Clinical Endocrinology News

Pharmacist Mark Mikhael has lost 50 pounds over the past 12 months. He no longer has diabetes and finds himself “at my ideal body weight,” with his cholesterol below 200 for the first time in 20 years. “I feel fantastic,” he said.

Like millions of others, Mr. Mikhael credits the new class of weight loss drugs. But he isn’t using brand-name Wegovy or Zepbound. Mr. Mikhael, CEO of Orlando, Florida–based Olympia Pharmaceuticals, has been getting by with his own supply: injecting himself with copies of the drugs formulated by his company.

He’s far from alone. Mr. Mikhael and other industry officials estimate that several large compounding pharmacies like his are provisioning up to 2 million American patients with regular doses of semaglutide, the scientific name for Novo Nordisk’s Wegovy, Ozempic, and Rybelsus formulations, or tirzepatide, the active ingredient in Eli Lilly’s Zepbound and Mounjaro.

The drug-making behemoths fiercely oppose that compounding business. Novo Nordisk and Lilly lump the compounders together with Internet cowboys and unregulated medical spas peddling bogus semaglutide, and have high-powered legal teams trying to stop them. Novo Nordisk has filed at least 21 lawsuits nationwide against companies making purported copies of its drugs, said Brianna Kelley, a spokesperson for the company, and urges doctors to avoid them. The Food and Drug Administration (FDA), too, has cautioned about the potential danger of the compounds, and leading obesity medicine groups starkly warn patients against their use.

But this isn’t an illegal black market, though it has shades of gray.

The FDA allows and even encourages compounding pharmacies to produce and sell copycats when a drug is in short supply, and the wildly popular glucagon-like peptide 1 (GLP-1) drugs have enduring shortages — first reported in March 2022 for semaglutide and in December 2022 for tirzepatide. The drugs have registered unprecedented success in weight loss. They are also showing promise against heart, kidney, and liver diseases and are being tested against conditions as diverse as Alzheimer’s disease and drug addiction.

In recent years, the US health care system has come to depend on compounding pharmacies, many of which are run as nonprofits, to plug supply holes of crucial drugs like cancer medicines cisplatin, methotrexate, and 5-fluorouracil.

Most compounded drugs are old, cheap generics. Semaglutide and tirzepatide, on the other hand, are under patent and earn Novo Nordisk and Lilly billions of dollars a year. Sales of the diabetes and weight loss drugs in 2024 made Novo Nordisk Europe’s most valuable company and Lilly the world’s biggest pharmaceutical company.

While the companies can’t keep up with demand, they heatedly dispute the right of compounders to make and sell copies. Lilly spokesperson Kristiane Silva Bello said her company was “deeply concerned” about “serious health risks” from compounded drugs that “should not be on the market.”

Yet marketed they are. Even Hims & Hers Health — the telemedicine prescriber that got its start with erectile dysfunction drugs — is now peddling compounded semaglutide. It ran ads for the drugs during NBA playoff games. (According to a Hunterbrook Media report, Hims & Hers’ semaglutide supplier has faced legal scrutiny.)

The compounded forms are significantly cheaper than the branded drugs. Patients pay about $100-$450 a month, compared with list prices of roughly $1,000-$1,400 for Lilly and Novo Nordisk products.

Five compounders and distributors interviewed for this article said they conduct due diligence on every lot of semaglutide or tirzepatide they buy or produce, upholding standards of purity, sterility, and consistency similar to those practiced in the commercial drug industry. Compounders operate under strict federal and state standards, they noted.

However, the raw materials used in the compounded forms may differ from those produced for Novo Nordisk and Lilly, said GLP-1 coinventor Jens Juul Holst, of the University of Copenhagen, adding that care must be taken in drug production lest it cause potentially harmful immune reactions.

To date, according to FDA spokespeople, reports of side effects from taking compounded versions haven’t raised major alarms. But everyone with knowledge of the industry, including the compounders themselves, worry that a single batch of a poorly made drug could kill or maim people and destroy confidence in their business.

“I liken the compounding industry to the airline industry,” Mr. Mikhael said. “When you have an airline crash, it hurts everybody.”
 

Warnings From the Past

The industry endured just such a catastrophe in 2012, when the New England Compounding Center released a contaminated injectable steroid that killed at least 64 people and harmed hundreds more.

In response, Congress and the FDA had strengthened oversight. Mr. Mikhael’s company is an outsourcing facility, or 503B compounding pharmacy — so-named for a section of the 2013 law that set new requirements for drug compounders. The companies are licensed to make slightly different versions of FDA-approved drugs in response to shortages or a patient’s special needs.

The law created two classes of compounding pharmacies: The FDA regulates the larger 503B compounders with standards like commercial drug companies, while 503A pharmacies make smaller lots of drugs and are largely overseen by state boards of pharmacy.

The 503A facilities also are producing compounded semaglutide and tirzepatide for hundreds of thousands of patients. Like the 503Bs, these operations take the active ingredient, produced as a powder in FDA-registered factories, mostly in China, then reconstitute it with sterile water and an antimicrobial in small glass vials.

Together, the compounding pharmacies may account for up to 30% of the semaglutide sold in the United States, Mr. Mikhael said, although he cautions that is a “wild ballpark figure” since no one, including the FDA, is tracking sales in the industry.

The compounders say the companies should increase production if they’re worried about competition. Like the dozens of other drugs they produce for hospitals and medical practices, the compounders say, the two diet drugs are essential products.

“If you don’t want a 503B facility to make a copy, it’s pretty simple: Don’t go short,” said Lee Rosebush, chair of a trade association for 503B pharmacies. “FDA created this system because these are necessary drugs.”

Novo Nordisk hasn’t specified why it can’t keep up with demand, but the bottleneck apparently lies in the company’s inability to fill and sterilize enough of its special drug auto-injectors, said Evan Seigerman, a managing director at BMO Capital Markets.

The company announced June 24 that it was investing $4.1 billion in new production lines at its Clayton, North Carolina, site. In 2023, the FDA issued a warning over procedural violations at the site and separate cautions at an Indiana facility that Novo Nordisk took over recently.
 

Compounding for Dummies

At least 28 companies, mostly in China, are registered with the FDA to produce or distribute semaglutide. At least half the companies have entered the market in the past 12 months, driving the raw material’s price down by 35%, according to Scott Welch, who runs a 503A pharmacy in Arlington, Virginia.

Compounders can buy powdered semaglutide from some US distributors for less than $4,000 a gram, said Matthew Johnson, president and CEO of distributor Pharma Source Direct. That comes out to as little as $10 per weekly 2.5-microgram dose – not including overhead and other costs.

While Ozempic or Wegovy patients use a Novo Nordisk device to inject the drug, patients using compounded products draw them from a vial with a small needle, like the device diabetics use for insulin.

Some medical practices provide the compounded drug to patients as part of a weight loss package, with markups. In July 2023, Tabitha Ries, a single mother of six who works as a home health care aide in Garfield, Washington, found an online clinic that charged her $1,000 for 3 months of semaglutide along with counseling. She has lost 35 pounds.

She gets the drug from Mindful Weight Loss, a mostly telehealth-based operation led by physician Vivek Gupta, MD, of Manhattan Beach, California. Dr. Gupta said he’s prescribed the weight loss drugs to 1,500 patients, with about 60% using compounded versions from a 503A pharmacy.

He hasn’t seen any essential difference in patients using the branded and compounded forms, although “some people say the compounding is a little less effective,” Dr. Gupta said.

There’s some risk in using the non–FDA-approved product, he acknowledged, and he requires patients to sign an informed consent waiver.

“Nothing in life is without risk, but I would also argue that the status quo is not safe for people who need the medicine and can’t get it,” he said. “They’re constantly triggered by all this food that’s causing their weight to go up and their sugar to go high, increasing their insulin resistance and affecting their limbs and eyes.”

Compounding semaglutide is a helpful sideline for pharmacists like him, Mr. Welch said, especially given the pinch on drug sale revenue that has led many independents to close in recent years. He figures he earns 95% of his revenue from compounding drugs, rather than traditional prescriptions.

It’s important to distinguish compounded semaglutide from unregulated powders sold as “generic Ozempic” and the like, which may be contaminated or counterfeit, said FDA spokesperson Amanda Hils. But since compounded forms of the drug are not FDA approved, those who make, prescribe, or use them also should have “an increased level of responsibility or awareness,” she said.
 

Corporate Battles

Novo Nordisk and Lilly, in lawsuits each company has filed against competitors, say their own testing has found bacteria and other impurities in products made by compounding pharmacies. The companies also report patent infringement, but compounders, pointing to the FDA loophole for drugs in shortage, appear to have defeated that argument for now.

When the FDA removes the drugs from the shortage list, 503B compounders must immediately stop selling them. Smaller compounders may be able to produce their products for a reduced number of patients, said Scott Brunner, CEO of the Alliance for Pharmacy Compounding, which represents 503A compounders.

The evaporation of the compounded drug supply could come as a shock to patients.

“I dread it,” said David Wertheimer, an internist in Franklin Lakes, New Jersey, who prescribes compounded semaglutide to some patients. “People are not going to be able to plunk down a grand every month. A lot of people will go off the drug, and that’s a shame.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Pharmacist Mark Mikhael has lost 50 pounds over the past 12 months. He no longer has diabetes and finds himself “at my ideal body weight,” with his cholesterol below 200 for the first time in 20 years. “I feel fantastic,” he said.

Like millions of others, Mr. Mikhael credits the new class of weight loss drugs. But he isn’t using brand-name Wegovy or Zepbound. Mr. Mikhael, CEO of Orlando, Florida–based Olympia Pharmaceuticals, has been getting by with his own supply: injecting himself with copies of the drugs formulated by his company.

He’s far from alone. Mr. Mikhael and other industry officials estimate that several large compounding pharmacies like his are provisioning up to 2 million American patients with regular doses of semaglutide, the scientific name for Novo Nordisk’s Wegovy, Ozempic, and Rybelsus formulations, or tirzepatide, the active ingredient in Eli Lilly’s Zepbound and Mounjaro.

The drug-making behemoths fiercely oppose that compounding business. Novo Nordisk and Lilly lump the compounders together with Internet cowboys and unregulated medical spas peddling bogus semaglutide, and have high-powered legal teams trying to stop them. Novo Nordisk has filed at least 21 lawsuits nationwide against companies making purported copies of its drugs, said Brianna Kelley, a spokesperson for the company, and urges doctors to avoid them. The Food and Drug Administration (FDA), too, has cautioned about the potential danger of the compounds, and leading obesity medicine groups starkly warn patients against their use.

But this isn’t an illegal black market, though it has shades of gray.

The FDA allows and even encourages compounding pharmacies to produce and sell copycats when a drug is in short supply, and the wildly popular glucagon-like peptide 1 (GLP-1) drugs have enduring shortages — first reported in March 2022 for semaglutide and in December 2022 for tirzepatide. The drugs have registered unprecedented success in weight loss. They are also showing promise against heart, kidney, and liver diseases and are being tested against conditions as diverse as Alzheimer’s disease and drug addiction.

In recent years, the US health care system has come to depend on compounding pharmacies, many of which are run as nonprofits, to plug supply holes of crucial drugs like cancer medicines cisplatin, methotrexate, and 5-fluorouracil.

Most compounded drugs are old, cheap generics. Semaglutide and tirzepatide, on the other hand, are under patent and earn Novo Nordisk and Lilly billions of dollars a year. Sales of the diabetes and weight loss drugs in 2024 made Novo Nordisk Europe’s most valuable company and Lilly the world’s biggest pharmaceutical company.

While the companies can’t keep up with demand, they heatedly dispute the right of compounders to make and sell copies. Lilly spokesperson Kristiane Silva Bello said her company was “deeply concerned” about “serious health risks” from compounded drugs that “should not be on the market.”

Yet marketed they are. Even Hims & Hers Health — the telemedicine prescriber that got its start with erectile dysfunction drugs — is now peddling compounded semaglutide. It ran ads for the drugs during NBA playoff games. (According to a Hunterbrook Media report, Hims & Hers’ semaglutide supplier has faced legal scrutiny.)

The compounded forms are significantly cheaper than the branded drugs. Patients pay about $100-$450 a month, compared with list prices of roughly $1,000-$1,400 for Lilly and Novo Nordisk products.

Five compounders and distributors interviewed for this article said they conduct due diligence on every lot of semaglutide or tirzepatide they buy or produce, upholding standards of purity, sterility, and consistency similar to those practiced in the commercial drug industry. Compounders operate under strict federal and state standards, they noted.

However, the raw materials used in the compounded forms may differ from those produced for Novo Nordisk and Lilly, said GLP-1 coinventor Jens Juul Holst, of the University of Copenhagen, adding that care must be taken in drug production lest it cause potentially harmful immune reactions.

To date, according to FDA spokespeople, reports of side effects from taking compounded versions haven’t raised major alarms. But everyone with knowledge of the industry, including the compounders themselves, worry that a single batch of a poorly made drug could kill or maim people and destroy confidence in their business.

“I liken the compounding industry to the airline industry,” Mr. Mikhael said. “When you have an airline crash, it hurts everybody.”
 

Warnings From the Past

The industry endured just such a catastrophe in 2012, when the New England Compounding Center released a contaminated injectable steroid that killed at least 64 people and harmed hundreds more.

In response, Congress and the FDA had strengthened oversight. Mr. Mikhael’s company is an outsourcing facility, or 503B compounding pharmacy — so-named for a section of the 2013 law that set new requirements for drug compounders. The companies are licensed to make slightly different versions of FDA-approved drugs in response to shortages or a patient’s special needs.

The law created two classes of compounding pharmacies: The FDA regulates the larger 503B compounders with standards like commercial drug companies, while 503A pharmacies make smaller lots of drugs and are largely overseen by state boards of pharmacy.

The 503A facilities also are producing compounded semaglutide and tirzepatide for hundreds of thousands of patients. Like the 503Bs, these operations take the active ingredient, produced as a powder in FDA-registered factories, mostly in China, then reconstitute it with sterile water and an antimicrobial in small glass vials.

Together, the compounding pharmacies may account for up to 30% of the semaglutide sold in the United States, Mr. Mikhael said, although he cautions that is a “wild ballpark figure” since no one, including the FDA, is tracking sales in the industry.

The compounders say the companies should increase production if they’re worried about competition. Like the dozens of other drugs they produce for hospitals and medical practices, the compounders say, the two diet drugs are essential products.

“If you don’t want a 503B facility to make a copy, it’s pretty simple: Don’t go short,” said Lee Rosebush, chair of a trade association for 503B pharmacies. “FDA created this system because these are necessary drugs.”

Novo Nordisk hasn’t specified why it can’t keep up with demand, but the bottleneck apparently lies in the company’s inability to fill and sterilize enough of its special drug auto-injectors, said Evan Seigerman, a managing director at BMO Capital Markets.

The company announced June 24 that it was investing $4.1 billion in new production lines at its Clayton, North Carolina, site. In 2023, the FDA issued a warning over procedural violations at the site and separate cautions at an Indiana facility that Novo Nordisk took over recently.
 

Compounding for Dummies

At least 28 companies, mostly in China, are registered with the FDA to produce or distribute semaglutide. At least half the companies have entered the market in the past 12 months, driving the raw material’s price down by 35%, according to Scott Welch, who runs a 503A pharmacy in Arlington, Virginia.

Compounders can buy powdered semaglutide from some US distributors for less than $4,000 a gram, said Matthew Johnson, president and CEO of distributor Pharma Source Direct. That comes out to as little as $10 per weekly 2.5-microgram dose – not including overhead and other costs.

While Ozempic or Wegovy patients use a Novo Nordisk device to inject the drug, patients using compounded products draw them from a vial with a small needle, like the device diabetics use for insulin.

Some medical practices provide the compounded drug to patients as part of a weight loss package, with markups. In July 2023, Tabitha Ries, a single mother of six who works as a home health care aide in Garfield, Washington, found an online clinic that charged her $1,000 for 3 months of semaglutide along with counseling. She has lost 35 pounds.

She gets the drug from Mindful Weight Loss, a mostly telehealth-based operation led by physician Vivek Gupta, MD, of Manhattan Beach, California. Dr. Gupta said he’s prescribed the weight loss drugs to 1,500 patients, with about 60% using compounded versions from a 503A pharmacy.

He hasn’t seen any essential difference in patients using the branded and compounded forms, although “some people say the compounding is a little less effective,” Dr. Gupta said.

There’s some risk in using the non–FDA-approved product, he acknowledged, and he requires patients to sign an informed consent waiver.

“Nothing in life is without risk, but I would also argue that the status quo is not safe for people who need the medicine and can’t get it,” he said. “They’re constantly triggered by all this food that’s causing their weight to go up and their sugar to go high, increasing their insulin resistance and affecting their limbs and eyes.”

Compounding semaglutide is a helpful sideline for pharmacists like him, Mr. Welch said, especially given the pinch on drug sale revenue that has led many independents to close in recent years. He figures he earns 95% of his revenue from compounding drugs, rather than traditional prescriptions.

It’s important to distinguish compounded semaglutide from unregulated powders sold as “generic Ozempic” and the like, which may be contaminated or counterfeit, said FDA spokesperson Amanda Hils. But since compounded forms of the drug are not FDA approved, those who make, prescribe, or use them also should have “an increased level of responsibility or awareness,” she said.
 

Corporate Battles

Novo Nordisk and Lilly, in lawsuits each company has filed against competitors, say their own testing has found bacteria and other impurities in products made by compounding pharmacies. The companies also report patent infringement, but compounders, pointing to the FDA loophole for drugs in shortage, appear to have defeated that argument for now.

When the FDA removes the drugs from the shortage list, 503B compounders must immediately stop selling them. Smaller compounders may be able to produce their products for a reduced number of patients, said Scott Brunner, CEO of the Alliance for Pharmacy Compounding, which represents 503A compounders.

The evaporation of the compounded drug supply could come as a shock to patients.

“I dread it,” said David Wertheimer, an internist in Franklin Lakes, New Jersey, who prescribes compounded semaglutide to some patients. “People are not going to be able to plunk down a grand every month. A lot of people will go off the drug, and that’s a shame.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Pharmacist Mark Mikhael has lost 50 pounds over the past 12 months. He no longer has diabetes and finds himself “at my ideal body weight,” with his cholesterol below 200 for the first time in 20 years. “I feel fantastic,” he said.

Like millions of others, Mr. Mikhael credits the new class of weight loss drugs. But he isn’t using brand-name Wegovy or Zepbound. Mr. Mikhael, CEO of Orlando, Florida–based Olympia Pharmaceuticals, has been getting by with his own supply: injecting himself with copies of the drugs formulated by his company.

He’s far from alone. Mr. Mikhael and other industry officials estimate that several large compounding pharmacies like his are provisioning up to 2 million American patients with regular doses of semaglutide, the scientific name for Novo Nordisk’s Wegovy, Ozempic, and Rybelsus formulations, or tirzepatide, the active ingredient in Eli Lilly’s Zepbound and Mounjaro.

The drug-making behemoths fiercely oppose that compounding business. Novo Nordisk and Lilly lump the compounders together with Internet cowboys and unregulated medical spas peddling bogus semaglutide, and have high-powered legal teams trying to stop them. Novo Nordisk has filed at least 21 lawsuits nationwide against companies making purported copies of its drugs, said Brianna Kelley, a spokesperson for the company, and urges doctors to avoid them. The Food and Drug Administration (FDA), too, has cautioned about the potential danger of the compounds, and leading obesity medicine groups starkly warn patients against their use.

But this isn’t an illegal black market, though it has shades of gray.

The FDA allows and even encourages compounding pharmacies to produce and sell copycats when a drug is in short supply, and the wildly popular glucagon-like peptide 1 (GLP-1) drugs have enduring shortages — first reported in March 2022 for semaglutide and in December 2022 for tirzepatide. The drugs have registered unprecedented success in weight loss. They are also showing promise against heart, kidney, and liver diseases and are being tested against conditions as diverse as Alzheimer’s disease and drug addiction.

In recent years, the US health care system has come to depend on compounding pharmacies, many of which are run as nonprofits, to plug supply holes of crucial drugs like cancer medicines cisplatin, methotrexate, and 5-fluorouracil.

Most compounded drugs are old, cheap generics. Semaglutide and tirzepatide, on the other hand, are under patent and earn Novo Nordisk and Lilly billions of dollars a year. Sales of the diabetes and weight loss drugs in 2024 made Novo Nordisk Europe’s most valuable company and Lilly the world’s biggest pharmaceutical company.

While the companies can’t keep up with demand, they heatedly dispute the right of compounders to make and sell copies. Lilly spokesperson Kristiane Silva Bello said her company was “deeply concerned” about “serious health risks” from compounded drugs that “should not be on the market.”

Yet marketed they are. Even Hims & Hers Health — the telemedicine prescriber that got its start with erectile dysfunction drugs — is now peddling compounded semaglutide. It ran ads for the drugs during NBA playoff games. (According to a Hunterbrook Media report, Hims & Hers’ semaglutide supplier has faced legal scrutiny.)

The compounded forms are significantly cheaper than the branded drugs. Patients pay about $100-$450 a month, compared with list prices of roughly $1,000-$1,400 for Lilly and Novo Nordisk products.

Five compounders and distributors interviewed for this article said they conduct due diligence on every lot of semaglutide or tirzepatide they buy or produce, upholding standards of purity, sterility, and consistency similar to those practiced in the commercial drug industry. Compounders operate under strict federal and state standards, they noted.

However, the raw materials used in the compounded forms may differ from those produced for Novo Nordisk and Lilly, said GLP-1 coinventor Jens Juul Holst, of the University of Copenhagen, adding that care must be taken in drug production lest it cause potentially harmful immune reactions.

To date, according to FDA spokespeople, reports of side effects from taking compounded versions haven’t raised major alarms. But everyone with knowledge of the industry, including the compounders themselves, worry that a single batch of a poorly made drug could kill or maim people and destroy confidence in their business.

“I liken the compounding industry to the airline industry,” Mr. Mikhael said. “When you have an airline crash, it hurts everybody.”
 

Warnings From the Past

The industry endured just such a catastrophe in 2012, when the New England Compounding Center released a contaminated injectable steroid that killed at least 64 people and harmed hundreds more.

In response, Congress and the FDA had strengthened oversight. Mr. Mikhael’s company is an outsourcing facility, or 503B compounding pharmacy — so-named for a section of the 2013 law that set new requirements for drug compounders. The companies are licensed to make slightly different versions of FDA-approved drugs in response to shortages or a patient’s special needs.

The law created two classes of compounding pharmacies: The FDA regulates the larger 503B compounders with standards like commercial drug companies, while 503A pharmacies make smaller lots of drugs and are largely overseen by state boards of pharmacy.

The 503A facilities also are producing compounded semaglutide and tirzepatide for hundreds of thousands of patients. Like the 503Bs, these operations take the active ingredient, produced as a powder in FDA-registered factories, mostly in China, then reconstitute it with sterile water and an antimicrobial in small glass vials.

Together, the compounding pharmacies may account for up to 30% of the semaglutide sold in the United States, Mr. Mikhael said, although he cautions that is a “wild ballpark figure” since no one, including the FDA, is tracking sales in the industry.

The compounders say the companies should increase production if they’re worried about competition. Like the dozens of other drugs they produce for hospitals and medical practices, the compounders say, the two diet drugs are essential products.

“If you don’t want a 503B facility to make a copy, it’s pretty simple: Don’t go short,” said Lee Rosebush, chair of a trade association for 503B pharmacies. “FDA created this system because these are necessary drugs.”

Novo Nordisk hasn’t specified why it can’t keep up with demand, but the bottleneck apparently lies in the company’s inability to fill and sterilize enough of its special drug auto-injectors, said Evan Seigerman, a managing director at BMO Capital Markets.

The company announced June 24 that it was investing $4.1 billion in new production lines at its Clayton, North Carolina, site. In 2023, the FDA issued a warning over procedural violations at the site and separate cautions at an Indiana facility that Novo Nordisk took over recently.
 

Compounding for Dummies

At least 28 companies, mostly in China, are registered with the FDA to produce or distribute semaglutide. At least half the companies have entered the market in the past 12 months, driving the raw material’s price down by 35%, according to Scott Welch, who runs a 503A pharmacy in Arlington, Virginia.

Compounders can buy powdered semaglutide from some US distributors for less than $4,000 a gram, said Matthew Johnson, president and CEO of distributor Pharma Source Direct. That comes out to as little as $10 per weekly 2.5-microgram dose – not including overhead and other costs.

While Ozempic or Wegovy patients use a Novo Nordisk device to inject the drug, patients using compounded products draw them from a vial with a small needle, like the device diabetics use for insulin.

