Hello, everyone. Good afternoon. My name is Benita Arroda, Dr. Arroda. I'm a director of diabetes clinical research at Brigham and Women's Hospital and associate professor of medicine at Harvard Medical School. I'm so pleased to be joined today by our patient advocate, Katerina Garrett. Would you like to say hello? Thank you, Dr. Arroda, yes. Hello, everyone. Well, we have a treat for you today. So we are incorporating the patient point of view and share decision-making in the management of type 2 diabetes with comorbidities. These aren't my disclosures. I've had the privilege of being part of the clinical trial programs for many of our treatments in the type 2 diabetes space. And Ms. Perry has no commercial relationships to disclose. Okay, so let's get to learning. What's unique about this program is even the objectives of the program that we came up with are evidence-based. So based on kind of the educational initiatives and review of the landscape, the following gaps were identified that clinicians do feel challenged with how do you incorporate the latest evidence on GLP-1 receptor agonists and SGLT2 inhibitors and the management of individual patients with type 2 diabetes and comorbidities. And that patient provider communication in type 2 diabetes can potentially be suboptimal and then that can affect adherence to treatment. So therefore, our learning objectives are to apply the recent data regarding these two cardiometabolic classes of medications, GLP-1 receptor agonists and SGLT2 inhibitors, and incorporate the shared decision-making strategies, incorporating our patient voice here, thanks to Ms. Perry, to optimize type 2 diabetes care and enhance treatment endurance. So let's get right to it. Good question, rhetorical question. Where does person-centered care begin? From all with the person in the middle. So I've been privileged to be part of the ADA and EASD international consensus that has updated the guidance and recommendations for management of type 2 diabetes. And at all of our meetings, it was where does care begin? The goals of care start with the patient in the middle to prevent complications and to optimize the quality of life. And what you can see here is that it was a circle of care. It was a circle of priorities. There's no beginning, there's no end. We continuously revisit the same care goals with our patients with type 2 diabetes. So whether it's medications for glycemic management, weight management, cardiovascular risk factor management, cardio-renal protection, using the right medications to help reduce the risk, these are all important components of care that we revisit iteratively. And in terms of principles of care, this could be an ever-expanding list where it just takes a lot for us to get it right, where we have to use the right language. We have to make sure it's an equal level shared decision-making process. We have to consider the patient in front of us and consider what's the underlying physiology. We have to think about the comorbidities, the accesses, and the list goes on. So now I'm gonna hand it over to you, Ms. Perry, and I think I can call you Katerina. Yes, absolutely. From our previous interactions. Do you wanna share a little bit about your history? Yes, of course. So I've been a patient with initially diagnosed with a thyroid condition very early in my life and developed prediabetes and type 2 diabetes many years ago and have lived with, struggled with this diagnosis for quite some time. And it really, it takes over your life. You know, there is just so, there are so many attributes that weigh in on a patient who has this disease state that overarch into other areas. And I can honestly say that throughout my course of treatment throughout my life, it's been a bit of a struggle to try and find the exact right team that suits my needs. And I'm happy and blessed to say that I finally have. And the approach for me now has been almost, almost enjoyable in that I've been able to find collaborative, compassionate care, which has made all the difference in the world to my ability to lead a better quality of life. That's wonderful. I think it's, when we learn about ourselves, there's a lot of enjoyment in that. So I love how unprompted this was and that your treatment goals completely line up with the goals that we've have in the national and international recommendations, really focusing on quality of life. When we talk to patients with type 2 diabetes, a lot of times they'll say, I wanna dance at my daughter's or my granddaughter's wedding. So it's really about that quality of life. And you shared two important points and I'm gonna ask you to elaborate. So you mentioned that your journey was fraught with guilt and shame. We have a lot of learners in the audience. Can you address how we might be able to tackle this to change that experience? I think, yes. I think listening is very important and understanding is very important and not making the assumption that the patient doesn't understand the struggle. I think for me, when I speak of guilt and shame, I've had many interactions with the medical community over the course of my treatment where the conversations were sort of, whether they be sort of dumbed down for my ability to understand or people just weren't necessarily considering me in the conversation. I've had instances where I've had a doctor walk into the room, not even introduce himself to me, look at me and say, I can't do anything for you. You need surgery. I don't think it's any surprise to anyone. I never went back to that doctor. For me, it's always been about being compassionate. I'm not someone who responds to directives or tough love, as I like to say. We're not dumb people. People in this disease state, we're not stupid. We know what we look like. We know what the challenges are we have. We live it. I live in this body every day. I can tell you better than you probably know the struggles that I have, but it was never really sort of provided to me in sort of a compassionate, I want to help you way. It was just sort of this sort of textbook kind of conversation where if you do this, this, this and