Dr. Jay Shubrook
There is something eerily familiar about Athens, Ohio, even if you
grew up in New York City. It’s the accessible beauty of Appalachia,
which surrounds the town — the gentle hills, the long, flat fields, the
meandering brooks and neat, smallish farms.
It’s something more nefarious as well: the profound rural poverty
vivid in the mini-malls and convenience stores on the outskirts of town.
It’s the curse of plenty — the deal with the devil that this area made
long ago with large mining corporations and fast-food chains. And it’s
the number of overweight and obese people of all ages in stores and on
the streets. People in Athens are pleasant and helpful, but they seem
exhausted and desperate, both from generations of poverty and hard
physical labor on farms and in mines, but also from the hard work of
moving with extra weight. The self seems buried, like a trapped animal,
in the body.
The data is mind-numbing: two-thirds of all Americans are overweight
or obese, putting them at increased risk for diabetes. Many of us
already have the disease and don’t know it. It’s an epidemic: according
to the Centers for Disease Control and Prevention, in 2010, one in 10
Americans had type 2 diabetes. And roughly one in every 10 health-care
dollars is spent on diabetes every year.
Today, if you’re diagnosed with type 2 diabetes — the most common
form — your treatment would likely go like this: Your doctor would tell
you to change your lifestyle, exercise more, lose weight, eat more
fruits and vegetables. You’d be given a device to check your
blood-glucose levels, and you’d be told to come back in a couple of
months. After an average of two years of checking your glucose levels,
you’d be put on metformin, the most common medicine for type 2
diabetics. Then the disheartening process of “stacking meds” would
start. In addition to
metformin,
which lowers blood sugar by reducing the amount of sugar produced by
the liver and helps the body better use its own insulin, you’d be put on
sulfonylureas, drugs that stimulate the pancreas to release additional
insulin. As this combination became ineffective, you would be put on any
of nine other classes of drugs, an average of one additional med every
two years. At the end of 10 years, you’d finally be shown how to inject
insulin several times a day to lower your blood sugar. If you’re like
most patients, this is when you’d feel like a failure. And you’d have
spent 10 years thinking you were the victim of a disease.
But Athens resident
Jay Shubrook, an associate professor of family medicine and director of clinical research at Ohio University
Heritage College of Osteopathic Medicine, is developing another story.
• • • • • • • • • • • • • • •
When Shubrook goes to the grocery store, people stop him in the
aisles to ask questions, or often to just say thank you. Although his
two teenage daughters have come to dread these trips (a run to the store
is never quick), he doesn’t mind: the encounters mean his patients
trust him. And trust is critical for doctors working with patients who
have a chronic disease, because success depends on the patients’ ability
to manage their own health.
That ability is particularly important to Shubrook, because the
multipronged approach he’s taking in his research on diabetes is
revolutionary. He refuses to treat his patients as passive victims. He
asks them to fight — to take certain risks, and face deep fears. And he
is turning the practice of stacking meds upside down.
• • • • • • • • • • • • • • •
In 1991, fresh out of the University of California,
Santa
Cruz, with an undergraduate degree in psychobiology, Jay Shubrook got
on his bike and pedaled to Appalachia and Ohio University’s medical
school. Shubrook can seem Zelig-like. With his blond hair, boyish face,
and freckles, he’d fit right in on the beaches of Southern California.
His succinct delivery wouldn’t be out of place in a fast-paced city. But
he chose small-town Athens because Ohio University had an osteopathic
medical school where the students were trained to look at the whole
person rather than the specific problem or disease.
When he was a fourth-year medical student, Shubrook did an
endocrinology rotation with Frank Schwartz, a doctor in private practice
in nearby West Virginia. It was a pivotal meeting for Shubrook:
Schwartz had spent almost two decades helping people with diabetes. “I
loved my time with him,” Shubrook says. So much so that, in 1998, as a
resident, Shubrook requested another rotation with Schwartz.
At the time, many people saw diabetes as a hopeless death sentence.
