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Dr. Anne Peters

In June, Dr. Anne Peters received what many would term the most prestigious award for a clinical endocrinologist – the ADA Outstanding Physician Clinical Award. Dr. Peters certainly deserves the title for her many contributions to the diabetes field. Dr. Peters is impressive as she has worn many impressive hats, including her role as a top researcher in LookAHEAD and the JDRF artificial pancreas study; as an editor and author (she is on the editorial board of Diabetes Care and author of the oft-cited Conquering Diabetes); as a top-ranked physician in the US treating diabetes; as a member of the American Board of Internal Medicine; and as a leader of two well-known diabetes clinics in Beverly Hills and East LA. The latter was begun so Dr. Peters could work with underserved populations - we applaud her efforts to bring good care to the people who most need it.

Kelly Close: Dr. Peters, we really appreciate your taking the time to talk to us. To start off, can you give us a little background about your practice and about your philosophy on medicine?

Anne Peters: About my practice, I started seeing patients in 1989 at my practice in Beverly Hills and in East LA started in 2000. I have a team with a nurse practitioner and a dietician, and we co-manage anybody with diabetes who is referred to us. I have a program in Beverly Hills where I see people who have health insurance. Many of our patients have type 1 diabetes and are on insulin pumps, and we particularly enjoy managing women with type 1 diabetes during their pregnancy. It is a bit like a private practice even though it is administered through USC.

I also run the diabetes program at the Royal Comprehensive Health Center under the direction of the Department of Health Services for the County of LA. It is located in is in East LA, which is one of the poorest parts of town. At first, it was designed as a pilot program to demonstrate that we could provide good care to an underserved population. It turned out to be a success, and the County continued to set up four other locations. We are really trying to unify care throughout the County of Los Angeles for the underserved, and we have worked together with the International Diabetes Center in Minneapolis to write the L.A. County Quick Guide to diabetes care.

Another thing I do is if a drug or technology that I think would be beneficial to patients in our healthcare system comes onto the market, I go to the LA County Department of Health Services Formulary Committee, and I try to get the drug on the formulary. My goal is to provide good care to all people who need it, rich or poor. Of course this is always done with an awareness of cost—with limited budgets decisions need to be made as to costs and benefits. However, the County has made a commitment to quality, which is important. We have the largest number of uninsured people with type 2 diabetes in the United States and therefore they stand the most to benefit from enhanced care. I try to advocate for patients in the County, and I have been encouraged by the County's willingness to try and improve life for patients with diabetes.

Kelly: What did you do when you found out you had been named the ADA Physician of the Year? What do you hope the ADA can help do in the next year during your tenure as Physician of the Year?

Dr. Peters: I think the award is not so much "of the year" but rather a broader acknowledgement of work over time. The official title is "ADA Outstanding Physician Clinician Award." I found out I won through Dr. Irl Hirsch. I had received a message that said "Call Dr. Hirsch as soon as possible!," and I immediately flashed back to being in school and getting into trouble (not that I did get in trouble, but I worried a lot). I realized that since I had not seen Irl in months and had not made any recent major blunders that he was not likely to call urgently with bad news but maybe with good news. It made me truly happy to receive this honor, and I just hope I can keep on doing what I've always done and not lose energy or enthusiasm.

On the research front

Melissa Tjota: Could you tell us about some of the research you are involved in? We know you're a technology expert and also an expert on diabetes prevention.

Dr. Peters: Currently, I have an NIH grant as part of the LookAHEAD study, which is studying the effects of lifestyle on the treatment of type 2 diabetes. I also have the JDRF artificial pancreas project through which I am studying the benefits of continuous glucose monitoring in our East LA Clinic. I also have various small projects that are looking at how to improve health patterns in the East LA and South LA communities. I would rather find ways to prevent the disease than treat the disease.

Kelly: Congratulations on the JDRF study – it was great to see it put together so quickly and to be published in NEJM. What do you think are the most important lessons to come out of this study?

Dr. Peters: The JDRF study that was published was the one I am a part of, but I am a sub-study. It turns out that my patient data could not be included because my patients all come from an underserved population where they did not know the basics of carb counting and/or insulin dose adjustments. We had to follow a cross-over design in order to account for the learning that had to occur in all individuals as they entered the study. Our patients also have a varying degree of literacy and could not follow the standard directions for the study. We are still working on our part of the study, and we are hoping to be allowed to continue through this upcoming year to collect data on how we can use this technology in a less sophisticated patient population.

