Three ways to prevent diabetes | Professor Naveed Sattar

Certainly the biggest myth my patients often hear when I tell them that they may have type two or be at risk is that they don't eat a lot of sugar. Oral type 2

diabetes

is a disease of excess weight at a level in itself that leads to too much fat in the wrong places, including the liver. Nid Satar is a

professor

of metabolic medicine at the Institute of Cardiovascular and Medical Sciences at the Glasco University and Honorary Consultant in Metabolic Medicine at Glasgow Royal Infirmary. You know that there are 100 million people with pre

diabetes

. In the US people no longer store fat peripherally and excess fat is deposited in some of the body's key organs that are exquisitely sensitive to excess fat, which will disrupt your ability to control sugar levels.

I think that's a little scary, but it's also really clear if there is a difference between men and women in terms of diabetes risk. Women have a lower risk of type 2 diabetes than men. This is related to where they store the body. Is it possible to reverse some of this if you want to reduce the risk of diabetes? diabetes, the key facts Welcome to Zoe, science and nutrition, where world-leading scientists explain how their research can improve your health. Navid we are really glad to see you again. Thank you for joining me today. My pleasure, Jonathan, that's why we have this tradition on the show that we al

ways

start. with a quick round of questions from our listeners, uh, and the rules are really simple, you can say yes or no, or if you absolutely have to, you can have a single sentence to answer it, it's specially designed to be really difficult for teachers, you are willing?

To try, yes, absolutely, yes, okay, are there millions of people around the world who don't know that they are living with type 2 diabetes? Yes, does type 2 diabetes significantly increase my risk of other diseases such as heart disease and cancer? Yes, it is true that almost 100 million Americans have prediabetes, which seems like a high number, it is possible. I think it's probably a little overrated in my opinion. Okay, let's dive into that. It's a CDC quote, so I'm. I'm intrigued to get into if the foods I eat cause big blood sugar spikes day after day, can this significantly increase my risk of type 2 diabetes?

Probably yes, but it would generally tend to do so through weight gain. Do women control better? your blood sugar level than men women have a lower risk of type 2 diabetes than men for reasons related to where they are in the body F I think we'll definitely want to talk about that and then finally the last question and you can definitely have a sentence or two for this one and what's the biggest myth about type 2 diabetes that you come across as an expert in this area. Without a doubt, the biggest myth of my patients when I tell them that they may have type two or be at risk is that they don't eat much.

Predominantly sugar type 2 diabetes is a disease of excess in most people, excess weight reaches a level in themselves that leads to too much fat in the wrong places, including the liver, they got it and that's why they say "hey, but not me." I eat a lot of sugar, so how can I get type two diabetes? And the answer is: they still have it, they still have it and it's predominantly because people can gain weight for various reasons, not necessarily just from high sugar, but also obviously from too much fat, hello. It means a lot to me and the entire team that you hear this every week.

We put many hours into this podcast and launched this program for free and without advertising to help millions of people improve their health with cutting-edge science. come back all I ask is that you help us on this mission by hitting the subscribe button below it really helps thank you and get on with the show look let's start diving into all of this and you know just to get started I guess. Many listeners to this podcast know that I have a personal interest in blood sugar because my own blood sugar control is pretty poor, but I didn't actually know this was happening inside of me until I wore a continuous glucose monitor.

When I participated in the first clinical trial of Zoe Predict uh, which was done about five or six years ago, and it was a complete eye-opener for me to understand that my blood sugar was often very high for hours after eating certain foods. food and it was quite high. You know even, you know, when I woke up in the morning on an empty stomach because I didn't feel anything. I had no idea about this. So you know I'm really fascinated with this topic now, before I get carried away and jump into all the things I'd love to discuss about what I could do to improve my blood sugar control.

Can we start from the beginning and maybe start with what blood sugar is and why it is important? Well, sugar is one of the key fuels that many cells in the body require to produce energy and perform normal function, so in particular, of course, the brain depends on PE to function and it is its fuel source for cells to function. In addition to requiring oxygen, also when we are sick the body is very good at conserving sugar for immune cells, the cells that fight infection or help repair tissue, and again they require a lot of fuel for that, for those mechanisms. fight infection or repair tissue, and so when you're sick, it makes sense that the body would try to preserve more sugar for those cells, but all cells in the body need sugar, basically to function normally.

It's one of the things that I think people often mention when they talk about diabetes, you often hear this word insulin, um, what is insulin and why does it ever come up in a discussion about blood sugar and diabetes? So insulin is a hormone, um, so if I had to and I just ate a banana and my body is breaking down that banana putting its breakdown products, one of which is sugar, into my blood, but I wouldn't want that be my blood for a long time. I want to be able to do it. store that energy in various tissues insulin is a bit like a key that opens some of my cells to absorb that sugar and store it when I don't need it, this also

prevent

s my own body from producing sugar when I don't need it so I just took a lot sugar, I expect my insulin to start going up, you put the sugar in the right places and it's probably also telling my liver to stop making more sugar because there's already a lot going in.