“When I was in school, and even after, the more chronic the disease was,
the less sexy — precisely because there is no magic pill,” Shubrook
says. “My predecessors were fascinated with medicines. No one wanted to
work on diabetes.”
Type 1 diabetes, an autoimmune disease that accounts for 5 to 10
percent of all cases, is diagnosed most often in children and teenagers.
In this form of the disease, the immune system mistakenly attacks the
beta cells in the pancreas that produce the insulin needed to maintain
normal blood sugar, effectively shutting down insulin production. But 90
to 95 percent of all diabetes diagnoses are type 2 — the kind that can
be brought on by obesity. People with type 2 can produce insulin, but
their cells don’t recognize it, so blood sugar isn’t metabolized
properly and rises and falls to dangerous levels.
Dr. Frank Schwartz in his lab at Ohio University in Athens. (John Sattler/Ohio University)
In reality, Shubrook explains, there are more than just two types of
diabetes; there are many types — and many misconceptions about them. A
lot of people think only adults get type 2 diabetes and only kids get
type 1. And a lot of people think you can treat all kinds of diabetes
the same way. “I have had some families think they can cure their child
who has type 1 diabetes with diet and exercise,” Shubrook says, “and
this is just not the case.”
Type 2 diabetes rates have increased for all ages in this country,
and among people in their 30s, it has risen by 70 percent in just the
past 10 years. That has meant increases in the ghastly problems that can
accompany diabetes: dental disease, kidney disease, nervous-system
disorders, blindness, limb amputation, heart disease, and strokes.
Because of the nation’s high obesity rates, type 2 diabetes — once only
seen in adults — has become a common diagnosis in teenagers. In Ohio,
more than 10 percent of the population has diabetes, and in Appalachian
Ohio, that rate can be twice as high as in other regions of the state.
• • • • • • • • • • • • • • •
In 2003, Schwartz was asked by Ohio University to start a diabetes
center — which gave him an opportunity to return to diabetes research.
Looking to develop a diabetes practice that focused on health and
prevention, Shubrook and Schwartz opened the
Appalachian Rural Health Institute Diabetes/Endocrine Center.
Since then, Shubrook, Schwartz, and the teams they hired have been
transforming diabetes care in Appalachian Ohio. With nearly $1.3 million
in funding from the National Institutes of Health, they partnered with
Mary de Groot, of the
Diabetes Translational Research Center at Indiana University, to start
Program ACTIVE, which combines talk therapy and exercise for patients with type 2. The team also opened
Athens’s Diabetes Free Clinic
for people without insurance. And Shubrook launched programs for
health-care workers and educators, and for obese children and their
parents.
Schwartz and Shubrook also pursued new research. In 2004, Schwartz
and a team of computer engineers, biologists, endocrinologists, and
others began working on, among other things, artificial-intelligence
software and smartphone applications that will automatically detect
blood-glucose problems and recommend solutions. In 2009, Schwartz and a
team of researchers received nearly $900,000 to develop a natural
compound called
phenylmethimazole (C10), which blocks proteins that can trigger abnormal cell responses and that play a role in a number of diseases.
Their work has won some 30 awards in the past decade. “Frank is the
gas, and I am the brakes,” Shubrook says. Shubrook’s energy never seems
to lag, so this statement seemed questionable. But then I spent a day
following Schwartz: a 6 a.m. lecture, followed by a seminar, followed by
a development meeting, followed by a lab meeting where Schwartz, who’d
had only one cup of coffee, quietly directed scientists, facilitators,
and students.
• • • • • • • • • • • • • • •
All the while, Shubrook was well aware that patients were frustrated
with the stacking of meds and how long lifestyle changes can take to
have an effect. “We were always a step behind,” he says. “We were
chasing the disease. The burden on patients was significant.”