Some medical practices provide the compounded drug to patients as part of a weight loss package, with markups. In July 2023, Tabitha Ries, a single mother of six who works as a home health care aide in Garfield, Washington, found an online clinic that charged her $1,000 for 3 months of semaglutide along with counseling. She has lost 35 pounds.

She gets the drug from Mindful Weight Loss, a mostly telehealth-based operation led by physician Vivek Gupta, MD, of Manhattan Beach, California. Dr. Gupta said he’s prescribed the weight loss drugs to 1,500 patients, with about 60% using compounded versions from a 503A pharmacy.

He hasn’t seen any essential difference in patients using the branded and compounded forms, although “some people say the compounding is a little less effective,” Dr. Gupta said.

There’s some risk in using the non–FDA-approved product, he acknowledged, and he requires patients to sign an informed consent waiver.

“Nothing in life is without risk, but I would also argue that the status quo is not safe for people who need the medicine and can’t get it,” he said. “They’re constantly triggered by all this food that’s causing their weight to go up and their sugar to go high, increasing their insulin resistance and affecting their limbs and eyes.”

Compounding semaglutide is a helpful sideline for pharmacists like him, Mr. Welch said, especially given the pinch on drug sale revenue that has led many independents to close in recent years. He figures he earns 95% of his revenue from compounding drugs, rather than traditional prescriptions.

It’s important to distinguish compounded semaglutide from unregulated powders sold as “generic Ozempic” and the like, which may be contaminated or counterfeit, said FDA spokesperson Amanda Hils. But since compounded forms of the drug are not FDA approved, those who make, prescribe, or use them also should have “an increased level of responsibility or awareness,” she said.
 

Corporate Battles

Novo Nordisk and Lilly, in lawsuits each company has filed against competitors, say their own testing has found bacteria and other impurities in products made by compounding pharmacies. The companies also report patent infringement, but compounders, pointing to the FDA loophole for drugs in shortage, appear to have defeated that argument for now.

When the FDA removes the drugs from the shortage list, 503B compounders must immediately stop selling them. Smaller compounders may be able to produce their products for a reduced number of patients, said Scott Brunner, CEO of the Alliance for Pharmacy Compounding, which represents 503A compounders.

The evaporation of the compounded drug supply could come as a shock to patients.

“I dread it,” said David Wertheimer, an internist in Franklin Lakes, New Jersey, who prescribes compounded semaglutide to some patients. “People are not going to be able to plunk down a grand every month. A lot of people will go off the drug, and that’s a shame.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This transcript has been edited for clarity.

On today’s edition of Beyond BMI, I’ll be discussing weight plateaus. This is something that our patients are very familiar with. Sometimes, they’re happy with their weight when they plateau; sometimes, they’re not. A weight plateau is simply a state of equilibrium.

There’s a common adage that the last 5 pounds are the hardest. When people decrease their calorie intake and increase their activity — as we instruct our patients to do to lose weight — the body starts to fight back because it believes this is a famine state. Our bodies feel that we are running around the jungle looking for food to help us survive a perceived famine state.

The body does a few things to help us keep weight on, and this is what leads to the frustration of not being able to lose those last 5 pounds. The first thing that happens in this process, which is called metabolic adaptation, is that when someone loses weight, the body naturally increases appetite signals from the brain, so the person becomes hungrier. Satiety signals from the stomach also decrease, so they feel more hungry and less full. And finally, stable fat cells form to allow the person to seek out more food without losing weight. This eventually leads the patient to regain weight, or they may plateau at a weight they’re not happy with.

I’m sure you’ve seen many studies looking at weight plateaus and the amount of weight loss people are able to achieve with diet, exercise, and behavior change alone vs the same lifestyle modifications plus medication. Studies show that patients who are taking anti-obesity medications achieve far more weight loss than do those who are not taking medications. The reason is related to the different mechanisms of action of the anti-obesity medications. Patients taking these medications are able to tolerate a lower caloric intake for a longer period of time, thus they’re able to burn more fat cells and lose more weight. Some medications perform this by decreasing appetite signals, so patients can continue to eat a small number of calories. Some medications affect the stability of fat cells. Some medications also increase satiety signals, so patients can move beyond that degree of metabolic adaptation and get beyond their previous plateau.

What can we do for patients who are frustrated with their weight plateau? I recommend taking a dive into their daily routine. Find out how many calories they are eating. Find out how much exercise they are doing and see whether there’s any room to reorganize the day or change their meals to create a caloric deficit. Are they eating things that are not filling enough, so they can’t get to the next meal without having a snack in between? We are looking at the quality of the meals as well and making sure there’s an adequate amount of protein and fiber in their meals to help with those increased appetite signals. We should also make sure these patients are getting adequate fluid intake.

These are all strategies that can help our patients try to get beyond their weight plateaus.

If the patient meets criteria for anti-obesity medication, which means a body mass index (BMI) of 27-29 with a weight-related comorbidity or BMI ≥ 30 with or without a comorbidity, you may want to consider anti-obesity medication to help that patient get beyond the plateau.

Plateaus will occur as a natural process because of the appetite signaling and hormonal changes that occur when patients lose weight from any modality. It’s important that we work with our patients to determine whether their weight plateau is due to metabolic adaptation. If they aren’t meeting their goals and they have weight-related comorbidities, we can use other available modalities to help those patients continue to lose weight. Of course, whenever we are prescribing a medication, we need to make sure that it is safe for the patient and the patient is on board with the potential side effects and risks. And we should always make sure our patients know we are their advocates in their weight journey.

Holly Lofton, clinical associate professor of surgery and medicine, NYU Langone Health, New York, NY, has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

On today’s edition of Beyond BMI, I’ll be discussing weight plateaus. This is something that our patients are very familiar with. Sometimes, they’re happy with their weight when they plateau; sometimes, they’re not. A weight plateau is simply a state of equilibrium.

There’s a common adage that the last 5 pounds are the hardest. When people decrease their calorie intake and increase their activity — as we instruct our patients to do to lose weight — the body starts to fight back because it believes this is a famine state. Our bodies feel that we are running around the jungle looking for food to help us survive a perceived famine state.

The body does a few things to help us keep weight on, and this is what leads to the frustration of not being able to lose those last 5 pounds. The first thing that happens in this process, which is called metabolic adaptation, is that when someone loses weight, the body naturally increases appetite signals from the brain, so the person becomes hungrier. Satiety signals from the stomach also decrease, so they feel more hungry and less full. And finally, stable fat cells form to allow the person to seek out more food without losing weight. This eventually leads the patient to regain weight, or they may plateau at a weight they’re not happy with.

I’m sure you’ve seen many studies looking at weight plateaus and the amount of weight loss people are able to achieve with diet, exercise, and behavior change alone vs the same lifestyle modifications plus medication. Studies show that patients who are taking anti-obesity medications achieve far more weight loss than do those who are not taking medications. The reason is related to the different mechanisms of action of the anti-obesity medications. Patients taking these medications are able to tolerate a lower caloric intake for a longer period of time, thus they’re able to burn more fat cells and lose more weight. Some medications perform this by decreasing appetite signals, so patients can continue to eat a small number of calories. Some medications affect the stability of fat cells. Some medications also increase satiety signals, so patients can move beyond that degree of metabolic adaptation and get beyond their previous plateau.

What can we do for patients who are frustrated with their weight plateau? I recommend taking a dive into their daily routine. Find out how many calories they are eating. Find out how much exercise they are doing and see whether there’s any room to reorganize the day or change their meals to create a caloric deficit. Are they eating things that are not filling enough, so they can’t get to the next meal without having a snack in between? We are looking at the quality of the meals as well and making sure there’s an adequate amount of protein and fiber in their meals to help with those increased appetite signals. We should also make sure these patients are getting adequate fluid intake.

These are all strategies that can help our patients try to get beyond their weight plateaus.

If the patient meets criteria for anti-obesity medication, which means a body mass index (BMI) of 27-29 with a weight-related comorbidity or BMI ≥ 30 with or without a comorbidity, you may want to consider anti-obesity medication to help that patient get beyond the plateau.

Plateaus will occur as a natural process because of the appetite signaling and hormonal changes that occur when patients lose weight from any modality. It’s important that we work with our patients to determine whether their weight plateau is due to metabolic adaptation. If they aren’t meeting their goals and they have weight-related comorbidities, we can use other available modalities to help those patients continue to lose weight. Of course, whenever we are prescribing a medication, we need to make sure that it is safe for the patient and the patient is on board with the potential side effects and risks. And we should always make sure our patients know we are their advocates in their weight journey.

Holly Lofton, clinical associate professor of surgery and medicine, NYU Langone Health, New York, NY, has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

On today’s edition of Beyond BMI, I’ll be discussing weight plateaus. This is something that our patients are very familiar with. Sometimes, they’re happy with their weight when they plateau; sometimes, they’re not. A weight plateau is simply a state of equilibrium.

There’s a common adage that the last 5 pounds are the hardest. When people decrease their calorie intake and increase their activity — as we instruct our patients to do to lose weight — the body starts to fight back because it believes this is a famine state. Our bodies feel that we are running around the jungle looking for food to help us survive a perceived famine state.

The body does a few things to help us keep weight on, and this is what leads to the frustration of not being able to lose those last 5 pounds. The first thing that happens in this process, which is called metabolic adaptation, is that when someone loses weight, the body naturally increases appetite signals from the brain, so the person becomes hungrier. Satiety signals from the stomach also decrease, so they feel more hungry and less full. And finally, stable fat cells form to allow the person to seek out more food without losing weight. This eventually leads the patient to regain weight, or they may plateau at a weight they’re not happy with.

I’m sure you’ve seen many studies looking at weight plateaus and the amount of weight loss people are able to achieve with diet, exercise, and behavior change alone vs the same lifestyle modifications plus medication. Studies show that patients who are taking anti-obesity medications achieve far more weight loss than do those who are not taking medications. The reason is related to the different mechanisms of action of the anti-obesity medications. Patients taking these medications are able to tolerate a lower caloric intake for a longer period of time, thus they’re able to burn more fat cells and lose more weight. Some medications perform this by decreasing appetite signals, so patients can continue to eat a small number of calories. Some medications affect the stability of fat cells. Some medications also increase satiety signals, so patients can move beyond that degree of metabolic adaptation and get beyond their previous plateau.

What can we do for patients who are frustrated with their weight plateau? I recommend taking a dive into their daily routine. Find out how many calories they are eating. Find out how much exercise they are doing and see whether there’s any room to reorganize the day or change their meals to create a caloric deficit. Are they eating things that are not filling enough, so they can’t get to the next meal without having a snack in between? We are looking at the quality of the meals as well and making sure there’s an adequate amount of protein and fiber in their meals to help with those increased appetite signals. We should also make sure these patients are getting adequate fluid intake.

These are all strategies that can help our patients try to get beyond their weight plateaus.

If the patient meets criteria for anti-obesity medication, which means a body mass index (BMI) of 27-29 with a weight-related comorbidity or BMI ≥ 30 with or without a comorbidity, you may want to consider anti-obesity medication to help that patient get beyond the plateau.

Plateaus will occur as a natural process because of the appetite signaling and hormonal changes that occur when patients lose weight from any modality. It’s important that we work with our patients to determine whether their weight plateau is due to metabolic adaptation. If they aren’t meeting their goals and they have weight-related comorbidities, we can use other available modalities to help those patients continue to lose weight. Of course, whenever we are prescribing a medication, we need to make sure that it is safe for the patient and the patient is on board with the potential side effects and risks. And we should always make sure our patients know we are their advocates in their weight journey.

Holly Lofton, clinical associate professor of surgery and medicine, NYU Langone Health, New York, NY, has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Irregular sleep duration was associated with a higher risk for diabetes in middle-aged to older adults in a new UK Biobank study.

The analysis of more than 84,000 participants with 7-day accelerometry data suggested that individuals with the most irregular sleep duration patterns had a 34% higher risk for diabetes compared with their peers who had more consistent sleep patterns.

“It’s recommended to have 7-9 hours of nightly sleep, but what is not considered much in policy guidelines or at the clinical level is how regularly that’s needed,” Sina Kianersi, PhD, of Brigham and Women’s Hospital in Boston, Massachusetts, said in an interview. “What our study added is that it’s not just the duration but keeping it consistent. Patients can reduce their risk of diabetes by maintaining their 7-9 hours of sleep, not just for 1 night but throughout life.”

The study was published online in Diabetes Care.
 

Modifiable Lifestyle Factor

Researchers analyzed data from 84,421 UK Biobank participants who were free of diabetes when they provided accelerometer data in 2013-2015 and who were followed for a median of 7.5 years (622,080 person-years).

Participants had an average age of 62 years, 57% were women, 97% were White individuals, and 50% were employed in non–shift work jobs.

Sleep duration variability was quantified by the within-person standard deviation (SD) of 7-night accelerometer-measured sleep duration.

Participants with higher sleep duration SD were younger and more likely to be women, shift workers, or current smokers; those who reported definite “evening” chronotype (natural preference of the body to sleep at a certain time); those having lower socioeconomic status, higher body mass index, and shorter mean sleep duration; and were less likely to be White individuals.

In addition, a family history of diabetes and of depression was more prevalent among these participants.

A total of 2058 incident diabetes cases occurred during follow-up.

After adjustment for age, sex, and race, compared with a sleep duration SD ≤ 30 minutes, the hazard ratio (HR) was 1.15 for 31-45 minutes, 1.28 for 46-60 minutes, 1.54 for 61-90 minutes, and 1.59 for ≥ 91 minutes.

After the initial adjustment, individuals with a sleep duration SD of > 60 vs ≤ 60 minutes had a 34% higher diabetes risk. However, further adjustment for lifestyle, comorbidities, environmental factors, and adiposity attenuated the association — ie, the HR comparing sleep duration SD of > 60 vs ≤ 60 minutes was 1.11.

Furthermore, researchers found that the association between sleep duration and diabetes was stronger among individuals with lower diabetes polygenic risk score. 

“One possible explanation for this finding is that the impact of sleep irregularity on diabetes risk may be less noticeable in individuals with a high genetic predisposition, where genetic factors dominate,” Dr. Kianersi said. “However, it is important to note that these sleep-gene interaction effects were not consistently observed across different measures and gene-related variables. This is something that remains to be further studied.”

Nevertheless, he added, “I want to emphasize that the association between irregular sleep duration and increased diabetes risk was evident across all levels of diabetes polygenic risk scores.”

The association also was stronger with longer sleep duration. The authors suggested that longer sleep duration “might reduce daylight exposure, which could, in turn, give rise to circadian disruption.”

Overall, Dr. Kianersi said, “Our study identified a modifiable lifestyle factor that can help lower the risk of developing type 2 diabetes.”

The study had several limitations. There was a time lag of a median of 5 years between sleep duration measurements and covariate assessments, which might bias lifestyle behaviors that may vary over time. In addition, a single 7-day sleep duration measurement may not capture long-term sleep patterns. A constrained random sampling approach was used to select participants, raising the potential of selection bias.
 

Regular Sleep Routine Best

Ana Krieger, MD, MPH, director of the Center for Sleep Medicine at Weill Cornell Medicine in New York City, commented on the study for this news organization. “This is a very interesting study, as it adds to the literature,” she said. “Previous research studies have shown metabolic abnormalities with variations in sleep time and duration.”

“This particular study evaluated a large sample of patients in the UK which were mostly White middle-aged and may not be representative of the general population,” she noted. “A similar study in a Hispanic/Latino group failed to demonstrate any significant association between sleep timing variability and incidence of diabetes. It would be desirable to see if prospective studies are able to demonstrate a reduction in diabetes risk by implementing a more regular sleep routine.”

The importance of the body’s natural circadian rhythm in regulating and anchoring many physiological processes was highlighted by the 2017 Nobel Prize of Medicine, which was awarded to three researchers in circadian biology, she pointed out.

“Alterations in the circadian rhythm are known to affect mood regulation, gastrointestinal function, and alertness, among other factors,” she said. “Keeping a regular sleep routine will help to improve our circadian rhythm and better regulate many processes, including our metabolism and appetite-controlling hormones.”

Notably, a study published online in Diabetologia in a racially and economically diverse US population also found that adults with persistent suboptimal sleep durations (< 7 or > 9 hours nightly over a mean of 5 years) were more likely to develop incident diabetes. The strongest association was found among participants reporting extreme changes and higher variability in their sleep durations.

This study was supported by the National Institutes of Health (grant number R01HL155395) and the UKB project 85501. Dr. Kianersi was supported by the American Heart Association Postdoctoral Fellowship. Dr. Kianersi and Dr. Krieger reported no conflicts of interest.

A version of this article first appeared on Medscape.com.

Irregular sleep duration was associated with a higher risk for diabetes in middle-aged to older adults in a new UK Biobank study.

The analysis of more than 84,000 participants with 7-day accelerometry data suggested that individuals with the most irregular sleep duration patterns had a 34% higher risk for diabetes compared with their peers who had more consistent sleep patterns.

“It’s recommended to have 7-9 hours of nightly sleep, but what is not considered much in policy guidelines or at the clinical level is how regularly that’s needed,” Sina Kianersi, PhD, of Brigham and Women’s Hospital in Boston, Massachusetts, said in an interview. “What our study added is that it’s not just the duration but keeping it consistent. Patients can reduce their risk of diabetes by maintaining their 7-9 hours of sleep, not just for 1 night but throughout life.”

The study was published online in Diabetes Care.
 

Modifiable Lifestyle Factor

Researchers analyzed data from 84,421 UK Biobank participants who were free of diabetes when they provided accelerometer data in 2013-2015 and who were followed for a median of 7.5 years (622,080 person-years).

Participants had an average age of 62 years, 57% were women, 97% were White individuals, and 50% were employed in non–shift work jobs.

Sleep duration variability was quantified by the within-person standard deviation (SD) of 7-night accelerometer-measured sleep duration.

Participants with higher sleep duration SD were younger and more likely to be women, shift workers, or current smokers; those who reported definite “evening” chronotype (natural preference of the body to sleep at a certain time); those having lower socioeconomic status, higher body mass index, and shorter mean sleep duration; and were less likely to be White individuals.

In addition, a family history of diabetes and of depression was more prevalent among these participants.

A total of 2058 incident diabetes cases occurred during follow-up.

After adjustment for age, sex, and race, compared with a sleep duration SD ≤ 30 minutes, the hazard ratio (HR) was 1.15 for 31-45 minutes, 1.28 for 46-60 minutes, 1.54 for 61-90 minutes, and 1.59 for ≥ 91 minutes.

After the initial adjustment, individuals with a sleep duration SD of > 60 vs ≤ 60 minutes had a 34% higher diabetes risk. However, further adjustment for lifestyle, comorbidities, environmental factors, and adiposity attenuated the association — ie, the HR comparing sleep duration SD of > 60 vs ≤ 60 minutes was 1.11.

Furthermore, researchers found that the association between sleep duration and diabetes was stronger among individuals with lower diabetes polygenic risk score. 

“One possible explanation for this finding is that the impact of sleep irregularity on diabetes risk may be less noticeable in individuals with a high genetic predisposition, where genetic factors dominate,” Dr. Kianersi said. “However, it is important to note that these sleep-gene interaction effects were not consistently observed across different measures and gene-related variables. This is something that remains to be further studied.”

Nevertheless, he added, “I want to emphasize that the association between irregular sleep duration and increased diabetes risk was evident across all levels of diabetes polygenic risk scores.”

The association also was stronger with longer sleep duration. The authors suggested that longer sleep duration “might reduce daylight exposure, which could, in turn, give rise to circadian disruption.”

Overall, Dr. Kianersi said, “Our study identified a modifiable lifestyle factor that can help lower the risk of developing type 2 diabetes.”

The study had several limitations. There was a time lag of a median of 5 years between sleep duration measurements and covariate assessments, which might bias lifestyle behaviors that may vary over time. In addition, a single 7-day sleep duration measurement may not capture long-term sleep patterns. A constrained random sampling approach was used to select participants, raising the potential of selection bias.
 

Regular Sleep Routine Best

Ana Krieger, MD, MPH, director of the Center for Sleep Medicine at Weill Cornell Medicine in New York City, commented on the study for this news organization. “This is a very interesting study, as it adds to the literature,” she said. “Previous research studies have shown metabolic abnormalities with variations in sleep time and duration.”

“This particular study evaluated a large sample of patients in the UK which were mostly White middle-aged and may not be representative of the general population,” she noted. “A similar study in a Hispanic/Latino group failed to demonstrate any significant association between sleep timing variability and incidence of diabetes. It would be desirable to see if prospective studies are able to demonstrate a reduction in diabetes risk by implementing a more regular sleep routine.”

The importance of the body’s natural circadian rhythm in regulating and anchoring many physiological processes was highlighted by the 2017 Nobel Prize of Medicine, which was awarded to three researchers in circadian biology, she pointed out.

“Alterations in the circadian rhythm are known to affect mood regulation, gastrointestinal function, and alertness, among other factors,” she said. “Keeping a regular sleep routine will help to improve our circadian rhythm and better regulate many processes, including our metabolism and appetite-controlling hormones.”

Notably, a study published online in Diabetologia in a racially and economically diverse US population also found that adults with persistent suboptimal sleep durations (< 7 or > 9 hours nightly over a mean of 5 years) were more likely to develop incident diabetes. The strongest association was found among participants reporting extreme changes and higher variability in their sleep durations.

This study was supported by the National Institutes of Health (grant number R01HL155395) and the UKB project 85501. Dr. Kianersi was supported by the American Heart Association Postdoctoral Fellowship. Dr. Kianersi and Dr. Krieger reported no conflicts of interest.

A version of this article first appeared on Medscape.com.

Irregular sleep duration was associated with a higher risk for diabetes in middle-aged to older adults in a new UK Biobank study.

The analysis of more than 84,000 participants with 7-day accelerometry data suggested that individuals with the most irregular sleep duration patterns had a 34% higher risk for diabetes compared with their peers who had more consistent sleep patterns.

“It’s recommended to have 7-9 hours of nightly sleep, but what is not considered much in policy guidelines or at the clinical level is how regularly that’s needed,” Sina Kianersi, PhD, of Brigham and Women’s Hospital in Boston, Massachusetts, said in an interview. “What our study added is that it’s not just the duration but keeping it consistent. Patients can reduce their risk of diabetes by maintaining their 7-9 hours of sleep, not just for 1 night but throughout life.”

The study was published online in Diabetes Care.
 

Modifiable Lifestyle Factor

Researchers analyzed data from 84,421 UK Biobank participants who were free of diabetes when they provided accelerometer data in 2013-2015 and who were followed for a median of 7.5 years (622,080 person-years).

Participants had an average age of 62 years, 57% were women, 97% were White individuals, and 50% were employed in non–shift work jobs.

Sleep duration variability was quantified by the within-person standard deviation (SD) of 7-night accelerometer-measured sleep duration.

Participants with higher sleep duration SD were younger and more likely to be women, shift workers, or current smokers; those who reported definite “evening” chronotype (natural preference of the body to sleep at a certain time); those having lower socioeconomic status, higher body mass index, and shorter mean sleep duration; and were less likely to be White individuals.

In addition, a family history of diabetes and of depression was more prevalent among these participants.

A total of 2058 incident diabetes cases occurred during follow-up.

After adjustment for age, sex, and race, compared with a sleep duration SD ≤ 30 minutes, the hazard ratio (HR) was 1.15 for 31-45 minutes, 1.28 for 46-60 minutes, 1.54 for 61-90 minutes, and 1.59 for ≥ 91 minutes.

After the initial adjustment, individuals with a sleep duration SD of > 60 vs ≤ 60 minutes had a 34% higher diabetes risk. However, further adjustment for lifestyle, comorbidities, environmental factors, and adiposity attenuated the association — ie, the HR comparing sleep duration SD of > 60 vs ≤ 60 minutes was 1.11.

Furthermore, researchers found that the association between sleep duration and diabetes was stronger among individuals with lower diabetes polygenic risk score. 

“One possible explanation for this finding is that the impact of sleep irregularity on diabetes risk may be less noticeable in individuals with a high genetic predisposition, where genetic factors dominate,” Dr. Kianersi said. “However, it is important to note that these sleep-gene interaction effects were not consistently observed across different measures and gene-related variables. This is something that remains to be further studied.”

Nevertheless, he added, “I want to emphasize that the association between irregular sleep duration and increased diabetes risk was evident across all levels of diabetes polygenic risk scores.”

The association also was stronger with longer sleep duration. The authors suggested that longer sleep duration “might reduce daylight exposure, which could, in turn, give rise to circadian disruption.”

