Damien

Okay, so yeah, good evening, everyone, and thank you for joining us.

Once again we're joined here for another evening webinar at Benenden Hospital this week on diabetes and endocrinology. Now, my name's Damien, and I'm going to be hosting your session this evening, and I'm delighted to be joined by our expert speaker, Dr Sameer Sighakoli a Consultant Endocrinologist.

Now, tonight's session will be a presentation from, Mr Sighakoli, followed by a live Q&A. Now, if you have questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screen.

You're welcome to ask anonymously, or include your name, but just a quick note that the session is being recorded, so any names will be visible in the recording.

So to help us get through as many questions as possible, please try to keep those brief. And if you're interested in booking a consultation, we'll share all the relevant contact details for you at the end of the session.

So I will pass you over to Doctor Sighakoli. Nice to have you.

Dr Sameer Sighakoli

Thank you very much, Damien, and welcome everyone to this webinar. So without any further delay. I'm just going on to the presentation.

So I am a consultant physician in diabetes, general medicine, and technology, and I have nine years’ experience as an NHS consultant, and I joined Benenden this year.

And I do my diabetes and endocrine clinics here in the outpatients.

I have special interest in Type 1 diabetes, diabetes in young adults, incident pump therapy, and diabetes related complications. It also has special interest in other endocrine conditions like thyroid and parathyroid disorders and also review conditions in general endocrinology.

So this is going to be my format where I'll be talking about diabetes in general and go through the different types of diabetes, the common symptoms, the different treatment options in brief, and what happens during consultation, especially with regards to monitoring of glucose.

And towards the end, I'll be talking about living with diabetes and looking forward to the interesting question and answer session.

So diabetes mellitus is the most common endocrine condition. It leads to excess glucose in a blood.

It literally means sweet urine. In the past, historically, that's how it was identified. I'm talking about several hundred years ago.

This is a situation where the body or the cells are not in a position to utilize the glucose. There's enough glucose in the system, but the cells are not able to absorb that.

And this can happen due to either an insufficient insulin production or complete absence of insulin production.

Then a commonly used term is insulin resistance, where the body is not able to make use of the insulin that is around to help in the absorption of glucose.

There are several subtypes of diabetes.

Type 2 diabetes is most common with 90% of cases, followed by Type 1 diabetes, then gestational diabetes, which basically means diabetes in pregnancy.

Then there could be diabetes due to other pancreatic disorders. So if there's any damage to the pancreas due to drugs that can lead to diabetes.

There's some rarer varieties, like monogenic diabetes or LADA, also called latent autoimmune diabetes in adults. It's also called 1.5 diabetes.

Type 2 diabetes is being the most common. I'll talk a bit more in detail about Type 2 diabetes.

Six million people in the UK have diabetes. It's nearly around eight to nine percent of the whole population.

And the incidence is increasing with age irrespective of their ethnicities.

From an ethnicity perspective the South Asian followed by Afro-Caribbean and Hispanic ethnicities are at a high risk to develop Type 2 diabetes.

Again, as I mentioned about gestational diabetes previously which is a diabetes during pregnancy, there's risk of developing Type 2 diabetes after pregnancy, some studies quote the risk could be up to fifty percent in ten years’ time.

And what is important is the annual monitoring and people who are high risk.

The uniqueness about diabetes is that it can present several years even before diagnosis. So people may be relatively feeling well in themselves.

And by the time diagnosis is made, it may be well three to five years down the line.

Important terminology here is about prediabetes and obesity.

Prediabetes is a high-risk factor for developing diabetes.

And people who have obesity are at high risk of developing Type 2 diabetes.

So we need to identify individuals who are at risk so as to Intervene at the right time.

Now, Type 2 diabetes has been increasing in incidence even in younger people.

Overall, the incidence and prevalence is increasing across the population, in fact, across the globe.

Unlike some conditions, Type 2 diabetes has a variable clinical presentation. Starting from no symptoms to severe symptoms.

If untreated, the symptoms can worsen, it could have a major impact on one's life.

Fortunately, there are several classes of medications now available to treat Type 2 diabetes compared to more than twenty years ago. We have options, multiple options.