It is like a master regulator that keeps sugar levels within the correct levels in the blood, putting it in the places where you need to store it for future needs and also helping you release it when you need it, and that actually happens when insulin levels drop below so maybe when you're sleeping and you don't have sugar in your body, your sugar levels, your insulin is low and your liver is still producing enough sugar to feed all your cells and your brain, etc., you know. for normal Bly function, so insulin is a master regulator in all of us for our sugar levels and thank you, it's very clear.

I think you have this type of insulin to maintain the level. I guess the obvious question is why not. our body just lets all the sugar stay in our blood, you know, like the refrigerator, you keep putting more stuff in it and then you know, my brain or something else could take the sugar out, um, when they want it, why can? I just let it rise higher and higher, yes I know it's a brilliant question, so when you think about sugar, if you spill sugar, especially in the context of water, it becomes very sticky, when the sugar levels rise a lot in the blood, it begins to meet a low level of our body proteins and changing their function makes them abnormal, so for example, some of the damage that occurs in the eyes is because the very high level of sugar begins to adhere, So many proteins are relevant to some aspects of eye function and alter it, leading to what is known as retinopathy. eye damage.

The same thing happens in the kidneys. The same thing happens with some of the parts of the body. There are many proteins as raw materials in our body and therefore they disrupt many normal functions and cause damage. I think that's very clear and very scary. This analogy with sugar on the sticky table. I can see that's not what you want. in a way causing through your blood is a process in part called gation and it effectively changes the structure of your molecules from what is normal to abnormal and that means it's almost if you think about it you know if you're building a house. and you start making bricks and the incorrect shape of that building will be altered and potentially not have the same level of integrity and it will decompose and crumble, that is effectively what is happening inside your eyes, your kidneys, your nerve cells, yes your sugar. levels are high, you are changing the structure of proteins so that they no longer do what is healthy and you are building tissues and an abnormal shape that leads to disease.

Thank you so much. I think that's a little scary. but also very clearly, could you explain then what happens when someone has prediabetes or type 2 diabetes? What does that really mean? Obviously there is an increased risk of developing diabetes, they don't inevitably develop diabetes, so the term prediabetes does not mean that it is al

ways

inevitable that people who have prediabetes, some stay at that level for years, others may return. to normal sugar levels or that because if they try their lifestyle, um, but if you have prediabetes, your risk of developing diabetes is clearly higher. Likewise, your risk of heart disease is about double compared to people who have normal GL, you know, not sugar levels.

I do not have prediabetes or healthy glucose levels. I just want to make sure I understand that you're saying that if you have prediabetes, your risk of heart disease is actually twice as high as if you don't have prediabetes. diabetes in general terms, but here is the problem at the level of prediabetes, that risk is not caused by sugar levels because they are not at the level of diabetes, what is caused are the processes that have led you to develop prediabetes in the first place, so, for example, for me to develop prediabetes, I would probably need to add another four or five kilos of weight to that excess weight, which will also mean that my blood pressure will increase.

My blood fats and cholesterol levels will be altered, so I will have higher weight, higher blood pressure, more abnormal levels of toxic lipids, and possibly other changes as well, and those are the things that cause my increased risk of heart disease, um, they will too. I have the feeling that they are stressing my sugar levels. I can still keep them within the range without diabetes, but they are stressed because I have put fat in the wrong places on my body and not. ju just want to make sure we all understand what prediabetes and PRI diabetes is and then I would love to understand more how they are related so what does it mean for someone to have prediabetes or type? two diabetes and how that relates to your blood sugar level that we were talking about a minute ago, so let me explain it in terms of a hemoglobin A1c level, which is a common test that we use that gives us an average level of sugar for an individual for

three

months, so our normal hemoglobin A1c, um, in the UK, it doesn't really matter the units, you know, it's 41 thousandths per mole or less.

Hopefully, you and I sitting here have levels of, you know, I don't know somewhere. between 32 and 41 is fine for prediabetes in the United Kingdom and others, you know, in Europe it is between 42 and 47, diabetes is when you reach 48 or more and in the United States, the criteria for prediabetes is a little broader than the one we use in the UK. is 39 to 47, which is probably why the category is perhaps over 100 million. I don't think it's that high, there's always some interpretation based on the CDC data that they have to extrapolate and Bas, you know, some caveats, but still that's what it is um, in older terms of hemoglobin A1, the levels.

What we had in mind was diabetes is 6.5%. We use the percentage of prediabetes which is 6 to 6.4 in the UK or 5.7 to 6.4 in the US and effectively that is hemoglobin A1c. and it's capturing your average sugar levels your average exposure to sugar levels over 3 months it's a very good stable measure that we measure in the clinic all the time it's increasingly used to diagnose diabetes or diagnose prediabetes and I've heard from doctors often refer to this as hba1c is the correct hb1c hemoglobin e1c and as I understand it I just want to make sure I'm reproducing it correctly as I understand it you know your blood sugar changes all the time so I you ate that banana at this time and your blood sugar levelit's probably starting to spike, so you'll take the insulin that you describe, it won't come back down and this hba1c is kind of like this average measurement of your blood sugar, like something like that on the tank in the car that tells you what's the average, like months, um, instead of this thing that changes all the time, that's perfectly fine, so, um, you know, after my banana, I can maintain my sugar levels. go too high and stay within the normal range, could you tell?