Overall, Dr. Kianersi said, “Our study identified a modifiable lifestyle factor that can help lower the risk of developing type 2 diabetes.”

The study had several limitations. There was a time lag of a median of 5 years between sleep duration measurements and covariate assessments, which might bias lifestyle behaviors that may vary over time. In addition, a single 7-day sleep duration measurement may not capture long-term sleep patterns. A constrained random sampling approach was used to select participants, raising the potential of selection bias.
 

Regular Sleep Routine Best

Ana Krieger, MD, MPH, director of the Center for Sleep Medicine at Weill Cornell Medicine in New York City, commented on the study for this news organization. “This is a very interesting study, as it adds to the literature,” she said. “Previous research studies have shown metabolic abnormalities with variations in sleep time and duration.”

“This particular study evaluated a large sample of patients in the UK which were mostly White middle-aged and may not be representative of the general population,” she noted. “A similar study in a Hispanic/Latino group failed to demonstrate any significant association between sleep timing variability and incidence of diabetes. It would be desirable to see if prospective studies are able to demonstrate a reduction in diabetes risk by implementing a more regular sleep routine.”

The importance of the body’s natural circadian rhythm in regulating and anchoring many physiological processes was highlighted by the 2017 Nobel Prize of Medicine, which was awarded to three researchers in circadian biology, she pointed out.

“Alterations in the circadian rhythm are known to affect mood regulation, gastrointestinal function, and alertness, among other factors,” she said. “Keeping a regular sleep routine will help to improve our circadian rhythm and better regulate many processes, including our metabolism and appetite-controlling hormones.”

Notably, a study published online in Diabetologia in a racially and economically diverse US population also found that adults with persistent suboptimal sleep durations (< 7 or > 9 hours nightly over a mean of 5 years) were more likely to develop incident diabetes. The strongest association was found among participants reporting extreme changes and higher variability in their sleep durations.

This study was supported by the National Institutes of Health (grant number R01HL155395) and the UKB project 85501. Dr. Kianersi was supported by the American Heart Association Postdoctoral Fellowship. Dr. Kianersi and Dr. Krieger reported no conflicts of interest.

A version of this article first appeared on Medscape.com.

The role of body mass index (BMI) in defining obesity and the definition of obesity as a disease merit reevaluation to avoid unintended consequences, experts said in three new opinion papers.

The three statements were published on July 22, 2024, in Annals of Internal Medicine. In one, the authors expressed caution about the recent movement away from using BMI alone to define obesity, noting that the measure remains a useful population-level and clinical tool for addressing adiposity, particularly within racial and ethnic groups. But the authors of a second paper pointed out that the use of lower BMI cutoffs to define obesity in Asian populations, in place since 2004, is inadequate in part because it doesn’t account for heterogeneity among different Asian groups.

And in the third paper, an editorial, an Annals editor cautioned that the recent framing of obesity exclusively as a “disease” rather than a “broader, more inclusive construct” may inadvertently reinforce the bias it was meant to combat.

Asked to comment on the issues raised in the papers, Professor Gijs Goossens of Maastricht University Medical Center, Maastricht, the Netherlands, said, “It is important to emphasize that the management and treatment of obesity have wider objectives than weight loss alone and include the prevention, resolution, or improvement of obesity-related complications; achieving better quality of life and mental well-being; and improvement of physical and social functioning.”

Added Dr. Goossens, who was an author of a recent European Association for the Study of Obesity (EASO) framework calling for moving beyond BMI in defining obesity, “Personalized therapeutic goals should be set at the beginning of the treatment, according to the stage of obesity, taking into account available therapeutic options, possible side effects or risks, and patient preferences. The drivers of obesity and possible barriers to treatment should also be discussed with the patient.” Dr. Goossens emphasized that he was providing his personal views and not speaking for the EASO or his coauthors.
 

BMI: ‘Not a Perfect Measure of Adiposity but Remains Useful’

In their “Ideas and Opinions” paper, Adolfo G. Cuevas, PhD, of New York University School of Global Public Health, New York City, and Walter C. Willett, MD, DrPH, of Harvard T.H. Chan School of Public Health, Boston, argued that “BMI, although not a perfect measure of adiposity, remains a useful population-level and clinical tool for addressing adiposity, including within groups defined by race and ethnicity.”

They added that despite the criticism that BMI doesn’t distinguish between fat and lean body mass, the measure still strongly correlates with fat mass as well as cardiovascular risk and mortality, and it does so similarly across racial and ethnic groups.

Clinically, Dr. Cuevas and Dr. Willett pointed out that BMI correlates fat mass as assessed with the gold standard measure dual x-ray absorptiometry but is far simpler and less expensive. Measuring waist circumference can provide additional information about visceral fat and disease risk but is “more difficult to standardize and suffers from the same limitations as BMI when cut points are used.”

They suggest the addition of change in weight since early adulthood and over time as a “simple and sensitive variable” for assessing adiposity.

Luca Busetto, MD, associate professor of medicine at the University of Padua, Italy, and the first author of the EASO framework, said, “The paper from Cuevas and Willett sounds like a strong defense of BMI, and I can substantially agree with this defense ... We remain anchored on BMI, but we tried to move beyond it adding an estimate of high risk abdominal fat — waist to height ratio — and coupling the anthropometric assessment with a complete clinical evaluation and staging.”

Dr. Goossens said, “I agree with the authors that despite the limitations of BMI as a measure of body fatness, it remains a useful clinical screening tool. Yet the diagnosis of obesity should not be based solely on BMI” due to the stronger association of abdominal fat with cardiometabolic complications.

That link, he noted, “also applies to individuals with a BMI level below the current cutoff values for obesity, who may already have medical, functional, or psychological impairments. We should be aware of the risk of undertreatment in this particular group of patients.”
 

Does Calling Obesity a ‘Disease’ Have Unintended Consequences?

In her editorial, Christina C. Wee, MD, senior deputy editor, Annals of Internal Medicine, wrote, “Beyond diagnostic challenges, framing obesity exclusively as a disease rather than a broader, more inclusive construct may have unintended consequences — including reinforcing the weight bias this framing was in part intended to combat.”

Focusing solely on biological causes of obesity while ignoring psychosocial, cultural, environmental, and behavioral contexts could undermine public health and policy efforts to address those factors, Dr. Wee argued.

Moreover, she wrote, “Ironically, framing obesity as a disease to justify coverage for treatment reinforces weight bias. It conflates the need to label a condition a disease with healthcare reimbursement and raises the stakes for developing accurate diagnostic criteria ... By exclusively linking obesity as a disease to reimbursement, it sends the message that only those who manifest disease from excess adiposity warrant treatment — and, by inference, those on the continuum who have not yet manifested disease do not warrant treatment.”

Likening obesity to other risk factors such as hypertension or dyslipidemia for which treatment is typically reimbursed, Dr. Wee pointed out that Medicare still prohibits coverage of medications for obesity.

Regarding the high costs of newer obesity medications and the need for payers and clinicians to ration their use, Dr. Wee argued, “Rather than focusing on whether one’s adiposity conforms to an expert panel’s definition of ‘disease,’ we should address how to best stage obesity risk with sufficient accuracy and fairness and reach a consensus on how to prioritize and match treatments to individual patients.”

Dr. Busetto said that EASO stands by its definition of obesity as a disease, adding “we can adhere to the suggestion of a holistic approach deciding treatment modalities according to the risk and the presence of mental, functional, and medical complications of impairments. Of course, we cannot agree on any proposal that is oriented at leaving patients with obesity still in the asymptomatic phase of the disease without treatment. This would be like treating diabetes only after the occurrence of nephropathy or managing hypertension only after a stroke. Prevention of the symptomatic stage is a part of obesity management, even beyond weight loss.”

Dr. Goossens said, “indeed, it is of utmost importance to develop accurate risk stratification tools for adequately clinical staging of obesity, according to the severity of its medical, psychological and functional impairments.”
 

Do the Current Lower BMI Cutoffs for Defining Obesity in Asian People Make Sense?

Simar S. Bajaj, AB, of Harvard University, Cambridge, Massachusetts, and colleagues, all of Harvard Medical School, Boston, raised several concerns regarding the 2004 World Health Organization’s suggestion to use lower BMI categories for defining overweight and obesity in Asian populations, that is, 23-27.5 kg/m² and 27.5 kg/m² or higher for obesity, respectively, as opposed to 25-29.9 and ≥ 30, respectively, for other populations.

Different Asian countries have created their own obesity BMI cutoffs, ranging from 25 kg/m² in India to 28 kg/m² in China. But “Asian Americans continue to be treated as a monolith without official disaggregated cutoffs,” Mr. Bajaj and colleagues noted.

The heterogeneity translates to different risk levels across Asian subgroups. For example, in one study, age- and sex-adjusted BMI cutoffs for increased risk of developing type 2 diabetes were 23.9 kg/m² in South Asian populations, 26.6 kg/m² in Arab populations, 26.9 kg/m² in Chinese populations, and 28.1 kg/m² in Black populations.

These findings raise important questions, the researchers said. “Does it make sense for people of Chinese descent to use the same BMI threshold as the South Asian group when their ‘equivalent risk cutoff’ is closer to that of Arab and Black groups who share the standard BMI threshold?” Most data in this area are cross-sectional rather than the longitudinal data needed to answer those questions, they noted.

They suggest that professional diabetes and obesity organizations consider BMI thresholds to be “placeholders” until more sensitive and specific thresholds can be defined for Asian American populations.

Mr. Bajaj and colleagues also noted the need for disaggregated data is not unique to Asian groups but that they focused on Asian Americans for two main reasons. “First, success would create a precedent for complete disaggregation and help ensure that other groups do not stall at an intermediary level. Second, substantial research into Asian ethnic groups — and the WHO’s precedent 20 years ago — creates a solid foundation to build upon.”

Ultimately, they said, “advancing equity will require funding research that engages diverse Asian communities and developing tailored interventions for all ethnicities.”

Dr. Cuevas, Dr. Willett, Mr. Bajaj, and Dr. Wee had no disclosures. Dr. Goossens received research funding from the European Foundation for the Study of Diabetes, the Dutch Diabetes Research Foundation, and the Dutch Research Council. Dr. Busetto received personal funding from Novo Nordisk, Boehringer Ingelheim, Eli Lilly, Pfizer, and Bruno Farmaceutici as a member of advisory boards and from Rhythm Pharmaceuticals and Pronokal as a speaker.
 

A version of this article first appeared on Medscape.com.

The role of body mass index (BMI) in defining obesity and the definition of obesity as a disease merit reevaluation to avoid unintended consequences, experts said in three new opinion papers.

The three statements were published on July 22, 2024, in Annals of Internal Medicine. In one, the authors expressed caution about the recent movement away from using BMI alone to define obesity, noting that the measure remains a useful population-level and clinical tool for addressing adiposity, particularly within racial and ethnic groups. But the authors of a second paper pointed out that the use of lower BMI cutoffs to define obesity in Asian populations, in place since 2004, is inadequate in part because it doesn’t account for heterogeneity among different Asian groups.

And in the third paper, an editorial, an Annals editor cautioned that the recent framing of obesity exclusively as a “disease” rather than a “broader, more inclusive construct” may inadvertently reinforce the bias it was meant to combat.

Asked to comment on the issues raised in the papers, Professor Gijs Goossens of Maastricht University Medical Center, Maastricht, the Netherlands, said, “It is important to emphasize that the management and treatment of obesity have wider objectives than weight loss alone and include the prevention, resolution, or improvement of obesity-related complications; achieving better quality of life and mental well-being; and improvement of physical and social functioning.”

Added Dr. Goossens, who was an author of a recent European Association for the Study of Obesity (EASO) framework calling for moving beyond BMI in defining obesity, “Personalized therapeutic goals should be set at the beginning of the treatment, according to the stage of obesity, taking into account available therapeutic options, possible side effects or risks, and patient preferences. The drivers of obesity and possible barriers to treatment should also be discussed with the patient.” Dr. Goossens emphasized that he was providing his personal views and not speaking for the EASO or his coauthors.
 

BMI: ‘Not a Perfect Measure of Adiposity but Remains Useful’

In their “Ideas and Opinions” paper, Adolfo G. Cuevas, PhD, of New York University School of Global Public Health, New York City, and Walter C. Willett, MD, DrPH, of Harvard T.H. Chan School of Public Health, Boston, argued that “BMI, although not a perfect measure of adiposity, remains a useful population-level and clinical tool for addressing adiposity, including within groups defined by race and ethnicity.”

They added that despite the criticism that BMI doesn’t distinguish between fat and lean body mass, the measure still strongly correlates with fat mass as well as cardiovascular risk and mortality, and it does so similarly across racial and ethnic groups.

Clinically, Dr. Cuevas and Dr. Willett pointed out that BMI correlates fat mass as assessed with the gold standard measure dual x-ray absorptiometry but is far simpler and less expensive. Measuring waist circumference can provide additional information about visceral fat and disease risk but is “more difficult to standardize and suffers from the same limitations as BMI when cut points are used.”

They suggest the addition of change in weight since early adulthood and over time as a “simple and sensitive variable” for assessing adiposity.

Luca Busetto, MD, associate professor of medicine at the University of Padua, Italy, and the first author of the EASO framework, said, “The paper from Cuevas and Willett sounds like a strong defense of BMI, and I can substantially agree with this defense ... We remain anchored on BMI, but we tried to move beyond it adding an estimate of high risk abdominal fat — waist to height ratio — and coupling the anthropometric assessment with a complete clinical evaluation and staging.”

Dr. Goossens said, “I agree with the authors that despite the limitations of BMI as a measure of body fatness, it remains a useful clinical screening tool. Yet the diagnosis of obesity should not be based solely on BMI” due to the stronger association of abdominal fat with cardiometabolic complications.

That link, he noted, “also applies to individuals with a BMI level below the current cutoff values for obesity, who may already have medical, functional, or psychological impairments. We should be aware of the risk of undertreatment in this particular group of patients.”
 

Does Calling Obesity a ‘Disease’ Have Unintended Consequences?

In her editorial, Christina C. Wee, MD, senior deputy editor, Annals of Internal Medicine, wrote, “Beyond diagnostic challenges, framing obesity exclusively as a disease rather than a broader, more inclusive construct may have unintended consequences — including reinforcing the weight bias this framing was in part intended to combat.”

Focusing solely on biological causes of obesity while ignoring psychosocial, cultural, environmental, and behavioral contexts could undermine public health and policy efforts to address those factors, Dr. Wee argued.

Moreover, she wrote, “Ironically, framing obesity as a disease to justify coverage for treatment reinforces weight bias. It conflates the need to label a condition a disease with healthcare reimbursement and raises the stakes for developing accurate diagnostic criteria ... By exclusively linking obesity as a disease to reimbursement, it sends the message that only those who manifest disease from excess adiposity warrant treatment — and, by inference, those on the continuum who have not yet manifested disease do not warrant treatment.”

Likening obesity to other risk factors such as hypertension or dyslipidemia for which treatment is typically reimbursed, Dr. Wee pointed out that Medicare still prohibits coverage of medications for obesity.

Regarding the high costs of newer obesity medications and the need for payers and clinicians to ration their use, Dr. Wee argued, “Rather than focusing on whether one’s adiposity conforms to an expert panel’s definition of ‘disease,’ we should address how to best stage obesity risk with sufficient accuracy and fairness and reach a consensus on how to prioritize and match treatments to individual patients.”

Dr. Busetto said that EASO stands by its definition of obesity as a disease, adding “we can adhere to the suggestion of a holistic approach deciding treatment modalities according to the risk and the presence of mental, functional, and medical complications of impairments. Of course, we cannot agree on any proposal that is oriented at leaving patients with obesity still in the asymptomatic phase of the disease without treatment. This would be like treating diabetes only after the occurrence of nephropathy or managing hypertension only after a stroke. Prevention of the symptomatic stage is a part of obesity management, even beyond weight loss.”

Dr. Goossens said, “indeed, it is of utmost importance to develop accurate risk stratification tools for adequately clinical staging of obesity, according to the severity of its medical, psychological and functional impairments.”
 

Do the Current Lower BMI Cutoffs for Defining Obesity in Asian People Make Sense?

Simar S. Bajaj, AB, of Harvard University, Cambridge, Massachusetts, and colleagues, all of Harvard Medical School, Boston, raised several concerns regarding the 2004 World Health Organization’s suggestion to use lower BMI categories for defining overweight and obesity in Asian populations, that is, 23-27.5 kg/m² and 27.5 kg/m² or higher for obesity, respectively, as opposed to 25-29.9 and ≥ 30, respectively, for other populations.

Different Asian countries have created their own obesity BMI cutoffs, ranging from 25 kg/m² in India to 28 kg/m² in China. But “Asian Americans continue to be treated as a monolith without official disaggregated cutoffs,” Mr. Bajaj and colleagues noted.

The heterogeneity translates to different risk levels across Asian subgroups. For example, in one study, age- and sex-adjusted BMI cutoffs for increased risk of developing type 2 diabetes were 23.9 kg/m² in South Asian populations, 26.6 kg/m² in Arab populations, 26.9 kg/m² in Chinese populations, and 28.1 kg/m² in Black populations.

These findings raise important questions, the researchers said. “Does it make sense for people of Chinese descent to use the same BMI threshold as the South Asian group when their ‘equivalent risk cutoff’ is closer to that of Arab and Black groups who share the standard BMI threshold?” Most data in this area are cross-sectional rather than the longitudinal data needed to answer those questions, they noted.

They suggest that professional diabetes and obesity organizations consider BMI thresholds to be “placeholders” until more sensitive and specific thresholds can be defined for Asian American populations.

Mr. Bajaj and colleagues also noted the need for disaggregated data is not unique to Asian groups but that they focused on Asian Americans for two main reasons. “First, success would create a precedent for complete disaggregation and help ensure that other groups do not stall at an intermediary level. Second, substantial research into Asian ethnic groups — and the WHO’s precedent 20 years ago — creates a solid foundation to build upon.”

Ultimately, they said, “advancing equity will require funding research that engages diverse Asian communities and developing tailored interventions for all ethnicities.”

Dr. Cuevas, Dr. Willett, Mr. Bajaj, and Dr. Wee had no disclosures. Dr. Goossens received research funding from the European Foundation for the Study of Diabetes, the Dutch Diabetes Research Foundation, and the Dutch Research Council. Dr. Busetto received personal funding from Novo Nordisk, Boehringer Ingelheim, Eli Lilly, Pfizer, and Bruno Farmaceutici as a member of advisory boards and from Rhythm Pharmaceuticals and Pronokal as a speaker.
 

A version of this article first appeared on Medscape.com.

The role of body mass index (BMI) in defining obesity and the definition of obesity as a disease merit reevaluation to avoid unintended consequences, experts said in three new opinion papers.

The three statements were published on July 22, 2024, in Annals of Internal Medicine. In one, the authors expressed caution about the recent movement away from using BMI alone to define obesity, noting that the measure remains a useful population-level and clinical tool for addressing adiposity, particularly within racial and ethnic groups. But the authors of a second paper pointed out that the use of lower BMI cutoffs to define obesity in Asian populations, in place since 2004, is inadequate in part because it doesn’t account for heterogeneity among different Asian groups.

And in the third paper, an editorial, an Annals editor cautioned that the recent framing of obesity exclusively as a “disease” rather than a “broader, more inclusive construct” may inadvertently reinforce the bias it was meant to combat.

Asked to comment on the issues raised in the papers, Professor Gijs Goossens of Maastricht University Medical Center, Maastricht, the Netherlands, said, “It is important to emphasize that the management and treatment of obesity have wider objectives than weight loss alone and include the prevention, resolution, or improvement of obesity-related complications; achieving better quality of life and mental well-being; and improvement of physical and social functioning.”

Added Dr. Goossens, who was an author of a recent European Association for the Study of Obesity (EASO) framework calling for moving beyond BMI in defining obesity, “Personalized therapeutic goals should be set at the beginning of the treatment, according to the stage of obesity, taking into account available therapeutic options, possible side effects or risks, and patient preferences. The drivers of obesity and possible barriers to treatment should also be discussed with the patient.” Dr. Goossens emphasized that he was providing his personal views and not speaking for the EASO or his coauthors.
 

BMI: ‘Not a Perfect Measure of Adiposity but Remains Useful’

In their “Ideas and Opinions” paper, Adolfo G. Cuevas, PhD, of New York University School of Global Public Health, New York City, and Walter C. Willett, MD, DrPH, of Harvard T.H. Chan School of Public Health, Boston, argued that “BMI, although not a perfect measure of adiposity, remains a useful population-level and clinical tool for addressing adiposity, including within groups defined by race and ethnicity.”

They added that despite the criticism that BMI doesn’t distinguish between fat and lean body mass, the measure still strongly correlates with fat mass as well as cardiovascular risk and mortality, and it does so similarly across racial and ethnic groups.

Clinically, Dr. Cuevas and Dr. Willett pointed out that BMI correlates fat mass as assessed with the gold standard measure dual x-ray absorptiometry but is far simpler and less expensive. Measuring waist circumference can provide additional information about visceral fat and disease risk but is “more difficult to standardize and suffers from the same limitations as BMI when cut points are used.”

They suggest the addition of change in weight since early adulthood and over time as a “simple and sensitive variable” for assessing adiposity.

Luca Busetto, MD, associate professor of medicine at the University of Padua, Italy, and the first author of the EASO framework, said, “The paper from Cuevas and Willett sounds like a strong defense of BMI, and I can substantially agree with this defense ... We remain anchored on BMI, but we tried to move beyond it adding an estimate of high risk abdominal fat — waist to height ratio — and coupling the anthropometric assessment with a complete clinical evaluation and staging.”

Dr. Goossens said, “I agree with the authors that despite the limitations of BMI as a measure of body fatness, it remains a useful clinical screening tool. Yet the diagnosis of obesity should not be based solely on BMI” due to the stronger association of abdominal fat with cardiometabolic complications.

That link, he noted, “also applies to individuals with a BMI level below the current cutoff values for obesity, who may already have medical, functional, or psychological impairments. We should be aware of the risk of undertreatment in this particular group of patients.”
 

Does Calling Obesity a ‘Disease’ Have Unintended Consequences?

In her editorial, Christina C. Wee, MD, senior deputy editor, Annals of Internal Medicine, wrote, “Beyond diagnostic challenges, framing obesity exclusively as a disease rather than a broader, more inclusive construct may have unintended consequences — including reinforcing the weight bias this framing was in part intended to combat.”

Focusing solely on biological causes of obesity while ignoring psychosocial, cultural, environmental, and behavioral contexts could undermine public health and policy efforts to address those factors, Dr. Wee argued.

Moreover, she wrote, “Ironically, framing obesity as a disease to justify coverage for treatment reinforces weight bias. It conflates the need to label a condition a disease with healthcare reimbursement and raises the stakes for developing accurate diagnostic criteria ... By exclusively linking obesity as a disease to reimbursement, it sends the message that only those who manifest disease from excess adiposity warrant treatment — and, by inference, those on the continuum who have not yet manifested disease do not warrant treatment.”

Likening obesity to other risk factors such as hypertension or dyslipidemia for which treatment is typically reimbursed, Dr. Wee pointed out that Medicare still prohibits coverage of medications for obesity.

Regarding the high costs of newer obesity medications and the need for payers and clinicians to ration their use, Dr. Wee argued, “Rather than focusing on whether one’s adiposity conforms to an expert panel’s definition of ‘disease,’ we should address how to best stage obesity risk with sufficient accuracy and fairness and reach a consensus on how to prioritize and match treatments to individual patients.”

Dr. Busetto said that EASO stands by its definition of obesity as a disease, adding “we can adhere to the suggestion of a holistic approach deciding treatment modalities according to the risk and the presence of mental, functional, and medical complications of impairments. Of course, we cannot agree on any proposal that is oriented at leaving patients with obesity still in the asymptomatic phase of the disease without treatment. This would be like treating diabetes only after the occurrence of nephropathy or managing hypertension only after a stroke. Prevention of the symptomatic stage is a part of obesity management, even beyond weight loss.”

Dr. Goossens said, “indeed, it is of utmost importance to develop accurate risk stratification tools for adequately clinical staging of obesity, according to the severity of its medical, psychological and functional impairments.”
 

Do the Current Lower BMI Cutoffs for Defining Obesity in Asian People Make Sense?

Simar S. Bajaj, AB, of Harvard University, Cambridge, Massachusetts, and colleagues, all of Harvard Medical School, Boston, raised several concerns regarding the 2004 World Health Organization’s suggestion to use lower BMI categories for defining overweight and obesity in Asian populations, that is, 23-27.5 kg/m² and 27.5 kg/m² or higher for obesity, respectively, as opposed to 25-29.9 and ≥ 30, respectively, for other populations.