that, then you will lose weight. So there must be something wrong with you because you're not doing, if you're doing X, Y, and Z, then you should be A, B, or C. And it's not that simple. So one of the ways we tackled this, thank you for sharing that. So insightful. While not all patients are doctors, all doctors are also patients. So we want to treat each other with respect and compassionate care as you highlighted. So I think one of the areas in terms of where it starts is establishing the common care goals. Was that done early with you or how does that manifest itself in care? I will say that I haven't, again, just recently, I would say in the last five years, I've really connected with a great care team and everything that I kind of would have wished for early on in my life, I've now been able to achieve with my care team. I think the difference now is the collaboration. You had mentioned earlier, Dr. Irota, the common conversation and listening to one another. And I think that's really important. On the patient side as well. I mean, this is not just the responsibility of the medical provider, it's the patient's responsibility to become a team, trust your team, be honest with your team. And I think that certainly for me has made all the difference. Thank you for sharing. Thank you for sharing. In a way, when we establish the care goals, everything else becomes easier because everything else is a tool to support those common care goals. So let's move into type 2 diabetes. The unique thing about type 2 diabetes is there's not a part of the body that it doesn't affect. We know that type 2 diabetes is complex. It contributes to increased risk of comorbidity and mortality, including increased risk of cerebrovascular disease, diabetic retinopathy, hypertension, obesity, cancer, gastroparesis, chronic kidney disease, peripheral vascular disease, and the list goes on. So this can be a bit frightening to hear and to consider. And so again, part of our treatments are geared towards addressing the increased comorbidity and reducing that morbidity, reducing that mortality. And we've known since the very foundational UKPDS study that early glycemic management can help reduce the risk of these complications and that every 1% lower risk of A1C is associated with decreased risk of all of the complications from stroke, eye complications, heart failure, heart attack, peripheral vascular disease, death related to diabetes or others. Now, as part of the consensus, we really looked at the goals in diabetes care and we simplified it into two different branches. I'm gonna go over this in a little bit more detail. So on the left side, we said, okay, with every patient with type 2 diabetes, we have two primary goals. On the left side is, I want to help you to protect your organs. So cardio renal protection in individuals who are at high risk of developing complications. On the right side was, I want to help you to achieve your blood sugar and weight goals to reduce the risk of complications. So we simplified it to two key assessment and plan areas, if you will. And every single word on this is entirely evidence-based. So with glycemic management in previous guidelines, it was all about the medications, one, two, three, four, treat with all of these different medications. And here we said, let's keep our eye on the prize. Let's focus on the goals. So with glycemic management, you need to choose agents that provide adequate efficacy to achieve and maintain treatment goals. Because again, it's maintaining glycemia reduces the risk of complications. Now that could be metformin. It could be combination therapy. It could be one of the higher efficacy therapies that we have. And we listed the efficacy order so that that information can be part of the conversation. We know that in type 2 diabetes, that there are differences in the medications and how effective they are. What we've learned recently in the last few years is that the GLP-1 receptor agonist, the newer generations are very highly effective. So it's not the same as the traditional treatments. We are now seeing average A1C reductions that we have not seen before. So we do have highly effective therapies within the GLP-1 receptor agonist class shown on both curves. So now back to an important part of the shared decision-making conversation is the relationship between glucose and weight. So Katerina, you shared that, again, these keywords that your journey was fraught with guilt and shame. And this was revolving around losing weight. Can you share a little bit about your history there and a little bit about the conversation about weight and whether you have any tips for others, patients or clinicians, as they have the conversation about weight? So I think the weight portion becomes the primary goal for the patient when you live in this world and the mindset needs to change. And I think the patient mindset needs to change to becoming healthier, not... The weight loss is a side effect, right? So for me, anyway, the weight loss was a side effect. When I really started to focus with my new medical team about really understanding A1C and what that meant and really understanding kidney health and neuropathy and eye health and this total body experience and talking about those goals is when the weight... I don't wanna give someone a misleading idea, but the weight just sort of came off for me because I was focusing on living a healthier life, being better, really focusing on my A1C. I am so proud today to say that when I first started this journey five years ago, my A1C was well over 10 and I just took it this morning, it was 6.3. I'm thrilled, I'm thrilled. I keep them on my fridge, like pictures from my kid's school or a kid's school. And I think that's the message needs to be changed. Your patients will come to you looking for solutions to look better. It's just, that is the truth because we see what we see when we wake up in the mirror and everybody sees what they see. So our primary goal in reaching out initially is to look better. That notion, that idea needs to change. And I think the patient needs the medical community's help