And for me, every time I eat food, if I keep it relatively within the normal range, my Hba1c will stay within the normal range because, on average, my sugar levels have remained normal. amazing and to make sure that I just want to make sure that I have this, you're like saying you know we all have a sugar level that we would normally have in our blood, we can measure it with this hba1c and if anyone listening to this has been diagnosed with prediabetes or type 2 diabetes, this is higher than it should be and this is the concern and then talk a little bit more about um uh, about what it means and what you could do about it, that's generally correct, I mean, and the reason why I think I am.

You clearly know that we can measure sugar levels and they can also give us an indication. Know particularly when you are fasting that you know that we believe that the sugar level should be below 7 ml/month per liter. We can do it on an empty stomach, but there is certainly progress being made in the UK and also in the US and many other countries around the world to diagnose. diabetes have started using HB hba1c more and more because of its stability because you don't have to do it on an empty stomach because it can also be measured when people have infections or are admitted to the hospital because none of those things are going to change on average over

three

months, so it's a very good added marker.

Now it's not perfect all the time. There are some circumstances such as people have very severe anemia or have a different type of hemoglobin, the so-called hemoglobinopathy. You know, we have to be a little careful, but that's a very small percentage of the population, so in the vast majority of circumstances, Hba1c is a very good aggregate measure of sugar exposure to which your body has been exposed and gives us an indication of whether you have prediabetes, diabetes or an AG anol. so I think the obvious F in the question is why has there been this huge explosion in people with diabetes and prediabetes.

The team was again sharing some of these statistics and apparently there's sort of a four-fold increase in the number of people with diabetes. The world likes hundreds and hundreds of millions of people, um, and I know when we look at our own data of the people who do the Zoe study, there's hundreds of thousands, you just look at this ex, you see there's a lot of people whose levels. they are so far. much lower than the levels you're describing from people with diabetes, so clearly you know there's a big change. I guess I think like my children.

I don't know what his Hba1c is, but I'm pretty sure it's way below. these these levels, right, they are not there, so what is happening, what is causing, what I think, I think we could describe it as an epidemic of type 2 diabetes with all the terrifying implications that you are describing and why. It's a lot more common now, even as a kid growing up, so I think you know, it's obviously a brilliant question. I'm sure many listeners can figure out some of the main causes and one of them, of course, is um. Increasing levels of weight and wasting girths in society, because as you gain weight, people gain weight and the average levels of body mass index or any level of wasting girths have increased in communities, that means that more people have. to the point where they can no longer store fat peripherally and that fat (excess fat) is deposited in some of the key organs of the body that are exquisitely sensitive to excess fat and are relevant to how well one makes or stores sugar and whether If you put too much fat in some of these organs you will disrupt their ability to control sugar levels, for example too much fat in the liver means that it will continue to produce excess sugar than the body needs when you don't.

Not needing too much fat in your muscles means your body won't absorb sugar in response to insulin as well as it normally would if your fat levels and muscles were lower, as a simple example, so weight gain is one of them. Another key factor is that it is actually related to success, in part, another risk factor for diabetes, actually, living longer, as life expectancy increases and more and more people live longer, we have more diabetes and part of that reason happens is this, in my simple Keep in mind that there are three things that determine the risk of diabetes: the weight you reach and the amount of fat you put on your organs, your muscle mass because that is your driving force burn sugar and how well your pancreas works.

Now, two of those three things probably change with age, as we age, our muscle mass decreases, the pancreas becomes smaller, which is the organ that produces insulin, it becomes less plastic, so to speak. , your ability to produce more insulin to keep sugar levels down decreases over time and also as we age. we tend to gain more weight in the stomach and we tend to lose fat from the periphery and from the arms and legs and, you know, for peripheral reasons, so by living longer, we also increase the likelihood of diabetes and that's not only in high-income countries, if you think about all the millions of people, billions of people, in fact, in low-income countries, as they have proven their hygiene gradually and you know that people from industrialization no longer die between 30 and 40 years old, they live to be 40 and 50 years old, so they can develop diabetes between 50 and 60 years old when they didn't because they died from an infection or something else, so there are multiple reasons, but the increase in weight, increased life expectancy are probably the two main ones, so neither i i just want to. to unpack that and make sure that I have understood it and our listeners have understood it completely, so maybe to start with the first one, I think you said something really interesting which is about increasing weight levels in particular places, so It's not just a matter of whether someone has gained weight generically, but the fact that that weight is actually being stored, so fat is stored within crucial organs in our body and that's really what starts to trigger the diabetes, I got that right, so yeah, that's what's called ectopic fat, where normally it's not supposed to be at any kind of high level, so for example all of our liver fat level should be below 5%, ideally, usually if you look at the normal range below 2%, but when the liver accumulates more fat because your body has not been able to store the fat in other areas because your weight has reached such level that the body looks for other places to eliminate excess fat. of which tends to be the liver as fat levels in the liver increase, which disrupts the liver's ability to regulate sugar levels normally and the liver actually begins to produce excess sugar beyond the needs of the body, which then keeps the sugar levels high, so that is one of the examples, an ectopic fact, it is not the only cause, some people also have, let's say, pancreases that produce insulin, which are incapable of produce as much insulin, perhaps as a healthy individual, so that for everyone, even when they are not very overweight, their pancreas The ability of the pancreas to produce insulin declines very rapidly with age and then it is type 2 diabetes driven by the pancreas, but even if you know genetically that you can't produce as much insulin as the other person, weight gain is usually the trigger. for diabetes and people tend to have to gain less weight to have diabetes, so there is an interaction between how well you put the incas can produce insulin, how much fat you put in the wrong organs and how good your muscle mass is .

