 Joining us is Dr. Renna Malek, endocrinologist at the University of Maryland Center for Diabetes and a associate professor of medicine at the University of Maryland School of Medicine. Dr. Thank you for joining us. My pleasure. Thank you for having me. Big news is the price of insulin coming down. What does that mean to your patients? It means a lot. I think it's important to have some context about the price of insulin. So about 30 million Americans have diabetes and of those 30 million, about 7 million need insulin to manage their diabetes. In the last over a 20-year period from 1996 to 2016, the price of insulin went up 700 percent when adjusted for inflation. So for example, a vial of insulin went from $21 in 1996 to $255. So those were, that was a huge economic burden on patients. Some of the viewers may be saying, well, when I go to the pharmacy, I pay a copay for my insulin. It never costs that much. Well, for uninsured patients or patients with high deductible plans and until recently Medicare patients, they were often paying those list prices and paying hundreds of dollars, if not thousands per month for their insulin prices. There's been a lot of pressure to try to bring those prices down from patient groups and professional organizations. And most recently, the Biden administration was able to pass an inflation reduction act last year that the cost of insulin for Medicare recipients can't be more than $35 a month. But again, it didn't help those who did not have Medicare insurance. And so because of some market forces, so there's a generic version of insulin that's been approved in the last year and some alternative sources of insulin like the state of California is going to produce its own cheap insulin and a nonprofit group that's a pharmaceutical company called Civica is also going to be producing low cost insulin for that will be available for about a third of the Americans that need insulin therapy. So all of these market forces played a role in kind of pushing the hand of the pharmaceutical industry to lower that cost. And so now for our patients where they were paying these really high prices, they can plan to anticipate paying less per month for their insulin, the craziness of list prices at a pharmacy, all sorts of medicines is probably another another show with the world of discount coupons and all that. What did it mean for the patients of yours who didn't have the money who were trying to maybe stretch out the insulin? Exactly. Insulin is different than a pill, right? You take a pill once a day whereas insulin the dose you would take may depend on what you're eating, your physical activity, and so you have some flexibility sometimes in the dose. But if someone had to buy two vials of insulin and pay close to $600 a month for it, they may say well instead of taking the 15 units with my dinner that Dr. Malik prescribed, I may only take five so I can make that dose last over time. What that does is that leads to higher blood sugars and we know that higher blood sugars increases your risk of eye disease, kidney disease, heart disease, and what people were doing was they were sacrificing their future health because of these economic constraints. And as a society what matters is the fact that we spend one in four healthcare dollars on diabetes costs. So we are paying the price for this economic price gouging as well further down the line with healthcare. So for our patients now what I hope we can see happen is that they can use the right prescribed amount of insulin because they can afford what they're getting at the pharmacy. The other thing I will say is that because of this increase in prices we've actually been using older insulins lately. These older insulins that we were using much more in the 1980s and 1990s called MPH and regular that people could get for $20 at Walmart, we've been prescribing a lot of them. They're a little less nuanced than these newer insulins and so those patients that have been using those we can probably switch to some of these newer brands of insulin. Let me remind our viewers if you have a question for our guest give us a call at the number on the screen or send an email to livequestions at mpt.org. Give us a primer on diabetes there's two different types. So there's type 1 diabetes which is affects a little under 2 million Americans. That is where your own body destroys the cells in your pancreas that make insulin. We think of it as an illness that children get but people can get diagnosed in adulthood and we even have people who are diagnosed in their elderly years. And then there's type 2 diabetes which is a catchphrase for everything else. People with type 1 diabetes must use insulin to manage their diabetes. People with type 2 diabetes the majority are able to be managed with non-insulin medications. Let's take a phone call from Allegheny County. This is Lisa. Lisa, thank you for the call. Go ahead. I think diabetic and she uses two different types of insulin. One is a long term and the other is a short term. Can you explain the difference to the public? Yes, so you know your blood sugar doesn't just go up from the food that you eat. I tell people that your well your brain needs sugar to function and your body has to have a constant source of producing sugar so that your brain can function because if you didn't eat when you slept and your sugar went to zero you would die in your sleep. So that's really what the liver is for. The liver holds onto sugar and when someone isn't eating releases that sugar. In the situation of diabetes the liver goes a little wild and just dumps sugar into the bloodstream and so long acting insulin is used to control the liver's supply of sugar that's coming out. The short acting insulin is used to control