Diabetes doctors sometimes see patients with such high levels of
glucose, or hyperglycemia, that the treatment has to be aggressive,
which means insulin is the only option. “We had these people who were
really hyperglycemic, so we knew meds would not work quickly enough,”
says Shubrook. “We put them on insulin first. We knew it wouldn’t harm
them.”
How the Artificial Pancreas Eases Diabetes Therapy
A handful of researchers in America and Europe aim to change type 1
diabetes treatment with a simple-sounding solution: an artificial
pancreas.
(Click the image to read the story.)
Shubrook wondered whether using insulin first would also work in
patients who weren’t severely hyperglycemic. “That made a lot of people
nervous,” he says. “I was told, ‘You can’t do that, because
[blood-glucose levels] will drop too low,’ ” making the patient
hypoglycemic, the opposite of hyperglycemic. Other doctors and
researchers saw it as a shockingly aggressive approach. Shubrook almost
didn’t get funding for his Insulin First study, because funders thought
he’d never find participants who were willing to try first what had long
been a last resort. But Shubrook understood his patients in this corner
of Appalachia; he knew they were ready to try something, anything,
different.
In 2006, Shubrook began a series of trials with a group of patients
who’d been newly diagnosed with type 2. Instead of 10 years to build up
to insulin, they were taught to give themselves four shots a day almost
immediately.
The results were undeniable. In six to eight weeks, the patients’
blood-sugar levels started to normalize. Shubrook and his team then,
with close monitoring, started to withdraw the insulin. In three to four
months, the patients no longer needed the injections to regulate their
blood sugar. And many were able to stay off all medicines for up to
three or more years. Shubrook asked people to work at maintaining a
balanced diet and as much exercise as they could do, but, “We did not
ask them to do any more than we ask of all our patients,” he explains.
“I love taking people off medicine,” Shubrook says. When blood sugar
gets high, he adds, it’s toxic to the pancreas; using insulin to get rid
of that toxicity allows the pancreas to work again. “In the old way of
thinking, it was just a matter of time before the toxicity would return.
We believe that a pulse of 12 to 16 weeks of complete insulin
replacement allows the pancreas to rest and recover. We see dramatic
drops in glucose in the first few weeks.” He adds, “What is surprising
is we tell patients that this may not last, and, at some point, we will
likely need to treat them with some medications. But all of them have
said they would prefer insulin if they need treatment. They like the
lack of side effects and the control it gives them, and they prefer the
notion of a ‘booster’ treatment.” Even if patients have to come in for
insulin treatment every three to four years, he says, that’s still
better than the slow stacking of increasingly ineffective meds.
Today, Shubrook is nearing the end of his second trial, with 30 type
2 patients who were randomly chosen to receive either the standard care
or a course of insulin replacement. Shubrook can’t release the full
results until the summer of 2013, but he says that, so far, the rate of
hypoglycemia, the dropping of glucose levels feared by doctors and
funders, has been extremely low among the patients given insulin.
“We have learned that it is safe and effective to start with
insulin,” he says. “We do not see increased rates of hypoglycemia, and
we do not see the weight gain typically seen when insulin is used as a
last treatment.”
What surprised Shubrook was that several of his other diabetes
patients wanted to join the trial but didn’t want to run the risk of not
getting insulin first by being randomly assigned to a meds-first group.
Those patients are now part of his case-study work on insulin-first
treatment. Their openness to using insulin as a first course of
treatment amazed Shubrook and a lot of other diabetes health workers,
because injecting insulin carries so much social stigma: it’s seen as a
last resort and considered tantamount to an admission of failure.
“There’s always been a lot of fatalism in diabetes patients,”
Shubrook says. “A kind of ‘it’s just a question of how long you keep
them alive’ mentality. So many of our assumptions, including assumptions
about the role of genes, no longer hold true. Many people assume that
if they start on insulin, they’ll be on it for the rest of their lives.
We don’t believe this is true.”
I got a sense of the shame that can come with diabetes when, as an
experiment, a nurse at Shubrook’s clinic inserted a glucose sensor in my
abdomen so that we could watch my blood-glucose levels for 24 hours.