I'm sorry, I can not. Just before you jump in because I think the weight of your organs affects the way they function, that makes sense and you're describing the pancreas as one of these examples, it's so important that it produces insulin, could you explain? muscle mass for a minute, why does muscle mass have any impact on diabetes? So the key type of organ you know, muscle mass is often, uh, it's a measure of how active you are, so the activity plus, you know, as an example, you know my muscle. dough used to not be so good, actually it's probably a little better now that I have a dog and a psychiatrist etc., congratulations, that's it, yeah, you know, and my HDL has gone up and I can see it.

I can see him as a Bome. has increased, you know, it's actually almost doubled, which is good, which is very good because I have a family history, so I think my pancreas is probably genetically South Asian, or the fan story has a, has a Lower reserve to continue producing insulin at the levels that I need to overcome, you know, any resistance in my tissues, so to speak, by building muscle and being more active, I have an engine that burns more sugar, that means it's me . I have an engine that can burn sugar, which means the sugar won't stay as high if that makes sense.

It will also burn fat, so by having more muscle, it will actually take the sugar out of my blood and burn it off. so that's like it makes everything better and if I don't have it, I'm more likely to store it in my liver and in my car. It's a little bit exactly, it's like having a very efficient engine, um, and a larger engine by the amount. of fuel, if you fill the car too much with fuel, you know too much oil, the oil will damage the engine, um, you know, and if you keep the engine clean and bigger, you might be able to run on more oil, you know?

Is that kind of analogy simple? Can I continue with the point about the differences between people because I'm really interested in that? And um, you were just talking about you know South Asian heritage and you love to understand a little bit. More on that, but the other thing I was interested in is kind of the difference between men and women because I know that when we've had other conversations related to other risk factors, we've had this conversation about women, particularly before menopause. of storing fat in different places and is there a difference between men and women in terms of their diabetes risks as well?

So I'm really curious to know for people listening how these things can be different depending on who they are. Yeah, well, let's explain all those risks in the prism of where the fat is stored, so women generally have a much larger subcutaneous, you know, so they can store fat peripherally, thighs, legs and, obviously, you know, the shape of women is such that you already know. They have other fat reserves, let's say, so women generally, in a sense, have a greater fat storage capacity in the peripheral area, which means they have to gain more weight before the fat starts to leak out. in the liver and in the peripheral zone. to make sure, basically, because for anyone who hasn't seen the video where nid helps point out, you're basically saying that everywhere, not on my torso and around my abdomen, women can store a lot more fat there and some of the The reason women have to store more fat is partly because women have children, they have to feed the children, they have to breastfeed, they have to supply nutrients to the child.

One of the things that happens during pregnancy is that the placenta can suck a lot of nutrients from mom, so if mom, you know that if mom doesn't have enough fat storage, they often can't get pregnant. You see that in athletes, then you like the need for your body to be like you, talking about evolution over millions of years, not necessarily. It doesn't mean that you as a person listening to this have to get pregnant, but the point is that this is how our bodies have evolved, yes, that is exactly right, if you compare men and women in terms of how much fat they have in the liver, even at healthy levels.

Men tend to have higher levels of liver fat compared to women, which means that, and also men, when they generally gain weight, it is usually accompanied by an immediate increase in the girth of their waste because they tend to to store them. Everything is already closer to the threshold of fat going to the wrong places, so with a little weight gain, men's fat generally goes to the wrong places; However, women can generally put more fat in the peripheral regions of the thighs and other areas before reaching the most damaging places such as the liver and legs.muscles, so to speak, that explains why men in all ethnic groups have a higher risk of diabetes and women of type 2 diabetes.

It probably also explains in part why men have a higher risk of heart disease than women in all ethnicities in general and with the same prism if you compare us and me Jonathan uh, you know that you are sitting there, you know that you are Caucasian or white. I'm South Asian, we know South Asians on average. I have 10% less muscle mass on average and I already have more fat mass and we also have higher levels of fat in the liver even when we are healthy so compared to you I have a higher level of fat so I'm closer to where I'm going to put too much fat in my liver enough to develop diabetes than you.