So with the help of these medications and with assistance from technology we can, a person with diabetes can lead a near normal life.

So what are symptoms of poorly controlled diabetes?

Passing urine even more frequently, especially at night.

Being constantly thirsty or being able to quench the thirst, fatigue is a very common symptom, unintentional weight loss, visual changes.

So I have seen people who were presented to the clinic and mentioned that they had to change the lens in the glasses because the power had to be changed.

And there's also potential history of recurrent infections, for example, foot infection, urinary tract infections, or skin infections.

Now, in terms of diagnosis.

As I said, it can have variable presentation. So during the consultation we go through the symptoms and a simple blood test is done.

Both for screening and diagnosing diabetes there are several tests, like a random blood glucose or a fasting blood glucose.

A popular one is in HbA1c test, which helps understand the duration of poor control of diabetes over the last three months.

These tests are actually cheap, and this can be done in the primary care.

Okay, so during an outpatient consultation in following the assessment.

We can request some standard blood test, and if required, we'll do a urine test to assess the kidney function.

It's an opportunity to assess the risk of other complications which may be associated with diabetes at the time of diagnosis.

If it is mild, we start with standard lifestyle changes.

Give three to six months’ time to see if there's any positive or adequate response to lifestyle changes.

If that doesn't help, we can try tablets.

And if tablets don't help, and if indicated. We can also use those weight loss medications, but at different doses for diabetes.

And in severe cases we can give insulin.

When an assessment is done for complications, and if found to have one, I would refer to the appropriate specialist.

I mentioned about assessing other conditions at the time of initial review for diabetes.

So we would be having a review of history regarding heart disease, kidney disease, any eye problems.

Obviously, we won't, I will not be able to assess the retinal changes in a diabetes clinic that's done by specialist eye services.

Review the possibility of any nerve damage. Some people with diabetes would present with symptoms of numbness and tingling in the toes. That could be the first presentation.

And a very important but less known condition is fatty liver, where there is deposition of fat in the liver.

It may not cause any symptoms, but if persisting or a prolonged period of time, it can cause complications.

There could be other associated conditions with diabetes like thyroid disease or celiac disease.

There's also an association between diabetes and memory impairment like dementia.

So treatment, what do we do? What are we trying to achieve here?

Basically, two things. One, Try to attain and maintain blood glucose levels within safe targets for that particular individual.

Safe targets does not necessarily mean the normal values.

It may differ from person to person depending upon their other health conditions and complications, but we would endeavour to achieve as normal values as possible, but without compromising safety.

The second goal is to prevent or delay any complications, which is very important.

So how do you approach the treatment which I mentioned previously.

We start with lifestyle, but before that, every clinician endeavours to deliver individualized care because the circumstances for every person are different.

When I use the lifestyle in this context of the discussion, it's not a general term, it's a medical term.

It encompasses several aspects of management, it's about healthy eating patterns, not just having certain periods of healthy eating in, but also to have regular physical activity.

So, regular physical activity helps In burning the calories, it can also help in losing weight.

But one may not necessarily achieve significant weight loss, but a combination of changes can help.

There's not much emphasis on sleep, but I would like to emphasize that as well. Good, refreshing, adequate sleep is important.

And very important and crucial is regular medical monitoring, irrespective of what phase of diabetes you are in.

As mentioned before, we have several classes of medications that can be used in the management of Type 2 diabetes.

I will not be going into detail. I've just listed some of the common class of medicines that are used for the treatment of Type 2 diabetes.

I'll just mention briefly about the GLP1- agonist, which is very popular as a weight loss because it's used as weight loss medication.

We can always use insulin in the treatment of diabetes if it is not too, not well controlled.

So with regards to GLP1- agonist, a few points, it's more popular as a weight loss medicine, but it can be used for the treatment of Type 2 diabetes. In fact, it was started as one of the drugs for managing Type 2 diabetes but at different doses.

Basically, it helps reduce our appetite and acts through several mechanisms in the body by acting on the brain and also on the stomach.

It provides additional benefits, It's like an all-rounder. It provides heart protection.

When used on its own, it is unlikely to cause extremely or low dangerous glucose readings.

And it indirectly has a positive impact on the blood pressure and the lipid profile for the cholesterol levels.

