[0:00] - Welcome, my name's Dr. Warrick Bishop. I'm a cardiologist, I'm an author, [0:04] and [0:05] a keynote speaker. [0:06] I'm CEO of the Healthy Heart Network. I'm all about trying to help people [0:12] Live as well as possible. [0:13] for as long as possible. [0:15] Heart disease is huge in Australia. [0:18] Every 20 minutes someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. [0:26] This podcast is all about helping you understand [0:29] blood pressure, weight, cholesterol, [0:32] for better health. [0:33] If you enjoy this podcast, I would be honored for a five-star review. You can share it with your family and friends. It may well save you. [0:41] Someone you love. [0:43] Hi, it's Dr. Warrick here and welcome to my podcast and videocast station. Really appreciate you tuning in as always. [0:52] Today I'd like to talk about diabetes. Now, I haven't spoken about diabetes a whole lot. [0:59] Of course, I talk about cardiovascular disease, and we know that diabetes is a significant risk factor. I talk about lifestyle, diabetes, [1:08] well-being, diabetes, and weight gain is closely linked to that. I've talked about some of the weight loss drugs, and I'll touch on those today, and they're all linked. What we're sort of seeing is this concept of cardiometabolic disease, which is, well, [1:23] The impact of... [1:26] Heart disease... [1:27] renal disease, [1:29] and diabetes all coming together, even with some impact on the brain. So we're talking different ways. [1:38] overlying processes if you like. I thought I'd take the opportunity to speak about diabetes, even though I'm not a diabetologist, but I am interested in it and have been interested particularly in insulin resistance for years. So for those watching this on YouTube, [1:59] or on a video. I'm going to share screen for those listening. You can just listen. So let's talk about diabetes. [2:07] What it is... [2:08] why it matters, and what you might be able to do about it. [2:13] Essentially diabetes is [2:17] failure of adequate control of blood sugar. It was first diagnosed by sugar in the urine. And that was because there was too much [2:28] sugar within the blood spilling into the kidneys, if you like, and therefore being lost in the urine. The body doesn't normally do that. And there's two main reasons that you might end up with too much sugar. [2:42] in the bloodstream. [2:44] One of them is that you have too little insulin [2:49] to help regulate the sugar in the bloodstream [2:53] Or the other reason could be that you've got a poor response to insulin. So the insulin isn't lowering blood sugar levels as it often will do. [3:04] So, same outcome really, or two different ways to the same outcome, which was insulin failure. [3:11] Yeah. [3:12] Insulin is a really important hormone because it moves... [3:16] glucose, sugar into the cells, and this is part of energy storage and energy use. [3:26] You will have heard of different types of diabetes. There's a number of different types. I'm going to keep it really simple because there's a couple of extra ones which are complex and are beyond the scope of this presentation. But there's type 1 diabetes you will have heard of. [3:39] type 2 diabetes and pre-diabetes. [3:45] Let's talk about type 1 first. [3:48] This is considered an autoimmune disease. That means that the body is attacking itself. It tends to lead to destruction of the cells that produce insulin within the pancreas. Now, this is a condition that affects teenagers. [4:04] Most commonly. We may well know someone who's been affected by this. These individuals will present with several weeks of... [4:15] perhaps even longer of poor health, they will have lost significant weight, they will be dehydrated, and their sugars will be up through the roof because their body is not producing any insulin. [4:28] They don't put juice insulin. But these people are... [4:32] managed. [4:34] treated beautifully by the replacement of exogenous insulin. So by injecting these individuals with [4:43] using a needle to give them insulin, that blood sugar can be controlled. And these people can be managed incredibly well. And as you're probably aware, there's all sorts of clever mechanisms to improve the way we control those sugars for those individuals with things like continuous monitoring devices that can be applied to the skin and sense the blood sugar level to help those individuals [5:13] levels and what they might be eating. [5:17] Type 2 diabetes is a different beast. Remember we said the blood sugar level can rise, the blood sugar level can go up. In one circumstance, the blood sugar level can go up if there's not enough insulin. [5:34] In the other situation, which is type 2 diabetes, there can be enough insulin, but it's not working on the cells properly. We call this insulin resistance. This has a really strong genetic link, and it's strongly linked to lifestyle as well, and aging. This is the type of diabetes we see in people as they get older and as they put on weight. So we're... [5:58] We've got two different types of people in our mind if you're thinking type 1, [6:03] teenagers losing weight, presenting very sick. Type 2 creeps up on people, generally overweight and older. So quite different things. [6:13] conditions if you like one related to complete lack of insulin or very little or low levels of insulin that's type one and the other related to insulin or working properly that's type two. [6:27] Prediabetes is really linked to type 2, and it's the stages before the sugar levels hit levels that we consider clinically important. [6:38] needed to make the diagnosis of diabetes. [6:42] Well... [6:43] Why does diabetes matter? It can, because of the raised sugar levels and the associated molecules with that, end up causing chronic damage over time to multiple organ systems. And really importantly, particularly for the type 2s, it can be silent for a long time, so people may not be aware. So it's really important. [7:06] That's got a huge disease burden, and particularly on that older age group where it can creep up on people. [7:13] We know it's really closely linked to cardiovascular disease, heart attack, stroke. It accelerates atherosclerosis and often because it's associated with high blood pressure. Sorry, often because it's associated with increased weight, it'll be associated with high blood pressure. It'll also be associated with adverse profiles of the cholesterol components or lipid components or fats within the blood. [7:38] We also know it seems to have a real impact on the brain with increased risk of dementia and the associated cognitive decline. [7:47] You really don't want too much sugar floating around. [7:51] in the bloodstream as it does have an impact. [7:56] The