You are closer than average. You know, let's say women of comparable age. That explains the risk for men versus women. It also explains whites versus non-whites and every non-white individual. Compared to whites they have a higher risk of diabetes, one of the reasons is where people put fat, it is not the only other reason why blacks. I think there is another mechanism that we don't fully understand that maybe has to do with how well the pancreas can produce insulin, but certainly For South Asians, in a sense our body composition is such that we are in favor of a lower increase in insulin. weight, we will start putting fat in the wrong places and therefore develop diabetes with a lower average weight gain than when I want to take a quick Stop here and we will tell you something new.

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Yes, no, you're right, generally speaking, South Asians are at risk for diabetes, so you know compare age for age and know sex for sex, somewhere between two and four times higher risk of type 2 diabetes. four times higher, so there's a huge difference in the RIS and even in the south, you know, in the South Asian groups there's a gradient of RIS, so the highest groups in the big countries are actually in Bangladesh, then Pakistan, then India and a nice Do you know a possible explanation for why Bangladeshi, compared to Pakistanis, is height and early growth because height is different from how much muscle you have?

Bangladeshis tend to be shorter than Pakistanis, so they tend to be shorter than Indians on average. It is fascinating. What I would say is, of course, these are just averages, so you can have this huge because I mean, and listeners will have heard this. I don't want to bore you, but I actually have quite a bit of fat stored around my abdomen. in terrible places and very little anywhere else which I had no idea about until, as part of Zoe's first clinical study, I had a Dexter scan and I remember the face, I remember the look of the nurse doing it, who was really surprised and the The answer was apparently what I think is called caramel or something and it turns out that I have very well stored fat around my liver and elsewhere and I remember Tim explaining to me that this was really bad news.

And of course there are these ethnic differences, but obviously there's also very large personal variation, so you know some person, I guess, has a much higher risk of diabetes than anything else, I mean, and there may be several genes that They also influence. and you know the question I would ask you if you were my, you know, if you were one of my patients, Jonathan is: do you have a family history of type two diabetes? Your BMI is obviously not high, it's pretty good, and you know it may not be. Whether this is actually a BMI factor clearly because you don't know that you're clearly not heavy, it may be that you have a specific gene that doesn't allow you to export liver fat from your liver into your circulation, I don't know, but that's something you should interrogate, but generally I will follow this in detail after this call.

I'm aware that I need to do it, I want to move on because I don't want to. I know you had a limited time before you had to go back to the clinic. I'd love to talk for a minute before we talk about what we do, what the symptoms are, so let's say someone is listening to this and they say, Oh, I wonder if I have diabetes, what are the symptoms that I'm going to experience and they're going to respond. that question for me? So most people who have type 2. Diabetics who increase their sugar levels usually have very vague symptoms and some are completely asymptomatic because that change has been so gradual that they are not so asymptomatic meaning they are not aware of any symptoms. .

Yes Yes. Symptoms usually appear when sugar levels get too high, at which point the sugar gets too high, the kidney's ability to reabsorb that sugar decreases and you push more sugar into the urine, the sugar can't go on its own. You have to carry water with you, so you tend to urinate a lot, urinate more during the day, urinate more at night, the so-called polyurea, then you can get more infections because you have higher sugar levels and you tend to feel tired and fatigued at night. part because if you start urinating sugar, your body's efficiency and the way it uses sugar for optimal function decreases, so you're fatigued, so fatigue, more infections, urinating more, other kind of important symptoms, you know . and it sounds like those symptoms you're describing aren't when you have prediabetes or even diabetes for the first time.

It's not like when you get a cold or something. You don't have these symptoms when you have prediabetes or even diabetes. I already lived with that, yes exactly, you know that sugar levels are rising relatively slowly and you know it, so most people usually don't know it, maybe they have a vague feeling that I don't have as much energy as before . a I'm sleeping a little more erratically and you know vague symptoms and some may not, it depends on how fast the sugar level rises, it depends on the period it rises, it depends on how old you are, we know that younger people develop diabetes .

Sugar levels rise faster than older people and excess weight is a much bigger factor in younger people developing diabetes and older people, so there are many different dimensions. I would say we did a study of 100 Asian men and white men. Of those 100 Asians, 13 had diabetes and they didn't know it, well, they didn't know they had diabetes, so there were 100 Asians that you studied, none of them thought they had diabetes, none of them thought they knew they had it and 13, one of each 13. Turns out yes, so that's huge. 13% had this and they had no idea that they exactly had this serious illness, yeah, yeah, so I think everyone who hears about this now is going to be a little scared if you haven't talked to them.

It's okay for someone to think that they have some concerns, so maybe I think you're describing some of the reasons, like you think that maybe you've gained more weight around your belly and well, it's more than that, Jonathan, yeah, so the things you should do there are simple scores you can look up you know what my diabetes risk is High low medium you know and you can do this this what is this this the uk diabetes risk score you can get online is the diabetes leester The score is what is known as diabetes Q online and the risk scores capture your age, your family history of diabetes, your ethnicity, whether you are male or female, and your weight, in general, and a couple of other things, and they will do it.