Different Asian countries have created their own obesity BMI cutoffs, ranging from 25 kg/m² in India to 28 kg/m² in China. But “Asian Americans continue to be treated as a monolith without official disaggregated cutoffs,” Mr. Bajaj and colleagues noted.

The heterogeneity translates to different risk levels across Asian subgroups. For example, in one study, age- and sex-adjusted BMI cutoffs for increased risk of developing type 2 diabetes were 23.9 kg/m² in South Asian populations, 26.6 kg/m² in Arab populations, 26.9 kg/m² in Chinese populations, and 28.1 kg/m² in Black populations.

These findings raise important questions, the researchers said. “Does it make sense for people of Chinese descent to use the same BMI threshold as the South Asian group when their ‘equivalent risk cutoff’ is closer to that of Arab and Black groups who share the standard BMI threshold?” Most data in this area are cross-sectional rather than the longitudinal data needed to answer those questions, they noted.

They suggest that professional diabetes and obesity organizations consider BMI thresholds to be “placeholders” until more sensitive and specific thresholds can be defined for Asian American populations.

Mr. Bajaj and colleagues also noted the need for disaggregated data is not unique to Asian groups but that they focused on Asian Americans for two main reasons. “First, success would create a precedent for complete disaggregation and help ensure that other groups do not stall at an intermediary level. Second, substantial research into Asian ethnic groups — and the WHO’s precedent 20 years ago — creates a solid foundation to build upon.”

Ultimately, they said, “advancing equity will require funding research that engages diverse Asian communities and developing tailored interventions for all ethnicities.”

Dr. Cuevas, Dr. Willett, Mr. Bajaj, and Dr. Wee had no disclosures. Dr. Goossens received research funding from the European Foundation for the Study of Diabetes, the Dutch Diabetes Research Foundation, and the Dutch Research Council. Dr. Busetto received personal funding from Novo Nordisk, Boehringer Ingelheim, Eli Lilly, Pfizer, and Bruno Farmaceutici as a member of advisory boards and from Rhythm Pharmaceuticals and Pronokal as a speaker.
 

A version of this article first appeared on Medscape.com.

Ahmad Reza Djalali, an Iranian-Swedish physician specializing in disaster medicine, has begun a hunger strike after being sentenced to death in 2017.

Last year, Iran set a grim record, leading the world in executions. The country carried out at least 853 executions, which accounted for three quarters of the officially recorded executions worldwide. The Iranian government uses the death penalty to intimidate political opponents, especially since the women’s uprising in 2022, and to exert pressure on Western states in diplomatic standoffs.

Among the thousands of political prisoners currently on death row in Tehran’s notorious Evin prison is Dr. Djalali, a 52-year-old physician.

He emigrated to Sweden in 2009 and joined the Karolinska Institutet in Stockholm, Sweden. Over the years, he became one of Europe’s leading experts in disaster medicine. His work has been cited more than 700 times in medical literature, and he played a key role in establishing the emergency and disaster research center at the University of Piedmont.

In Italy, Denmark, and Sweden, Dr. Djalali helped hospitals and healthcare professionals in preparing for earthquakes, nuclear accidents, and terrorist attacks and designed several disaster medicine training programs.
 

‘Spreading Corruption’

Despite settling in Sweden with his family, Dr. Djalali never forgot his Iranian roots. His doctoral thesis was dedicated to the victims of the 2003 Bam earthquake in Iran, which killed 23,000 people. He expressed a desire to share his knowledge with his Iranian colleagues to help people. So when he was invited to participate in a 2016 conference at the University of Tehran, he accepted without hesitation.

Unfortunately, this decision had severe consequences. On April 25, 2016, as he was concluding his trip to Iran, the researcher was arrested by intelligence agents. After being held incommunicado for several days, he was officially accused of passing confidential information to Israeli intelligence services. According to his family, this accusation was baseless. They believed he was targeted for refusing to work for Iranian intelligence services in Europe.

On October 21, 2017, Dr. Djalali was sentenced to death for “spreading corruption on Earth,” a vague charge often used by Islamic courts against those who allegedly have challenged the regime. A few days later, a video of his “confessions” was broadcast on Iranian television. These confessions were coerced; Dr. Djalali later revealed that Iranian police had threatened to harm his mother in Iran and his family in Sweden.

Since then, Dr. Djalali and his loved ones have anxiously awaited the moment when the regime might carry out the sentence. Several times over the years, he has seemed on the verge of execution, only to receive a last-minute reprieve each time.

His imprisonment has taken a severe toll on his physical and mental health. He has reportedly lost 24 kg since his incarceration, and his family, who receive sporadic updates, suspect he has leukemia. Despite his deteriorating condition, the authorities have refused him access to a hematologist.
 

‘Forgotten’ in Exchange

The international medical community has rallied to secure Dr. Djalali’s release, but their efforts have so far been fruitless. The United Nations, the European Union, Amnesty International, several universities, and the World Medical Association have called for his release. In 2018, Sweden granted him citizenship in an attempt to increase pressure on Tehran, but Iranian law does not recognize dual citizenship.

On June 16, after nearly 7 years on death row, Dr. Djalali informed his family that he had begun a hunger strike. “It’s the only way to make my voice heard in the world,” he explained. “As a doctor, Ahmad Reza knows all too well that his fragile physical state makes a hunger strike potentially fatal, but he sees no other option. He suffers from cardiac arrhythmia, bradycardia, hypotension, chronic gastritis, anemia, and extreme weight loss following his two previous hunger strikes,” his wife told the press.

Aside from a potential (and unlikely) act of clemency by the Iranian authorities, Dr. Djalali’s best hope lies in a prisoner exchange. The Iranian government often imprisons foreign nationals to exchange them for Iranians detained in Western countries.

On June 15, Sweden agreed to release an Iranian dignitary serving a life sentence in exchange for the release of Swedish nationals detained in Iran. For a long time, Dr. Djalali’s family had hoped he would be included in this exchange.

However, to avoid jeopardizing the deal, the Swedish prime minister chose to accept the release of only two other Swedish nationals, leaving Dr. Djalali to his grim fate. “Mr Prime Minister, you have decided to abandon me at the enormous risk of being executed,” Dr. Djalali responded bitterly, knowing he could be hanged at any moment.
 

This story was translated from JIM using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Ahmad Reza Djalali, an Iranian-Swedish physician specializing in disaster medicine, has begun a hunger strike after being sentenced to death in 2017.

Last year, Iran set a grim record, leading the world in executions. The country carried out at least 853 executions, which accounted for three quarters of the officially recorded executions worldwide. The Iranian government uses the death penalty to intimidate political opponents, especially since the women’s uprising in 2022, and to exert pressure on Western states in diplomatic standoffs.

Among the thousands of political prisoners currently on death row in Tehran’s notorious Evin prison is Dr. Djalali, a 52-year-old physician.

He emigrated to Sweden in 2009 and joined the Karolinska Institutet in Stockholm, Sweden. Over the years, he became one of Europe’s leading experts in disaster medicine. His work has been cited more than 700 times in medical literature, and he played a key role in establishing the emergency and disaster research center at the University of Piedmont.

In Italy, Denmark, and Sweden, Dr. Djalali helped hospitals and healthcare professionals in preparing for earthquakes, nuclear accidents, and terrorist attacks and designed several disaster medicine training programs.
 

‘Spreading Corruption’

Despite settling in Sweden with his family, Dr. Djalali never forgot his Iranian roots. His doctoral thesis was dedicated to the victims of the 2003 Bam earthquake in Iran, which killed 23,000 people. He expressed a desire to share his knowledge with his Iranian colleagues to help people. So when he was invited to participate in a 2016 conference at the University of Tehran, he accepted without hesitation.

Unfortunately, this decision had severe consequences. On April 25, 2016, as he was concluding his trip to Iran, the researcher was arrested by intelligence agents. After being held incommunicado for several days, he was officially accused of passing confidential information to Israeli intelligence services. According to his family, this accusation was baseless. They believed he was targeted for refusing to work for Iranian intelligence services in Europe.

On October 21, 2017, Dr. Djalali was sentenced to death for “spreading corruption on Earth,” a vague charge often used by Islamic courts against those who allegedly have challenged the regime. A few days later, a video of his “confessions” was broadcast on Iranian television. These confessions were coerced; Dr. Djalali later revealed that Iranian police had threatened to harm his mother in Iran and his family in Sweden.

Since then, Dr. Djalali and his loved ones have anxiously awaited the moment when the regime might carry out the sentence. Several times over the years, he has seemed on the verge of execution, only to receive a last-minute reprieve each time.

His imprisonment has taken a severe toll on his physical and mental health. He has reportedly lost 24 kg since his incarceration, and his family, who receive sporadic updates, suspect he has leukemia. Despite his deteriorating condition, the authorities have refused him access to a hematologist.
 

‘Forgotten’ in Exchange

The international medical community has rallied to secure Dr. Djalali’s release, but their efforts have so far been fruitless. The United Nations, the European Union, Amnesty International, several universities, and the World Medical Association have called for his release. In 2018, Sweden granted him citizenship in an attempt to increase pressure on Tehran, but Iranian law does not recognize dual citizenship.

On June 16, after nearly 7 years on death row, Dr. Djalali informed his family that he had begun a hunger strike. “It’s the only way to make my voice heard in the world,” he explained. “As a doctor, Ahmad Reza knows all too well that his fragile physical state makes a hunger strike potentially fatal, but he sees no other option. He suffers from cardiac arrhythmia, bradycardia, hypotension, chronic gastritis, anemia, and extreme weight loss following his two previous hunger strikes,” his wife told the press.

Aside from a potential (and unlikely) act of clemency by the Iranian authorities, Dr. Djalali’s best hope lies in a prisoner exchange. The Iranian government often imprisons foreign nationals to exchange them for Iranians detained in Western countries.

On June 15, Sweden agreed to release an Iranian dignitary serving a life sentence in exchange for the release of Swedish nationals detained in Iran. For a long time, Dr. Djalali’s family had hoped he would be included in this exchange.

However, to avoid jeopardizing the deal, the Swedish prime minister chose to accept the release of only two other Swedish nationals, leaving Dr. Djalali to his grim fate. “Mr Prime Minister, you have decided to abandon me at the enormous risk of being executed,” Dr. Djalali responded bitterly, knowing he could be hanged at any moment.
 

This story was translated from JIM using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Ahmad Reza Djalali, an Iranian-Swedish physician specializing in disaster medicine, has begun a hunger strike after being sentenced to death in 2017.

Last year, Iran set a grim record, leading the world in executions. The country carried out at least 853 executions, which accounted for three quarters of the officially recorded executions worldwide. The Iranian government uses the death penalty to intimidate political opponents, especially since the women’s uprising in 2022, and to exert pressure on Western states in diplomatic standoffs.

Among the thousands of political prisoners currently on death row in Tehran’s notorious Evin prison is Dr. Djalali, a 52-year-old physician.

He emigrated to Sweden in 2009 and joined the Karolinska Institutet in Stockholm, Sweden. Over the years, he became one of Europe’s leading experts in disaster medicine. His work has been cited more than 700 times in medical literature, and he played a key role in establishing the emergency and disaster research center at the University of Piedmont.

In Italy, Denmark, and Sweden, Dr. Djalali helped hospitals and healthcare professionals in preparing for earthquakes, nuclear accidents, and terrorist attacks and designed several disaster medicine training programs.
 

‘Spreading Corruption’

Despite settling in Sweden with his family, Dr. Djalali never forgot his Iranian roots. His doctoral thesis was dedicated to the victims of the 2003 Bam earthquake in Iran, which killed 23,000 people. He expressed a desire to share his knowledge with his Iranian colleagues to help people. So when he was invited to participate in a 2016 conference at the University of Tehran, he accepted without hesitation.

Unfortunately, this decision had severe consequences. On April 25, 2016, as he was concluding his trip to Iran, the researcher was arrested by intelligence agents. After being held incommunicado for several days, he was officially accused of passing confidential information to Israeli intelligence services. According to his family, this accusation was baseless. They believed he was targeted for refusing to work for Iranian intelligence services in Europe.

On October 21, 2017, Dr. Djalali was sentenced to death for “spreading corruption on Earth,” a vague charge often used by Islamic courts against those who allegedly have challenged the regime. A few days later, a video of his “confessions” was broadcast on Iranian television. These confessions were coerced; Dr. Djalali later revealed that Iranian police had threatened to harm his mother in Iran and his family in Sweden.

Since then, Dr. Djalali and his loved ones have anxiously awaited the moment when the regime might carry out the sentence. Several times over the years, he has seemed on the verge of execution, only to receive a last-minute reprieve each time.

His imprisonment has taken a severe toll on his physical and mental health. He has reportedly lost 24 kg since his incarceration, and his family, who receive sporadic updates, suspect he has leukemia. Despite his deteriorating condition, the authorities have refused him access to a hematologist.
 

‘Forgotten’ in Exchange

The international medical community has rallied to secure Dr. Djalali’s release, but their efforts have so far been fruitless. The United Nations, the European Union, Amnesty International, several universities, and the World Medical Association have called for his release. In 2018, Sweden granted him citizenship in an attempt to increase pressure on Tehran, but Iranian law does not recognize dual citizenship.

On June 16, after nearly 7 years on death row, Dr. Djalali informed his family that he had begun a hunger strike. “It’s the only way to make my voice heard in the world,” he explained. “As a doctor, Ahmad Reza knows all too well that his fragile physical state makes a hunger strike potentially fatal, but he sees no other option. He suffers from cardiac arrhythmia, bradycardia, hypotension, chronic gastritis, anemia, and extreme weight loss following his two previous hunger strikes,” his wife told the press.

Aside from a potential (and unlikely) act of clemency by the Iranian authorities, Dr. Djalali’s best hope lies in a prisoner exchange. The Iranian government often imprisons foreign nationals to exchange them for Iranians detained in Western countries.

On June 15, Sweden agreed to release an Iranian dignitary serving a life sentence in exchange for the release of Swedish nationals detained in Iran. For a long time, Dr. Djalali’s family had hoped he would be included in this exchange.

However, to avoid jeopardizing the deal, the Swedish prime minister chose to accept the release of only two other Swedish nationals, leaving Dr. Djalali to his grim fate. “Mr Prime Minister, you have decided to abandon me at the enormous risk of being executed,” Dr. Djalali responded bitterly, knowing he could be hanged at any moment.
 

This story was translated from JIM using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

TOPLINE:

Over the past 20 years in Denmark, the incidence of type 2 diabetes–related outcomes and many treatment-related harms have both decreased without increased medication expenses despite an aging and more comorbid population; however, challenges remain.

METHODOLOGY:

• Analysis of data from 461,805 individuals in the Danish population with type 2 diabetes between 2002 and 2020.
• Multivariate analyses adjusted for potential confounders, including age, sex, and socioeconomic status.

TAKEAWAY:

• The population grew 2.7-fold from 2002 to 2020 (n = 113,105 to 306,962), the median age increased from 66 to 68 years, and the mean number of diseases per person increased from 5.2 to 8.8, with an increase in Charlson Comorbidity Index from 1.78 to 1.93.
• After adjustments, mortality per 1000 person-years decreased by 28% from 2002 to 2020, with the largest risk reduction, 63%, in acute myocardial infarction.
• The mean number of annually redeemed medications per person increased from 8.1 to 9.0, with statin and antihypertensive use increasing to 65% and 69%, respectively.
• Antiplatelet medication (aspirin and clopidogrel) use peaked at 48% in 2009 and dropped to 31% in 2020.
• Anticoagulant (warfarin and direct-acting oral anticoagulants) use gradually increased from 5% in 2002 to 14% in 2020.
• For glucose-lowering treatment, there was a shift away from using sulfonylureas to metformin and other medications.
• Diagnoses of hypoglycemia, falls, and gastric bleeding decreased over the study period, but incidences of volume depletion, ketoacidosis, infections, and electrolyte imbalances requiring hospitalization increased.
• Cumulative expenses for the population increased from €132,000,000 to €327,000,000 (approximately $144,406,680 to $357,734,730), corresponding to a 148% increase over the study period.
• However, the average medication cost per individual was 8% less in 2020 compared with 2002 despite increasing medication use, mainly driven by reduced costs of antiplatelets, antihypertensives, and statins, among others.
• In contrast, expenses for glucose-lowering medications have gradually increased, with the average more than doubling (138% increase) from €220 ($240) in 2002 to €524 ($573) in 2020.

IN PRACTICE:

“Although these trends suggest improvements in rational pharmacotherapy, they cannot be solely attributed to improved pharmacotherapy and appear to be multifactorial,” the authors wrote.

“Advancements in diabetes management have improved the balance between medication benefits, harms, and costs ... Remaining challenges, such as an increased risk of ketoacidosis and electrolyte imbalances as well as rising costs for glucose-lowering medications, highlight the importance of individualized treatment and continuous risk-benefits evaluations,” they added.
 

SOURCE:

This study was conducted by Karl Sebastian Johansson, of the Department of Clinical Pharmacology, Copenhagen University Hospital, Copenhagen, Denmark, and colleagues and was published online in Diabetes Care.

LIMITATIONS:

Analysis was confined to events diagnosed in hospital-based inpatient and outpatient settings, not primary healthcare. Only predefined adverse events were analyzed.

DISCLOSURES:

The study was funded by the Capital Region of Denmark. The authors reported no potential conflicts of interest relevant to this article.

A version of this article first appeared on Medscape.com.

TOPLINE:

Over the past 20 years in Denmark, the incidence of type 2 diabetes–related outcomes and many treatment-related harms have both decreased without increased medication expenses despite an aging and more comorbid population; however, challenges remain.

METHODOLOGY:

• Analysis of data from 461,805 individuals in the Danish population with type 2 diabetes between 2002 and 2020.
• Multivariate analyses adjusted for potential confounders, including age, sex, and socioeconomic status.

TAKEAWAY:

• The population grew 2.7-fold from 2002 to 2020 (n = 113,105 to 306,962), the median age increased from 66 to 68 years, and the mean number of diseases per person increased from 5.2 to 8.8, with an increase in Charlson Comorbidity Index from 1.78 to 1.93.
• After adjustments, mortality per 1000 person-years decreased by 28% from 2002 to 2020, with the largest risk reduction, 63%, in acute myocardial infarction.
• The mean number of annually redeemed medications per person increased from 8.1 to 9.0, with statin and antihypertensive use increasing to 65% and 69%, respectively.
• Antiplatelet medication (aspirin and clopidogrel) use peaked at 48% in 2009 and dropped to 31% in 2020.
• Anticoagulant (warfarin and direct-acting oral anticoagulants) use gradually increased from 5% in 2002 to 14% in 2020.
• For glucose-lowering treatment, there was a shift away from using sulfonylureas to metformin and other medications.
• Diagnoses of hypoglycemia, falls, and gastric bleeding decreased over the study period, but incidences of volume depletion, ketoacidosis, infections, and electrolyte imbalances requiring hospitalization increased.
• Cumulative expenses for the population increased from €132,000,000 to €327,000,000 (approximately $144,406,680 to $357,734,730), corresponding to a 148% increase over the study period.
• However, the average medication cost per individual was 8% less in 2020 compared with 2002 despite increasing medication use, mainly driven by reduced costs of antiplatelets, antihypertensives, and statins, among others.
• In contrast, expenses for glucose-lowering medications have gradually increased, with the average more than doubling (138% increase) from €220 ($240) in 2002 to €524 ($573) in 2020.

IN PRACTICE:

“Although these trends suggest improvements in rational pharmacotherapy, they cannot be solely attributed to improved pharmacotherapy and appear to be multifactorial,” the authors wrote.

“Advancements in diabetes management have improved the balance between medication benefits, harms, and costs ... Remaining challenges, such as an increased risk of ketoacidosis and electrolyte imbalances as well as rising costs for glucose-lowering medications, highlight the importance of individualized treatment and continuous risk-benefits evaluations,” they added.
 

SOURCE:

This study was conducted by Karl Sebastian Johansson, of the Department of Clinical Pharmacology, Copenhagen University Hospital, Copenhagen, Denmark, and colleagues and was published online in Diabetes Care.

LIMITATIONS:

Analysis was confined to events diagnosed in hospital-based inpatient and outpatient settings, not primary healthcare. Only predefined adverse events were analyzed.

DISCLOSURES:

The study was funded by the Capital Region of Denmark. The authors reported no potential conflicts of interest relevant to this article.

A version of this article first appeared on Medscape.com.

TOPLINE:

Over the past 20 years in Denmark, the incidence of type 2 diabetes–related outcomes and many treatment-related harms have both decreased without increased medication expenses despite an aging and more comorbid population; however, challenges remain.

METHODOLOGY:

• Analysis of data from 461,805 individuals in the Danish population with type 2 diabetes between 2002 and 2020.
• Multivariate analyses adjusted for potential confounders, including age, sex, and socioeconomic status.

TAKEAWAY:

• The population grew 2.7-fold from 2002 to 2020 (n = 113,105 to 306,962), the median age increased from 66 to 68 years, and the mean number of diseases per person increased from 5.2 to 8.8, with an increase in Charlson Comorbidity Index from 1.78 to 1.93.
• After adjustments, mortality per 1000 person-years decreased by 28% from 2002 to 2020, with the largest risk reduction, 63%, in acute myocardial infarction.
• The mean number of annually redeemed medications per person increased from 8.1 to 9.0, with statin and antihypertensive use increasing to 65% and 69%, respectively.
• Antiplatelet medication (aspirin and clopidogrel) use peaked at 48% in 2009 and dropped to 31% in 2020.
• Anticoagulant (warfarin and direct-acting oral anticoagulants) use gradually increased from 5% in 2002 to 14% in 2020.
• For glucose-lowering treatment, there was a shift away from using sulfonylureas to metformin and other medications.
• Diagnoses of hypoglycemia, falls, and gastric bleeding decreased over the study period, but incidences of volume depletion, ketoacidosis, infections, and electrolyte imbalances requiring hospitalization increased.
• Cumulative expenses for the population increased from €132,000,000 to €327,000,000 (approximately $144,406,680 to $357,734,730), corresponding to a 148% increase over the study period.
• However, the average medication cost per individual was 8% less in 2020 compared with 2002 despite increasing medication use, mainly driven by reduced costs of antiplatelets, antihypertensives, and statins, among others.
• In contrast, expenses for glucose-lowering medications have gradually increased, with the average more than doubling (138% increase) from €220 ($240) in 2002 to €524 ($573) in 2020.

IN PRACTICE:

“Although these trends suggest improvements in rational pharmacotherapy, they cannot be solely attributed to improved pharmacotherapy and appear to be multifactorial,” the authors wrote.

“Advancements in diabetes management have improved the balance between medication benefits, harms, and costs ... Remaining challenges, such as an increased risk of ketoacidosis and electrolyte imbalances as well as rising costs for glucose-lowering medications, highlight the importance of individualized treatment and continuous risk-benefits evaluations,” they added.
 

SOURCE:

This study was conducted by Karl Sebastian Johansson, of the Department of Clinical Pharmacology, Copenhagen University Hospital, Copenhagen, Denmark, and colleagues and was published online in Diabetes Care.

LIMITATIONS:

Analysis was confined to events diagnosed in hospital-based inpatient and outpatient settings, not primary healthcare. Only predefined adverse events were analyzed.

DISCLOSURES:

The study was funded by the Capital Region of Denmark. The authors reported no potential conflicts of interest relevant to this article.

A version of this article first appeared on Medscape.com.

Your odds are 1 in 562,400.

Or, as Bill Mallon, the past president and cofounder of the International Society of Olympic Historians, has said, aspiring athletes have a 0.00000178% chance of making the Games.

Now imagine the odds of making the Olympics and then going on to become a physician. And maybe it’s not surprising that those who have done it credit the training they received as Olympic athletes as key to their success in medicine.

“Dealing with poor outcomes and having to get back up and try again,” said Olympian-turned-physician Ogonna Nnamani Silva, MD, “that reiterative process of trying to obtain perfection in your craft — that’s athletics 101.”

This connection isn’t just anecdotal. It has been discussed in medical journals and examined in surveys. The consensus is that, yes, there are specific characteristics elite athletes develop that physicians — regardless of their athletic background — can learn to apply to their work in medicine.

Maybe it’s something else, too: Certain mindsets don’t worry about long odds. They seek out crucibles again and again without concern for the heat involved. Because the outcome is worth it.

Here are four athletes who became high-performing physicians and how they did it.
 