other organs involved are the eyes, and you will have heard of diabetic retinopathy. You will have heard of diabetic peripheral nephropathy, and you will have heard of diabetic kidney disease. All these are huge organs. [8:09] morbidities that [8:11] Go hand in hand with diabetes and so the importance of managing sugar and avoiding it. [8:16] in the first place. [8:18] Thank you. [8:19] The big problem is, to my mind, insulin resistance and [8:24] To identify this early is, I think, incredibly important, because once we're waiting for the sugar levels to climb up, we've already missed a lot of the opportunity of trying to reverse that insulin resistance. So I tend to test for this and look for it regularly. Fasting glucose alone often won't tell you exactly what that insulin resistance is. [8:49] is a marker of the hemoglobin affected by sugar levels. It gives us an idea of what someone's sugar does over a long period of time, several months. My personal habit is to... [9:03] for people who are not diabetic, who I'm suspicious may be at risk, is to undertake a fasting insulin level [9:09] combine that with the glucose level, fasting, and put that into an equation called an HOMA, or a homeostatic metabolic assessment. Homeostatic metabolic assessment, no wonder they call it a HOMA. Now that calculation actually gives us a nice idea as to whether that individual is using a lot of insulin, [9:33] to control their sugar levels or not. And it can be a really helpful marker [9:38] to flag for people if they could be at risk of insulin resistance, progressing to diabetes. I use it regularly, and it's a really good reminder for those individuals to think about reducing the sugar exposure to their body so they're not needing as much insulin. And the way to do that would be by reduction of carbohydrate and exercise. So simple things like reducing carbohydrates, exercise, [10:05] regular exercise, [10:08] and weight loss will all improve insulin resistance. [10:12] Whole foods are really important. Refined foods are obviously a problem. But it's really important that you understand that even what we sometimes think that could be a healthy food, like a healthy grainy bread, [10:26] We may eat that as a loaf of bread, but our teeth, our gullet, the acid in our stomach, all the enzymes in our body break that bread down to its basic constituents. And at the end of the day, flour is a carbohydrate. So the body doesn't... [10:46] necessarily [10:48] absorb bread as bread. It absorbs it as its building blocks. So you've got to really be aware and it [10:55] And it's... [10:56] often the case that I find patients who are wanting to improve their lot when it comes to [11:03] reduction of their insulin sensitivity, but they haven't got rid of the carbohydrates out of their diet because many creep in. [11:14] I alluded to weight loss. It's incredibly important. And one of the other things that's part of the impact [11:22] strategy to help people in this situation is to make sure that stress and sleep are well catered for. We know if people don't sleep well, that that can impact their cortisol and cortisol impacts glucose metabolism. So rising cortisol levels will drag the glucose up as well. And poor sleep actually also leads to poor decisions when it comes to food selection. There are a number of [11:52] Platform is an oldie, but a goodie. It's still around, but some of the newer agents, the GLP-1As, and you might know. [12:02] the GLP-1As as the weight loss medications. These are the Zampic, Wegovi type medications, and they are working incredibly well. [12:12] There's also a group of drugs called sodium glucose transport inhibitors. Now these sodium glucose transport inhibitors actually work the kidney and they grab [12:24] the pump that has an impact on [12:30] holding glucose in the urine if urine [12:35] contains sugar. Because if we're thinking about our evolutionary past, we didn't want to lose calories through the urine. We wanted to hold on to calories. So our body has mechanisms to hold on to sugar if it detects it in the urine. Now, we talked about [12:54] Thank you. [12:55] sugar in the blood spilling over to sugar in the urine. [12:59] Well, the SGLT2 inhibitors actually block [13:05] the [13:07] pumps that would reabsorb that sugar. And so by doing that, they allow the sugar to pass out in the urine, lowering sugar levels and taking a little bit of fluid with them. So there are some amazing medications. I won't dive into those, but we do have some great stuff. We know that the GLP-1As and SGLT-2s, [13:28] have not only, oh, and met Foreman, have not only had benefit in controlling [13:33] the level of sugar within the bloodstream, but we also know they have [13:38] an impact on outcomes, which is really important. So things like improvements in risk of cardiovascular disease, improvements in risk of renal disease. So really interesting, not only are they having [13:56] sugar control benefit, they're having prognostic benefit. [14:00] The really big picture though is that this metabolic health process, this concept of insulin resistance is long term and it develops over years. What's the call to action? What am I going to ask you to do? Check your numbers. If you've got weight around the tummy, then you need to be checking in with your doctor because weight around your tummy specifically [14:24] is [14:26] an indicator of the sort of distribution of adipose tissue or fat tissue that we're likely to see with type 2 diabetes. It is much easier to prevent it than to treat it. I've actually done a YouTube [14:42] clip on this called Redefining Insulin and Carbs, why we should shift the focus from sugar to insulin. I'd love you to check it out if you are interested. [14:54] Well, that's me and... [14:57] diabetes. As always, super grateful that you've taken the time to listen. I really hope I've given you something to think about. If you are carrying some weight around the middle, we can call that a hazardous waste. Go and get checked or start. [15:13] some regular exercise, maybe drop a little bit of weight and reduce your carbohydrates, particularly if you're eating any simple carbohydrates. As a starting point, follow up with your doctor as well. [15:24] And for now, I am going to wish you the very best. I do hope you live as well as possible for as long as possible. [15:31] Thank you once more, take care and bye for now. Did you know that coronary artery disease kills one in four people? So most of us are likely to carry some risk or know someone who does. If you're interested in finding out more about how to evaluate that risk, [15:49] check out www.virtualheartcheck.com.au. It'll give you information about risk, [15:58] And what else can be done to be even more precise?