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Leading endocrinologist awarded Master of ACE
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Yehuda Handelsman, MD, FACP, FACE, FNLA , was honored in May with the 2017 Master of the American College of Endocrinology at the American Association of Clinical Endocrinologists Annual Scientific and Clinical Congress.
The award recognizes a distinguished endocrinologist who is a role model and contributor to the field.
Endocrine Today spoke with Handelsman, who is a member of the Endocrine Today Editorial Board, and medical director and principal investigator of the Metabolic Institute of America in Tarzana, California, about his work in his private practice and the growing field of diabetes technology.
What area of your field most interests you right now , and why?
Handelsman : The field that interests me very much right now is the whole concept of the relationship of obesity, diabetes — therefore, insulin resistance — and cardiometabolic conditions with cardiovascular disease. I did my training and fellowship with George Bray, MD, in the department of diabetes, endocrinology and clinical nutrition at the University of Southern California, and since then it has been clear that it is difficult to separate obesity from type 2 diabetes, and CVD. As time goes by, these types of relationships become more apparent. The obesity rate in the U.S. keeps going up — it’s now near 34% — and it is coupled with the diabetes rate, which is also going up and is over 10%. Just about one-third of people with obesity have diabetes. So, is it all foods? People tend to think of McDonald’s and Kentucky Fried Chicken — the Western diet — as the main reason, but it’s more than that. We must recognize that our technologic advancements, such as smartphones, actually reduce our energy expenditure. This reflects the energy balance of the body. It’s not just energy (food) in, but also energy (metabolic rate) out, and therefore, understanding how the body manages energy is so important. Energy imbalance causes an overabundance of fat. Combined with insulin resistance, too much adipose tissue is what is leading to a lot of CV complications.
What has been the greatest challenge in your career thus far?
Handelsman : For a while, my focus on these areas was working well for my patients and me, within my practice. I am a solo physician and see patients in the office practically every day. I also do clinical research, and my education activities involve conferences nationally and internationally. What has happened in the last few years, parallel to the Affordable Care Act, is the development of mega-groups, where hospitals are buying more and more physician practices and forming large groups and their own networks. For somebody like me, who wants to preserve his independence and style of practice, working for a hospital or a large group is not an option. Hence, all of a sudden, I’m cut away from a lot of the professionals who used to refer me patients. We are now at the point where the current environment may threaten my ability to practice; it’s really a challenge.
There is also a challenge to do the best for my patients. We have such wonderful tools today that are based on science, not only on money. We have the ability to control a patient’s diet, to control a patient’s appetite, and to control a patient’s glucose, blood pressure and lipids; we need to do all of this to reduce CV morbidity and mortality and to improve quality of life. For a while I was doing well with my patients. They used to be able to get everything they needed, but in the past 5 to 7 years, there are more restrictions on their ability to get the needed medications we prescribe, to get the exposure to essential lifestyle modifications, and their ability to choose their preferred physicians, including specialists. All of a sudden, I find that my ability to perform is limited, my function as the good doctor who is the advocate for his patients is extremely curtailed. Instead, I find myself being a manager, a gatekeeper for the formulary of one insurance or another. I went into medicine to communicate face-to-face with patients and not spend my time looking at a computer screen. All of these changes impede on our ability to work. The innumerable number of hours I spend on administrative tasks and not patient care is not why I went into medicine.
What do you think will have the greatest influence on your field in the next 10 years?
Handelsman : If I look specifically at diabetes, I think technology and innovation are going to dominate the field. I always believed that the continuous glucose monitors would change the life of the person with diabetes. Surely, it would be a great advantage for a person with type 1 diabetes because it can predict before they get hypoglycemia. I believe that technology and innovation will make the CGMs far less expensive. I predict that it will be so affordable that people with type 2 diabetes will be able to use it. Once people with type 2 diabetes use it, they could see what meals are doing to their glucose as well as individual foods. Should they eat salad? Are they OK with cheesecake? Is a small piece of chocolate OK? Is pineapple better than a strawberry? And so on.
