Madi Cheever - TypeOneTypeFun (00:00.393)
So photo first, let's do.
Sarah Hormachea (00:02.158)
Okay.
Madi Cheever - TypeOneTypeFun (00:05.525)
Perfect. Okay, cool. I'm gonna put my sleeve back down real quick, because otherwise it will bother me full time.
Sarah Hormachea (00:11.47)
It's only fun for certain groups. Like, what world was this fun? if you're in Diabetes Care and Education, right, it's rewarding.
Madi Cheever - TypeOneTypeFun (00:17.287)
I know, I know. Yes, if you get it, can. Yes, I love it. Horma Chaya. Okay, here we go. Ready? Okay. Alrighty, folks, Sarah Horma Chaya is a registered dietitian nutritionist and certified diabetes care and education specialist with advanced board certification in diabetes management. That's a round of applause from me.
She brings more than a decade of experience working across endocrinology, primary care, and diabetes technology. Sarah has contributed to national clinical resources, including recent updates to the American Diabetes Association and the Academy of Nutrition and Dietetics materials on nutrition, weight management, and type 1 diabetes. Her work centers on evidence-based approaches to weight and metabolic health in people living with type 1 diabetes. Sarah.
It is such a privilege to have you. And if it's all right with you, I wanna jump right in. Right, so there's so many awesome things to cover today. So let's start with weight management. I think weight management in type 1 diabetes is often pretty complex and it's uniquely complex. So from a physiologic standpoint, what can weight loss, what can make weight loss more challenging in this population of type 1 diabetes?
Sarah Hormachea (01:17.07)
Yes, yes.
Madi Cheever - TypeOneTypeFun (01:42.057)
compared to the general population or even type 2 diabetes.
Sarah Hormachea (01:46.147)
Yeah, that's a great question. Think oftentimes individuals living with type 1 who would like to lose weight approach it from the same system and the same recommendations as everyone else, people living with type 2, pre-diabetes, and those without any metabolic dysfunction. And the reality is it doesn't always work the same. There's a lot of underlying physiological factors that make
weight management uniquely challenging. We know that in the setting of type one, when beta cells are lost in the pancreas, it affects a lot of other helper hormones, right? We see some really unique changes to things like Inchrotin bodies like GLP-1, GIP. We see changes in the way our body stores fat.
We see changes in the way our body dips into cells for glucose utilization, even shifts in our behavior. When we experience a low blood sugar, we have to eat. There's no way around it. And that is unique from other people who pursue or seek out weight loss in a very calorie deficit driven approach.
So understandings are these unique physiological differences and working with someone who understands that can be the difference between successfully losing weight and maybe feeling that it's a bit of a struggle.
Madi Cheever - TypeOneTypeFun (03:13.673)
Absolutely. And I really appreciate you touching on this because this can feel complex and overwhelming. And I want listeners to know that we are breaking it down, making it make sense. But of course, I'm getting ahead of myself. But there's information in the show notes. If you ever have questions, we will make sure you have resources and connections to Sarah herself. And so actually, speaking of that, I know that you have a list of recommendations for weight management and type one diabetes. Can we run through that list and also for people who are
listening or excuse me watching and rather than just listening we're also going to put these tips on the screen. So Sarah take it away.
Sarah Hormachea (03:51.84)
Yeah, so first and foremost, rather than come at weight management or weight loss with a really aggressive calorie restriction, we want to look more broadly at dietary patterns, right? Really taking a food forward approach. We can look at things like dietary guidelines for Americans, though I know they're changing rapidly and may not always be appropriate in the setting of diabetes, but looking more broadly, right? What is our holistic, more broader approach to nutrition? We do need to
a slight calorie deficit, but it can't be as aggressive, right? As maybe someone looking to lose one, two, even three pounds a week, which is very aggressive. And we especially can't dip really low in carbohydrates. So things like ketogenic eating patterns, while really effective in type two, right? We've seen this through some of the programs like for the health. We have to be very cautious in the setting of type one where insulin often needs to be adjusted in tandem. And some people are
really comfortable making those adjustments and others, it's a dynamic, a back and forth, right, with their care team. So if we cut carbs really significantly and we don't have the medication adjustment to follow, it can really backfire. In looking at the insulin titration, sometimes clinicians will jump in and say, you're having lows, you need to eat more, right? But we want to move away from that recommendation, right? We don't want to eat up to our medication.