The Gymnast/The Pediatric Surgeon

“Gymnastics helped me build a skill set for my career,” said Canadian Olympic gymnast-turned-pediatric orthopedic surgeon Lise Leveille, MD. “It led me to be successful as a medical student and ultimately obtain the job that I want in the area that I want working with the people that I want.”

The skills Dr. Leveille prizes include time management, teamwork, goal setting, and a strong work ethic, all of which propel an athlete to the crucial moment of “performance.”

“I miss performing,” said Dr. Leveille. “It defines who I was at that time. I miss being able to work toward something and then deliver when it counted” — like when she qualified for the 1998 Commonwealth games in Kuala Lumpur at 16.

The Canadian national team came third at that event, and Dr. Leveille built on that success at the Pan American Games, taking gold on the balance beam and as a team, and then qualifying for the Olympics at the 1999 World Championships. She competed in the team and five individual events at the 2000 Olympic Games in Sydney.

Though Dr. Leveille started gymnastics at age 3, her parents, both teachers, instilled in her the importance of education. Gymnastics opened academic doors for her, like being recruited to Stanford where she completed her undergraduate degree in biomedical engineering and human biology in 2004 before entering medical school at the University of British Columbia in Vancouver.

Now 41, Dr. Leveille accepts that she’ll never nail another gymnastics routine, but she channels that love of sticking the landing into the operating room at British Columbia Children’s Hospital, also in Vancouver.

“Some of the unknown variables within the operating room and how you deal with those unknown variables is exactly like showing up for a competition,” Dr. Leveille said. “When I have one of those cases where I have to perform under pressure and everything comes together, that’s exactly like nailing your routine when it counts most.”
 

The Pole Vaulter/The Emergency Medicine Physician

Tunisian American pole vaulter Leila Ben-Youssef, MD, had what could be considered a disappointing showing at the 2008 Olympic Games in Beijing. She collapsed from severe abdominal pain during the opening ceremony and had to be carried out. On the day of competition, she was still suffering. “I could barely run down the runway,” she recalled. “I cleared one bar. I was just happy to have been able to do that.”

When Dr. Ben-Youssef, who grew up in Montana, returned home, she underwent emergency surgery to remove the source of the pain: A large, benign tumor.

While some might be devastated by such bad luck, Dr. Ben-Youssef focuses on the success of her journey — the fact that she qualified and competed at the Olympics in the first place. The ability to accept setbacks is something she said comes with the territory.

“As an athlete, you’re always facing injury, and someone told me early in my career that the best athletes are the ones that know how to manage their expectations because it’s bound to happen,” she said. “So, there is disappointment. But recognizing that I did qualify for the Olympics despite being uncomfortable and having issues, I was still able to meet my goal.”

Prior to the games, Dr. Ben-Youssef had been accepted into medical school at the University of Washington School of Medicine at Montana State University in Bozeman, Montana. Thankfully, the school was supportive of Dr. Ben-Youssef’s Olympic dreams and allowed her to begin her studies a month behind her class. Upon her return from Beijing, she spent the rest of her medical school training with her head down, grinding.

“Medicine is hard,” said Dr. Ben-Youssef. “It’s grueling both physically and emotionally, and I think that’s similar to any elite sport. You’re going to deal with challenges and disappointment. I think having gone through that as an athlete really prepares you for the medical education system, for residency, and even for day-to-day work.”

Now a physician working in emergency medicine in Hawaii, Dr. Ben-Youssef feels the setbacks she experienced as an athlete help her connect with her patients as they deal with health challenges.

And as a volunteer pole vaulting coach for a local high school, Dr. Ben-Youssef has been able to surround herself with the positive, joyful energy of athletes. “Emergency medicine is often a sad place,” she said. “But in a sports environment, if people don’t succeed or are injured, there is still that energy there that strives for something, and it’s so fun to be around.”
 

The Rower/The Sports Medicine Specialist

Three-time US Olympic rower Genevra “Gevvie” Stone, MD, wanted to be a doctor even before she gave a thought to rowing. She was in eighth grade when she dislocated her knee for the third time. Her parents took her to a pediatric orthopedist, and Dr. Stone, according to her mom, declared: “That’s what I want to do when I grow up.”

“I’m a very stubborn person, and when I make a decision like that, I usually don’t veer from it,” Dr. Stone said.

That laser focus combined with a deep love of both sports and medicine has served Dr. Stone well. “Becoming a doctor and becoming an Olympian require you to dedicate not just your time and your energy but also your passion to that focus,” she said. “In both, you aren’t going to be successful if you don’t love what you’re doing. Finding the reward in it is what makes it achievable.”

Dr. Stone actually resisted rowing until she was 16 because both of her parents were Olympians in the sport and met on the US team. “It was their thing, and I didn’t want it to be my thing,” she recalled.

Nonetheless, Dr. Stone easily fell into the sport in her late teens and was recruited by Princeton University. “I had grown up around Olympians and kind of took it for granted that if you worked hard enough and were decent at rowing, then you could be one of the best in the world, without really realizing how difficult it would be to achieve that,” she said.

Dr. Stone’s team won the NCAA Championship in 2006 and was invited to try out for the 2008 Olympic team at the US training center after she graduated from college. But she didn’t make it.

Instead, Dr. Stone entered medical school at Tufts University School of Medicine, Boston, thinking her competitive rowing career had come to end. But her love for the sport was still strong, and she realized she wasn’t finished.

After 2 years of medical school, Dr. Stone requested 2 years off so she might have another shot at making the Olympic team. The timing was right. She went to the London Olympics in 2012, graduated from medical school in 2014, and then took 2 more years off to train full time for the 2016 Olympics in Rio where she won silver.

At the 2020 Olympic Games in Tokyo, Dr. Stone took fifth place in the double sculls. While she continues to race the master’s circuit, she’s primarily dedicated to completing her sports medicine fellowship at University of Utah Health.

Fortunately, Dr. Stone’s parents, coaches, and teachers always supported her goals. “No one turned to me and told me I was crazy, just choose medicine or rowing,” she said. “Everyone said that if this is what you want to do, we’re here to support you, and I wouldn’t have been able to do it without that support.”
 

The Volleyball Player/The Plastic Surgeon

Dr. Nnamani Silva’s journey to the Olympics was also paved with an extensive list of supporters, beginning with her parents. And she has taken that sense of collaboration, coordination, and teamwork into her medical career.

The daughter of Nigerian immigrants who came to the United States to escape civil war, Dr. Nnamani Silva said her parents embraced the American dream. “To see what they were able to do with hard work, dedication, and sacrifice, I had no choice but to work hard because I saw their example. And that love for and belief in America was so strong in my house growing up,” she said.

Dreams of practicing medicine came first. A severe asthmatic growing up, Dr. Nnamani Silva recalled having wonderful doctors. “I had so many emergency room visits and hospitalizations,” she said. “But the doctors always gave me hope, and they literally transformed my life. I thought if I could pass that on to my future patients, that would be the greatest honor of my life.”

Volleyball gave Dr. Nnamani Silva the opportunity to attend Stanford, and she took time off during her junior year to train and compete in the 2004 Olympic Games in Athens. She also played for the United States at the 2008 Olympic Games in Beijing where the team took silver. Afterward, she continued to play overseas for several years.

At 33, and with a newborn daughter, Dr. Nnamani Silva returned to her original goal of becoming a doctor. She attended the University of California, San Francisco, and is currently a resident in the Harvard Plastic Surgery Program. She includes her husband, parents, and in-laws in this achievement, whom she said “saved” her. “There is no chance I would have finished medical school and survived residency without them.”

As a volleyball player, Dr. Nnamani Silva said she “believes in teams wholeheartedly,” valuing the exchange of energy and skill that she feels brings out the best in people. As a medical student, she initially didn’t realize how her previous life would apply to teamwork in the operating room. But it soon became clear.

“In surgery, when you harness the talents of everyone around you and you create that synergy, it’s an amazing feeling,” she said. And the stakes are often high. “It requires a lot of focus, discipline, determination, and resilience because you’re going to be humbled all the time.” Something athletes know a little bit about.

A version of this article first appeared on Medscape.com.

Your odds are 1 in 562,400.

Or, as Bill Mallon, the past president and cofounder of the International Society of Olympic Historians, has said, aspiring athletes have a 0.00000178% chance of making the Games.

Now imagine the odds of making the Olympics and then going on to become a physician. And maybe it’s not surprising that those who have done it credit the training they received as Olympic athletes as key to their success in medicine.

“Dealing with poor outcomes and having to get back up and try again,” said Olympian-turned-physician Ogonna Nnamani Silva, MD, “that reiterative process of trying to obtain perfection in your craft — that’s athletics 101.”

This connection isn’t just anecdotal. It has been discussed in medical journals and examined in surveys. The consensus is that, yes, there are specific characteristics elite athletes develop that physicians — regardless of their athletic background — can learn to apply to their work in medicine.

Maybe it’s something else, too: Certain mindsets don’t worry about long odds. They seek out crucibles again and again without concern for the heat involved. Because the outcome is worth it.

Here are four athletes who became high-performing physicians and how they did it.
 

The Gymnast/The Pediatric Surgeon

“Gymnastics helped me build a skill set for my career,” said Canadian Olympic gymnast-turned-pediatric orthopedic surgeon Lise Leveille, MD. “It led me to be successful as a medical student and ultimately obtain the job that I want in the area that I want working with the people that I want.”

The skills Dr. Leveille prizes include time management, teamwork, goal setting, and a strong work ethic, all of which propel an athlete to the crucial moment of “performance.”

“I miss performing,” said Dr. Leveille. “It defines who I was at that time. I miss being able to work toward something and then deliver when it counted” — like when she qualified for the 1998 Commonwealth games in Kuala Lumpur at 16.

The Canadian national team came third at that event, and Dr. Leveille built on that success at the Pan American Games, taking gold on the balance beam and as a team, and then qualifying for the Olympics at the 1999 World Championships. She competed in the team and five individual events at the 2000 Olympic Games in Sydney.

Though Dr. Leveille started gymnastics at age 3, her parents, both teachers, instilled in her the importance of education. Gymnastics opened academic doors for her, like being recruited to Stanford where she completed her undergraduate degree in biomedical engineering and human biology in 2004 before entering medical school at the University of British Columbia in Vancouver.

Now 41, Dr. Leveille accepts that she’ll never nail another gymnastics routine, but she channels that love of sticking the landing into the operating room at British Columbia Children’s Hospital, also in Vancouver.

“Some of the unknown variables within the operating room and how you deal with those unknown variables is exactly like showing up for a competition,” Dr. Leveille said. “When I have one of those cases where I have to perform under pressure and everything comes together, that’s exactly like nailing your routine when it counts most.”
 

The Pole Vaulter/The Emergency Medicine Physician

Tunisian American pole vaulter Leila Ben-Youssef, MD, had what could be considered a disappointing showing at the 2008 Olympic Games in Beijing. She collapsed from severe abdominal pain during the opening ceremony and had to be carried out. On the day of competition, she was still suffering. “I could barely run down the runway,” she recalled. “I cleared one bar. I was just happy to have been able to do that.”

When Dr. Ben-Youssef, who grew up in Montana, returned home, she underwent emergency surgery to remove the source of the pain: A large, benign tumor.

While some might be devastated by such bad luck, Dr. Ben-Youssef focuses on the success of her journey — the fact that she qualified and competed at the Olympics in the first place. The ability to accept setbacks is something she said comes with the territory.

“As an athlete, you’re always facing injury, and someone told me early in my career that the best athletes are the ones that know how to manage their expectations because it’s bound to happen,” she said. “So, there is disappointment. But recognizing that I did qualify for the Olympics despite being uncomfortable and having issues, I was still able to meet my goal.”

Prior to the games, Dr. Ben-Youssef had been accepted into medical school at the University of Washington School of Medicine at Montana State University in Bozeman, Montana. Thankfully, the school was supportive of Dr. Ben-Youssef’s Olympic dreams and allowed her to begin her studies a month behind her class. Upon her return from Beijing, she spent the rest of her medical school training with her head down, grinding.

“Medicine is hard,” said Dr. Ben-Youssef. “It’s grueling both physically and emotionally, and I think that’s similar to any elite sport. You’re going to deal with challenges and disappointment. I think having gone through that as an athlete really prepares you for the medical education system, for residency, and even for day-to-day work.”

Now a physician working in emergency medicine in Hawaii, Dr. Ben-Youssef feels the setbacks she experienced as an athlete help her connect with her patients as they deal with health challenges.

And as a volunteer pole vaulting coach for a local high school, Dr. Ben-Youssef has been able to surround herself with the positive, joyful energy of athletes. “Emergency medicine is often a sad place,” she said. “But in a sports environment, if people don’t succeed or are injured, there is still that energy there that strives for something, and it’s so fun to be around.”
 

The Rower/The Sports Medicine Specialist

Three-time US Olympic rower Genevra “Gevvie” Stone, MD, wanted to be a doctor even before she gave a thought to rowing. She was in eighth grade when she dislocated her knee for the third time. Her parents took her to a pediatric orthopedist, and Dr. Stone, according to her mom, declared: “That’s what I want to do when I grow up.”

“I’m a very stubborn person, and when I make a decision like that, I usually don’t veer from it,” Dr. Stone said.

That laser focus combined with a deep love of both sports and medicine has served Dr. Stone well. “Becoming a doctor and becoming an Olympian require you to dedicate not just your time and your energy but also your passion to that focus,” she said. “In both, you aren’t going to be successful if you don’t love what you’re doing. Finding the reward in it is what makes it achievable.”

Dr. Stone actually resisted rowing until she was 16 because both of her parents were Olympians in the sport and met on the US team. “It was their thing, and I didn’t want it to be my thing,” she recalled.

Nonetheless, Dr. Stone easily fell into the sport in her late teens and was recruited by Princeton University. “I had grown up around Olympians and kind of took it for granted that if you worked hard enough and were decent at rowing, then you could be one of the best in the world, without really realizing how difficult it would be to achieve that,” she said.

Dr. Stone’s team won the NCAA Championship in 2006 and was invited to try out for the 2008 Olympic team at the US training center after she graduated from college. But she didn’t make it.

Instead, Dr. Stone entered medical school at Tufts University School of Medicine, Boston, thinking her competitive rowing career had come to end. But her love for the sport was still strong, and she realized she wasn’t finished.

After 2 years of medical school, Dr. Stone requested 2 years off so she might have another shot at making the Olympic team. The timing was right. She went to the London Olympics in 2012, graduated from medical school in 2014, and then took 2 more years off to train full time for the 2016 Olympics in Rio where she won silver.

At the 2020 Olympic Games in Tokyo, Dr. Stone took fifth place in the double sculls. While she continues to race the master’s circuit, she’s primarily dedicated to completing her sports medicine fellowship at University of Utah Health.

Fortunately, Dr. Stone’s parents, coaches, and teachers always supported her goals. “No one turned to me and told me I was crazy, just choose medicine or rowing,” she said. “Everyone said that if this is what you want to do, we’re here to support you, and I wouldn’t have been able to do it without that support.”
 

The Volleyball Player/The Plastic Surgeon

Dr. Nnamani Silva’s journey to the Olympics was also paved with an extensive list of supporters, beginning with her parents. And she has taken that sense of collaboration, coordination, and teamwork into her medical career.

The daughter of Nigerian immigrants who came to the United States to escape civil war, Dr. Nnamani Silva said her parents embraced the American dream. “To see what they were able to do with hard work, dedication, and sacrifice, I had no choice but to work hard because I saw their example. And that love for and belief in America was so strong in my house growing up,” she said.

Dreams of practicing medicine came first. A severe asthmatic growing up, Dr. Nnamani Silva recalled having wonderful doctors. “I had so many emergency room visits and hospitalizations,” she said. “But the doctors always gave me hope, and they literally transformed my life. I thought if I could pass that on to my future patients, that would be the greatest honor of my life.”

Volleyball gave Dr. Nnamani Silva the opportunity to attend Stanford, and she took time off during her junior year to train and compete in the 2004 Olympic Games in Athens. She also played for the United States at the 2008 Olympic Games in Beijing where the team took silver. Afterward, she continued to play overseas for several years.

At 33, and with a newborn daughter, Dr. Nnamani Silva returned to her original goal of becoming a doctor. She attended the University of California, San Francisco, and is currently a resident in the Harvard Plastic Surgery Program. She includes her husband, parents, and in-laws in this achievement, whom she said “saved” her. “There is no chance I would have finished medical school and survived residency without them.”

As a volleyball player, Dr. Nnamani Silva said she “believes in teams wholeheartedly,” valuing the exchange of energy and skill that she feels brings out the best in people. As a medical student, she initially didn’t realize how her previous life would apply to teamwork in the operating room. But it soon became clear.

“In surgery, when you harness the talents of everyone around you and you create that synergy, it’s an amazing feeling,” she said. And the stakes are often high. “It requires a lot of focus, discipline, determination, and resilience because you’re going to be humbled all the time.” Something athletes know a little bit about.

A version of this article first appeared on Medscape.com.

Your odds are 1 in 562,400.

Or, as Bill Mallon, the past president and cofounder of the International Society of Olympic Historians, has said, aspiring athletes have a 0.00000178% chance of making the Games.

Now imagine the odds of making the Olympics and then going on to become a physician. And maybe it’s not surprising that those who have done it credit the training they received as Olympic athletes as key to their success in medicine.

“Dealing with poor outcomes and having to get back up and try again,” said Olympian-turned-physician Ogonna Nnamani Silva, MD, “that reiterative process of trying to obtain perfection in your craft — that’s athletics 101.”

This connection isn’t just anecdotal. It has been discussed in medical journals and examined in surveys. The consensus is that, yes, there are specific characteristics elite athletes develop that physicians — regardless of their athletic background — can learn to apply to their work in medicine.

Maybe it’s something else, too: Certain mindsets don’t worry about long odds. They seek out crucibles again and again without concern for the heat involved. Because the outcome is worth it.

Here are four athletes who became high-performing physicians and how they did it.
 

The Gymnast/The Pediatric Surgeon

“Gymnastics helped me build a skill set for my career,” said Canadian Olympic gymnast-turned-pediatric orthopedic surgeon Lise Leveille, MD. “It led me to be successful as a medical student and ultimately obtain the job that I want in the area that I want working with the people that I want.”

The skills Dr. Leveille prizes include time management, teamwork, goal setting, and a strong work ethic, all of which propel an athlete to the crucial moment of “performance.”

“I miss performing,” said Dr. Leveille. “It defines who I was at that time. I miss being able to work toward something and then deliver when it counted” — like when she qualified for the 1998 Commonwealth games in Kuala Lumpur at 16.

The Canadian national team came third at that event, and Dr. Leveille built on that success at the Pan American Games, taking gold on the balance beam and as a team, and then qualifying for the Olympics at the 1999 World Championships. She competed in the team and five individual events at the 2000 Olympic Games in Sydney.

Though Dr. Leveille started gymnastics at age 3, her parents, both teachers, instilled in her the importance of education. Gymnastics opened academic doors for her, like being recruited to Stanford where she completed her undergraduate degree in biomedical engineering and human biology in 2004 before entering medical school at the University of British Columbia in Vancouver.

Now 41, Dr. Leveille accepts that she’ll never nail another gymnastics routine, but she channels that love of sticking the landing into the operating room at British Columbia Children’s Hospital, also in Vancouver.

“Some of the unknown variables within the operating room and how you deal with those unknown variables is exactly like showing up for a competition,” Dr. Leveille said. “When I have one of those cases where I have to perform under pressure and everything comes together, that’s exactly like nailing your routine when it counts most.”
 

The Pole Vaulter/The Emergency Medicine Physician

Tunisian American pole vaulter Leila Ben-Youssef, MD, had what could be considered a disappointing showing at the 2008 Olympic Games in Beijing. She collapsed from severe abdominal pain during the opening ceremony and had to be carried out. On the day of competition, she was still suffering. “I could barely run down the runway,” she recalled. “I cleared one bar. I was just happy to have been able to do that.”

When Dr. Ben-Youssef, who grew up in Montana, returned home, she underwent emergency surgery to remove the source of the pain: A large, benign tumor.

While some might be devastated by such bad luck, Dr. Ben-Youssef focuses on the success of her journey — the fact that she qualified and competed at the Olympics in the first place. The ability to accept setbacks is something she said comes with the territory.

“As an athlete, you’re always facing injury, and someone told me early in my career that the best athletes are the ones that know how to manage their expectations because it’s bound to happen,” she said. “So, there is disappointment. But recognizing that I did qualify for the Olympics despite being uncomfortable and having issues, I was still able to meet my goal.”

Prior to the games, Dr. Ben-Youssef had been accepted into medical school at the University of Washington School of Medicine at Montana State University in Bozeman, Montana. Thankfully, the school was supportive of Dr. Ben-Youssef’s Olympic dreams and allowed her to begin her studies a month behind her class. Upon her return from Beijing, she spent the rest of her medical school training with her head down, grinding.

“Medicine is hard,” said Dr. Ben-Youssef. “It’s grueling both physically and emotionally, and I think that’s similar to any elite sport. You’re going to deal with challenges and disappointment. I think having gone through that as an athlete really prepares you for the medical education system, for residency, and even for day-to-day work.”

Now a physician working in emergency medicine in Hawaii, Dr. Ben-Youssef feels the setbacks she experienced as an athlete help her connect with her patients as they deal with health challenges.

And as a volunteer pole vaulting coach for a local high school, Dr. Ben-Youssef has been able to surround herself with the positive, joyful energy of athletes. “Emergency medicine is often a sad place,” she said. “But in a sports environment, if people don’t succeed or are injured, there is still that energy there that strives for something, and it’s so fun to be around.”
 

The Rower/The Sports Medicine Specialist

Three-time US Olympic rower Genevra “Gevvie” Stone, MD, wanted to be a doctor even before she gave a thought to rowing. She was in eighth grade when she dislocated her knee for the third time. Her parents took her to a pediatric orthopedist, and Dr. Stone, according to her mom, declared: “That’s what I want to do when I grow up.”

“I’m a very stubborn person, and when I make a decision like that, I usually don’t veer from it,” Dr. Stone said.

That laser focus combined with a deep love of both sports and medicine has served Dr. Stone well. “Becoming a doctor and becoming an Olympian require you to dedicate not just your time and your energy but also your passion to that focus,” she said. “In both, you aren’t going to be successful if you don’t love what you’re doing. Finding the reward in it is what makes it achievable.”

Dr. Stone actually resisted rowing until she was 16 because both of her parents were Olympians in the sport and met on the US team. “It was their thing, and I didn’t want it to be my thing,” she recalled.

Nonetheless, Dr. Stone easily fell into the sport in her late teens and was recruited by Princeton University. “I had grown up around Olympians and kind of took it for granted that if you worked hard enough and were decent at rowing, then you could be one of the best in the world, without really realizing how difficult it would be to achieve that,” she said.

Dr. Stone’s team won the NCAA Championship in 2006 and was invited to try out for the 2008 Olympic team at the US training center after she graduated from college. But she didn’t make it.

Instead, Dr. Stone entered medical school at Tufts University School of Medicine, Boston, thinking her competitive rowing career had come to end. But her love for the sport was still strong, and she realized she wasn’t finished.

After 2 years of medical school, Dr. Stone requested 2 years off so she might have another shot at making the Olympic team. The timing was right. She went to the London Olympics in 2012, graduated from medical school in 2014, and then took 2 more years off to train full time for the 2016 Olympics in Rio where she won silver.

At the 2020 Olympic Games in Tokyo, Dr. Stone took fifth place in the double sculls. While she continues to race the master’s circuit, she’s primarily dedicated to completing her sports medicine fellowship at University of Utah Health.

Fortunately, Dr. Stone’s parents, coaches, and teachers always supported her goals. “No one turned to me and told me I was crazy, just choose medicine or rowing,” she said. “Everyone said that if this is what you want to do, we’re here to support you, and I wouldn’t have been able to do it without that support.”
 

The Volleyball Player/The Plastic Surgeon

Dr. Nnamani Silva’s journey to the Olympics was also paved with an extensive list of supporters, beginning with her parents. And she has taken that sense of collaboration, coordination, and teamwork into her medical career.

The daughter of Nigerian immigrants who came to the United States to escape civil war, Dr. Nnamani Silva said her parents embraced the American dream. “To see what they were able to do with hard work, dedication, and sacrifice, I had no choice but to work hard because I saw their example. And that love for and belief in America was so strong in my house growing up,” she said.

Dreams of practicing medicine came first. A severe asthmatic growing up, Dr. Nnamani Silva recalled having wonderful doctors. “I had so many emergency room visits and hospitalizations,” she said. “But the doctors always gave me hope, and they literally transformed my life. I thought if I could pass that on to my future patients, that would be the greatest honor of my life.”