I'll give you an idea and it may be that when you put that risk or it comes up, the vast majority will be really low, in which case don't worry, it's very unlikely that you'll have diabetes if the level is medium or high, so at that point, You might want to contact your GP and say, "Look, I've already done this score. Could you do my HB1C test? I'd like to know and just get a notification, so to speak, and that's what we do to make sure." that it makes sense to everyone who's not in the UK listening and who might not know what that is, what you're saying is that I think if I play it correctly, there's a sheet music first and we'll put a link in the liner notes. program. for anyone listening to this who can figure out the correct way to rate this for your country, which basically gives you an indication of your risk probability and what it's saying, I think, is that if that risk is medium or high, then don't do it.

I don't feel bad about going and talking to your doctor, your doctor, and that this same thing exists um, is it a very difficult test to do and then discover this hba1c? No, it's effective, it's a uh, it's a blood test, um, that the GP you know or the health professional or you can take um um or a checkup can take any time of the day um and it costs approximately in terms British one to 2 pounds, you know, it's not very exp and probably a little bit more expensive in the US and elsewhere, so it's not very cheap, it's not very expensive, the test is always much more expensive in the US, yes, but we won't go to discuss that now, it's completely different, but it's relatively easy anyway, it's already done. the result within a day and he comes up with the hog glob A1 test, so you wouldn't be because I think sometimes people say oh, you know, if you're not really sick, you shouldn't know, are you like that? creating all these people worrying for no reason, they go with the vast majority of listeners when they do this test, the risk will be low, okay, the vast majority and then they calm down, it doesn't mean they can, you know I still have to all They have to try to live the best life they can and enjoy life too and um, but as an example, be someone like me.

I have a diabetes family, so I have a number. I have a risk factor. Also, getting older, you know that in itself is not a risk factor, but because I have a family history and I'm South Asian, so you know it's probably going to motivate you if I do my diabetes RIS, it shows up as a 15% chance. of the next 10 years, so there's a one in six or seven chance that I will and I had a hemoglobin A1 test and it came back because it's actually fine, but it's getting close to, you know, it's getting close to the range of prediabetes that fits. with my family history, the reason I kept it low because I kept my muscle mass high, you know, my father and mother developed diabetes in their 40s and 50s, you know what a brilliant transition.

Point um um because I would love to talk about that so what do you know to avoid hopefully getting diabetes prediabetes in the first place? And it seems like you're literally living this yourself, so um, I'm fascinated. and you mentioned that I wasn't sure the dog was part of this solution, but tell me I think you've painted a pretty clear picture that you'd really like to avoid this because of all the serious implications. If anyone is listening to this and says they would like to take the right actions, could they please speak up? I think based on your own research, but I also think it's fascinating to hear what you're doing yourself as an expert.

I mean it's not even my research, I think it's based on the kind of global evidence that we know from all the randomized trials, all the various studies and around the world, you know the evidence based on the following is that if you want reduce your risk of diabetes, the key aspects are to keep ourselves as healthy as possible, so you know diet makes a lot of sense and probably all the listeners here are well attuned to that and staying relatively physically active, and those are the two things main thing that I can't stop getting older, you know, the only thing I would also say and I think I've hinted at this Jonathan, I'm 56 now, six, if I can delay the development of diabetes until I'm 75, I'm a lot less worried because if my level of sugar starts to escape from the high, so I don't have many more years for that sugar to cause harm.

High sugar levels immediately do not cause harm, it takes 5 to 10 or 15 years and also the older you get. To get diabetes, the slower your blood sugar will rise because it is less related to weight gain. The younger you develop diabetes, the more toxic it is. Is amore toxic disease because sugar levels rise faster. You tend to need more weight, the reason you tend to need to have. more weight to C to trigger diabetes because when you're young you tend to have a bigger muscle because you're young and your pancreas is healthier because you're young, in other words, to overcome those, you know, your better buffering capacity because you're younger , you need to increase, you need to stress the system more by putting more fat in the wrong places, but that comes with all the other risk factors, which means your risk is much higher, yeah, so you're saying can I hold on.

I'll leave it off until I'm 75, then at that point maybe you could start eating the uh, you could eat quason chocolate all day. You have to think, but, but I know that diabetes then is, you know, but you're less worried. about DI diabetes is because not going to it will not greatly affect my life expectancy, if anything, it will not lead me to have an eye disease or a kidney disease or a nerve disease, if you know about it, whereas if, if it is in You are between 40 and 50 years old and you have prediabetes, some small sustainable changes in Lifest Child mean that you either stay the same, gain a little muscle mass or we lose three or four kilograms and keep them off and can stay healthy. with a little bit of activity to keep you from gaining weight means you're probably going to delay developing diabetes for five, you know, three, four, five or 10 years, you know, up to 10 years, some people can delay this for a long time or even reverse it. at normal sugar levels, so you're effectively improving your muscle mass, reducing your weight, ectopic fat enough to stress your glucose control mechanisms and could we talk a little bit about?