to understand that. I can tell you now that I have lost a substantial amount of weight and just my overall quality of health could not be better. I feel better, I move better. And that's what makes me happy now, not what I look at in the mirror, not the fact that I was able to buy a smaller clothes size or something like that. I'm like, I call my family now when I get my A1C results, it's like, oh, it's 6.3. That narrative needs to change because right now the narrative is very much on external things. And that comes directly to you from the patient. So you're not in an easy position and that's why I keep stressing, certainly for me, this open discussions with compassion and collaboration are so important. If I can change my mindset, then other people definitely can. I love, again, it's kind of reframing the conversation around health goals. So, and because weight can fluctuate up and down and we, and, but health, it's, health is the journey. So in terms of weight, for the first time ever, we incorporated this in our treatment algorithm for care of type two diabetes. This has never been done before. And the reason being is that we know that when we address body weight, we are also addressing the underlying pathophysiology of type two diabetes. And we know there's a number of ways that one can support individualized weight management goals. There's general lifestyle advice, there's medical nutrition counseling, physical therapy activity, intensive structured weight management programs, medications for weight loss, metabolic surgery. But when we have a choice with our type two diabetes treatment agents, we actually have agents that have high to very high effect on both glucose and body weight. So we incorporated those here with the very high ones being semaglutide and trisepatide. And so here again, our network meta-analysis showing that not all diabetes medications are treated equally in terms of their effects on body weight. You can see with the newer medications, the potent GLP-1 receptor agonist, followed then by the SGLT2 inhibitors, we have a greater weight loss that accompanies the glucose control. So the field has really shifted recently. And in fact, this is one of the papers by Professor Lingvay and colleagues that really nicely captures the reframing of the conversation. Now, a lot of times, historically, we focus on the glucose because we know that if we lower the glucose, we lower the risk of complications. But what comes upstream to the glucose, it's obesity or adiposopathy or abnormal fat. And that leads to increased risk of diabetes, but also increased risk of other conditions. And this is in effect across the entire continuum. So if we can target weight, we can prevent the development of metabolic morbidities across the entire continuum. I love sharing this study from 1986 by my own mentor, Dr. Bob Henry, where he asked the very simple question, if you target weight loss, can you affect the pathologic mechanisms that contribute to high blood sugar? And yes, the answer was yes. He put people on a very low calorie diet, very regulated and did all the physiologic studies showing that with about 16% weight loss was what it was on this very low calorie diet. There was improvement in the hepatic glucose production, lower fasting glucose, improvement in the insulin sensitivity of the body, even at the fat level itself through fat biopsies, and even the pancreatic beta cells all worked better. There was enhanced sensitivity to the oral glucose. And we know that all of these defects contribute to the high blood sugar, but targeting weight loss itself can reverse some of those defects. So back to you, Katerina, can you tell us more about your history? Yes, so relative to my medical path, I think one of the things that has really helped me significantly in recent years is having a team of physicians that have taught me about all of the comorbidities and the effects that it's having on me, in addition to really focusing on total body health. Sort of, you know, very fortunate now to have a team where there's a podiatrist on site, there's an ophthalmologist on site, there's a physiologist, nutrition people, whatnot, sort of one-stop shopping. So it can be very confusing when you're talking about comorbidities. There are so many that can affect you, and to try and find those resources on your own, it's frightening. But working within a team that understands all of the different components, even sort of to a holistic nature, there's been some times when I've had side effects, nausea, side effects, and things like that, and I've spoken to my medical team, and it's like, well, try this ginger, or make sure you stay hydrated, or try this mint tea, or something like that. So that's been very, very refreshing and very helpful. Being in a diabetic state is frightening because of all the comorbidities, but you really don't, I hadn't until recently had a medical team that really taught me, took the time to teach me what those comorbidities mean. I mean, I just, for the longest time, I thought I was diabetic and needed to lose weight, and that was the end of it. Didn't really understand why I was diabetic, number one, and why losing weight would help the total body experience and the total body health and fitness. It really is a holistic process. I thank you for sharing. I wish we could, we are capturing this for future generations and how we're gonna deliver care. So in starting a GLP-1 receptor agonist, what kind of education or pointers were you given before starting? And now from a patient perspective, because that's probably the most perspective, what pointers might you provide another person who's about to start these medications? I'd say education is so important because it's very easy to lose direction and lose hope and get depressed or in your head about, well, this is causing me to be nauseous and what does that look like? So again, having a team sort of explain the process to you and what could possibly happen from something, but there are ways to do this. Now I don't have just a, you will do this. I have a, well, this is plan A, this is plan B, this