rather we want to work with someone or get the support to reduce medication, especially as our weight starts to decrease, right? And we become more sensitive to insulin. So there's a bit of a misconception, right? That insulin resistance is only in the setting of pre-diabetes or type two, but.
insulin resistance can occur in anyone, especially in folks living with type one. So having a good understanding of how that impacts medication needs more broadly can be helpful. And then looking at where changes impact fasting versus post-parendial can be helpful as well. Sometimes we make these recommendations as clinicians around food and fasting. But if we look more
Sarah Hormachea (06:09.295)
Broadly, fasting glucose or overnight glucose really is more impacted by broader factors, Like sleep, stress, and hormones. And so things like eat a bedtime snack.
Well, if someone's trying to lose weight, eating a bedtime snack is maybe not in line or in alignment with that goal. And it can be counterintuitive. So again, looking more broadly at when we're recommending eating for glucose management versus when we shouldn't versus when it comes more from medication management. And then finally, really looking at the cognitive or the behavioral side of weight management. Living with diabetes, I don't have to explain this to you.
It is not the most natural way to think about food, right? And it can lend itself to disordered eating or even eating disorders. So making sure as clinicians, we're keeping an eye on that. And then as people living with diabetes, if the way you think about food is really impacting your quality of life, recognize that that may be at odds with your goal or desire for healthy weight loss.
Madi Cheever - TypeOneTypeFun (07:16.329)
man, you are incredible. This is such a privilege to get to be having this conversation. And there's something that stood out to me that I want to reiterate for anyone who is listening. As a point of safety, I've also worked at, know, I'm a dietician as well. I've worked in weight loss as well. And oftentimes it's what people think of when they think dietician, weight loss, right? And so that's working in type one specifically. If you do find yourself...
on a journey of potential weight loss and you're noticing that sensitivity with your insulin, your blood sugar keeps dipping low. Number one, you're not crazy. That is a real thing. And number two, absolutely having someone who speaks the language and understands help you to feed yourself appropriately and not feed the insulin, right? Feeding the insulin means that we have to eat because we're low, eat because we're low, eat because we're low and make sure we maintain those levels. Finding the balance makes
all of a different. So for safety purposes, just want to make sure everyone has that very clearly understood. If you're on that journey, noticing that pattern, find someone. Okay. So thank you, Sarah. That's so awesome to know and to understand that just a little bit more. And maybe to dive even further, I know that we are seeing higher rates of metabolic syndrome and insulin resistance in adults with type one diabetes.
Do you know why this is happening and how does insulin resistance change the weight management conversation of T1D specifically?
Sarah Hormachea (08:42.571)
Yeah. Part of this is better screening and diagnosis in adults, right? So historical bias would lend itself to the assumption that children develop type 1, adults develop type 2. And we've come a long way in our understanding of how type 1 presents, especially in adulthood. And we now know that well over half of new onset type 1 occurs in adults.
And those adults may already be living with overweight or obesity. They may already be at a weight that's higher than their preferred weight. So they could be coming into a new type 1 diagnosis already having insulin resistance, which can occur when we live in a larger body, at a larger weight. We also know that age-related changes over time can increase our risk.
A big time for women is peri and postmenopause. So as estrogen levels decrease, we see insulin rise, resistance rise, LDL cholesterol rise, visceral adiposity go up. So certain age-related changes can put us at higher risk. Stress and cortisol, that's a very buzzy word right now, can impact our insulin resistance as well. So some of these same metabolic pathways that are happening to
many adults living in the United States are also impacting people living with type 1. When it comes then to weight management, one of the biggest issues we run into is that there are not as many tools available for people living with type 1. So when we look at, for example, medication treatments, like Metformin, it's not indicated in type 1. Or we look at GLP-1, GIP therapy. Again, anything for type 1 is used off label.
We used to have, and we still do though, not widely prescribed, an amylin replacement that was used, you would take it right before you eat and it would help with delayed absorption, post-prandial excursions, though not really used in weight management. It's not used very much anymore. I haven't seen it in a long time. So from a therapy and a toolbox standpoint, there's just not as much out there to assist and help.