To me, the key points from the recently published study seem to be: 1. Wear the sensor! The best outcomes were seen in patients who wore the sensor constantly. I realize that many patients don't like the hassle of having two sites on their body that is attached to a device, but it is most helpful if patients rely on it for constant input. 2. The teen years are tough for having diabetes (we all knew that). Using the sensor or not did not make a difference in the adolescent group. It would be interesting to work with this age group to figure out what else, in combination with a sensor, could improve their outcomes.

Kelly: Can you comment on the LookAHEAD study as to when we might hear more? What are you expecting to see?

Dr. Peters: LookAHEAD has published the one year outcomes and is starting to look at four year outcomes. The first year data showed that we were able to surpass our weight loss goals and that along with this expected improvements were seen. Improvements happened in patients from all ethnicities, and although quite resource-intense, it is wonderful to see that patients treated for their type 2 diabetes can lose weight and improve their one year outcomes. The real challenge is now to see how this weight loss can be sustained over time and if it translates to reductions in cardiovascular events. As a strong advocate for the benefit of lifestyle modification, (and leading a healthy lifestyle is important whether or not someone has diabetes) I am hoping we can prove its benefits.

Searching for a specialty, helping the underserved

Kelly: Please tell us a little more about how you decided to go into diabetes.

Dr. Peters: First of all, I wanted to be a doctor since the age of five. I loved people and science and thought medicine combined both. I also knew I needed to be a specialist since I am always insecure about not knowing enough. At least as a specialist there is a more limited amount of knowledge to master, compared to a generalist. Second, I knew that I liked long term relationships and wanted to get to know people over time, which meant treating a chronic disease. Third, I was very interested in the mind-body connection because I knew that hormones, or at least what I figured out were hormones when I was ten, had such a significant impact on mood. I thought that endocrinology would be fascinating. Originally, I wanted to do neuroscience and become a researcher, but I did a summer project during my first summer of medical school looking at neurotransmitters, and I realized that in my lifetime I was not going to change anything. By being a practicing physician I am able to help a lot of people with diabetes and get the immediate gratification of an improved A1c level. I want to do something such that at the end of the day I feel like I've made a difference. Lastly, I knew that diabetes was underserved and that it was going to be an epidemic, so why not? To be honest, I also wanted a field of medicine where I did not have to wake up at three in the morning and go do a procedure.

Kelly: You mentioned earlier your practice in East LA. Did you know you wanted to serve underserved populations from the beginning?

Dr. Peters: Ever since I was a little girl, I've always been interested in helping the underserved. It's a long story, but I went to PS 40 in New York City when I was little and they had twin desks where they would sit a good student with one who was doing as well in school. I sat next to a little African-American boy, and my goal in school was to teach him how to read. Unfortunately, he was sick so much that he could never come to school, so I could never teach him to read and that is when I began to realize the effect illness had on education and poverty. At that point, I first decided that I wanted to work in underserved communities. I have always done volunteer work, and I try to give back to people who have less than I do.

Kelly: Did you realize when you first went into diabetes that it was so intellectually interesting?

Dr. Peters: No, I was not very surprised because I was at the University of Chicago, with several leading diabetologists. Dr. Arthur Rubenstein was my advisor and my mentor, and Drs. Ken Polonsky, Jonathan Jaspan and Steve Shoelson were there. For my senior year of medical school I worked in Arthur's lab doing radioimmunoassays and I also went and worked in Africa. I was in the right world for diabetes.

Kelly: That is amazing - thank you so much for giving us all that background – it is especially inspiring for residents and fellows and young doctors and for all those developing new products for people with diabetes.

The downside of being a popular author

Melissa: No doubt! So we were wondering about your book Conquering Diabetes. It seems like you were ahead of the times because you were talking about pre-diabetes long before it became a common concept. How was the process of writing it for you and how has the reception been for it?

Dr. Peters: First of all, I did not want to write the book. I have always meant to write a book, but I wanted to do it when I was done practicing medicine. There was a story about me in the New York Times discussing diabetes prevention, and one of the editors from Penguin contacted me and asked, "This could be a great book. Would you be interested in writing one?" I told her that I was too busy with my patients to think about writing a book, and I declined the offer. Then my husband told me that "Penguin doesn't come calling very often to ask someone to write a book." So, I called them back and agreed to write the book. To be honest, my first instinct was right.

