few ... Trulicity and Ozempic are the brand names that I know the most of those long acting ones. You may also be familiar. This is the same class of drug as the newly approved anti-obesity medication. And I don't know how it's pronounced is it Wegovy something like that. Yeah.

Teresa Owens (33:41):
Maybe anyway same class of drug as those. So if you've just heard me say it, the same class of drug is this anti obesity drugs, big thing that these drugs have going for them is that they have, they can have a lot of weight loss associated with them. And that's one of the things that I really like about these drugs over the over Januvia is that all of the drugs in these class have weight loss associated with them. So Januvia the big, the big difference between Januvia and these GLP's, is what we call them, is that Januvia is what we call weight neutral. So you don't gain weight, but you also don't lose any weight on them.

Dr. Angela Zechmann (34:27):
It's a nice, it's nice. The GLP really do help with weight loss. And also, did you know that there's a, there's an oral form now, too?

Teresa Owens (34:35):
There is. I have, I have not heard of anybody getting it covered by insurance yet.

Dr. Angela Zechmann (34:40):
Yeah. That's been, apparently there's a $10 coupon. So some of my patients have been, oh, there's just always so much to think about when it comes to these medications for our podcast listeners. Like, yeah. It all depends on your insurance, but we just want you to know what the options are.

Teresa Owens (34:58):
Yeah. And I will say I I haven't even tried because I've just like, I've gotten really good at getting really good at getting the injectables covered that I'm, you know, I kinda know the tricks to get the injectables covered. So I haven't even tried. Most of my patients are really good. So one of the things, a lot of times when people think, oh my goodness, it's an injectable. It must be insulin. It is not insulin. It's not insulin at all.

Teresa Owens (35:26):
A lot of people also say, oh my goodness, I've, I've failed because I have to take this drug. That's injectable. No, it's not. A lot of people are afraid because this injection is going to be painful. The daily ones, especially are tiny, tiny little needle that you barely even notice. It's not painful. I say this as somebody who's taken thousands of injections now in my life I don't even notice it. The the, I will say that Trulicity isn't pleasant, but it happens once a week and it's not the end of the world. It's not, again, it's, it hurts less than putting a sensor in my arm. Okay. so that's not that it's not that big a deal. And it, it takes less than five seconds to do it. So, you know, they're pretty easy. And for a lot of people, I have them pick it up at the pharmacy and bring it in and we do the first injection in my office.

Dr. Angela Zechmann (36:25):

Teresa Owens (36:26):
Or we do it over, we do it together over video. So yeah, so it makes it a little bit easier to talk them through it. And we can just do it together. So cause a lot of it there's fear behind how does it work if you've never taken, if you've never given yourself an injection before it can be really frightening. It's really not that big of a deal. Yeah. It seems like it is. And we work really, really work it up in our brains. But when push comes to shove, it's not that it, you know, take a deep breath and be done with it. Yeah. So that's the next class.

Teresa Owens (37:04):
And then the third drug that is the third class of drugs that happen, that is also recommended second line behind Metformin by the these two tables, is a class of drug called the SGLT2 inhibitors.

Teresa Owens (37:22):
And these are the drugs. The brand names that I know are Invokana and Jardiance and there's another one that's really common. I also call them the the Flozins.

Teresa Owens (37:34):
Anyway, these drugs are they, the way that they work is they filter the sugar out in the kidneys. And so you basically pee out the excess sugar in your ... You take in the sugar and pees out the excess sugar and it's pretty remarkable the way it works. There's few downsides to them. One is that it can, they can cause yeast infections, particularly in women who are prone to yeast infections. So if you are prone to yeast infections, pay attention to that.

Teresa Owens (38:31):
I do not think that that is a reason not to take this drug. It depends on how bothersome the yeast infections are. If you have, you know, some, some women with diabetes already have chronic yeast infections and maybe they need to be taking a medication to prevent those chronic yeast infections. And this drug, you know, unless, you know, you're suddenly getting yeast infections that you've never had before. And these yeast infections are big and bad. That might be a reason to stop. But I think that this is, these are drugs that are worth trying and and they're really excellent at lowering the blood sugar by a couple of points of A1C. They also are excellent for weight loss like the and oh, I forgot to mention about the GLP's, and the, and this drug also have cardiovascular benefits that have been proven now in studies as well.

Teresa Owens (39:30):
So it's pretty remarkable that there's and the Flozins have, so this SGLT two class also have kidney indications as well because they help with kidney function. Yeah. So they're pretty remarkable. These, these medications that the things that they're finding out that they can do this is the drug that I was mentioning, however, that you should not absolutely should not be doing a ketogenic diet when you are on this medication. Unless your medical provider is very aware that you are doing a ketogenic diet and they are monitoring you. So do not do not do not do a ketogenic diet on your own, if you are taking an SGLT two inhibitor. So that's Jardiance, Invokana any of the Flozin drugs because they are, they can be dehydrating and they can if you are insulin deficient and you didn't know you were insulin deficient, they can bring your blood sugar down.