is plan C. If we do plan A, this is how it might affect your life, but we can also try this. And it's a very collaborative approach, which I've always sort of appreciated and has been unbelievably important for me and my health goals. I will say to the patient, stay the course, stay the course. Find someone and keep trying. Don't give up, don't give up. I'm gonna be 57 years old next week. And it took me until I was about 50 to find the right team. And I can't tell you how happy I am. Life begins at 50, as they say, and it certainly did for me. Stay the course, find the right team, trust that team. Be honest with that team. We're responsible for our own health as well. It's not just on the doctor. Make sure you're being honest with your medical team. They can't help you if you're not. I've been able to find that right solution for me, and it's been an unbelievably worthwhile experience, but stay the course, don't give up, don't get frustrated or depressed, and find your people who are gonna lift you up. But stay on the course. In a way, the education goes both ways. So education, education, education. So now I'm gonna, again, put on the physician hat. What do we think about before we prescribe a GLP-1? There's very few contraindications. The two, so the one absolute is if there's a personal or family history of medullary thyroid cancer. This is extremely, extremely rare. And the reason why is because there was a risk of C-cell cancer in rats, but this has not panned out in human studies. And we do know that there's a difference between rodent thyroids and human thyroids, that in this case, humans are not mice. So we know that rodent thyroids have abundant C-cells, human thyroids do not. Rodent thyroids have high GLP-1 expression, human thyroids do not. Rodent thyroids' response to calcitonin secretion in response to GLP-1 receptor agonists, human thyroids do not. But I say this because if you don't, if you're not proactive about it, patients will look online and they'll say, doc, you didn't tell me about the seabird. So know the evidence and that this is why those with medullary thyroid cancer, it's listed as a contraindication. The other kind of relative, it's not listed in all the labels, but pancreatitis is another caution. If someone has a history of pancreatitis, that's where I would have caution in using this class. So here's a list of areas of caution and opportunities for education. So we do know that there's a small, but increased risk of gallbladder disease, whether that's related to weight loss or direct mechanism of action is not clear. So we educate patients about signs and symptoms of gallbladder disease when they should check back with you. They're developing right upper quadrant pain, especially after eating. Pancreatitis cases have been reported, but causality has not been established. But because of this, you wanna make sure you're educating about the signs and symptoms of pancreatitis. If there's persistent nausea, vomiting, abdominal pain, radiating to the back, then you'll want to pause the medication and come in for evaluation. In terms of retinopathy, we know that anytime there's a significant reduction in glucose lowering, that it could increase potentially retinopathy complications. And this has also been seen with insulin. So if someone has known proliferative diabetic retinopathy, you wanna make sure that they're plugged into their ophthalmologist as you're getting their glucoses under control. Now, in terms of kidney function, there's not a direct adverse effect on kidney function. In fact, the flow trial just showed kidney protection. But if there is gastrointestinal intolerability, such as nausea or dehydration, that can cause a change in volume status, which can then precipitate a change in renal function. So this is where you just wanna put on your general medicine hat and monitor renal function if there's any significant volume status change. So these are just the overall cautions. And then back to the education, education, education. I love working with these agents because it allows you to really integrate and incorporate lifestyle counseling just by virtue of prescribing them and educating patients about them. So, you know, we often talk about the mechanism of action. These medications work by slowing the transit of food from the stomach to the intestines. They work on decreasing appetite. They also work to enhance your sense of satiety. So listen to those signals, have mindful eating. You may reduce your meal size. For some people, it's gonna be half of what they ate before. So it's okay to reduce your meal size, have mindfulness, avoid high fat, spicy foods, moderate alcohol intake. And if you're feeling nausea, you know, you can have some crackers, have smaller meal sizes. There's ginger chews, mints, teas, you know, just kind of the TLC approach. We also have options with escalation of the doses. We can take it slower. We can take it more gradually in terms of the dose escalation. So we usually start low and go slow per the label but we have dosing flexibility to pause, to reduce, to really listen to the patient and work with the patient. If there are side effects, again, this is putting on our general internal medicine hat of, you know, addressing them with lifestyle behavioral changes. But if we need, there are pharmacologic treatments available. For example, if there's reflux, we have anti-reflux medications. If there's persistent nausea, we do have anti-nausea medications. If there's problems with volume status or hydration, you know, we have recommendations there as well. So I highlight this really nice consensus by Wharton and colleagues, which gives you the different scenarios and when you might want to consider additional therapies, but there's really not a consensus that every person needs to be treated pharmacologically if there's side effects. I tend to favor more of the lifestyle counseling approach and helping patients learn their body and learning the signals with these medications. Another really exciting area is, you know, we're all used to adding medications, but guess what? With the GLP-1 receptor