I wanted to write a book that would teach people how to be proactive and empower themselves in their own communities. What the book did was create a nightmare in two ways. One was that it made me too popular, and people wanted me on several television and radio shows. It was a good way to advocate for people with diabetes, but it was not a good way to educate people with diabetes. I definitely believe in using the media to inform the public, but after writing the book, I felt that too much of the focus was on me and not on the cause. The second, much bigger issue, was that it caused an influx of people who tried to see me as though I was a cure. Diabetes is a process, and I can only help people who are able to come to see me and connect with me. I cannot properly take care of people who only communicate with me through e-mails and telephone calls. It made me sad because there were so many desperate people, and I could not say no, so I would ask them to let me help them find someone in their community. I prefer to focus on my immediate work and see my patients be successful, rather than deal with the media world that surrounds publishing a book.

About the feedback, I have gotten a great deal of positive feedback, and it has made me more aware of other great programs available across the country. It has encouraged me to do what I've been trying to do, which is to raise the bar and to improve access to care for everybody.

Reaching out to primary care doctors

Kelly: At ADA this year there was a lot of talk about individualizing therapy, and all of your work has shown the value of that through creating the county guide and teaching other doctors. Can you talk a little bit about the needs there?

Dr. Peters: I love teaching doctors. I want to seek out primary care doctors in each community and educate them on how to do a better job because that is how my skills are going to be best used. LA County was also thinking about a kind of diabetes expert on demand where specialists could talk with practitioners seeing patients on the Internet and provide more readily accessible care. I think there are all sorts of ways to use someone like me better, but it is really through the liaison with primary care that I can make a difference. For instance, Steve Edelman is wonderful, and he does a great job connecting with patients (as well as providers). I think I am pretty good at taking science and translating it to something that can be taught to primary care providers and used to enhance the provision of diabetes treatment.

Kelly: Could you tell us what you think is the most interesting research questions to you now?

Dr. Peters: The first area that I think is very interesting is the attempt to make a partially closed loop system, integrating sensors and pumps and allowing people to have more freedom from making constant insulin dosing decisions. Those of us who frequently deal with pumps and sensors can lead the way in terms of improving technologies and glycemic control in people with type 1 diabetes. In type 2 diabetes, the research that I am the most interested in is from the LookAHEAD study as well as the diabetes program I run in East LA. I know that with the right people, I can significantly improve outcomes in a given patient if they can be seen in our program, but once they graduate, they do not do nearly as well in controlling their glycemic levels.

I would like to integrate some sort of community-based system of peer educators or promotoras and figure out a way to sustain improvements. I believe that sustaining improved outcomes is one of the biggest issues in diabetes care. It is not just about getting someone to a specific target but making sure they keep that target for the next 20 years. The medical system as it stands currently is not going to be able to provide that level of care. That is why using novel approaches to providing long term care and connection could be very helpful, and we have been working on this in my East LA clinic as well as in the South LA population. We know what we need to do, but how to do it in terms of the most effective utilization of is a big challenge. Prevention is also extremely important, but that is an entirely different issue given that so many patients with diagnosed diabetes aren't getting adequate care.

The biggest changes in care

Kelly: On to some big-picture questions! What has changed the most in diabetes in the last five years in your view? What has the biggest potential to change in the next five?

Dr. Peters: The biggest changes for type 2 patients and type 1 patients are different. In the type 2 realm, medications have been the great change in my practice. TZD's have played a large role in helping to maintain beta-cell function over time, and I have seen many patients of TZDs whose disease has not progressed over time, as would be predicted. Byetta has also been an important addition to treating type 2 diabetes. There will be a lot of ongoing interest in new GLP-1-related products such as long acting exenatide and liraglutide as they come on the market. People will also continue looking at novel ways of achieving weight reduction such as through gastric bypass surgery. My caveat with gastric bypass surgery is that we know that it works, but it is not practical on a large population level, and long-term risks and benefits are not known. So, there may be other ways of technology assisted weight reduction, particularly with minimally invasive surgical techniques.

For type 1 diabetes, the technologic improvements have been tremendous. The availability of analog insulins has made treatment much easier, and smarter pumps, especially in combination with sensors, have made achieving and maintaining tight control much more possible in my patients. As I stated above, the idea of developing a partially closed loop system for treating patients with type 1 diabetes would be very beneficial and will hopefully happen within the next few years. In terms of a "cure", however, the biggest changes may occur in the research lab rather than in immediate patient care. We need both a method to replace beta-cells in people with type 1 diabetes and a way to turn off the immune system so that the beta-cells aren't destroyed. The immune system in people with type 1 diabetes mistakenly attacks and kills beta-cells. When islet cell transplants are given, patients have to take immunosuppressive medications that "turn down" the immune system so the new cells aren't destroyed. Obviously there are risks when doing this because the immune system is meant to protect us from sickness and it needs to function as close to normally as possible. Researchers are looking into ways to encapsulate beta-cells, which essentially means putting an inert coating around them so the immune system doesn't destroy them. However, this coating has to allow glucose in and insulin out so that the beta-cells can work normally. We also need a way to make enough beta-cells to give to patients, which is where areas like stem cell research could help. Finally, if someone could figure out how to selectively turn off the antibodies that destroy beta-cells, it is possible that the body could make enough of it's own beta-cells over time to function normally.