Teresa Owens (40:34):
So things look like they're going really well, but then you could have what they call euglycemic diabetic ketoacidosis, which means that your blood sugar looks great, but you end up in the hospital with ketoacidosis and that is very bad. Yeah. So that, those, that would be the big warning that I have about that drug. So the other thing about all these drugs, those three drugs that I just mentioned or three classes of drugs, three classes of drugs. Yes. Three classes of drugs plus Metformin is that you can stack them. So when you're taking Metformin, the recommendations are that you know, so a lot of times I'll have somebody come in and say, oh, you know, I really want to try and do this all without medication because I just, you know, I know, I know I can do this without medication.

Dr. Angela Zechmann (41:31):
I hear that all the time.

Teresa Owens (41:34):
And my first response is okay. We can try that. But I want, I want to talk a little bit about what the motivation for doing it without my medication is. And also I want to talk about the fact that the quicker we get things under control, the less likely it is to progress Fastly ,fast quickly. That's the word I just made up.

Dr. Angela Zechmann (42:03):
The less likely it is to rapidly progress. So I would rather get somebody started on medication right away and be able to, to drop the medications later.

Dr. Angela Zechmann (42:14):
Yeah. that's one thing people don't understand. It's like, if you can get diabetes under control very quickly, your long-term outcomes 10 years from now are so much better. And the research is really validating that.

Teresa Owens (42:27):
Yeah, it is. It is, the research is solid on that. Yeah. And you know, th the, the earlier the faster we can get things under control the better, which is why. So if somebody says, I, you know, is really absolutely firm in their conviction that they don't want to do medication. Okay. The longest I'm going to give them is three months. If you can turn it around in three months, then we'll talk. But, you know, and, and we'll, I'll say, okay, so here's, and then here's the things that you really need to do.

Teresa Owens (42:59):
And then these also need to be things that you're willing to do for the rest of your life and not just for three months. Right. So, you know, it's not just to show me that you can bring your A1C down in three months. It's show me that you can bring your A1C down, and then you can keep doing these things for the rest of your life because diabetes doesn't go away. Yeah. It can go into reversal, but it can't, it doesn't go away. Your body's still gonna, that is still going to be there. So so I want to start on medication right away. If Metformin in three months, this is what the, the table recommends. If, if Metformin doesn't work in three months, then you add a second agent.

Dr. Angela Zechmann (43:39):
So that's what you mean by stacking, you're going to stack medication.

Teresa Owens (43:42):
So you've got, so say I start Metformin on somebody. And three months later through my, what I say three months later, I say three months after they've gotten up to the full dose that they tolerate. Right? So they might not, it might take them two months to get up to the dose of what we want them to. So if they're, you know, so it, five months later, they're still not at what their A1C goal is. The blood sugar goal that we want them to be at. Then I'm going to add another drug. And so we're going to talk about which drug we want to add. So say we're going to add one of the flows. So the one that, because they don't want to do an injection yet. So we're going to add the one where they pee out the sugar. So fantastic. So we're going to add that one, three months later, their, their blood sugars better.

Teresa Owens (44:31):
They've done doing their lifestyle work. Things are looking better, but they're still not at goal. We've got two other drugs that we can try. No, we would never stack the DPP-4, which is the Januvia and the injectable that I talked about those GLPs, because those two do the same thing. Even though they're different class of drug, they do the same thing, even though they do it differently. So then I would choose either the Januvia, the oral one, or the GLP or the injectable one. And you know, if they, if weight loss was an issue and they wanted to work on losing weight, then we would probably recommend the the injectable. Yeah. The GLP. But if they really didn't like, no, I'm not going to take an injectable. Okay. Then we'll do the DPP-4. And then we'll still, so, you know, we keep stacking and then if they're still not managed after that, that's when we start looking at it, adding insulin.

Teresa Owens (45:32):
So we're not going to talk about insulin today, other than to say that at some point, because we do really need to worry about those long-term microvascular concerns, because we don't want blindness kidney failure and amputations.

Dr. Angela Zechmann (45:49):
Well, there's another treatment that you have not mentioned.