what happens to your blood sugar if you eat a sandwich or you eat a meal and so people with type 1 diabetes need to be taking both types of insulin in order to control their blood sugars. Why are more people coming down with diabetes? So that is a very complicated question and and I often say that when we think of diabetes we we tend to think of it as a disease of the individual right. It is a person's responsibility to eat right. It's a person's responsibility to maintain a healthy weight and a person's responsibility to exercise. That's all true but where we're missing the boat is that all of those individual decisions are influenced by the society we've structured. So we have food policies that make healthy foods more expensive and foods that are bad for you very cheap. We subsidize corn production, we put high fructose corn syrup in just about every processed food that we eat. Those processed foods are actually designed to make you want to eat more. They have a lot of salt and sugar and fat but they also don't make you feel full and they have addictive properties. We have food deserts. I practice in West Baltimore where access to stores that sell healthy foods and vegetables is really limited and we know that that's tied to to obesity and cardiovascular disease and we market unhealthy foods to children and so people from a young age are kind of starting to eat these highly processed foods. I joke that my daughters who are the daughters of endocrinologists can tell you basically about every flavor of potato chip that's out there because that's what's being targeted to them and their peers. Do you let them eat it? No I do my best to restrict it but you know they're not always in my in my in my sights. Someday they won't be here right? Exactly so you have to really be teaching nutrition. When we think about exercise and maintaining it right it means having access to places to exercise. Gyms aren't necessarily covered by health insurance and your access to safe sidewalks, safe neighborhoods, public parks are all influenced by the zip code that you're living in. So I often say that we've structured our society to make it really easy to get diabetes and really difficult to take care of yourself. So this trend towards more people developing diabetes is it just the United States? Is it just the western world? Are there places on the planet where it's not happening? Where it's not happening so it tends to be diabetes is rising wherever there starts to be more availability of easy to eat processed foods. So we see really high rates of diabetes rising for example in India in more affluent areas in Nigeria. We're seeing high rates of diabetes in in the Middle East but it's all tied to these specific issues related to processed foods, limited exercise. Viewer question, well we see less insulin dependent diabetics because of the new easy ways to determine blood sugar and determine what to eat. It was always difficult to stick your finger all the time. So I think that the individual is referring to the way we monitor blood sugar. So the old fashioned ways you literally pricked your finger drop of blood on a litmus paper essentially. We now have these devices called continuous glucose monitors that you wear for 10 to 14 days depending on the brand and it'll tell you your blood sugar at all times. It'll actually send your blood sugar to your phone. It can be your home screen. Your partner can follow your blood sugars and know any time you cheated for example. And so it makes it easier to monitor and it allows people to modulate their behavior. If you know that a piece of cake is going to take your sugar to 300 you may not eat as much or you may not eat the cake. It may not necessarily result in less people developing diabetes but I think what it will do, what we know it does from studies is that it improves the control of people with diabetes. You have a diabetes prevention program, University of Maryland Medical Center Midtown? Yes, based at Midtown and we are doing it in conjunction with an HSCRC grant with Johns Hopkins. So it's a Baltimore diabetes prevention program system. What do you do there? So the diabetes prevention program is born out of a study several years ago where we looked at people with pre-diabetes and so if you have pre-diabetes I tell people it doesn't mean you're automatically going to get diabetes but you've bought a whole lot more tickets to the lottery. So if nothing changes your risk is higher. And so we learned several years ago that if we can help people make intensive lifestyle changes that results in body weight loss of 7 percent we can reduce their risk of going on to develop diabetes. And so the diabetes prevention program is a structured 16-week course with like usually it's a diabetes educator who helps lead these classes, proper nutrition, exercise, stress management, and the idea is that at the end of the study the 16 weeks you will have lost weight and reduce that risk of diabetes. And just a sentence if you can, what symptoms should people be on the lookout for? For diabetes. So the first thing I would say is that there are a lot of people that don't have any symptoms. So type 2 diabetes develops over time and if your sugar slowly goes up over time you get used to that. And so that's why about a third of people with diabetes don't even know they have it. When the sugars get high enough people may notice excessive thirst, frequently having to go to the bathroom, weight loss, blurry vision. Dr. Renna Malick will have to leave it there with the University Maryland Center for Diabetes and Endocrinology. Thanks for the time. Thank you for having me. Your health segments are a co-production of Maryland Public Television and the University of Maryland Medical System.