Volleyball gave Dr. Nnamani Silva the opportunity to attend Stanford, and she took time off during her junior year to train and compete in the 2004 Olympic Games in Athens. She also played for the United States at the 2008 Olympic Games in Beijing where the team took silver. Afterward, she continued to play overseas for several years.

At 33, and with a newborn daughter, Dr. Nnamani Silva returned to her original goal of becoming a doctor. She attended the University of California, San Francisco, and is currently a resident in the Harvard Plastic Surgery Program. She includes her husband, parents, and in-laws in this achievement, whom she said “saved” her. “There is no chance I would have finished medical school and survived residency without them.”

As a volleyball player, Dr. Nnamani Silva said she “believes in teams wholeheartedly,” valuing the exchange of energy and skill that she feels brings out the best in people. As a medical student, she initially didn’t realize how her previous life would apply to teamwork in the operating room. But it soon became clear.

“In surgery, when you harness the talents of everyone around you and you create that synergy, it’s an amazing feeling,” she said. And the stakes are often high. “It requires a lot of focus, discipline, determination, and resilience because you’re going to be humbled all the time.” Something athletes know a little bit about.

A version of this article first appeared on Medscape.com.

Across the world, healthcare workers experience workplace violence, which can differ by gender, seniority, and the type of workplace, according to a recent study.

An analysis found that men were more likely to report physical violence, while women were more likely to face nonphysical violence, such as verbal abuse, sexual harassment, and bullying.

“Our study was sparked by the increasing research on workplace violence in healthcare settings. Yet, there’s less empirical data about workplace violence based on gender, its effects on individuals and the collective workforce, and its subsequent impact on patient care and healthcare organizations,” study author Basnama Ayaz, a PhD candidate in nursing at the University of Toronto, told this news organization.

“Workplace violence in healthcare settings is a critical issue that requires attention and action from all stakeholders, including individual providers, healthcare and other institutions, policymakers, and the community,” she said. “By recognizing the problem and implementing evidence-based solutions, we can create safer work environments that protect healthcare workers and improve quality care for patients and organizational effectiveness.”

The study was published online in PLOS Global Public Health.
 

Widespread and Severe

Although women represent most of the healthcare workforce worldwide, hierarchical structures tend to reflect traditional gender norms, where men hold leadership positions and women serve in front-line care roles, said Ms. Ayaz. Women are often marginalized, and their concerns dismissed, which can exacerbate their vulnerability to gender-based workplace violence, she added.

To better understand these imbalances on a global scale, the investigators conducted a scoping review of the prevalence of and risk factors for gender-based workplace violence in healthcare settings. Participants included physicians, nurses, and midwives, between 2010 and 2024. Although the authors acknowledged that gender-based workplace violence affects the full gender spectrum, only a handful of studies included information about nonbinary personnel, so the review focused on men and women.

Among 226 studies, half focused on physicians, 22% focused on nurses, and 28% included physicians, nurses, midwives, and other medical workers. About 64% of studies reported a higher prevalence of all forms of workplace violence for women, including sexual violence, verbal abuse, discrimination, bullying, and physical violence, while 17% reported a higher prevalence for men.

Overall, across most countries, men experienced more physical violence than did women, and women experienced more verbal abuse, sexual harassment, and bullying. Female nurses were particularly likely to experience violence.

Healthcare workers were also more likely to experience violence if they were younger, less experienced, had a lower professional status, or were part of a minority group based on ethnicity, nationality, culture, or language. These factors were sensitive to gender, “reflecting women’s structural disadvantages in the workplace,” wrote the authors.

As a result of workplace violence, women were more likely to report changes in mental health and social behaviors, as well as dissatisfaction, burnout, and changes in their career goals.

The research team identified various factors linked to violent episodes. In clinical settings where most perpetrators were patients and their relatives, abuse and violence could be related to overcrowding, waiting time, and heavy workloads for healthcare providers. When supervisors or colleagues were the perpetrators, workplace violence appeared to be more likely with long hours, night shifts, and certain clinical settings, such as emergency departments, psychiatric settings, operating rooms, and maternity wards, said Ms. Ayaz. Sexual or gender harassment toward women was more prevalent in male-dominated surgical specialties.

“We were surprised by the extent and severity of workplace violence that healthcare workers face around the globe based on gender,” she said. “One aspect that stood out was the significant role that organizational culture and support systems play either in mitigating or exacerbating these incidents, particularly the power structures between and within professions.”

For instance, trainees in lower hierarchical positions often face a higher risk for violence, especially gender-based harassment, she said. Many times, they feel they can’t report these incidents to trainers or managers, who may also be the perpetrators, she added.
 

Addressing Systemic Issues

In 2002, the World Health Organization, International Council of Nurses, and other major medical and labor groups worldwide launched a program focused on ways to eliminate workplace violence in healthcare settings. Since 2020, the call for a solution has grown louder as clinicians, nurses, and other health professionals faced more physical and verbal violence during the COVID-19 pandemic, often leading to burnout.

“Workplace violence is very important because it is more prevalent in healthcare workers than in many other settings and is on the rise,” said Karen Abrams, MD, assistant professor of psychiatry at the University of Toronto. Dr. Abrams, who wasn’t involved with this study, has researched physicians’ experiences of stalking by patients.

Workplace violence “can affect physical and mental health and lead to burnout, depression, anxiety, and symptoms of PTSD,” said Dr. Abrams. “It can affect one’s sleep and concentration and, therefore, ability to perform one’s job.”

Dr. Ayaz and colleagues suggested recommendations to improve gender-based workplace violence, noting the complex and multifaceted aspects of enhancing current policies, fortifying institutional capacities to respond, and implementing tailored interventions. Changes are needed at various levels, including at the healthcare system and provincial, territorial, and national levels, she said.

In Canada, for instance, lawmakers passed a bill in 2021 that amended the national criminal code to make intimidation or bullying a healthcare worker punishable by as many as 10 years in prison. The changes also required courts to consider more serious penalties for offenders who target healthcare workers aggressively.

But more needs to be done, medical professional groups say. The Canadian Nurses Association and Canadian Federation of Nurses Unions, as well as provincial groups, have called for a pan-Canadian violence-prevention framework, targeted funding for violence prevention infrastructure, and an update to the nation’s health human resources strategy to address severe staffing shortages across the country.

“Canada needs a bold vision for the future of our healthcare. Amid an ongoing staffing crisis, the cracks in our public healthcare systems have only grown deeper and wider, with too many going without the care they need when they need it,” Linda Silas, president of the Canadian Federation of Nurses Unions, told this news organization.

“Access to care relies on safe staffing. Years of unsafe working conditions and insufficient staffing are pushing nurses out of our public healthcare system,” she said. “Working collaboratively, we can make healthcare jobs the best jobs in our communities.”

The authors received no specific funding for the study. Ms. Ayaz, Dr. Abrams, and Ms. Silas reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Across the world, healthcare workers experience workplace violence, which can differ by gender, seniority, and the type of workplace, according to a recent study.

An analysis found that men were more likely to report physical violence, while women were more likely to face nonphysical violence, such as verbal abuse, sexual harassment, and bullying.

“Our study was sparked by the increasing research on workplace violence in healthcare settings. Yet, there’s less empirical data about workplace violence based on gender, its effects on individuals and the collective workforce, and its subsequent impact on patient care and healthcare organizations,” study author Basnama Ayaz, a PhD candidate in nursing at the University of Toronto, told this news organization.

“Workplace violence in healthcare settings is a critical issue that requires attention and action from all stakeholders, including individual providers, healthcare and other institutions, policymakers, and the community,” she said. “By recognizing the problem and implementing evidence-based solutions, we can create safer work environments that protect healthcare workers and improve quality care for patients and organizational effectiveness.”

The study was published online in PLOS Global Public Health.
 

Widespread and Severe

Although women represent most of the healthcare workforce worldwide, hierarchical structures tend to reflect traditional gender norms, where men hold leadership positions and women serve in front-line care roles, said Ms. Ayaz. Women are often marginalized, and their concerns dismissed, which can exacerbate their vulnerability to gender-based workplace violence, she added.

To better understand these imbalances on a global scale, the investigators conducted a scoping review of the prevalence of and risk factors for gender-based workplace violence in healthcare settings. Participants included physicians, nurses, and midwives, between 2010 and 2024. Although the authors acknowledged that gender-based workplace violence affects the full gender spectrum, only a handful of studies included information about nonbinary personnel, so the review focused on men and women.

Among 226 studies, half focused on physicians, 22% focused on nurses, and 28% included physicians, nurses, midwives, and other medical workers. About 64% of studies reported a higher prevalence of all forms of workplace violence for women, including sexual violence, verbal abuse, discrimination, bullying, and physical violence, while 17% reported a higher prevalence for men.

Overall, across most countries, men experienced more physical violence than did women, and women experienced more verbal abuse, sexual harassment, and bullying. Female nurses were particularly likely to experience violence.

Healthcare workers were also more likely to experience violence if they were younger, less experienced, had a lower professional status, or were part of a minority group based on ethnicity, nationality, culture, or language. These factors were sensitive to gender, “reflecting women’s structural disadvantages in the workplace,” wrote the authors.

As a result of workplace violence, women were more likely to report changes in mental health and social behaviors, as well as dissatisfaction, burnout, and changes in their career goals.

The research team identified various factors linked to violent episodes. In clinical settings where most perpetrators were patients and their relatives, abuse and violence could be related to overcrowding, waiting time, and heavy workloads for healthcare providers. When supervisors or colleagues were the perpetrators, workplace violence appeared to be more likely with long hours, night shifts, and certain clinical settings, such as emergency departments, psychiatric settings, operating rooms, and maternity wards, said Ms. Ayaz. Sexual or gender harassment toward women was more prevalent in male-dominated surgical specialties.

“We were surprised by the extent and severity of workplace violence that healthcare workers face around the globe based on gender,” she said. “One aspect that stood out was the significant role that organizational culture and support systems play either in mitigating or exacerbating these incidents, particularly the power structures between and within professions.”

For instance, trainees in lower hierarchical positions often face a higher risk for violence, especially gender-based harassment, she said. Many times, they feel they can’t report these incidents to trainers or managers, who may also be the perpetrators, she added.
 

Addressing Systemic Issues

In 2002, the World Health Organization, International Council of Nurses, and other major medical and labor groups worldwide launched a program focused on ways to eliminate workplace violence in healthcare settings. Since 2020, the call for a solution has grown louder as clinicians, nurses, and other health professionals faced more physical and verbal violence during the COVID-19 pandemic, often leading to burnout.

“Workplace violence is very important because it is more prevalent in healthcare workers than in many other settings and is on the rise,” said Karen Abrams, MD, assistant professor of psychiatry at the University of Toronto. Dr. Abrams, who wasn’t involved with this study, has researched physicians’ experiences of stalking by patients.

Workplace violence “can affect physical and mental health and lead to burnout, depression, anxiety, and symptoms of PTSD,” said Dr. Abrams. “It can affect one’s sleep and concentration and, therefore, ability to perform one’s job.”

Dr. Ayaz and colleagues suggested recommendations to improve gender-based workplace violence, noting the complex and multifaceted aspects of enhancing current policies, fortifying institutional capacities to respond, and implementing tailored interventions. Changes are needed at various levels, including at the healthcare system and provincial, territorial, and national levels, she said.

In Canada, for instance, lawmakers passed a bill in 2021 that amended the national criminal code to make intimidation or bullying a healthcare worker punishable by as many as 10 years in prison. The changes also required courts to consider more serious penalties for offenders who target healthcare workers aggressively.

But more needs to be done, medical professional groups say. The Canadian Nurses Association and Canadian Federation of Nurses Unions, as well as provincial groups, have called for a pan-Canadian violence-prevention framework, targeted funding for violence prevention infrastructure, and an update to the nation’s health human resources strategy to address severe staffing shortages across the country.

“Canada needs a bold vision for the future of our healthcare. Amid an ongoing staffing crisis, the cracks in our public healthcare systems have only grown deeper and wider, with too many going without the care they need when they need it,” Linda Silas, president of the Canadian Federation of Nurses Unions, told this news organization.

“Access to care relies on safe staffing. Years of unsafe working conditions and insufficient staffing are pushing nurses out of our public healthcare system,” she said. “Working collaboratively, we can make healthcare jobs the best jobs in our communities.”

The authors received no specific funding for the study. Ms. Ayaz, Dr. Abrams, and Ms. Silas reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Across the world, healthcare workers experience workplace violence, which can differ by gender, seniority, and the type of workplace, according to a recent study.

An analysis found that men were more likely to report physical violence, while women were more likely to face nonphysical violence, such as verbal abuse, sexual harassment, and bullying.

“Our study was sparked by the increasing research on workplace violence in healthcare settings. Yet, there’s less empirical data about workplace violence based on gender, its effects on individuals and the collective workforce, and its subsequent impact on patient care and healthcare organizations,” study author Basnama Ayaz, a PhD candidate in nursing at the University of Toronto, told this news organization.

“Workplace violence in healthcare settings is a critical issue that requires attention and action from all stakeholders, including individual providers, healthcare and other institutions, policymakers, and the community,” she said. “By recognizing the problem and implementing evidence-based solutions, we can create safer work environments that protect healthcare workers and improve quality care for patients and organizational effectiveness.”

The study was published online in PLOS Global Public Health.
 

Widespread and Severe

Although women represent most of the healthcare workforce worldwide, hierarchical structures tend to reflect traditional gender norms, where men hold leadership positions and women serve in front-line care roles, said Ms. Ayaz. Women are often marginalized, and their concerns dismissed, which can exacerbate their vulnerability to gender-based workplace violence, she added.

To better understand these imbalances on a global scale, the investigators conducted a scoping review of the prevalence of and risk factors for gender-based workplace violence in healthcare settings. Participants included physicians, nurses, and midwives, between 2010 and 2024. Although the authors acknowledged that gender-based workplace violence affects the full gender spectrum, only a handful of studies included information about nonbinary personnel, so the review focused on men and women.

Among 226 studies, half focused on physicians, 22% focused on nurses, and 28% included physicians, nurses, midwives, and other medical workers. About 64% of studies reported a higher prevalence of all forms of workplace violence for women, including sexual violence, verbal abuse, discrimination, bullying, and physical violence, while 17% reported a higher prevalence for men.

Overall, across most countries, men experienced more physical violence than did women, and women experienced more verbal abuse, sexual harassment, and bullying. Female nurses were particularly likely to experience violence.

Healthcare workers were also more likely to experience violence if they were younger, less experienced, had a lower professional status, or were part of a minority group based on ethnicity, nationality, culture, or language. These factors were sensitive to gender, “reflecting women’s structural disadvantages in the workplace,” wrote the authors.

As a result of workplace violence, women were more likely to report changes in mental health and social behaviors, as well as dissatisfaction, burnout, and changes in their career goals.

The research team identified various factors linked to violent episodes. In clinical settings where most perpetrators were patients and their relatives, abuse and violence could be related to overcrowding, waiting time, and heavy workloads for healthcare providers. When supervisors or colleagues were the perpetrators, workplace violence appeared to be more likely with long hours, night shifts, and certain clinical settings, such as emergency departments, psychiatric settings, operating rooms, and maternity wards, said Ms. Ayaz. Sexual or gender harassment toward women was more prevalent in male-dominated surgical specialties.

“We were surprised by the extent and severity of workplace violence that healthcare workers face around the globe based on gender,” she said. “One aspect that stood out was the significant role that organizational culture and support systems play either in mitigating or exacerbating these incidents, particularly the power structures between and within professions.”

For instance, trainees in lower hierarchical positions often face a higher risk for violence, especially gender-based harassment, she said. Many times, they feel they can’t report these incidents to trainers or managers, who may also be the perpetrators, she added.
 

Addressing Systemic Issues

In 2002, the World Health Organization, International Council of Nurses, and other major medical and labor groups worldwide launched a program focused on ways to eliminate workplace violence in healthcare settings. Since 2020, the call for a solution has grown louder as clinicians, nurses, and other health professionals faced more physical and verbal violence during the COVID-19 pandemic, often leading to burnout.

“Workplace violence is very important because it is more prevalent in healthcare workers than in many other settings and is on the rise,” said Karen Abrams, MD, assistant professor of psychiatry at the University of Toronto. Dr. Abrams, who wasn’t involved with this study, has researched physicians’ experiences of stalking by patients.

Workplace violence “can affect physical and mental health and lead to burnout, depression, anxiety, and symptoms of PTSD,” said Dr. Abrams. “It can affect one’s sleep and concentration and, therefore, ability to perform one’s job.”

Dr. Ayaz and colleagues suggested recommendations to improve gender-based workplace violence, noting the complex and multifaceted aspects of enhancing current policies, fortifying institutional capacities to respond, and implementing tailored interventions. Changes are needed at various levels, including at the healthcare system and provincial, territorial, and national levels, she said.

In Canada, for instance, lawmakers passed a bill in 2021 that amended the national criminal code to make intimidation or bullying a healthcare worker punishable by as many as 10 years in prison. The changes also required courts to consider more serious penalties for offenders who target healthcare workers aggressively.

But more needs to be done, medical professional groups say. The Canadian Nurses Association and Canadian Federation of Nurses Unions, as well as provincial groups, have called for a pan-Canadian violence-prevention framework, targeted funding for violence prevention infrastructure, and an update to the nation’s health human resources strategy to address severe staffing shortages across the country.

“Canada needs a bold vision for the future of our healthcare. Amid an ongoing staffing crisis, the cracks in our public healthcare systems have only grown deeper and wider, with too many going without the care they need when they need it,” Linda Silas, president of the Canadian Federation of Nurses Unions, told this news organization.

“Access to care relies on safe staffing. Years of unsafe working conditions and insufficient staffing are pushing nurses out of our public healthcare system,” she said. “Working collaboratively, we can make healthcare jobs the best jobs in our communities.”

The authors received no specific funding for the study. Ms. Ayaz, Dr. Abrams, and Ms. Silas reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The rapid adoption of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) for the treatment of diabetes and weight loss has led to a corresponding interest in their potential side effects. Several recent studies have sought to expound upon what role, if any, GLP-1 RAs may have in increasing the risk for specific gastrointestinal (GI) adverse events. 

Herein is a summary of the most current information on this topic, as well as my best guidance for clinicians on integrating it into the clinical care of their patients. 
 

Aspiration Risks

Albiglutide, dulaglutide, exenatide, liraglutide, lixisenatide, semaglutide, and tirzepatide are among the class of medications known as GLP-1 RAs. These medications all work by mimicking the action of hormonal incretins, which are released postprandially. Incretins affect the pancreatic glucose-dependent release of insulin, inhibit release of glucagon, stimulate satiety, and reduce gastric emptying. This last effect has raised concerns that patients taking GLP-1 RAs might be at an elevated risk for endoscopy-related aspiration. 

In June 2023, the American Society of Anesthesiologists released recommendations asking providers to consider holding back GLP-1 RAs in patients with scheduled elective procedures. 

In August 2023, five national GI societies — the American Gastroenterological Association, American Association for the Study of Liver Diseases, American College of Gastroenterology, American Society for Gastrointestinal Endoscopy, and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition — issued their own joint statement on the issue. 

In the absence of sufficient evidence, these groups suggested that healthcare providers “exercise best practices when performing endoscopy on these patients on GLP-1 [RAs].” They called for more data and encouraged key stakeholders to work together to develop the necessary evidence to provide guidance for these patients prior to elective endoscopy. A rapid clinical update issued by the American Gastroenterological Association in 2024 was consistent with these earlier multisociety recommendations. 

Two studies presented at 2024’s Digestive Disease Week provided additional reassurance that concerns about aspiration with these medications were perhaps unwarranted. 

The first (since published in The American Journal of Gastroenterology ) was a case-control study of 16,295 patients undergoing upper endoscopy, among whom 306 were taking GLP-1 RAs. It showed a higher rate of solid gastric residue among those taking GLP-1 RAs compared with controls (14% vs 4%, respectively). Patients who had prolonged fasting and clear liquids for concurrent colonoscopy had lower residue rates (2% vs 11%, respectively). However, there were no recorded incidents of procedural complications or aspiration. 

The second was a retrospective cohort study using TriNetX, a federated cloud-based network pulling millions of data points from multiple US healthcare organizations. It found that the incidence of aspiration pneumonitis and emergent intubation during or immediately after esophagogastroduodenoscopy and colonoscopy among those taking GLP-1 RAs was not increased compared with those not taking these medications. 

These were followed in June 2024 by a systematic review and meta-analysis published by Hiramoto and colleagues, which included 15 studies. The researchers showed a 36-minute prolongation for solid-food emptying and no delay in liquid emptying for patients taking GLP-1 RAs vs controls. The authors concluded that the minimal delay in solid-food emptying would be offset by standard preprocedural fasting periods. 

There is concern that patients with complicated type 2 diabetes may have a bit more of a risk for aspiration. However, this was not supported by an analysis from Barlowe and colleagues, who used a national claims database to identify 15,119 patients with type 2 diabetes on GLP-1 RAs. They found no increased events of pulmonary complications (ie, aspiration, pneumonia, respiratory failure) within 14 days following esophagogastroduodenoscopy. Additional evidence suggests that the risk for aspiration in these patients seems to be offset by prolonged fasting and intake of clear liquids. 

Although physicians clearly need to use clinical judgment when performing endoscopic procedures on these patients, the emerging evidence on safety has been encouraging. 
 

Association With GI Adverse Events

A recent retrospective analysis of real-world data from 10,328 new users of GLP-1 RAs with diabetes/obesity reported that the most common GI adverse events in this cohort were abdominal pain (57.6%), constipation (30.4%), diarrhea (32.7%), nausea and vomiting (23.4%), GI bleeding (15.9%), gastroparesis (5.1%), and pancreatitis (3.4%). 

Notably, dulaglutide and liraglutide had higher rates of abdominal pain, constipation, diarrhea, and nausea and vomiting than did semaglutide and exenatide. Compared with semaglutide, dulaglutide and liraglutide had slightly higher odds of abdominal pain, gastroparesis, and nausea and vomiting. There were no significant differences between the GLP-1 RAs in the risk for GI bleeding or pancreatitis. 

A 2023 report in JAMA observed that the risk for bowel obstruction is also elevated among patients using these agents for weight loss. Possible reasons for this are currently unknown. 

Studies are needed to analyze possible variations in safety profiles between GLP-1 RAs to better guide selection of these drugs, particularly in patients with GI risk factors. Furthermore, the causal relationship between GLP-1 RAs with other concomitant medications requires further investigation. 

Although relatively infrequent, the risk for GI adverse events should be given special consideration by providers when prescribing them for weight loss, because the risk/benefit ratios may be different from those in patients with diabetes. 
 

A Lack of Hepatic Concerns

GLP-1 RAs have demonstrated a significant impact on body weight and glycemic control, as well as beneficial effects on clinical, biochemical, and histologic markers in patients with metabolic dysfunction–associated steatotic liver disease (MASLD). These favorable changes are evident by reductions in the hepatic cytolysis markers (ie, aspartate aminotransferase and alanine aminotransferase). 

GLP-1 RAs may provide a protective function by reducing the accumulation of hepatic triglycerides and expression of several collagen genes. Some preclinical data suggest a risk reduction for progression to hepatocellular carcinoma, and animal studies indicate that complete suppression of hepatic carcinogenesis is achieved with liraglutide.

The most recent assessment of risk reduction for MASLD progression comes from a Scandinavian cohort analysis of national registries. In looking at 91,479 patients using GLP-1 RAs, investigators demonstrated this treatment was associated with a significant reduction in the composite primary endpoint of hepatocellular carcinoma, as well as both compensated and decompensated cirrhosis. 

Given the various favorable hepatic effects of GLP-1 RAs, it is likely that the composite benefit on MASLD is multifactorial. The current literature is clear that it is safe to use these agents across the spectrum of MASLD with or without fibrosis, although it must be noted that GLP-1 RAs are not approved by the Food and Drug Administration for this indication. 
 

Dr. Johnson is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. He disclosed ties with ISOTHRIVE and Johnson & Johnson.

A version of this article appeared on Medscape.com.

The rapid adoption of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) for the treatment of diabetes and weight loss has led to a corresponding interest in their potential side effects. Several recent studies have sought to expound upon what role, if any, GLP-1 RAs may have in increasing the risk for specific gastrointestinal (GI) adverse events. 

Herein is a summary of the most current information on this topic, as well as my best guidance for clinicians on integrating it into the clinical care of their patients. 
 