New Speaker (45:53):
Yeah. I haven't, and I love this one and people don't love this one, but I do. And that is bariatric surgery, weight loss, surgery, and weight loss surgery. How does that fix diabetes? And the answer is nobody is quite sure how, yeah, but it does. And I just watched a lecture just yesterday. And I wish that I had written down the statistics on this. And I will give them to you Angela, to post with your notes on what the percentages are of how many people put their diabetes fully into remission. So when I was a baby registered nurse working my first job on a hospital floor, they were doing bariatric surgeries on that floor.

Teresa Owens (46:50):
And I'm not sure if I ever told you this story, this is the first thing that made me interested in obesity medicine. I would see patients before they would go for surgery and they would have a sliding insulin scale taking just loads and loads of insulin. And I see them the night before, you know, they check in for their surgery the night before and, you know, we'd give them insulin. And then the next day after their surgery, they would have their sliding scale and they never needed insulin again, that's so fast. This surgery worked. Wow. They didn't need that. Came out of surgery, not needing insulin.

Dr. Angela Zechmann (47:34):
Yeah. That's incredible. Well, I've heard statistics that it's a 78% cure rate. That's from a few years back. I don't know what, the more recent statistics are.

Teresa Owens (47:45):
I think it was higher than that. The part of it is... And this is the thing that was interesting about the statistics that I saw in this lecture that I saw yesterday was that he broke it down into, I think, into how long it had been since diagnosis. And this is the important thing is that the earlier following your diagnosis, that you get the surgery, the better, the results are just like the earlier that you get on getting these, you know, that you get your diabetes under control. Initially the better your longterm prognosis is the better. So if you stack a few drugs and you get your A1C down and you get your diabetes under control, you might be able to come off. Some of those drugs, you might not, you might stay on them, but your blood sugars are more likely to stay under excellent control, longer term. You know, the earlier you do that stuff, the better, the results are the easier it is to make those, to get, to get your body, to respond the longer that it's been since your diagnosis, the data on how effective it is, goes down. Yeah. So it's still going to help. It's still going to improve your insulin sensitivity. It's still going to, because you're going to be losing weight, but it's not gonna have as dramatic an impact as and the impact won't necessarily be as long lasting. And I saw a statistic one time that showed how long the remission stays. And it was remarkable. Like it puts people into remission for like seven to 10 years before they even start getting their diabetes back, even if they're gaining some of their weight back.

Dr. Angela Zechmann (49:36):
So the story that I'm hearing from you, Teresa, is if you've got a diagnosis of diabetes, don't be afraid of medications, don't be afraid of surgery. Do whatever the heck it takes to get this under control and keep it under control as quickly you can so that you can live a more normal, happy, healthy life.

Teresa Owens (49:57):
So you can take your grandkids to Disneyland. Yeah. What is the thing you want to do when you're an old lady or an old man? I mean, what do I want to do those things? And, and that's honestly, one of the other things I talk about with my patients is what's your motivation? Why do you want to live a long, happy, healthy life? Why do you want to feel like one of the things that really motivates me is I love seeing beautiful things. I am so motivated to keep my blood sugars down because I can't imagine losing my eyesight. I just, that just like, I just can't even imagine not being able to watch the sunset, but just, I can't imagine not going for a walk. I mean, drives my husband crazy and we'd go for walks. I'd have to stop and look at every flower. I can't imagine not stopping, looking at every flower and talking to everyone and what would happen if I lost my eyesight, I wouldn't be able to do that anymore.

Dr. Angela Zechmann (50:56):

Teresa Owens (50:57):
And that is, that motivates me so much.

Dr. Angela Zechmann (51:01):
Yeah. Yeah. So find out what your, why is for getting your diabetes under control and then, and then do it and do it. Yeah. And then the other thing I'm hearing you say is don't be afraid to talk to your healthcare provider about new and different treatment methods. If, what, what they have, what's what you're doing. Isn't working.

Teresa Owens (51:24):

Dr. Angela Zechmann (51:27):
And don't blame yourself if it's not working either.

New Speaker (51:30):
Don't blame yourself. There could be something going on with you, not you. I mean, not, not wrong with you, but your body could be saying, well, this isn't the thing that works for me. It could be that there's something more that needs to be learned. So not only don't be afraid to talk to your provider, but if you talk to your provider and your provider isn't receptive and doesn't want it, it's okay to shop for a different provider!

Teresa Owens (51:52):
I think it's really important to have a provider that you can be in a team work with. And you know, we don't do that a lot of times we think, okay, well, we've been so trained in our culture that people that have medical training, they know what's best. So I need to pay attention and do what they tell me to do. Well, you only have your body, it's your body and you are the boss of your body. Yeah. So if you're not getting what you need from your provider and they're not taking your concern seriously enough, it's important that you find somebody that's been working in collaboration with you.

Dr. Angela Zechmann (52:36):
Find somebody you can talk to. Yeah.