agonist class, we've been able to learn how to decrease medications. Katerina, you shared on your previous story that you've cut your dose of insulin by half around. Yes. Yeah. So when I originally started, I was on two different types, a long-lasting and a fast-acting. I'm not on the fast-acting at all anymore and the long-lasting, I've significantly cut down to half of what my other dosage would be. So I'm very, very pleased. Wonderful. So based on your experience, as well as experience with many of our patients, Nicole Earhart at the University of Washington and I and a group of colleagues, we put together a kind of consensus recommendations on how to address people who are on insulin. So what we know is that the GLP-1 receptor agonist, they work in a glucose smart fashion, whereas insulin does not. Insulin works around the clock no matter what. And so you want to, I call it lift the foot off the brake. You want to kind of ease the insulin to let the GLP-1 do its job. So if someone has a reasonable A1C, then when you initiate the GLP-1 receptor agonist, go ahead and prophylactically reduce the dose of insulin. So I give a little bit of a scare by about 20%. And then instead of titration instructions, I give down titration instructions. So once your fasting glucose is start going to less than 100, keep reducing the insulin dose by about 10%. If you're having even lower blood sugars, then by about 20%. And then people who are treated with insulin, this is where a continuous glucose monitor might be of help in terms of seeing the glucose profiles during the day and then prophylactically and proactively reduce the dose of insulin or sulfonylurea to then allow the GLP-1 to have its optimal efficacy while minimizing the risk of hypoglycemia. So next, then back to you, Katerina, on starting an SGLT2 inhibitor. You started empagliflozin a few months after being treated with the GLP-1 receptor agonist. And do you know why you were started on it and what educational tips you were provided? So again, the collaboration, the medical team I have now is very informative. They're very open about why they feel I need to be on something, the benefits of it, the possible downside of it as well. So very, very much educated. I think for me, it was much of a preventative course, but being a participant in my own health journey has been very empowering to me. And I feel as though that's what I've been mainly gained from the relationship that I have now with my medical team. You feel like you're in charge of or have a voice in your own care, which is imperative, I think, certainly. But I can honestly say that I've been provided with no medication or anything without full information provided to me so that I could make the decision about what's best for me or what I'm willing to do or what I'm willing to not do. And that's been life-changing. Amazing. So we have come to learn with trials encompassing over 200,000 participants that have really shaped the field that we really have two cardiometabolic classes of medications. We have the GLP-1 receptor agonist as well as the SGLT2 inhibitors. Both classes reduce major adverse cardiovascular events, cardiovascular mortality, total mortality in persons who are at risk of cardiovascular disease. But in addition, the SGLT2 inhibitors reduce the risk of heart failure, reduce the risk of kidney progression. We know that GLP-1 receptor agonist reduce the risk of stroke to help target obesity. And now with the flow trial, also some effect on kidney progression as well. So the left side of the algorithm, again, simplified. What you'll see here is we did away with the arrows. There's no little arrows creating different paths. The left side is the cluster of individuals who are at higher risk of cardio renal complications. So for these individuals, we prioritize the two main cardiometabolic classes, the GLP-1 receptor agonist and the SGLT2 inhibitors. So how do SGLT2 inhibitors primarily work in terms of reducing glucose? They work at the level of the kidneys where they help excrete the glucose resulting in glucose urea. So that's important to realize because even though it's beneficial in terms of lowering the blood glucose in the bloodstream, the increased glucose in the urine can potentially increase the risk of infection. So we wanna really counsel patients on that. I highlight the CADIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. This is an extremely valuable resource. It's free, it's online. But some of the cautions with SGLT2 inhibitors, you wanna be careful if someone's sick or not eating because that could potentially increase the risk of diabetic ketoacidosis. You wanna withhold or stop the SGLT2 inhibitor at least two days in advance of hospitalization procedures and restart after procedure or surgery is over and when they're eating and drinking normally. The other potential contraindications is if someone is prone to genital infections, then this might not be the class of agents to use. If someone has foot ulcers based on one of the trials, that'll give you pause in terms of considering these agents. So again, a lot of room for education, education, education in terms of risk of low blood sugar, the same rules as with the insulin and sulfonylureas and the GLP1 receptor agonist in that if someone's glucose is already under reasonable control, they're not gonna need as much of the insulin or sulfonylurea. So you could be proactive at reducing these agents as you incorporate the SGLT2 inhibitor. And if someone is at a volume depletion risk, you wanna evaluate their concurrent diuretic use, their volume status and educate on maintaining good hydration as well. So looking at the whole picture, type 2 diabetes is not just about the blood sugar, it's actually about the long-term risks. So turning it back to you, Katerina, were you told that diabetes could increase the risk of heart and kidney disease? And do you have any feedback for clinicians on how we may wanna broach this conversation so that it's not frightening? So, yes, but not in the way that made sense to me from the patient experience. You hear about these things