These are the commonly known GLP1- agonists, Monjaro, Ozempic, Wegovy.

The ingredient or the chemical in that is a GLP1- agonist.

We have the options of using both injections and oral preparations and there are different doses available.

The most common side effect being bowel related can cause nausea and vomiting. Therefore, it has to be titrated over a period of time and different people can respond differently in terms of efficacy or the side effects.

And it's important to inform the doctor or your primary care physician if you're on this medicine.

Now, as the saying goes, prevention is always better than cure. So what can we do to prevent Type 2 diabetes?

We start by monitoring people who are at high risk. For example, those who are overweight or who would fall in the category of obesity, obese, or have a very strong positive family history of diabetes.

I mentioned about pre-diabetes previously, people who have a diagnosis of prediabetes are at slightly higher risk for heart disease compared to the general population who do not have diabetes.

Again, the same principles of management would be used to the lifestyle interventions which is individualized.

It's vital that we reduce the calories in people who have risk factors or who have prediabetes or Type 2 diabetes.

Different people have different types of meals, some are carb rich, some are fat rich. End of the day, the calories need to be reduced.

A dietitian would have a vital role in signposting to the right type of diet for that person, and also to give some information about the carb content of commonly ingested foods.

Physical activity is always helpful at every phase of diabetes.

Now, people who are obese are at a higher risk of developing Type 2 diabetes, and if the help of lifestyle changes or with the help of medications, there is a weight loss anywhere from five percent or higher.

It helps in preventing Type 2 diabetes and I, emphasize the need to have adequate sleep.

Due to the nature of changing work profiles, we now have more sedentary jobs, so we spent more hours sitting at the desk.

So it's important that we remain physically active.

Throughout the day and we're aiming for gradual weight loss because rapid weight loss can also cause complications.

Because I mentioned about obesity in the previous slides, I'll just Let's talk briefly about obesity.

It's now recognized as a disease. It's a chronic, progressive, relapsing, multifactorial and a treatable disease.

Just under one third of the UK population are obese and the most common cause of death in this cohort of people is cardiovascular cause and the worldwide obesity rate has doubled in the last thirty years, and hopefully with the appropriate use of the right medications and change in lifestyle, the rate of increase will hopefully slow down.

Now, obesity is defined based on the BMI and the BMI can change based on the ethnicity as well in terms of the diagnostic criteria.

When there's inadequate response to lifestyle management, if they fulfil the criteria and the conditions.

Pharmacological therapy would be indicated but there's some national guidelines and national criteria for initiating the weight loss medications but regular monitoring is recommended once these medications are started.

There are some situations, not always, where there could be a reason for the weight gain.

And therefore, if that is suspected during the clinical assessment, we would do some basic tests to exclude any hormonal problems related to weight gain.

For example, there might be mild weight gain due to an underactive thyroid gland.

But that can be assessed and investigated in the clinic.

As I mentioned before about lifestyle changes, dietitian input, and pharmacotherapy.

This is an ongoing treatment approach to managing diabetes.

In addition to treating the obesity, an assessment is required for review of other potential cardiovascular risk factors.

And if, for example, we pick up hypertension or high blood pressure during the assessment, we can start the treatment for that.

Now, the management of in the management of Type 2 diabetes, it's essential that we look into their cholesterol levels. A person with diabetes may have high cholesterol, even if that person is not overweight or obese.

Along with the cholesterol, we measure other parameters.

A person may have high cholesterol without having diabetes, for example. So, if high cholesterol is diagnosed, it's good to assess for diabetes by doing a simple screening blood test.

We have treatment options. In fact, statins are the most common class of drugs used for treating high cholesterol.

If intolerant, we have alternative treatment options for high cholesterol.

So I'll talk briefly about Type 1 diabetes.

Now, this can present in any age group but generally presents in the younger age.

It's a very demanding condition and it's a lifelong condition which has impact on the person as well as the family.

A diagnosis, these symptoms may be very severe, requiring hospital admission, unlike in Type 2 diabetes, where people may not necessarily have severe symptoms.

Especially in kids, when they're present, they could be having severe symptoms and rapid progression of the symptoms, requiring hospital admission.