Teresa Owens (52:38):
That's. Yeah. And that's honestly, that's one of the biggest things that drives my, my practice is that you know, I want to be that for my clients and that, you know, that they haven't been listened to. A lot of them haven't been listened too, because of they have excess weight. And so people think, well, that's, that's why they, that's why whatever is happening. And so that really drives my practice. I want to be that for them. I want them to have that collaborative feeling that they can get. And so I want everybody to be able to have a provider like that. So if you're not getting that, there's somebody out there for you find them.

Dr. Angela Zechmann (53:17):
So we're going to actually you're gonna send me links to the charts that you were talking about, the American College of Clinical Endocrinologists. Yes. so that people can actually have, you know, some sort of guidelines that they can take in and show their providers and say, Hey, you know, like here's, what's, here's what the recommendations are. And I'd like to, I'm interested in expanding my treatment options. You could use, you could use those words.

Teresa Owens (53:46):
Exactly. And again, it's not a do this. I'm the boss of my body because they are the people that have the medical knowledge. I'm here sitting in a room somewhere. I don't have the medical knowledge of anybody who that we're talking to right now. So I don't know, but you have the knowledge of your own body. Your medical provider has their medical knowledge and together you should be able to come up with what works for you. So, you know, but doing it in a collaborative way. And I think I mentioned, I think it was the last podcast that I mentioned that I took to my, I was tried to be very respectful whenever I took information to my provider and to acknowledge that she was the one that has the medical knowledge, but this was information that I found and I wanted to try and I never asked her to make the change at that appointment. I always said, can you please review this? And let's talk at our next appointment, or can you please review this and I'll schedule an appointment next week? Or can we have a phone call next week?

Teresa Owens (54:53):
Because I didn't want to put her on the spot and have her.... I didn't want to say, I know more than, you know, right. Yeah. Because at the end of the day, she was still the one with the medical knowledge. I wasn't, I was the one with knowledge of my own body. Yeah. And I read an article.

Dr. Angela Zechmann (55:17):
All right. Well that, this has been so awesome, Theresa, thank you so much for educating us about diabetes and what it's like to live with diabetes. And there's just so much to know. I feel like we could just go on and on and on right?

Teresa Owens (55:31):
so I could talk about diabetes forever.

Dr. Angela Zechmann (55:35):
Yeah. But it's a, you know, it's a huge piece of weight loss medicine, and really, you know, those of us in the field of weight loss medicine you know, we understand that the diabetes is out there and prevalent and we need to know about it. So I really, really appreciate your taking the time to educate all of us. Do you have any last minute thoughts at all?

Teresa Owens (56:04):
Don't be afraid to do it early and get it done.

Dr. Angela Zechmann (56:07):
Yeah, I think I would say that too, just don't be afraid of surgery either.

Teresa Owens (56:12):
Yeah. And that was the thing that really stuck out to me was that I think they said one in 160 people that it would benefit by getting surgery. Yeah. Was the statistic that...

Dr. Angela Zechmann (56:26):
And the quality of life is so much better after surgery. I mean, it's just, it's a really remarkable thing that they do, so, yeah. Yeah.

Teresa Owens (56:35):
So, and yeah, it's, I've seen lives completely changed by surgery and yeah. And like I said, it totally blew my baby nurse mind when, when I saw firsthand what was happening. So pretty remarkable. But yeah.

Dr. Angela Zechmann (56:58):
All right. Great. Well, thank you so much. And thanks to all of our podcasts listeners, if you have any questions or comments just go to journey beyond weight forward slash blog and type in your question or comment, or you can go to YouTube to Dr. Angela Zechmann on YouTube. The podcast gets posted there as well. And if you are interested in having Teresa as your advocate and a healthcare provider tell them where they can find you.

Teresa Owens (57:29):
So that only works if you are in physically in the state of Washington, because that's where my license allows me to treat people. But I do see people, I do see people virtually so you can be anywhere in the state of Washington that works. And you can find me at,

Dr. Angela Zechmann (57:50): And we'll put a link up on the show notes for that as well. So. Awesome. Well, thank you so much, Theresa.

Teresa Owens (57:59):
Thank you for having me!

Dr. Angela Zechmann (57:59):
All right. So bye everybody, and we'll see you next week.

Closing (58:04):
Hey, if you really want to lose weight and keep it off for good, your next step is to sign up for Dr. Angela's free weight loss course, where you're going to learn everything you need to get started on your weight loss journey, the right way, just head over to to sign up. Also, it would be awesome if you could take a few moments and write a review on iTunes. Thanks. And we'll see you in Journey Beyond Weight Loss. 


- Dr. Angela


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