Aspiration Risks

Albiglutide, dulaglutide, exenatide, liraglutide, lixisenatide, semaglutide, and tirzepatide are among the class of medications known as GLP-1 RAs. These medications all work by mimicking the action of hormonal incretins, which are released postprandially. Incretins affect the pancreatic glucose-dependent release of insulin, inhibit release of glucagon, stimulate satiety, and reduce gastric emptying. This last effect has raised concerns that patients taking GLP-1 RAs might be at an elevated risk for endoscopy-related aspiration. 

In June 2023, the American Society of Anesthesiologists released recommendations asking providers to consider holding back GLP-1 RAs in patients with scheduled elective procedures. 

In August 2023, five national GI societies — the American Gastroenterological Association, American Association for the Study of Liver Diseases, American College of Gastroenterology, American Society for Gastrointestinal Endoscopy, and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition — issued their own joint statement on the issue. 

In the absence of sufficient evidence, these groups suggested that healthcare providers “exercise best practices when performing endoscopy on these patients on GLP-1 [RAs].” They called for more data and encouraged key stakeholders to work together to develop the necessary evidence to provide guidance for these patients prior to elective endoscopy. A rapid clinical update issued by the American Gastroenterological Association in 2024 was consistent with these earlier multisociety recommendations. 

Two studies presented at 2024’s Digestive Disease Week provided additional reassurance that concerns about aspiration with these medications were perhaps unwarranted. 

The first (since published in The American Journal of Gastroenterology ) was a case-control study of 16,295 patients undergoing upper endoscopy, among whom 306 were taking GLP-1 RAs. It showed a higher rate of solid gastric residue among those taking GLP-1 RAs compared with controls (14% vs 4%, respectively). Patients who had prolonged fasting and clear liquids for concurrent colonoscopy had lower residue rates (2% vs 11%, respectively). However, there were no recorded incidents of procedural complications or aspiration. 

The second was a retrospective cohort study using TriNetX, a federated cloud-based network pulling millions of data points from multiple US healthcare organizations. It found that the incidence of aspiration pneumonitis and emergent intubation during or immediately after esophagogastroduodenoscopy and colonoscopy among those taking GLP-1 RAs was not increased compared with those not taking these medications. 

These were followed in June 2024 by a systematic review and meta-analysis published by Hiramoto and colleagues, which included 15 studies. The researchers showed a 36-minute prolongation for solid-food emptying and no delay in liquid emptying for patients taking GLP-1 RAs vs controls. The authors concluded that the minimal delay in solid-food emptying would be offset by standard preprocedural fasting periods. 

There is concern that patients with complicated type 2 diabetes may have a bit more of a risk for aspiration. However, this was not supported by an analysis from Barlowe and colleagues, who used a national claims database to identify 15,119 patients with type 2 diabetes on GLP-1 RAs. They found no increased events of pulmonary complications (ie, aspiration, pneumonia, respiratory failure) within 14 days following esophagogastroduodenoscopy. Additional evidence suggests that the risk for aspiration in these patients seems to be offset by prolonged fasting and intake of clear liquids. 

Although physicians clearly need to use clinical judgment when performing endoscopic procedures on these patients, the emerging evidence on safety has been encouraging. 
 

Association With GI Adverse Events

A recent retrospective analysis of real-world data from 10,328 new users of GLP-1 RAs with diabetes/obesity reported that the most common GI adverse events in this cohort were abdominal pain (57.6%), constipation (30.4%), diarrhea (32.7%), nausea and vomiting (23.4%), GI bleeding (15.9%), gastroparesis (5.1%), and pancreatitis (3.4%). 

Notably, dulaglutide and liraglutide had higher rates of abdominal pain, constipation, diarrhea, and nausea and vomiting than did semaglutide and exenatide. Compared with semaglutide, dulaglutide and liraglutide had slightly higher odds of abdominal pain, gastroparesis, and nausea and vomiting. There were no significant differences between the GLP-1 RAs in the risk for GI bleeding or pancreatitis. 

A 2023 report in JAMA observed that the risk for bowel obstruction is also elevated among patients using these agents for weight loss. Possible reasons for this are currently unknown. 

Studies are needed to analyze possible variations in safety profiles between GLP-1 RAs to better guide selection of these drugs, particularly in patients with GI risk factors. Furthermore, the causal relationship between GLP-1 RAs with other concomitant medications requires further investigation. 

Although relatively infrequent, the risk for GI adverse events should be given special consideration by providers when prescribing them for weight loss, because the risk/benefit ratios may be different from those in patients with diabetes. 
 

A Lack of Hepatic Concerns

GLP-1 RAs have demonstrated a significant impact on body weight and glycemic control, as well as beneficial effects on clinical, biochemical, and histologic markers in patients with metabolic dysfunction–associated steatotic liver disease (MASLD). These favorable changes are evident by reductions in the hepatic cytolysis markers (ie, aspartate aminotransferase and alanine aminotransferase). 

GLP-1 RAs may provide a protective function by reducing the accumulation of hepatic triglycerides and expression of several collagen genes. Some preclinical data suggest a risk reduction for progression to hepatocellular carcinoma, and animal studies indicate that complete suppression of hepatic carcinogenesis is achieved with liraglutide.

The most recent assessment of risk reduction for MASLD progression comes from a Scandinavian cohort analysis of national registries. In looking at 91,479 patients using GLP-1 RAs, investigators demonstrated this treatment was associated with a significant reduction in the composite primary endpoint of hepatocellular carcinoma, as well as both compensated and decompensated cirrhosis. 

Given the various favorable hepatic effects of GLP-1 RAs, it is likely that the composite benefit on MASLD is multifactorial. The current literature is clear that it is safe to use these agents across the spectrum of MASLD with or without fibrosis, although it must be noted that GLP-1 RAs are not approved by the Food and Drug Administration for this indication. 
 

Dr. Johnson is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. He disclosed ties with ISOTHRIVE and Johnson & Johnson.

A version of this article appeared on Medscape.com.

The rapid adoption of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) for the treatment of diabetes and weight loss has led to a corresponding interest in their potential side effects. Several recent studies have sought to expound upon what role, if any, GLP-1 RAs may have in increasing the risk for specific gastrointestinal (GI) adverse events. 

Herein is a summary of the most current information on this topic, as well as my best guidance for clinicians on integrating it into the clinical care of their patients. 
 

Aspiration Risks

Albiglutide, dulaglutide, exenatide, liraglutide, lixisenatide, semaglutide, and tirzepatide are among the class of medications known as GLP-1 RAs. These medications all work by mimicking the action of hormonal incretins, which are released postprandially. Incretins affect the pancreatic glucose-dependent release of insulin, inhibit release of glucagon, stimulate satiety, and reduce gastric emptying. This last effect has raised concerns that patients taking GLP-1 RAs might be at an elevated risk for endoscopy-related aspiration. 

In June 2023, the American Society of Anesthesiologists released recommendations asking providers to consider holding back GLP-1 RAs in patients with scheduled elective procedures. 

In August 2023, five national GI societies — the American Gastroenterological Association, American Association for the Study of Liver Diseases, American College of Gastroenterology, American Society for Gastrointestinal Endoscopy, and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition — issued their own joint statement on the issue. 

In the absence of sufficient evidence, these groups suggested that healthcare providers “exercise best practices when performing endoscopy on these patients on GLP-1 [RAs].” They called for more data and encouraged key stakeholders to work together to develop the necessary evidence to provide guidance for these patients prior to elective endoscopy. A rapid clinical update issued by the American Gastroenterological Association in 2024 was consistent with these earlier multisociety recommendations. 

Two studies presented at 2024’s Digestive Disease Week provided additional reassurance that concerns about aspiration with these medications were perhaps unwarranted. 

The first (since published in The American Journal of Gastroenterology ) was a case-control study of 16,295 patients undergoing upper endoscopy, among whom 306 were taking GLP-1 RAs. It showed a higher rate of solid gastric residue among those taking GLP-1 RAs compared with controls (14% vs 4%, respectively). Patients who had prolonged fasting and clear liquids for concurrent colonoscopy had lower residue rates (2% vs 11%, respectively). However, there were no recorded incidents of procedural complications or aspiration. 

The second was a retrospective cohort study using TriNetX, a federated cloud-based network pulling millions of data points from multiple US healthcare organizations. It found that the incidence of aspiration pneumonitis and emergent intubation during or immediately after esophagogastroduodenoscopy and colonoscopy among those taking GLP-1 RAs was not increased compared with those not taking these medications. 

These were followed in June 2024 by a systematic review and meta-analysis published by Hiramoto and colleagues, which included 15 studies. The researchers showed a 36-minute prolongation for solid-food emptying and no delay in liquid emptying for patients taking GLP-1 RAs vs controls. The authors concluded that the minimal delay in solid-food emptying would be offset by standard preprocedural fasting periods. 

There is concern that patients with complicated type 2 diabetes may have a bit more of a risk for aspiration. However, this was not supported by an analysis from Barlowe and colleagues, who used a national claims database to identify 15,119 patients with type 2 diabetes on GLP-1 RAs. They found no increased events of pulmonary complications (ie, aspiration, pneumonia, respiratory failure) within 14 days following esophagogastroduodenoscopy. Additional evidence suggests that the risk for aspiration in these patients seems to be offset by prolonged fasting and intake of clear liquids. 

Although physicians clearly need to use clinical judgment when performing endoscopic procedures on these patients, the emerging evidence on safety has been encouraging. 
 

Association With GI Adverse Events

A recent retrospective analysis of real-world data from 10,328 new users of GLP-1 RAs with diabetes/obesity reported that the most common GI adverse events in this cohort were abdominal pain (57.6%), constipation (30.4%), diarrhea (32.7%), nausea and vomiting (23.4%), GI bleeding (15.9%), gastroparesis (5.1%), and pancreatitis (3.4%). 

Notably, dulaglutide and liraglutide had higher rates of abdominal pain, constipation, diarrhea, and nausea and vomiting than did semaglutide and exenatide. Compared with semaglutide, dulaglutide and liraglutide had slightly higher odds of abdominal pain, gastroparesis, and nausea and vomiting. There were no significant differences between the GLP-1 RAs in the risk for GI bleeding or pancreatitis. 

A 2023 report in JAMA observed that the risk for bowel obstruction is also elevated among patients using these agents for weight loss. Possible reasons for this are currently unknown. 

Studies are needed to analyze possible variations in safety profiles between GLP-1 RAs to better guide selection of these drugs, particularly in patients with GI risk factors. Furthermore, the causal relationship between GLP-1 RAs with other concomitant medications requires further investigation. 

Although relatively infrequent, the risk for GI adverse events should be given special consideration by providers when prescribing them for weight loss, because the risk/benefit ratios may be different from those in patients with diabetes. 
 

A Lack of Hepatic Concerns

GLP-1 RAs have demonstrated a significant impact on body weight and glycemic control, as well as beneficial effects on clinical, biochemical, and histologic markers in patients with metabolic dysfunction–associated steatotic liver disease (MASLD). These favorable changes are evident by reductions in the hepatic cytolysis markers (ie, aspartate aminotransferase and alanine aminotransferase). 

GLP-1 RAs may provide a protective function by reducing the accumulation of hepatic triglycerides and expression of several collagen genes. Some preclinical data suggest a risk reduction for progression to hepatocellular carcinoma, and animal studies indicate that complete suppression of hepatic carcinogenesis is achieved with liraglutide.

The most recent assessment of risk reduction for MASLD progression comes from a Scandinavian cohort analysis of national registries. In looking at 91,479 patients using GLP-1 RAs, investigators demonstrated this treatment was associated with a significant reduction in the composite primary endpoint of hepatocellular carcinoma, as well as both compensated and decompensated cirrhosis. 

Given the various favorable hepatic effects of GLP-1 RAs, it is likely that the composite benefit on MASLD is multifactorial. The current literature is clear that it is safe to use these agents across the spectrum of MASLD with or without fibrosis, although it must be noted that GLP-1 RAs are not approved by the Food and Drug Administration for this indication. 
 

Dr. Johnson is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. He disclosed ties with ISOTHRIVE and Johnson & Johnson.

A version of this article appeared on Medscape.com.

For 3 years, Ajala Efem’s type 2 diabetes was so poorly controlled that her blood sugar often soared northward of 500 mg/dL despite insulin shots three to five times a day. She would experience dizziness, vomiting, severe headaches, and the neuropathy in her feet made walking painful. She was also — literally — frothing at the mouth. The 47-year-old single mother of two adult children with mental disabilities feared that she would die.

Ms. Efem lives in the South Bronx, which is among the poorest areas of New York City, where the combined rate of prediabetes and diabetes is close to 30%, the highest rate of any borough in the city.

She had to wait 8 months for an appointment with an endocrinologist, but that visit proved to be life-changing. She lost 28 pounds and got off 15 medications in a single month. She did not join a gym or count calories; she simply changed the food she ate and adopted a low-carb diet.

“I went from being sick to feeling so great,” she told her endocrinologist recently: “My feet aren’t hurting; I’m not in pain; I’m eating as much as I want, and I really enjoy my food so much.” 

Ms. Efem’s life-changing visit was with Mariela Glandt, MD, at the offices of Essen Health Care. One month earlier, Dr. Glandt’s company, OwnaHealth, was contracted by Essen to conduct a 100-person pilot program for endocrinology patients. Essen is the largest Medicaid provider in New York City, and “they were desperate for an endocrinologist,” said Dr. Glandt, who trained at Columbia University in New York. So she came — all the way from Madrid, Spain. She commutes monthly, staying for a week each visit.

Dr. Glandt keeps up this punishing schedule because, as she explains, “it’s such a high for me to see these incredible transformations.” Her mostly Black and Hispanic patients are poor and lack resources, yet they lose significant amounts of weight, and their health issues resolve.

“Food is medicine” is an idea very much in vogue. The concept was central to the landmark White House Conference on Hunger, Nutrition, and Health in 2022 and is now the focus of a number of a wide range of government programs. Recently, the Senate held a hearing aimed at further expanding food as medicine programs.

Still, only a single randomized controlled clinical trial has been conducted on this nutritional approach, with unexpectedly disappointing results. In the mid-Atlantic region, 456 food-insecure adults with type 2 diabetes were randomly assigned to usual care or the provision of weekly groceries for their entire families for about 1 year. Provisions for a Mediterranean-style diet included whole grains, fruits and vegetables, lean protein, low-fat dairy products, cereal, brown rice, and bread. In addition, participants received dietary consultations. Yet, those who got free food and coaching did not see improvements in their average blood sugar (the study’s primary outcome), and their low-density lipoprotein (LDL) cholesterol and high-density lipoprotein (HDL) cholesterol levels appeared to have worsened. 

“To be honest, I was surprised,” the study’s lead author, Joseph Doyle, PhD, professor at the Sloan School of Management at MIT in Cambridge, Massachusetts, told me. “I was hoping we would show improved outcomes, but the way to make progress is to do well-randomized trials to find out what works.”

I was not surprised by these results because a recent rigorous systematic review and meta-analysis in The BMJ did not show a Mediterranean-style diet to be the most effective for glycemic control. And Ms. Efem was not in fact following a Mediterranean-style diet.

Ms. Efem’s low-carb success story is anecdotal, but Dr. Glandt has an established track record from her 9 years’ experience as the medical director of the eponymous diabetes center she founded in Tel Aviv. A recent audit of 344 patients from the center found that after 6 months of following a very low–carbohydrate diet, 96.3% of those with diabetes saw their A1c fall from a median 7.6% to 6.3%. Weight loss was significant, with a median drop of 6.5 kg (14 pounds) for patients with diabetes and 5.7 kg for those with prediabetes. The diet comprises 5%-10% of calories from carbs, but Dr. Glandt does not use numeric targets with her patients.

Blood pressure, triglycerides, and liver enzymes also improved. And though LDL cholesterol went up by 8%, this result may have been offset by an accompanying 13% rise in HDL cholesterol. Of the 78 patients initially on insulin, 62 were able to stop this medication entirely.

Although these results aren’t from a clinical trial, they’re still highly meaningful because the current dietary standard of care for type 2 diabetes can only slow the progression of the disease, not cause remission. Indeed, the idea that type 2 diabetes could be put into remission was not seriously considered by the American Diabetes Association (ADA) until 2009. By 2019, an ADA report concluded that “[r]educing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia.” In other words, the best way to improve the key factor in diabetes is to reduce total carbohydrates. Yet, the ADA still advocates filling one quarter of one’s plate with carbohydrate-based foods, an amount that will prevent remission. Given that the ADA’s vision statement is “a life free of diabetes,” it seems negligent not to tell people with a deadly condition that they can reverse this diagnosis. 

A 2023 meta-analysis of 42 controlled clinical trials on 4809 patients showed that a very low–carbohydrate ketogenic diet (keto) was “superior” to alternatives for glycemic control. A more recent review of 11 clinical trials found that this diet was equal but not superior to other nutritional approaches in terms of blood sugar control, but this review also concluded that keto led to greater increases in HDL cholesterol and lower triglycerides. 

Dr. Glandt’s patients in the Bronx might not seem like obvious low-carb candidates. The diet is considered expensive and difficult to sustain. My interviews with a half dozen patients revealed some of these difficulties, but even for a woman living in a homeless shelter, the obstacles are not insurmountable.

Jerrilyn, who preferred that I use only her first name, lives in a shelter in Queens. While we strolled through a nearby park, she told me about her desire to lose weight and recover from polycystic ovary syndrome, which terrified her because it had caused dramatic hair loss. When she landed in Dr. Glandt’s office at age 28, she weighed 180 pounds. 

Less than 5 months later, Jerrilyn had lost 25 pounds, and her period had returned with some regularity. She said she used “food stamps,” known as the Supplemental Nutrition Assistance Program (SNAP), to buy most of her food at local delis because the meals served at the shelter were too heavy in starches. She starts her day with eggs, turkey bacon, and avocado. 

“It was hard to give up carbohydrates because in my culture [Latina], we have nothing but carbs: rice, potatoes, yuca,” Jerrilyn shared. She noticed that carbs make her hungrier, but after 3 days of going low-carb, her cravings diminished. “It was like getting over an addiction,” she said.

Jerrilyn told me she’d seen many doctors but none as involved as Dr. Glandt. “It feels awesome to know that I have a lot of really useful information coming from her all the time.” The OwnaHealth app tracks weight, blood pressure, blood sugar, ketones, meals, mood, and cravings. Patients wear continuous glucose monitors and enter other information manually. Ketone bodies are used to measure dietary adherence and are obtained through finger pricks and test strips provided by OwnaHealth. Dr. Glandt gives patients her own food plan, along with free visual guides to low-carbohydrate foods by dietdoctor.com. 

Dr. Glandt also sends her patients for regular blood work. She says she does not frequently see a rise in LDL cholesterol, which can sometimes occur on a low-carbohydrate diet. This effect is most common among people who are lean and fit. She says she doesn’t discontinue statins unless cholesterol levels improve significantly.

Samuel Gonzalez, age 56, weighed 275 pounds when he walked into Dr. Glandt’s office this past November. His A1c was 9.2%, but none of his previous doctors had diagnosed him with diabetes. “I was like a walking bag of sugar!” he joked. 

A low-carbohydrate diet seemed absurd to a Puerto Rican like himself: “Having coffee without sugar? That’s like sacrilegious in my culture!” exclaimed Mr. Gonzalez. Still, he managed, with SNAP, to cook eggs and bacon for breakfast and some kind of protein for dinner. He keeps lunch light, “like tuna fish,” and finds checking in with the OwnaHealth app to be very helpful. “Every day, I’m on it,” he said. In the past 7 months, he’s lost 50 pounds, normalized his cholesterol and blood pressure levels, and lowered his A1c to 5.5%.

Mr. Gonzalez gets disability payments due to a back injury, and Ms. Efem receives government payments because her husband died serving in the military. Ms. Efem says her new diet challenges her budget, but Mr. Gonzalez says he manages easily.

Mélissa Cruz, a 28-year-old studying to be a nail technician while also doing back office work at a physical therapy practice, says she’s stretched thin. “I end up sad because I can’t put energy into looking up recipes and cooking for me and my boyfriend,” she told me. She’ll often cook rice and plantains for him and meat for herself, but “it’s frustrating when I’m low on funds and can’t figure out what to eat.” 

Low-carbohydrate diets have a reputation for being expensive because people often start eating pricier foods, like meat and cheese, to replace cheaper starchy foods such as pasta and rice. Eggs and ground beef are less expensive low-carb meal options, and meat, unlike fruits and vegetables, is easy to freeze and doesn’t spoil quickly. These advantages can add up.

A 2019 cost analysis published in Nutrition & Dietetics compared a low-carbohydrate dietary pattern with the New Zealand government’s recommended guidelines (which are almost identical to those in the United States) and found that it cost only an extra $1.27 in US dollars per person per day. One explanation is that protein and fat are more satiating than carbohydrates, so people who mostly consume these macronutrients often cut back on snacks like packaged chips, crackers, and even fruits. Also, those on a ketogenic diet usually cut down on medications, so the additional $1.27 daily is likely offset by reduced spending at the pharmacy.

It’s not just Bronx residents with low socioeconomic status (SES) who adapt well to low-carbohydrate diets. Among Alabama state employees with diabetes enrolled in a low-carbohydrate dietary program provided by a company called Virta, the low SES population had the best outcomes. Virta also published survey data in 2023 showing that participants in a program with the Veteran’s Administration did not find additional costs to be an obstacle to dietary adherence. In fact, some participants saw cost reductions due to decreased spending on processed snacks and fast foods.

Ms. Cruz told me she struggles financially, yet she’s still lost nearly 30 pounds in 5 months, and her A1c went from 7.1% down to 5.9%, putting her diabetes into remission. Equally motivating for her are the improvements she’s seen in other hormonal issues. Since childhood, she’s had acanthosis, a condition that causes the skin to darken in velvety patches, and more recently, she developed severe hirsutism to the point of growing sideburns. “I had tried going vegan and fasting, but these just weren’t sustainable for me, and I was so overwhelmed with counting calories all the time.” Now, on a low-carbohydrate diet, which doesn’t require calorie counting, she’s finally seeing both these conditions improve significantly.

When I last checked in with Ms. Cruz, she said she had “kind of ghosted” Dr. Glandt due to her work and school constraints, but she hadn’t abandoned the diet. She appreciated, too, that Dr. Glandt had not given up on her and kept calling and messaging. “She’s not at all like a typical doctor who would just tell me to lose weight and shake their head at me,” Ms. Cruz said. 

Because Dr. Glandt’s approach is time-intensive and high-touch, it might seem impractical to scale up, but Dr. Glandt’s app uses artificial intelligence to help with communications thus allowing her, with help from part-time health coaches, to care for patients. 

This early success in one of the United States’ poorest and sickest neighborhoods should give us hope that type 2 diabetes need not to be a progressive irreversible disease, even among the disadvantaged. 

OwnaHealth’s track record, along with that of Virta and other similar low-carbohydrate medical practices also give hope to the food-is-medicine idea. Diabetes can go into remission, and people can be healed, provided that health practitioners prescribe the right foods. And in truth, it’s not a diet. It’s a way of eating that must be maintained. The sustainability of low-carbohydrate diets has been a point of contention, but the Virta trial, with 38% of patients sustaining remission at 2 years, showed that it’s possible. (OwnaHealth, for its part, offers long-term maintenance plans to help patients stay very low-carb permanently.) 

Given the tremendous costs and health burden of diabetes, this approach should no doubt be the first line of treatment for doctors and the ADA. The past two decades of clinical trial research have demonstrated that remission of type 2 diabetes is possible through diet alone. It turns out that for metabolic diseases, only certain foods are truly medicine. 
 

Tools and Tips for Clinicians: 

• Free two-page keto starter’s guide by OwnaHealth; Dr. Glandt uses this guide with her patients.
• Illustrated low-carb guides by dietdoctor.com
• Free low-carbohydrate starter guide by the Michigan Collaborative for Type 2 Diabetes
• Low-Carb for Any Budget, a free digital booklet by Mark Cucuzzella, MD, and Kristie Sullivan, PhD
• Recipe and meal ideas from Ruled.me, Keto-Mojo.com, and 

Dr. Teicholz is the founder of Nutrition Coalition, an independent nonprofit dedicated to ensuring that US dietary guidelines align with current science. She disclosed receiving book royalties from The Big Fat Surprise, and received honorarium not exceeding $2000 for speeches from various sources.

A version of this article appeared on Medscape.com.

For 3 years, Ajala Efem’s type 2 diabetes was so poorly controlled that her blood sugar often soared northward of 500 mg/dL despite insulin shots three to five times a day. She would experience dizziness, vomiting, severe headaches, and the neuropathy in her feet made walking painful. She was also — literally — frothing at the mouth. The 47-year-old single mother of two adult children with mental disabilities feared that she would die.