Sarah Hormachea (11:00.405)
like there is with pre-diabetes or type two. So that makes that complex. And then again, really understanding how autoimmune disorders affect other helper hormones, right? Things like glucagon. So people living with type one, they don't make as much glucagon. So we think, okay, you don't make as much insulin. So there's your gas. Now you don't make as much glucagon. There's your break. So what's left to drive your metabolic car?
it not not as much right you're lurking with fewer tools which just again makes the process a little more complex.
Madi Cheever - TypeOneTypeFun (11:36.415)
Absolutely. That's a great analogy, by the way. I appreciate you putting it into that perspective because that makes a lot of sense to me.
Madi Cheever - TypeOneTypeFun (11:46.294)
So, okay, so another thought, another question. Historically, it seems like there's been quite a bit of clinical bias surrounding people with type 1 diabetes and more specifically what we're expected to look like. I know for me personally, sometimes I tell people I have type 1 diabetes and they immediately say, but you're not fat. Whoa, and I know that's just the general population. I know the clinical setting can be different, but.
Do you have a perspective or an opinion on how that bias has influenced care, especially surrounding weight concerns, and maybe what are the consequences to patients or those of us with T1D?
Sarah Hormachea (12:26.604)
Yeah, I think we can see it on both sides of the spectrum, right? So someone might be less likely to be screened for type 1 because they are presenting at a higher weight. So someone might come in, they have a high A1c, they don't feel well. They have all the signs of what might point to type 1, but because they're living in a larger body, we might say, oh no, no, it's type 2, here's Betformin.
come back in six months, we'll do another A1C. Well, if you live with type, you know, if you're newly diagnosed with type one, you might need insulin right away. So coming back in six months could be quite dangerous. On the flip side, if someone comes in or presents with type one, we're not often recommending weight loss because we're not associating their weight with being a driver in their disease, right? In their chronic disease.
but only because we're not thinking about how it impacts insulin resistance and other cardio metabolic risk factors, Like blood pressure, cholesterol, et cetera. So I think as we get more exposure, there's more advocacy work being done by organizations like Breakthrough T1D or Beyond Type 1. We're understanding that diabetes is more on a spectrum, right? And people are going to have
clinical presentations that ebb and flow or converge or cross over and that really thinking about all the ways that we screen, monitor, diagnose, whether it's clinical presentation or it's auto antibodies or labs, see peptide, right? Just getting lots and lots of different data points to help us not necessarily classify and quantify people, but just treat their needs independently.
So if you're someone with type one and you need insulin, but you also present with insulin resistance, that we offer you all the tools and guidance available to treat what we're seeing and not how we've classified you.
Madi Cheever - TypeOneTypeFun (14:24.309)
So summary statement maybe is we're all unique and we deserve personalized care.
Sarah Hormachea (14:31.336)
Absolutely, yes. And that's from every part of your care team, from your endocrine provider to your health coach to your family too, right? And understanding like how nuanced diabetes is.
Madi Cheever - TypeOneTypeFun (14:44.169)
Yeah, I appreciate you saying that too. I know I've worked with siblings who have type one or mother daughter, father daughters, and all those dynamics, you know, we're family, right? So theoretically there's some similarities that might be drawn there, but nope, I find time after time, everyone is different. Something is different. One of them goes high when they're sick, one of them goes low when they're sick, whatever it may be, those things.
happens. again, being treated like an individual is extremely important and maybe a point of self advocacy. If you feel like you're being put in a box or you're not being heard or you're not being listened to, maybe that's something where you've got to ask some more questions, maybe explore some options. are a ton of providers out there and there are different pathways that you can take for yourself. for anyone who needs to hear it, some self advocacy for the day.
Something that you said earlier, you're willing to indulge me, I know you mentioned GLP and most people, I think, think of the GLP medications that are currently on the market. And we know there's a growing interest in GLP-1, GLP-1, GAP medications, yet none are FDA approved for type 1 diabetes, right? Okay, so how should clinicians and patients think about
Sarah Hormachea (15:59.532)
Correct.
Madi Cheever - TypeOneTypeFun (16:06.633)
potential off-label use, emerging research, safety, at least at this point in time.