I'd love to talk about what you yourself have done and I mentioned it maybe briefly, but I'd love to understand that it sounds like this is a real risk for you. You describe the fact that your parents developed it when they were very young and it sounds like this is really up to you and it just reminds me a little bit of Tim when he makes his own changes for his health, it sounds like this is live for you, what do you have How does it affect what you do? You know, obviously I'm lucky to live, you know?

I know that in an area where there is the opportunity to do more physical activity, I think the dog was not a necessary effort to maintain my diabetes, but the byproduct of the dog is that I am I have increased my walking much more than ever before and I enjoy it . Now I've been cycling to work for the last 10 years and I love it, so what I've almost changed. identity and who I am by becoming more physically active and finding things I really enjoy, the byproduct of that is my muscle mass. I can feel it has increased.

I probably reduced the excess fat in my liver quite a bit in 25 years. He's gotten a little bit heavier and one of my signs of diabetes was incredibly high and then, you know, it went down because he actually built more muscle, got rid of some of that fat mass and some of those changes have been very gradual as well. I've also made some changes to my diet, you know, eliminating some of the refined sugars, increasing the variety of foods that I eat that are higher in fiber, you know, retraining my palate to taste different, which takes a little bit of time. get used to it You know, would you believe I even enjoy grated wheat?

Now you know I love shredded wheat, but it's taking me a few weeks to get used to that flavor and texture, but I love it. Okay, add two or three grapes for a little sweetness. that's okay again so in a sense I've been on this gradual step by step journey to becoming eating better quality fuel having better quality activity which in a sense kept me from putting fat in the wrong places keeping my engine better to

prevent

me from getting diabetes when I'm 40 or 50 and I hope I can continue to do that by staying active. You know, even if I have diabetes when I am 60, I don't worry because we are better now.

I could lose weight. I could have this intervention, you know, I found some better medications on the way as well for someone listening to this who already has type two diabetes or maybe has been told they have prediabetes. It's possible? actually reverse some of this, can you really lower the blood sugar you were talking about? Yes, absolutely, it is like that in each individual, we all have a different slope between weight gain and pig globin, hb1c level, so in a sense there is almost a straight line between each of us and my line It's more pronounced than yours, Jonathan, because of my family history, so for a smaller amount of weight gain, my HBA will go up because I'll be putting fat in the wrong places and you know that.

We have shown in the direct trial that if you have a person who has developed diabetes in the last 3 to 4 years, if they lose 10 kilos, approximately 46% after 1 year or 33% after 2 years they no longer have diabetes because they They have gotten rid of it. fat liver fat goes down so the liver responds much better to insulin the liver produces less sugar your sugar normalizes a lot so there is a straight line between how much weight people lose and how well their HB once it improves in general and it also works the other way around, there is a straight line between the amount of weight you gain and it just that slope of that line is different for different individuals depending on whether you are a South Asian male or female or white and age doesn't matter. whatever you have, etc., that means you know wherever you are, there is something you can do and it is not something absolutely.

This morning I had a patient in the clinic who has diabetes. They had weight loss surgery, they had lost a lot of weight, their sugar levels had plummeted, you know, they're still in the diabetes range and what I talked to them about was they were starting to worry about mobility, can you really? now increase your muscle mass that you have done, you have lost and they had lost seven stone due to the surgery, but clearly they could, but they could do some resistance exercise, a bit more physical activity to improve mobility and improve the motor side . so everyone listening can do something, but what you need to do is find something that you can hold or enjoy to reinvent a new version of yourself that you enjoy and can hold for better health, whether it be physical diet, better sleep, all the things that you've talked about in Zoe in various podcasts, you know, you know, sleeping better gives you a better appetite, allows you to control your appetite better Mo, you know, de-stressing, maybe more physical activity, all those things and trying to do it a way that are small steps that you can achieve a little bit better health to keep some of these diseases away and also increase the life expectancy of a healthy life so to speak and contract an unhealthy life for the later years, which I think that everyone who listens to this podcast is interested, can I?

Ask one last question before we like the summary. There are some new medications that have been in the news like a zenic and there has been a lot of discussion. We are very lucky to talk to someone who is one of the best in the world. diabetes experts, what is your opinion on this? Now you know, in some ways, I wish we didn't need to have those tools, you know, because I wish we could change the environment, make it easier for people to leave easier lives because that's not the case. easy to change your diet it's not easy to become more physically active you know we talk about it and we have to overcome the weight stigma we have to talk about helping people navigate the environment that they live in if you're surrounded by food it's very difficult yeah , it's almost impossible, so, you know, I don't want people to think that I think it's easy, it's not easy, you know, some of the changes that we've all had to make, we've had to work on them, but even then , for many people willpower is not enough, the environment they live in is not enough, so I wish we had several of that.

There are millions of people living with obesity and chronic diseases. These medications are good powerful tools that help people control appetite. a fairly considerable amount of weight and therefore reduces and improves and reduces the risk of a number of chronic diseases, not only diabetes, but more recently, reduces the risk of heart attacks or strokes, improves symptoms and heart sensation, reduces the risk of kidney disease, improves quality of life, so I'm glad they're there, they're expensive, we don't have wide availability, so we need to figure out across healthcare systems how we can get them to the people who need them most to get the most benefit for those individuals and society and that's a big question and hopefully in the next 10 years we'll have more of those tools, the prices will come down, they'll be proven safe to use. long term and the benefits outweigh any potential risks. but it sounds like you're hoping to prescribe them to some people.