It's an autoimmune condition and therefore the risk of other autoimmune conditions is increased.

But the symptoms are more or less the same. It is symptoms of excessive thirst, passing urine more frequently, weight loss.

Throughout my presentation I'd be emphasizing on the concept of glucose monitoring and it's the same for Type 1 diabetes.

Where it is vital that the glucose levels are monitored regularly, fortunately, with advancement in the technology, we now have sensors or also called continuous glucose monitors.

The treatment is basically giving insulin or taking insulin, and we use a combination of different insulins to achieve optimum control.

As a legal requirement that a person who's on insulin should inform DVLA.

And along with The treatment of diabetes, should be regular screening and monitoring for other potential complications and hence the need for doing regular eye checkups.

Review of their foot and also monitor for the possibility of developing other autoimmune conditions like celiac disease, for example.

And there are several education programs online and in the NHS to educate regarding Type 1 diabetes and Always emphasize on glucose monitoring

It's important because it helps us with the information. It helps us Understand the trend in glucose values and gives a feedback to us, to the person living with diabetes and will help adapt their lifestyle.

This will increase the chances of maintaining or attaining good diabetes control and this will, in turn, prevent or delay the complications related to diabetes.

As a clinician, it also gives the information, the required information that's required to titrate the dose of insulin based on the glucose readings

and during the consultation we would be reviewing the regime and also decide on the titration if required, or if indicated.

I mentioned about the sensors also called continuous glucose monitors. This is just an example of one of the sensors. It's called Dexcom one place. Another popular sensor is Libre sensor, which is available free on the NHS.

This gives us more information, as I mentioned previously, about the patterns of the glucose readings in the body.

The trend whether it's going up or it's going to remain stable or it's going down and what's the percentage of glucose readings within the normal range.

Equally important is it has got this functionality of audible alerts. So if we can set the threshold as say for example, set the glucose threshold as fourteen and if glucose goes above fourteen, it'll bleep and it'll kind of, it lets us know that glucose is rising. So with that information we'll be able to act on it.

These are the traditional glucose meters. I've given some examples here, but this is a finger prick glucose monitor and the readings are accurate.

With regards to treatment for Type 1 diabetes, which I touched base previously, briefly, I also wanted to mention a few other points.

In addition to the insulin injections. We had the option of using a pump device to deliver the insulin instead of the pens.

It really is, it's important that the person with Type 1 diabetes knows how to carb count.

It'll help decide how much insulin needs to be administered after food, or sorry, before food or with food.

I spoke briefly about continuous glucose monitors, and it is free on the NHS.

So with that information, one can decide how much insulin needs to be given.

During every consultation, a cardiovascular risk assessment is done and I would also emphasize the importance of foot care in diabetes, not just Type 1 diabetes and currently there's no cure for Type 1 diabetes.

So I mentioned about insulin pumps in my previous slide, it's a portable device that delivers insulin. This is just an example of one of the pumps.

It is an efficient method of administering the insulin, provides more flexibility and generally gives better control and reduces risk of dangerously low glucose readings.

But this requires a multidiscipline input from the dietitian, from the diabetes specialist nurse, and the doctor.

And it's currently, not recommended for the treatment of Type 2 diabetes in UK.

I had mentioned about this condition in one of my previous slides. It's called LADA, also called 1.5 diabetes.

It occurs in adults as an autoimmune condition, a person with this condition will eventually need insulin, but we cannot predict when the person would end up on insulin.

It's important to recognize this condition early so that the right interventions can be started.

And a person may have features of both Type 2 and Type 1 diabetes, but the principles of treatment are still the same. It's regular monitoring, investigations, and treating.

Diabetes complications. I mentioned that this is the second goal when we are managing a person with diabetes, and that is to prevent or delay the complications.

There are two factors that determine the risk of developing complications. One is the severity of high glucose and second is the duration a person has had high glucose.

I've listed some complications, like the eye, retinopathy, nerves, there could be a problem of neuropathy. Again, with regards to the heart, people can have heart disease.

And, you know foot complications are also common. Every person is different, so we cannot predict who's going to develop the complication.

But we know people who have poor control are at a high risk of developing the complication the rates of progression may differ. For example, someone may have, say, kidney disease, stage one and we can't see when they're going to, when the person would go into stage two or stage three.