Ms. Efem lives in the South Bronx, which is among the poorest areas of New York City, where the combined rate of prediabetes and diabetes is close to 30%, the highest rate of any borough in the city.

She had to wait 8 months for an appointment with an endocrinologist, but that visit proved to be life-changing. She lost 28 pounds and got off 15 medications in a single month. She did not join a gym or count calories; she simply changed the food she ate and adopted a low-carb diet.

“I went from being sick to feeling so great,” she told her endocrinologist recently: “My feet aren’t hurting; I’m not in pain; I’m eating as much as I want, and I really enjoy my food so much.” 

Ms. Efem’s life-changing visit was with Mariela Glandt, MD, at the offices of Essen Health Care. One month earlier, Dr. Glandt’s company, OwnaHealth, was contracted by Essen to conduct a 100-person pilot program for endocrinology patients. Essen is the largest Medicaid provider in New York City, and “they were desperate for an endocrinologist,” said Dr. Glandt, who trained at Columbia University in New York. So she came — all the way from Madrid, Spain. She commutes monthly, staying for a week each visit.

Dr. Glandt keeps up this punishing schedule because, as she explains, “it’s such a high for me to see these incredible transformations.” Her mostly Black and Hispanic patients are poor and lack resources, yet they lose significant amounts of weight, and their health issues resolve.

“Food is medicine” is an idea very much in vogue. The concept was central to the landmark White House Conference on Hunger, Nutrition, and Health in 2022 and is now the focus of a number of a wide range of government programs. Recently, the Senate held a hearing aimed at further expanding food as medicine programs.

Still, only a single randomized controlled clinical trial has been conducted on this nutritional approach, with unexpectedly disappointing results. In the mid-Atlantic region, 456 food-insecure adults with type 2 diabetes were randomly assigned to usual care or the provision of weekly groceries for their entire families for about 1 year. Provisions for a Mediterranean-style diet included whole grains, fruits and vegetables, lean protein, low-fat dairy products, cereal, brown rice, and bread. In addition, participants received dietary consultations. Yet, those who got free food and coaching did not see improvements in their average blood sugar (the study’s primary outcome), and their low-density lipoprotein (LDL) cholesterol and high-density lipoprotein (HDL) cholesterol levels appeared to have worsened. 

“To be honest, I was surprised,” the study’s lead author, Joseph Doyle, PhD, professor at the Sloan School of Management at MIT in Cambridge, Massachusetts, told me. “I was hoping we would show improved outcomes, but the way to make progress is to do well-randomized trials to find out what works.”

I was not surprised by these results because a recent rigorous systematic review and meta-analysis in The BMJ did not show a Mediterranean-style diet to be the most effective for glycemic control. And Ms. Efem was not in fact following a Mediterranean-style diet.

Ms. Efem’s low-carb success story is anecdotal, but Dr. Glandt has an established track record from her 9 years’ experience as the medical director of the eponymous diabetes center she founded in Tel Aviv. A recent audit of 344 patients from the center found that after 6 months of following a very low–carbohydrate diet, 96.3% of those with diabetes saw their A1c fall from a median 7.6% to 6.3%. Weight loss was significant, with a median drop of 6.5 kg (14 pounds) for patients with diabetes and 5.7 kg for those with prediabetes. The diet comprises 5%-10% of calories from carbs, but Dr. Glandt does not use numeric targets with her patients.

Blood pressure, triglycerides, and liver enzymes also improved. And though LDL cholesterol went up by 8%, this result may have been offset by an accompanying 13% rise in HDL cholesterol. Of the 78 patients initially on insulin, 62 were able to stop this medication entirely.

Although these results aren’t from a clinical trial, they’re still highly meaningful because the current dietary standard of care for type 2 diabetes can only slow the progression of the disease, not cause remission. Indeed, the idea that type 2 diabetes could be put into remission was not seriously considered by the American Diabetes Association (ADA) until 2009. By 2019, an ADA report concluded that “[r]educing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia.” In other words, the best way to improve the key factor in diabetes is to reduce total carbohydrates. Yet, the ADA still advocates filling one quarter of one’s plate with carbohydrate-based foods, an amount that will prevent remission. Given that the ADA’s vision statement is “a life free of diabetes,” it seems negligent not to tell people with a deadly condition that they can reverse this diagnosis. 

A 2023 meta-analysis of 42 controlled clinical trials on 4809 patients showed that a very low–carbohydrate ketogenic diet (keto) was “superior” to alternatives for glycemic control. A more recent review of 11 clinical trials found that this diet was equal but not superior to other nutritional approaches in terms of blood sugar control, but this review also concluded that keto led to greater increases in HDL cholesterol and lower triglycerides. 

Dr. Glandt’s patients in the Bronx might not seem like obvious low-carb candidates. The diet is considered expensive and difficult to sustain. My interviews with a half dozen patients revealed some of these difficulties, but even for a woman living in a homeless shelter, the obstacles are not insurmountable.

Jerrilyn, who preferred that I use only her first name, lives in a shelter in Queens. While we strolled through a nearby park, she told me about her desire to lose weight and recover from polycystic ovary syndrome, which terrified her because it had caused dramatic hair loss. When she landed in Dr. Glandt’s office at age 28, she weighed 180 pounds. 

Less than 5 months later, Jerrilyn had lost 25 pounds, and her period had returned with some regularity. She said she used “food stamps,” known as the Supplemental Nutrition Assistance Program (SNAP), to buy most of her food at local delis because the meals served at the shelter were too heavy in starches. She starts her day with eggs, turkey bacon, and avocado. 

“It was hard to give up carbohydrates because in my culture [Latina], we have nothing but carbs: rice, potatoes, yuca,” Jerrilyn shared. She noticed that carbs make her hungrier, but after 3 days of going low-carb, her cravings diminished. “It was like getting over an addiction,” she said.

Jerrilyn told me she’d seen many doctors but none as involved as Dr. Glandt. “It feels awesome to know that I have a lot of really useful information coming from her all the time.” The OwnaHealth app tracks weight, blood pressure, blood sugar, ketones, meals, mood, and cravings. Patients wear continuous glucose monitors and enter other information manually. Ketone bodies are used to measure dietary adherence and are obtained through finger pricks and test strips provided by OwnaHealth. Dr. Glandt gives patients her own food plan, along with free visual guides to low-carbohydrate foods by dietdoctor.com. 

Dr. Glandt also sends her patients for regular blood work. She says she does not frequently see a rise in LDL cholesterol, which can sometimes occur on a low-carbohydrate diet. This effect is most common among people who are lean and fit. She says she doesn’t discontinue statins unless cholesterol levels improve significantly.

Samuel Gonzalez, age 56, weighed 275 pounds when he walked into Dr. Glandt’s office this past November. His A1c was 9.2%, but none of his previous doctors had diagnosed him with diabetes. “I was like a walking bag of sugar!” he joked. 

A low-carbohydrate diet seemed absurd to a Puerto Rican like himself: “Having coffee without sugar? That’s like sacrilegious in my culture!” exclaimed Mr. Gonzalez. Still, he managed, with SNAP, to cook eggs and bacon for breakfast and some kind of protein for dinner. He keeps lunch light, “like tuna fish,” and finds checking in with the OwnaHealth app to be very helpful. “Every day, I’m on it,” he said. In the past 7 months, he’s lost 50 pounds, normalized his cholesterol and blood pressure levels, and lowered his A1c to 5.5%.

Mr. Gonzalez gets disability payments due to a back injury, and Ms. Efem receives government payments because her husband died serving in the military. Ms. Efem says her new diet challenges her budget, but Mr. Gonzalez says he manages easily.

Mélissa Cruz, a 28-year-old studying to be a nail technician while also doing back office work at a physical therapy practice, says she’s stretched thin. “I end up sad because I can’t put energy into looking up recipes and cooking for me and my boyfriend,” she told me. She’ll often cook rice and plantains for him and meat for herself, but “it’s frustrating when I’m low on funds and can’t figure out what to eat.” 

Low-carbohydrate diets have a reputation for being expensive because people often start eating pricier foods, like meat and cheese, to replace cheaper starchy foods such as pasta and rice. Eggs and ground beef are less expensive low-carb meal options, and meat, unlike fruits and vegetables, is easy to freeze and doesn’t spoil quickly. These advantages can add up.

A 2019 cost analysis published in Nutrition & Dietetics compared a low-carbohydrate dietary pattern with the New Zealand government’s recommended guidelines (which are almost identical to those in the United States) and found that it cost only an extra $1.27 in US dollars per person per day. One explanation is that protein and fat are more satiating than carbohydrates, so people who mostly consume these macronutrients often cut back on snacks like packaged chips, crackers, and even fruits. Also, those on a ketogenic diet usually cut down on medications, so the additional $1.27 daily is likely offset by reduced spending at the pharmacy.

It’s not just Bronx residents with low socioeconomic status (SES) who adapt well to low-carbohydrate diets. Among Alabama state employees with diabetes enrolled in a low-carbohydrate dietary program provided by a company called Virta, the low SES population had the best outcomes. Virta also published survey data in 2023 showing that participants in a program with the Veteran’s Administration did not find additional costs to be an obstacle to dietary adherence. In fact, some participants saw cost reductions due to decreased spending on processed snacks and fast foods.

Ms. Cruz told me she struggles financially, yet she’s still lost nearly 30 pounds in 5 months, and her A1c went from 7.1% down to 5.9%, putting her diabetes into remission. Equally motivating for her are the improvements she’s seen in other hormonal issues. Since childhood, she’s had acanthosis, a condition that causes the skin to darken in velvety patches, and more recently, she developed severe hirsutism to the point of growing sideburns. “I had tried going vegan and fasting, but these just weren’t sustainable for me, and I was so overwhelmed with counting calories all the time.” Now, on a low-carbohydrate diet, which doesn’t require calorie counting, she’s finally seeing both these conditions improve significantly.

When I last checked in with Ms. Cruz, she said she had “kind of ghosted” Dr. Glandt due to her work and school constraints, but she hadn’t abandoned the diet. She appreciated, too, that Dr. Glandt had not given up on her and kept calling and messaging. “She’s not at all like a typical doctor who would just tell me to lose weight and shake their head at me,” Ms. Cruz said. 

Because Dr. Glandt’s approach is time-intensive and high-touch, it might seem impractical to scale up, but Dr. Glandt’s app uses artificial intelligence to help with communications thus allowing her, with help from part-time health coaches, to care for patients. 

This early success in one of the United States’ poorest and sickest neighborhoods should give us hope that type 2 diabetes need not to be a progressive irreversible disease, even among the disadvantaged. 

OwnaHealth’s track record, along with that of Virta and other similar low-carbohydrate medical practices also give hope to the food-is-medicine idea. Diabetes can go into remission, and people can be healed, provided that health practitioners prescribe the right foods. And in truth, it’s not a diet. It’s a way of eating that must be maintained. The sustainability of low-carbohydrate diets has been a point of contention, but the Virta trial, with 38% of patients sustaining remission at 2 years, showed that it’s possible. (OwnaHealth, for its part, offers long-term maintenance plans to help patients stay very low-carb permanently.) 

Given the tremendous costs and health burden of diabetes, this approach should no doubt be the first line of treatment for doctors and the ADA. The past two decades of clinical trial research have demonstrated that remission of type 2 diabetes is possible through diet alone. It turns out that for metabolic diseases, only certain foods are truly medicine. 
 

Tools and Tips for Clinicians: 

• Free two-page keto starter’s guide by OwnaHealth; Dr. Glandt uses this guide with her patients.
• Illustrated low-carb guides by dietdoctor.com
• Free low-carbohydrate starter guide by the Michigan Collaborative for Type 2 Diabetes
• Low-Carb for Any Budget, a free digital booklet by Mark Cucuzzella, MD, and Kristie Sullivan, PhD
• Recipe and meal ideas from Ruled.me, Keto-Mojo.com, and 

Dr. Teicholz is the founder of Nutrition Coalition, an independent nonprofit dedicated to ensuring that US dietary guidelines align with current science. She disclosed receiving book royalties from The Big Fat Surprise, and received honorarium not exceeding $2000 for speeches from various sources.

A version of this article appeared on Medscape.com.

For 3 years, Ajala Efem’s type 2 diabetes was so poorly controlled that her blood sugar often soared northward of 500 mg/dL despite insulin shots three to five times a day. She would experience dizziness, vomiting, severe headaches, and the neuropathy in her feet made walking painful. She was also — literally — frothing at the mouth. The 47-year-old single mother of two adult children with mental disabilities feared that she would die.

Ms. Efem lives in the South Bronx, which is among the poorest areas of New York City, where the combined rate of prediabetes and diabetes is close to 30%, the highest rate of any borough in the city.

She had to wait 8 months for an appointment with an endocrinologist, but that visit proved to be life-changing. She lost 28 pounds and got off 15 medications in a single month. She did not join a gym or count calories; she simply changed the food she ate and adopted a low-carb diet.

“I went from being sick to feeling so great,” she told her endocrinologist recently: “My feet aren’t hurting; I’m not in pain; I’m eating as much as I want, and I really enjoy my food so much.” 

Ms. Efem’s life-changing visit was with Mariela Glandt, MD, at the offices of Essen Health Care. One month earlier, Dr. Glandt’s company, OwnaHealth, was contracted by Essen to conduct a 100-person pilot program for endocrinology patients. Essen is the largest Medicaid provider in New York City, and “they were desperate for an endocrinologist,” said Dr. Glandt, who trained at Columbia University in New York. So she came — all the way from Madrid, Spain. She commutes monthly, staying for a week each visit.

Dr. Glandt keeps up this punishing schedule because, as she explains, “it’s such a high for me to see these incredible transformations.” Her mostly Black and Hispanic patients are poor and lack resources, yet they lose significant amounts of weight, and their health issues resolve.

“Food is medicine” is an idea very much in vogue. The concept was central to the landmark White House Conference on Hunger, Nutrition, and Health in 2022 and is now the focus of a number of a wide range of government programs. Recently, the Senate held a hearing aimed at further expanding food as medicine programs.

Still, only a single randomized controlled clinical trial has been conducted on this nutritional approach, with unexpectedly disappointing results. In the mid-Atlantic region, 456 food-insecure adults with type 2 diabetes were randomly assigned to usual care or the provision of weekly groceries for their entire families for about 1 year. Provisions for a Mediterranean-style diet included whole grains, fruits and vegetables, lean protein, low-fat dairy products, cereal, brown rice, and bread. In addition, participants received dietary consultations. Yet, those who got free food and coaching did not see improvements in their average blood sugar (the study’s primary outcome), and their low-density lipoprotein (LDL) cholesterol and high-density lipoprotein (HDL) cholesterol levels appeared to have worsened. 

“To be honest, I was surprised,” the study’s lead author, Joseph Doyle, PhD, professor at the Sloan School of Management at MIT in Cambridge, Massachusetts, told me. “I was hoping we would show improved outcomes, but the way to make progress is to do well-randomized trials to find out what works.”

I was not surprised by these results because a recent rigorous systematic review and meta-analysis in The BMJ did not show a Mediterranean-style diet to be the most effective for glycemic control. And Ms. Efem was not in fact following a Mediterranean-style diet.

Ms. Efem’s low-carb success story is anecdotal, but Dr. Glandt has an established track record from her 9 years’ experience as the medical director of the eponymous diabetes center she founded in Tel Aviv. A recent audit of 344 patients from the center found that after 6 months of following a very low–carbohydrate diet, 96.3% of those with diabetes saw their A1c fall from a median 7.6% to 6.3%. Weight loss was significant, with a median drop of 6.5 kg (14 pounds) for patients with diabetes and 5.7 kg for those with prediabetes. The diet comprises 5%-10% of calories from carbs, but Dr. Glandt does not use numeric targets with her patients.

Blood pressure, triglycerides, and liver enzymes also improved. And though LDL cholesterol went up by 8%, this result may have been offset by an accompanying 13% rise in HDL cholesterol. Of the 78 patients initially on insulin, 62 were able to stop this medication entirely.

Although these results aren’t from a clinical trial, they’re still highly meaningful because the current dietary standard of care for type 2 diabetes can only slow the progression of the disease, not cause remission. Indeed, the idea that type 2 diabetes could be put into remission was not seriously considered by the American Diabetes Association (ADA) until 2009. By 2019, an ADA report concluded that “[r]educing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia.” In other words, the best way to improve the key factor in diabetes is to reduce total carbohydrates. Yet, the ADA still advocates filling one quarter of one’s plate with carbohydrate-based foods, an amount that will prevent remission. Given that the ADA’s vision statement is “a life free of diabetes,” it seems negligent not to tell people with a deadly condition that they can reverse this diagnosis. 

A 2023 meta-analysis of 42 controlled clinical trials on 4809 patients showed that a very low–carbohydrate ketogenic diet (keto) was “superior” to alternatives for glycemic control. A more recent review of 11 clinical trials found that this diet was equal but not superior to other nutritional approaches in terms of blood sugar control, but this review also concluded that keto led to greater increases in HDL cholesterol and lower triglycerides. 

Dr. Glandt’s patients in the Bronx might not seem like obvious low-carb candidates. The diet is considered expensive and difficult to sustain. My interviews with a half dozen patients revealed some of these difficulties, but even for a woman living in a homeless shelter, the obstacles are not insurmountable.

Jerrilyn, who preferred that I use only her first name, lives in a shelter in Queens. While we strolled through a nearby park, she told me about her desire to lose weight and recover from polycystic ovary syndrome, which terrified her because it had caused dramatic hair loss. When she landed in Dr. Glandt’s office at age 28, she weighed 180 pounds. 

Less than 5 months later, Jerrilyn had lost 25 pounds, and her period had returned with some regularity. She said she used “food stamps,” known as the Supplemental Nutrition Assistance Program (SNAP), to buy most of her food at local delis because the meals served at the shelter were too heavy in starches. She starts her day with eggs, turkey bacon, and avocado. 

“It was hard to give up carbohydrates because in my culture [Latina], we have nothing but carbs: rice, potatoes, yuca,” Jerrilyn shared. She noticed that carbs make her hungrier, but after 3 days of going low-carb, her cravings diminished. “It was like getting over an addiction,” she said.

Jerrilyn told me she’d seen many doctors but none as involved as Dr. Glandt. “It feels awesome to know that I have a lot of really useful information coming from her all the time.” The OwnaHealth app tracks weight, blood pressure, blood sugar, ketones, meals, mood, and cravings. Patients wear continuous glucose monitors and enter other information manually. Ketone bodies are used to measure dietary adherence and are obtained through finger pricks and test strips provided by OwnaHealth. Dr. Glandt gives patients her own food plan, along with free visual guides to low-carbohydrate foods by dietdoctor.com. 

Dr. Glandt also sends her patients for regular blood work. She says she does not frequently see a rise in LDL cholesterol, which can sometimes occur on a low-carbohydrate diet. This effect is most common among people who are lean and fit. She says she doesn’t discontinue statins unless cholesterol levels improve significantly.

Samuel Gonzalez, age 56, weighed 275 pounds when he walked into Dr. Glandt’s office this past November. His A1c was 9.2%, but none of his previous doctors had diagnosed him with diabetes. “I was like a walking bag of sugar!” he joked. 

A low-carbohydrate diet seemed absurd to a Puerto Rican like himself: “Having coffee without sugar? That’s like sacrilegious in my culture!” exclaimed Mr. Gonzalez. Still, he managed, with SNAP, to cook eggs and bacon for breakfast and some kind of protein for dinner. He keeps lunch light, “like tuna fish,” and finds checking in with the OwnaHealth app to be very helpful. “Every day, I’m on it,” he said. In the past 7 months, he’s lost 50 pounds, normalized his cholesterol and blood pressure levels, and lowered his A1c to 5.5%.

Mr. Gonzalez gets disability payments due to a back injury, and Ms. Efem receives government payments because her husband died serving in the military. Ms. Efem says her new diet challenges her budget, but Mr. Gonzalez says he manages easily.

Mélissa Cruz, a 28-year-old studying to be a nail technician while also doing back office work at a physical therapy practice, says she’s stretched thin. “I end up sad because I can’t put energy into looking up recipes and cooking for me and my boyfriend,” she told me. She’ll often cook rice and plantains for him and meat for herself, but “it’s frustrating when I’m low on funds and can’t figure out what to eat.” 

Low-carbohydrate diets have a reputation for being expensive because people often start eating pricier foods, like meat and cheese, to replace cheaper starchy foods such as pasta and rice. Eggs and ground beef are less expensive low-carb meal options, and meat, unlike fruits and vegetables, is easy to freeze and doesn’t spoil quickly. These advantages can add up.

A 2019 cost analysis published in Nutrition & Dietetics compared a low-carbohydrate dietary pattern with the New Zealand government’s recommended guidelines (which are almost identical to those in the United States) and found that it cost only an extra $1.27 in US dollars per person per day. One explanation is that protein and fat are more satiating than carbohydrates, so people who mostly consume these macronutrients often cut back on snacks like packaged chips, crackers, and even fruits. Also, those on a ketogenic diet usually cut down on medications, so the additional $1.27 daily is likely offset by reduced spending at the pharmacy.

It’s not just Bronx residents with low socioeconomic status (SES) who adapt well to low-carbohydrate diets. Among Alabama state employees with diabetes enrolled in a low-carbohydrate dietary program provided by a company called Virta, the low SES population had the best outcomes. Virta also published survey data in 2023 showing that participants in a program with the Veteran’s Administration did not find additional costs to be an obstacle to dietary adherence. In fact, some participants saw cost reductions due to decreased spending on processed snacks and fast foods.

Ms. Cruz told me she struggles financially, yet she’s still lost nearly 30 pounds in 5 months, and her A1c went from 7.1% down to 5.9%, putting her diabetes into remission. Equally motivating for her are the improvements she’s seen in other hormonal issues. Since childhood, she’s had acanthosis, a condition that causes the skin to darken in velvety patches, and more recently, she developed severe hirsutism to the point of growing sideburns. “I had tried going vegan and fasting, but these just weren’t sustainable for me, and I was so overwhelmed with counting calories all the time.” Now, on a low-carbohydrate diet, which doesn’t require calorie counting, she’s finally seeing both these conditions improve significantly.

When I last checked in with Ms. Cruz, she said she had “kind of ghosted” Dr. Glandt due to her work and school constraints, but she hadn’t abandoned the diet. She appreciated, too, that Dr. Glandt had not given up on her and kept calling and messaging. “She’s not at all like a typical doctor who would just tell me to lose weight and shake their head at me,” Ms. Cruz said. 

Because Dr. Glandt’s approach is time-intensive and high-touch, it might seem impractical to scale up, but Dr. Glandt’s app uses artificial intelligence to help with communications thus allowing her, with help from part-time health coaches, to care for patients. 

This early success in one of the United States’ poorest and sickest neighborhoods should give us hope that type 2 diabetes need not to be a progressive irreversible disease, even among the disadvantaged. 

OwnaHealth’s track record, along with that of Virta and other similar low-carbohydrate medical practices also give hope to the food-is-medicine idea. Diabetes can go into remission, and people can be healed, provided that health practitioners prescribe the right foods. And in truth, it’s not a diet. It’s a way of eating that must be maintained. The sustainability of low-carbohydrate diets has been a point of contention, but the Virta trial, with 38% of patients sustaining remission at 2 years, showed that it’s possible. (OwnaHealth, for its part, offers long-term maintenance plans to help patients stay very low-carb permanently.) 

Given the tremendous costs and health burden of diabetes, this approach should no doubt be the first line of treatment for doctors and the ADA. The past two decades of clinical trial research have demonstrated that remission of type 2 diabetes is possible through diet alone. It turns out that for metabolic diseases, only certain foods are truly medicine. 
 

Tools and Tips for Clinicians: 

• Free two-page keto starter’s guide by OwnaHealth; Dr. Glandt uses this guide with her patients.
• Illustrated low-carb guides by dietdoctor.com
• Free low-carbohydrate starter guide by the Michigan Collaborative for Type 2 Diabetes
• Low-Carb for Any Budget, a free digital booklet by Mark Cucuzzella, MD, and Kristie Sullivan, PhD
• Recipe and meal ideas from Ruled.me, Keto-Mojo.com, and 

Dr. Teicholz is the founder of Nutrition Coalition, an independent nonprofit dedicated to ensuring that US dietary guidelines align with current science. She disclosed receiving book royalties from The Big Fat Surprise, and received honorarium not exceeding $2000 for speeches from various sources.

A version of this article appeared on Medscape.com.