I have already prescribed them to some people because we have to, but we need to do both prevention and treatment. We can't just do one and that's a completely different one. podcast that I would like to recover, it's na. I'd love to do a summary and make sure you understand this right before you go see another patient, if so, sure, then, um, I think. We started talking about why you would worry about blood sugar and you get this brilliant analogy of spilling sugar on the table and getting it wet and, um, that's a sticky mess and you don't want that on uh. in your blood vessels and what happens is that if you lose this control over your blood sugar because, for example, you're starting to have all this fat in your lier and your panc C, everyone else you're actually having this stickiness on these like little blood vessels and this is damaging your eyes and your nerves and it doesn't sound good so it's very clear that we don't want that and so the question is, why is this happening?

Because now it's happening where you know there's a 100 million people with prediabetes according to the CDC in the US and you know this huge increase and you say the main reason is we're starting to get number one that we're putting on fat in our organs in a way that is really bad for them and it hasn't really happened in the past and you talked particularly about it happening in the liver and in the pancreas and interestingly that's one of the reasons why we see so much variation between the risks. of diabetes is that different people have very different chances of storing excess weight in those places and that's why you describe that, for example, women before menopause have a much lower risk of diabetes because they tend to store their weight in almost anywhere other than the liver, but, interestingly, also As a man, you say that almost the first place where I am going to store this excess weight and in my particular case, that is obviously very true, is right in the liver and then It starts to cause all these problems that Interestingly, there are big ethnic differences and I think you described that type of person who is not Caucasian.

I think he said it's actually a significantly higher risk and then there are more differences between ethnicities that there are some tools online to look at this and We'll share those links in the show notes so you can understand your own risks, which are averages because I think What we always see with Zoe is that there is a lot of personal variation, but this is a free first step and it does seem high. You should go to your doctor and check it out and then I think we talked about the fact that I think one of the things that's pretty scary is that a lot of people don't feel symptoms, so you can have diabetes for a long time and this damage. it's starting to happen and you don't even realize it, which again is a reason to really believe in preventative healthcare and then we talked about what to do and I think the main answer is that, you know, for a lot of people listening this is do what nid has done so firstly get a dog secondly cycle to work basically find ways to be more physically active you are saying because it increases your muscles compared to this same way , you know, of not moving into who we tend to be. and try to figure out how to control your weight, which you know is a topic we talk about a lot on other podcasts and we know it's hard, but fundamentally, if your weight increases year after year, then you've got this. this issue is so physically active, healthy weight, so proper health, um, diet, and a lot of people need support on that, obviously, yeah, K and Jonathan, I'm absolutely sorry, um, and you know, we're part of what obviously we talk a lot on the podcast. this and of course we want people to ultimately decide that they would like to try the personalized program that is really focused on them, which we talked about and I thought one thing that you said that was really interesting is in your minds.

Actually, what you want to do is delay diabetes from your perspective. If you have diabetes when you're 75, you're actually not toostressed about it because it takes quite a while for them to damage you, so it's not like having a heart attack when you have diabetes it's more of a risk and then you're saying you want to eliminate it because actually, if you know maybe you're at a pretty high risk. , if you could eliminate it until age 75, you'll have Okay, and then the last thing you said, which I thought was really positive, is that you can reverse diabetes.

It's not like having cancer or a heart attack, like it's not a one-way street. In fact, by removing this fat from your liver, you can get to the point where you don't have diabetes or prediabetes PRI and I thought that was a beautiful and positive way to wrap it up perfectly. It's a fantastic summary. Jonathan and nid. Thank you so much. I know we like to jump a lot. of this very important topic and I know that you are doing a lot of research in these areas, uh, I hope that I can tempt you to come back in the future and we can be delighted, yes, absolutely particularly, whatever the comment is to try to unravel. some of the others you already know because it's obviously difficult to get into the specifics of VAR, there are some variations on various things, but I've given you an overview for the vast majority of people in terms of type two, we'd love to do that and we'll talk. much more about the diet aspect of course, Zoe.

Thank you very much for taking the time. A pleasure. Thank you for joining me today on Zoe's science and nutrition. It has been fascinating to learn so much about blood. sugar, how type 2 diabetes affects our health and how we can prevent and even reverse it. If you want to hear more insights from the podcast, you can download our free guide with our 10 most shocking findings by visiting the zoe.com podcast and following this conversation If you want to understand your own blood sugar levels in more detail and how they respond to the foods you eat, like I have, then you can learn more about becoming a Zoe member and get personalized advice on how to eat the best foods. reduce your blood sugar spikes, you can also get 10% off your membership.

Visiting the zoe.com podcast again as always. I'm your host Jonathan Wolf Zoe's Science and Nutrition is produced by the yellow huin Martin Richard Willen and Tilly fford until next time