I believe that with Google and many other innovative companies being in the space, we are going to see those gadgets coming soon to the field. We are going to see management tools, as well as glucose monitoring without needing a needle prick. I predict that glucose meters will be available to the majority of people with diabetes. I think technology like the hybrid closed-loop pump and implantable CGMs will lead to innovations like implantable closed-loop systems. The pumps may be insulin-only pumps, yet multihormone pumps are being explored. If a person with type 1 diabetes could get an implantable closed-loop pump, they would live a near-normal life. All the information will go to the cloud and use Bluetooth and mobile phones. Parents are able to monitor their children while they are apart, which is incredible. There are so many innovations, and that’s going to dominate the field.
What are some of the most exciting advances that you have been a part of?
Handelsman : The most exciting thing is the comprehensive approach to managing diabetes. Our understanding that managing every aspect of diabetes will improve outcomes and reduce morbidity and mortality has been an exciting advancement. One has to start managing glucose early on, typically with combination therapy, and addressing all risk factors beyond glucose, namely, obesity, BP, cholesterol, coagulation and other aspects of metabolism. We need to have a comprehensive approach and utilize combination therapy from the start, instead of treating sequentially, promoting success rather than chasing failure. I’m not the only one who chooses this approach. Leaders like Ralph DeFronzo, MD, have also been promoting combination therapy for years, and the Steno Diabetes Center from Sweden proved the value of comprehensive care.
Based on these concepts, AACE developed its guidelines for the comprehensive management of diabetes. Guidelines may be complicated and confusing to some, but to help clinicians, we developed a simpler algorithm for managing diabetes, which is clinically relevant and is based on safety first then efficacy. Recently, we developed another innovative guideline — addressing lipids to prevent CVD. With that document, we introduced a new “extreme risk” class and described appropriate measures to managing these patients. Being involved in these guidelines and algorithm, shaping the way to managing the high-risk patients with diabetes and, beyond that, as part of the leadership of AACE, has been so rewarding. These concepts resonated very well with physicians and other professionals and are being adopted by many in the U.S. and globally. We went through a terrible 8 years of craziness, when many were telling us that drugs for diabetes are not safe. In fact, a lot of cardiologist said, “Don’t treat their glucose as you will cause harm or even kill them with these drugs.” Luckily, recent trials show not only safety of these drugs, but several of the drugs have shown superiority in reduction of CV morbidity and mortality. This has been very exciting, and we have entered a whole new space, a new era in managing diabetes.
What are your hobbies/interests outside of work?
Handelsman : I love culture and the theater. I like to go to shows and have also been involved in the theater, as a producer and director. I also love museums and art shows. Though I myself am not an artist, unlike my very talented wife, I do love and appreciate art.
My wife and I like traveling and exploring what is unique to places when we get there. We like the beauty of nature and seeing how people live in the different parts of the world. It’s interesting to witness how the people of China are starting to live similarly to the people in the U.S., as strange as it sounds. To understand different cultures, to see the different foods and the architecture, these are all things I enjoy. How does one compare some of the older cities on the East Coast to San Francisco on the West Coast, just in terms of buildings? While traveling, I also seek to see the local art and culture and museums. I love every aspect, whether it’s classical or contemporary.
I also enjoy sports, especially swimming in the ocean. When we travel, we try to go to places near an ocean, where the water is warm, like Hawaii, Florida, Tel Aviv or Barcelona. I can tell you it’s not so great to swim in the cold ocean of California. Additionally, I love to watch and play basketball. And then the greatest form of exercise for me, both for the body and the soul, is dancing. Lastly, I enjoy reading. I love fiction, specifically detective books and espionage, yet I also like historical fiction, especially the ones that incorporate real historical facts in a fictional story. I also read and enjoy many and varied scientific journals in a weird fashion for a clinician. I am also intrigued by basic science articles, all of which allow me to be aware of new discoveries specifically in the fields that I am most interested in right now. – by Cassie Homer
Disclosure: Handelsman reports receiving research grants, consultant and speaker honoraria from Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, BI-Lilly, Grifols, Eisai, Intarcia, Janssen, Lexicon, Lilly, Merck, Merck-Pfizer, Novo Nordisk, Regeneron and Sanofi.