and you're told renal failure, heart disease, neuropathy, but you don't really know what those mean. And those were sort of words that I didn't really understand initially. I will say don't, to the patient experience, don't use Google. I think it's your enemy to a certain extent. Take the time to really express and have the patient understand what these mean to future health. I know what neuropathy is. I don't know how it affects me. I know what renal failure is, obviously. I don't know why it would happen to me or how it could happen to me. So don't take for granted that the person understands the disease state. We're not doctors. I'm the Katerina expert. I could tell you everything that's going on with me, but you're the medical expert. I need you to help me understand what all of that means. So it may be frustrating. It may be somewhat of a battle for people to sort of wanna hear these stories, but make sure that they understand because if they don't, they're not gonna make good decisions, sound decisions for their health. And certainly, again, as a patient, I say it flippantly, but truly try to reduce your amount of Google time because you think you're the armchair expert, right? But you're not. You don't know what you're talking about. Leave it to the experts. Leave it to your medical team. You tell them what you're feeling and how and what you need. Let them tell you what the medical piece is. I love it. You are the Katerina expert. And the truth is we actually have risk factors that we monitor. We look at urine microalbumin. We look at blood pressure. We look at lipids. We look at A1C. So we are tracking these because this is the long-haul journey. So we do know that type 2 diabetes does increase the risk of cardiovascular disease and death. And you see a twofold increase in the different types of coronary death and ischemic stroke. And we also know that cardiovascular disease is prevalent in people with type 2 diabetes. So there's really a lot that we're learning about the distribution of the type of cardiovascular disease that we see in type 2 diabetes, but all the more reason for us to want to address this picture in our choices of therapy. We also know that type 2 diabetes increases the risk of chronic kidney disease. So 15% of US adults are estimated to have chronic kidney disease. Most people don't know they have it. So number one, part of our guidelines, at least annual screening of the GFR and urine microalbumin level more if they are more advanced. And this is something that we actually have medications that can help preserve kidney function and help reduce the chances of progressing to dialysis. We know that chronic kidney disease attributable to diabetes is about 20% to 40%. And diabetes is the most common contribution to end-stage kidney disease. So we are in an exciting era where we actually have medications that can reduce the progression. So bringing it to the whole picture, I think, Katerina, you shared with us nicely from the A1C of 6.3 to the weight management, to the risk factors, to your choices of medications, you're on both the SGLT2 inhibitor and the GLP-1 receptor agonist, and really establishing the goals of care, establishing the collaborative communication. I think it's really validating for me to kind of hear your experience because it really was what we aimed to encapsulate in the recommendations of how care should be delivered, how person-centered care should be delivered for people with type 2 diabetes. So now another part of holistic approach is really healthy lifestyle behaviors. Can you share with us a little bit about your lifestyle journey and areas that you focus on with your clinicians when you go in for your visits? Absolutely. So again, very fortunate to have a partnership with an organization that has a medical team that has physiologists on-site that I can utilize, nutritionists on-site that I can utilize. Physiology, working with physiologists has been really beneficial to me because I had lived, still live somewhat of a sedentary life. I have a sit-down job, do a lot of counseling with other people, or not, you know, don't take the time to properly have breaks and build in snacks and things of that nature. So being able to work with nutritionists and physiologists have been really helpful. In particular with the physiologist, I think it's been very helpful to me to sort of understand, you know, meet me where I am. You know, you have to move. As a human being, you have to move. It becomes very, very difficult and very uncomfortable and painful and frightening when you're a certain size and, you know, you know you have to exercise, but you just can't. So working with physiologists who sort of met me where I was and gave me tools and techniques of things that I could do to be less sedentary, but in that size and in that realm really led me to being able to be more physically active. And I think I maybe had shared at one point with you, Dr. Arota, I just bought a bike. I haven't ridden a bike in years, but I just bought a bike and, you know, playing tennis, bad tennis, very bad tennis with my nephew. But I'm able to move in ways and be healthy in ways that I've never been able to before. So I think, you know, that has been unbelievably beneficial to me. And again, that holistic approach, you know, with regard to I can call up my doctor and say, hey, I'm suffering through this nausea or maybe this battle with, you know, constipation or even sometimes depression or something. And, you know, she can say to me, well, try this tea or try that. And it's not always sometimes I feel doctors always just go to the medicine route. I like the try this tea or try this or try taking a walk before bed or try this, you know, meditational thing. I can't sleep. We'll try this, you know, you know, noise machine in your room and things like that instead of just immediately going to try this pill or that shot or whatever. So I think my healthy lifestyle, my lifestyle overall has been unbelievably better, you know, better in the last five years. My healthy lifestyle has been better. I can actually say that I have now. I think