Keenly aware of the extra 10 pounds I was carrying, I kept a food and
activity journal to see how I reacted to meals, exercise, and sleep. A
glass of red wine caused a vivid spike on the graph that night, followed
by a spike in the morning after coffee and a muffin. Normal, randomly
taken blood-sugar levels range from around 70 to 145. My cup of coffee
brought my blood sugar up to a whopping 170. Then Shubrook showed me how
to inject myself (though not with insulin). The shot was painless, but
there was a certain shame in grabbing the fat and puncturing it. I felt
acutely aware of all the excesses in my life. I felt that I had
abandoned my body, my health, for childish appetites and a lifestyle
that wasn’t of my own design. I could imagine how closely depression and
self-hatred might shadow this disease.
• • • • • • • • • • • • • • •
Shubrook is “one of those oddballs that crosses disciplines,” says
Darlene Berryman,
associate professor of food and nutrition at Ohio University. “In just
five years, he has brought these two cultures together.” She adds, “From
a cultural perspective, it’s considered OK to be overweight here.
There’s a real distrust of doctors. Jay is able to cross that barrier.
He connects with the people in this community.”
On a crisp fall day, the Diabetes Center Clinic is in full swing by
7:30 a.m. Shubrook, who’s already been for a long run, has an
appointment with the first patient in his second trial: Laura, a student
who has type 2 diabetes. Laura went through the typical frustrating
rounds with medication: she’d start on a new drug, but inevitably her
blood sugar would go up again. “I felt like a failure,” she says.
Shubrook put her on insulin, and her blood sugar stabilized. She’s now
coming off the insulin trial, and Shubrook has put her on a brief fast.
“Here, more than anywhere else, it’s not a blame game,” she says. “On
the insulin, I felt energized, relaxed, and more able to focus. I ate
better, exercised more because walking was easier, and I lost weight.”
Robert, another of Shubrook’s patients (a case-study patient), was
put on insulin more than three years ago. Robert is a slurry technician
in a brickyard, where a workday can include moving tons of shale
manually. “Jay is an unusual doctor,” he says. “Old school. He doesn’t
use big medical terms. He listens to me, and I can talk to him.” After
six weeks of insulin shots, Robert says, he was sleeping better and had
more energy. “We’re not calling it a cure,” he says. “We’re giving my
pancreas a rest and calling it remission.”
• • • • • • • • • • • • • • •
More-aggressive interventions at early stages of type 2 diabetes have
gained in popularity, but Shubrook’s trials will need to be repeated
and expanded before the use of insulin as a first response could be
widely adopted. Finding better treatments is critical. Since Shubrook
started studying diabetes, the number of people with the disease has
only risen. The CDC predicts that by 2050, one in three Americans will
develop diabetes if current trends continue. The rates probably will be
higher in minority populations and in underserved areas such as
Appalachia.
“We have our work cut out for us,” Shubrook says. “People have free
will,” he adds, then shrugs. It’s an unusual gesture for such an
impassioned man. “It’s not my disease. I give them information. I can’t
do it all for them.”
Yet he’s committed to giving patients as much information as he can and to showing them how much they can do for themselves.
Shubrook and Schwartz dream of building a wellness center like the
Joslin Diabetes Center in Boston or the
International Diabetes Center
in Minnesota. But they think their incarnation would be better. It
would be a one-stop shop for people with diabetes. Patients would come
in for several-hour appointments and leave with a medical strategy and a
plan for changing their lifestyle. The clinic would be a place to
exercise, read, learn to cook, undergo supervised physical activity in a
gym. And there would be a restaurant with healthy choices and
carbohydrate counts on the menu. There would be laboratories where
researchers could do cutting-edge work, such as stem-cell research.
There would be fellowships for visiting nurses and doctors. As Shubrook
sums it up: “What if you came to the hospital four times a year to get
well?”
This article appeared in the May-June issue of Pacific Standard
under the title “Reversing the Course.”