Sarah Hormachea (16:13.738)
Yeah, it's out there. People are using it. They're going to use it whether they're advised on it or not. So I think being open and having good, honest conversations with people, no matter where you sit, of in this provider, person, insurer, healthcare system dynamic, right? Recognizing that people want access to tools and they're not gonna wait. And we saw this...
even with automated insulin delivery systems, right? The we're not waiting movement where people were out there programming their own DIY loop because they said, we're not gonna wait, right? We want this now. And we have practice-based evidence. We don't need to wait for the evidence-based practice to roll out. Some of my go-tos for research or just recommendations on this is a gal named Ginger Vera.
and she's maybe been on your podcast before, but she's a wonderful advocate for incretin therapy use in type one. In clinics that I've worked in, we've had some really creative care providers who have said like, hey, you're presenting with obesity and insulin resistance. You would do well from incretin therapy. You also live with type one. So we're gonna put both things on your problem list and we're gonna send.
Ozempic to your pharmacy under type two and we're going to send insulin to your pharmacy under type one and insurance can just deal with it. So things like that can be done or patients and people can go and pay out of pocket. It's not ideal, but that is an option. So we're just really being open to like what problem are we trying to solve? What are some avenues we can pursue to get there? Really bringing people.
onto your team, doing your research. If you're a person interested in trying this therapy, know, looking up really well known voices in the community. Ginger Brieara is one. Gary Shiner is another who advocate and talk about Ingram use in the setting of type one. But be cautious and be careful and really just make sure you're getting these recommendations and the drugs itself from reputable sources, because I do have concerns about
Sarah Hormachea (18:29.631)
different online avenues of getting these drugs.
Madi Cheever - TypeOneTypeFun (18:34.441)
Yeah, absolutely. And then I think another point of self advocacy, be mindful, be watchful. If this is a path that you go down, watch, what's your blood sugar doing? How are you feeling? Make sure that you're paying attention. And if you're noticing things, bringing them up to whoever your provider is talking about them. That's how we figure out whatever is going on. We can't help unless we know, right? So I appreciate you giving us a little bit of context on the world of GLP and
If you're willing to go even further, I'd love to talk a little bit about GLP-1 microdosing. Would you be okay with that? Okay, so basic questions maybe is like, how and why is it being used in type one? How do we determine patients or individuals who might be good or appropriate candidates for microdosing? What safety monitoring do you recommend? Anything I'm missing, you take it away.
Sarah Hormachea (19:10.196)
Yeah, yeah.
Sarah Hormachea (19:32.011)
Yeah, so with my dietitian cap on, right, I speak more broadly, generally, right, what we might see that's happening out in the community. You know, I don't prescribe and I don't make dosing recommendations, but I can provide insight and guidance based off of what I see in practice, right, and what we know in the package insert and what we've seen from like standards of care. So really microdosing, it's a buzzy term, but it just refers to
either using a prescription at a dose that's subtherapeutic, right? We have sort of these guideline doses where we know, hey, you need to get up to this dose for it to be therapeutically effective. So microdosing might be using something at or below that dose, or it might be using something at a dose that's not even available through the standard one and done pens.
So most of your incretin therapy up until recently, were injectables and a lot of them came in dosing pens, but there were individuals who might use a syringe to draw a much smaller amount. And then when a lot of the, when the pharmaceutical companies launched the medications in vials, that became even easier because just like insulin in a vial, you really can draw up whatever you want or whatever you need.
without worrying too much about the dosing. So this theory behind microdosing, at least in the setting of type one, is drawing like really small or tiny doses for use without necessarily having this really profound weight loss like we would see with someone who's using it primarily for obesity treatment. Now microdosing is also being used in other communities too. We're seeing it sort of in the athletic performance and aesthetic.
weight management group, we're seeing it in things like menopause treatment and just chronic inflammation. I can't speak as well to those, but at least in the type one community, using smaller therapeutic doses, might be, there may be, right, some benefit to weight management, to insulin sensitivity, to reducing your insulin needs, right? We know that the more insulin you have to dose, the more of a gamble it is that it's the right amount.