just as you pointed out the empowerment of your health journey, now you have empowerment in your healthy lifestyle journey. And yes, during our rehearsal, you shared that you played tennis with your nephew for the first time. And that's just, it's just, it's wonderful. So for the first time on the international consensus, again, type 2 diabetes care, we've traditionally thought about medications, but no, we've incorporated the 24-hour physical behaviors for type 2 diabetes, really the different areas that all make a difference. Now, a lot of the research out there is emerging. So some, a lot of the data is associative, but we do know that again, at every stage, the physical behaviors make a difference. So breaking up sedentary time, as you described Katerina, increasing steps in the day, even as little as 500 steps more in the day can help affect the glucose, making sure there's some kind of cardiovascular exercise, aerobic exercise, sweating, strengthening to make sure that you're maintaining your muscle mass as we're aging. And then sleep quality, a lot of research here. We've known that, you know, certain chronotypes, you know, those who stay up late at night or sleep in in the morning, that can be associated with higher blood sugar and higher blood pressure. So areas within our 24-hour physical behaviors that are within our realm of control and healthy lifestyle management. And it's encouraged to incorporate these as part of the counseling. And again, why I love using some of the newer agents is it's a natural integration. So take home messages. I'll start and then I'll let you, Katerina, have the last word. Here's my approach, and we're all going to come up with our own approaches of how we have conversations. But I like to think of three specific areas that center on the person with type 2 diabetes. One is, you know, what is the physiology? What is going on? We know that diabetes increases the risk of long-term complications and that better control of diabetes and these risk factors can reduce the risk of these complications and enhance the quality of life. We have very clear care goals to reduce complications and optimize quality of life. And that we have choices both within lifestyle as well as specific medications that can help support those goals. In terms of anticipatory guidance with the GLP-1 receptor agonist, education is extremely important in terms of educating on the mechanism of action of what the patient might experience. They may feel fuller faster, better control of their appetite. They may eat less, mindful eating. If they experience nausea, this typically improves. But if you're having persistent symptomatology, then to, you know, let your doctor know about this. And also to incorporate muscle resistance exercises because as one loses body weight, we want to retain the lean muscle mass. With the SGLT-2 inhibitors, an importance on good genital urinary hygiene to stay well hydrated and the cautions of, you know, holding the medication if one is fasting or planning any hospital procedures. So really kind of all in a nutshell. And I'm going to hand it over to you, Katarina, for your final kind of take-homes and messages. I think for me, and I've probably said it ad nauseum now at this point, the most beneficial part of my recent health changes has been finding a trusted partner that I can feel that I can be honest with in the most, you know, in some embarrassing questions or whatever. And the questions are going to be answered with care, with compassion, with kindness. But I also want to say to patients, you know, it is a two-way street and it is important that you're honest and give proper feedback. And if you're lying about something or not comfortable saying that I have dysnausia or whatever, you're not going to get better. And you're not doing your medical team any favors or yourself any favors. It really is a journey. It takes a village and it takes time. Don't go in thinking for a miracle cure and you see these commercials and you see these celebrities or this thing or that, you know, powder and this whatever. Don't go in there thinking that you want to come out of there looking better. Go into that office and come out feeling better. And I think that's the most important thing on both sides. It's about how you're feeling. It's about your longevity of life, your quality of life, not what you look like. Now's a good time if you want to put your questions in the chat, you can. And I already see lots of questions. Okay. So the most popular question, how can we navigate these issues when employers and administrators focus more on volume of patients rather than quality of care? How do we address these issues with the patient who sees you once in three to six months for just the 15 to 20 minutes at best? Gosh, what an important area and important question. And I hope there's administrators on this call too. But I would say this, sometimes it's about quality rather than quantity. You know, we know so much medicine that sometimes we want to take care of the 10 different things. But if we can focus on proper initiation of some of these, you know, medications, you know, setting people on the right foot, and then having our care extenders, having the care team, then that could do us, that little investment of time in the beginning can help in the long run. Katerina, do you have any thoughts on that, on how we can focus on quality of care? Yeah. I do. Understanding that the medical community is also a business, I think it's important for administrators to understand that if medical care is more focused on collaboration, kindness, compassion, I think your patient base is going to expand significantly. I believe, and I could be wrong, but I believe being part of the obese community, that there's an epidemic in this country because patients choose not to seek treatment. Because of the things that I may have said early on, you know, having been, you know, guilted or feeling ashamed or whatnot, if you find a doctor who provides you with that compassionate care, I think the floodgates will open and people will come to get care and people will come