I think there will be a lot of advancements in the care of people with diabetes, but people have to remember there is not going to be a magic bullet to fix everything.

Melissa: Is pancreatitis from treatment with Byetta something that patients should be worried about? Has the media been responsible in getting the right news to patients?

Dr. Peters: Providing fair balance on medical news is often tough. Many times key points are missed, and patients panic. It is extremely difficult to know what the long-term risks to medications are because we do not do the sort of follow-up that would provide us such data, and the clinical trials done to bring drugs to market include relatively small numbers of patients. I am not convinced that Byetta causes pancreatitis—the rate of pancreatitis in people with type 2 diabetes are increased and in any drug safety data set, whether for Byetta or the TZD's or Januvia, there are reports of pancreatitis. Does this mean that the drug caused pancreatitis? It is hard to know because we only know the numerator, not the denominator, and therefore cannot calculate a rate. With Byetta, under FOI (freedom of information) I obtained the FDA data on side effects of Byetta and Januvia. Pancreatitis occurred with both drugs, and in most cases there was another cause for the pancreatitis. So I think that the rate of pancreatitis with Byetta may not be much different than baseline rates, but I cannot know that for sure.

My general approach is to tell patients that all drugs have risks and newer drugs may have risks we don't know about. I tell patients to always let me know if they think they are having a reaction to a drug so we can stop it. I also try to use drugs only when necessary and discontinue them if they are not working or are unnecessary. When patients ask me what the worst side effect is to any given drug, I am honest and say "it could kill you," but I go on to explain that the disease the drug is treating is serious and worth the risk. In addition, I encourage all patients to read the patient package inserts so that they know what monitoring they need when on any given drug. Patients can minimize their risk by making sure they don't have any contraindications to the drug and then follow-up routinely for necessary testing.

Kelly: Some experts argue that type 2 diabetes – with its association with lifestyles and its impact on low-income populations – is less of a medical problem than a social problem. If that is true, what can health care providers do to confront the epidemic?

Dr. Peters: Type 2 diabetes is almost always an environmental as well as a genetic problem. In the poor communities where I work, individuals don't have access to healthy food in supermarkets or safe parks for walking. Many run out of food during the month, and I've heard of people selling food stamps to buy even cheaper food to feed their families. If having food at all is a big issue, people may be less likely to buy more expensive, potentially perishable healthy food, especially when cheaper, more filling, but less healthy food is readily available.

Through the Keck Foundation and a number of other grants, we have been working to understand our local environment and help make it healthier. The work I have done has been with Dr. Francine Kaufman and Children's Hospital Los Angeles. The premise of our projects has been that the communities need to be our guide to help them heal. We formed two community advisory boards in East and South LA, and at their suggestion, helped bring in farmer's markets, cooking classes, and grocery store tours to both areas. We are also working with schools to provide healthier meals and to start a high school to elementary school lifestyle mentoring program. These are small steps, but we are learning how to address issues of lifestyle change in underserved communities and will hopefully be able to help others embark on a similar process.

Kelly: What have you seen your Beverly Hills patients respond to the most in terms of diabetes care? East LA patients? How big a difference do resources make for someone with diabetes?

Dr. Peters: Patients respond most to not feeling judged and knowing that they have access to providers who care. In my Beverly Hills practice my patients email me all the time, sometimes daily, if they need me. It helps me help them, and I think it offers some comfort to my patients. In East LA we have care managers, nurses, and nurse practitioners who are available by phone and spend a lot of time talking with the patients and offering support and advice.

To have diabetes and not have access to health care turns a treatable disease into an incurable cancer. The patients I see in East LA have really suffered due to a lack of healthcare. Nearly every patient over the age of 24 already has significant diabetic complications. We have people in their 20's going blind, on dialysis, losing limbs. It is quite discouraging, especially since diabetes is a treatable disease but ONLY if patients have access to care.

Kelly: Thank you so much, and we really appreciate your time and just salute you for everything that you have done and will continue to do to help patients with diabetes.