Sarah Hormachea (21:53.632)
that it might be too much or it might cause a low down the road if you're really active after a meal. So anytime we can reduce our insulin needs is generally safer. And we're seeing some very real world practical use of IncaTen therapy at very small doses just to help with dosing insulin, which thereby helps with weight and weight management.
Madi Cheever - TypeOneTypeFun (22:18.335)
Thank you. feel like that actually, that paints the picture so much more than I even realized. It's so interesting to know. And I always talk about this. It gives me so much hope to know that so many medications, therapies, technology, it's all changing and improving. I think that is, that's where my hope lies when it comes to diabetes. I don't know if a cure is anywhere near, but knowing that things like this exist to support us with our individual needs is just so cool.
Sarah Hormachea (22:46.163)
Yeah, I hope. Fingers crossed.
Madi Cheever - TypeOneTypeFun (22:48.133)
No, can you squat always for sure? And so, okay, so big question, but if you had to simplify, big question, little answer maybe, if you had to simplify for clinicians and for individuals living with type one diabetes, what does safe evidence-based weight management actually look like in practice? And what advice maybe should we stop giving?
Sarah Hormachea (23:15.403)
Yeah, so if you're person and you're living with type one and you're looking to lose weight, to lose body fat, do not jump on the low calorie, low carb bandwagon, right? It often will backfire. So really get yourself linked in with somebody who can support you more holistically. Look at you big picture how your activity, your nutrition, the the
Madi Cheever - TypeOneTypeFun (23:18.611)
Yeah.
Sarah Hormachea (23:41.439)
the progression of your disease, right? Because type one evolves over time. Big picture and how they can support you in achieving weight loss. If you're a clinician, please do not recommend like very calorically restrictive diets for weight loss. Really think of your clients or your patients with type one as having unique weight management challenges. Again, needing a more holistic approach and.
consider how you might integrate GLP-1 therapy, whether you feel safe and comfortable recommending it or at least just discussing it yourself, or maybe you wanna loop the individual in with endocrine or obesity specialists, right? Just be open to it, even though it doesn't quite have an indication.
Many big, large teaching hospitals are already enrolling in clinical trials for GLP-1 use in type 1. So it's just a matter of time before it gets the stamp of approval. We might as well sort of get our brains thinking about it as a tool in the near future.
Madi Cheever - TypeOneTypeFun (24:46.921)
Yeah, that's awesome. And I think again, that goes to the point that everyone is different. Everyone has different needs. Also, everyone has different knowledge bases. So finding someone who feels like they are supporting you in the right kind of ways and the ways that feel comfortable, safe and supportive for you. And if you are that provider, maybe being really honest with yourself. I know that I say this a lot. Type one is my passion and I love it. And I talk about it all day every day and I live with it all day every day.
But type two scares me. And most people are the opposite, in fact. Most people are like, type two diabetes, I'll work with that, I'll talk to it, absolutely, the medication's done it. I'm like, that's overwhelming, I don't get it, I'm type one. So again, knowing yourself and knowing your skills or going out and seeking that further education, the continuing education units, there are so many ways to support your patients as well as you can. So there's my personal plug. with that being said, finding those supportive people,
Of course there will be some information in the show notes, but how can people listening find more info and get in touch with you?
Sarah Hormachea (25:53.898)
Yeah, so if you are someone living with type one or any type of diabetes or any metabolic condition, you can find me on my website. It's sarahkermachea.com. I do a mix of private practice and coaching and counseling. If you are a fellow diabetes care and education specialist or a clinician, I am looped in with the Academy of Nutrition and Dietetics. I help run on
a monthly podcast for a diabetes practice group. And I also serve on the board of directors for the association of diabetes care and education specialists. So you might find me on ADCS Connect or at an annual conference. And if you see me, please come up and introduce yourself and say hi.
Madi Cheever - TypeOneTypeFun (26:39.571)
I love it. And I'm hoping that we get to see each other some point this year. We'll have to connect on some conferences or travel things. But at least for now, this was a jam packed episode and I hope everyone listening benefited. And I know I did and I appreciate you for taking the time to be here with me. So thank you a million times over for all this awesome information. And with that, I hope that everyone has a wonderful week, a wonderful month, a wonderful year, wherever we're at in the year.
and we'll see you next time.
Sarah Hormachea (27:11.188)
Thanks for having me.