to receive the medical advice that they need. So I think it's sort of, you know, I completely understand being someone who works in the business world myself, I completely understand the concerns from the business perspective, but I also think that the level of care received, if it were allowed, if you were allowed to spend an hour with a patient versus 15 minutes, then I think you would have more patients, if that made any sense. Yeah. We'd have retention. Okay. So there's a bunch of questions and we have about five to six minutes. I'm going to do something called rapid fire. I hope this is okay because these are great questions. I want to get the knowledge nuggets out there. Ozempic and Monjaro, in terms of cardiovascular renal benefits, the same. So Ozempic is semaglutide, Monjaro is trizepatide. With semaglutide, we have the sustained six trial in people with type 2 diabetes demonstrating positive cardiovascular outcomes. We have the select trial in people with obesity without diabetes, but with established cardiovascular disease demonstrating, again, 20% reduction in cardiovascular outcomes. The studies with trizepatide are underway. Surpass should be completed per clinicaltrials.gov in about May of 2025. And then there's surmount multimorbidity study is underway. However, both are high efficacy in terms of lowering blood glucose, lowering body weight, and improving cardiovascular risk factors, including inflammation. Sometimes in persons with a history of pancreatitis, I am a cautious and conservative person. You want to look at the whole picture. If it was pancreatitis for which the cause has been removed, such as alcohol or gallbladder, gallstones, then I'm okay with it. However, if it's idiopathic or, you know, they were hospitalized with the pancreatitis and, you know, we all know the significant morbidities, or if they look like they're more type 1 for any reason, I'm hesitant and would not proceed. There are some case reports in the literature that one might want to look at. Using anti-nausea medications, Katerina, did you ever use anti-nausea medications with the GOP1? I did. Initially, when I first went on them, the nausea became, not a lot, rarely, but when it became overwhelming, I did. And if I may, I'd like to answer that question from my perspective, is no, I don't think having anti-nausea medications stunts in any way your ability to reduce the amount of food you're eating. For me, the use of these drugs, which might be a total separate conversation anyway, for me, what it's done is taken away my compulsion or my need to constantly be thinking about food. So you're not overwhelmed by it, so you don't want it as much because you're not thinking about it as much. The nausea medication really just took the edge off, just feeling really bad, but it didn't make me want to eat more. So here's a, that's super valuable, here's an opinion question then, Katerina. Would you have wished at the prescription of the GOP1 that you were also co-prescribed an anti-nausea medicine at the same time, or how we typically deal with it is deal with it, deal with the nausea as needed, and then prescribe something later only if needed? I'm definitely someone who's anti-drug, I take enough medication as it is, I absolutely only wanted it if it literally, I could not bear it anymore, I did a lot of other holistic type of things to avoid it, it was very rare that I used it, but I do think it should be as needed and as needed medication, because I think you need to sort of not have more stuff in your system. Yeah, and also really focusing on the educational aspects and how these work. So are there any major studies that support the use of somaglutide, trisepatite, et cetera, in type 1 diabetes? There was a program with liraglutide in type 1 diabetes, and that just never made it kind of past the FDA. I think there was just a lot of caution in this population, but this is a very high interest, and talking about this would be off-label, so I won't go there, but very high interest and really nice literature, including in JCENM in this last year on people's experience with it. No foot ulcers, but vascular disease, can you still use an SGLT2 inhibitor? Yes, and this is a great time to reinforce self-inspection of feet. Look at your feet once a week. If there's any changes, let us know. The foot ulcer came about with one of the canagliflozin studies, and it hasn't been borne out with the other SGLT2 inhibitor studies, but we've also incorporated a lot of education in these trials. And then the last question, threshold recommendations for SGLT2 inhibitors. So the guidelines and most of the prescribing labels allow for it to be used when the GFR is above 20. So that is the cutoff, but what I would say is if someone is in the 20s to 30 range, they should be also co-managed by a nephrologist. And realize that initial initiation with an SGLT2 inhibitor, there is a slight dip in the GFR and a slight increase in the creatinine, probably related to some of the hemodynamics. So you just, I think if they're really on that border within 20 to 30, you want to have a little bit of a conversation with the nephrologist, but by label and by the studies above 20 is okay. We got through it with one minute to spare, and there's the QR code. I hope everyone learned a lot, Katerina. My deep gratitude and appreciation. I've learned something important every single time we've spoken, and I just want to say thank you to you, and I'm going to let you have the final word. Well, thank you very much for allowing me to participate. It's been a struggle for me, and if there's anything that I can do or say to help educate anybody on how to best work with a patient who's maybe struggling the way I have and obviously continue to do, but getting better, I'm happy to help. So I hope some of my insights were helpful to understanding the patient experience. Beautiful. Thank you, everyone. Thank you.

person-centered care

type 2 diabetes

GLP-1 receptor agonists

SGLT2 inhibitors

patient-provider communication

personalized medicine

compassionate care

cardiovascular health

holistic lifestyle changes