But the aim in my care is to provide an individualized treatment regime that's practical and helps prevent and delay complications. In fact, every clinician endeavours to achieve this goal.

Because I mentioned about diabetes, foot. I would like to say a few points about the diabetic foot disease.

So diabetes can affect blood circulation in the in the feet, it can also affect the nerves.

So when there's chronic high glucose, it increases the risk of infection.

And because foot is at a high risk of injuries or trauma or impacts, there could be minor injuries.

In fact, the foot infection is the most frequent complication from diabetes requiring hospitalization.

So I just, I say in my practice, if one does not want to come to hospital. Make sure you take good care of the feet.

And the infection may start with a trivial trigger. It may be just a minor break in the skin, and it can spread superficially or it can go deep down into the bones.

When a person has chest pain or breathlessness, the person goes to the hospital and I would like to emphasize that if a person with diabetes has got any infection or ulcer in the foot, that person should seek medical attention.

So the principles of treatment are quite simple. Actually the time is the essence. Once you seek medical attention.

If infection is suspected, we start the appropriate antibiotics and if required, we do the wound debridement and do the proper dressings and depending upon the severity of the infection, we may have to do offloading.

It's a term that's used to use special footwear and prevent additional pressure on the foot which has got the ulcer or the infection.

That's an opportunity to also assess the blood circulation of the feet, and if there is reduced circulation, we may have to refer to the specialist for further treatment and strongly recommended to stop smoking, as smoking is an independent risk factor for reduced blood circulation in the feet.

And certain tests are requested like simple blood test or taking a swab from the ulcer. And if required, you can do some X-rays or even in an MRI scan.

Again, this is an opportunity to review the blood glucose levels and change the regime if not well controlled.

I keep emphasizing on this point of glucose monitoring, because anytime a person presents with a complication of diabetes, a comprehensive assessment it's ideal to review the glucose levels and titrate the dose of insulin if they're on insulin or review the medications if they're on tablets.

Now, technology has changed the landscape of diabetes and strongly recommended that people who are eligible for sensors or continuous glucose monitors make use of this technology to help manage the diabetes.

Now, finally, living with diabetes is a big challenge.

During the consultation, we may spend anywhere between fifteen to maybe forty-five minutes.

But the rest of the time it is the person with diabetes who's looking after the condition. So, the foundation Of diabetes management is self-care or I would say self-management.

And a person with diabetes needs to know the potential side effects of the medicines they're taking.

And as I mentioned about technology in the previous slides, this can help in managing diabetes.

A person with diabetes needs to inform DVLA if they're taking insulin because it’s illegal.

Can you hear me?

Damien

Yeah, we can hear you. Sorry. Thanks. Thanks, Dr Sighakoli. I think we just missed about thirty seconds. That was all.

Dr Sameer Sighakoli

Okay. Right. Thank you. So I'll be quick. So I was saying about the driving. So people with who are on insulin should inform DVLA and they may have to do some separate paperwork to allow them to drive.

It can also impact the work life because people have different shifts. People may have to do different shifts, including night shifts. They may have to take regular breaks to administer insulin.

Family has a crucial role in supporting a person with diabetes. They also need to be aware of the potential risks and complications associated with diabetes.

For example, if somebody were to have a dangerously low glucose and to collapse or pass out, the family would need to know what to do in that situation.

So that brings to the end of my presentation. But I would like to mention that during an endocrinology consultation, a thorough assessment is done of the symptoms, and a comprehensive review is done.

A comprehensive review of your glucose levels is done, and we also take into consideration the potential complications one may develop with diabetes.

So by the time you leave the consultation, you should be Able to go home with a clear plan after reviewing the different treatment options.

Thank you and I'll pass on to Damien.

Damien

Yeah, thank you, Dr Sighacoli, really interesting, much appreciated. Yeah, so if you get answers, if you've got any questions, please pop those into the Q&A box at the bottom of your screens. We've got some coming through now.

We've actually got, Ashok, asking, whether you could give a little bit more information on, on being pre-diabetic?

Perhaps maybe sort of symptoms to look for and well however you interpret that really.

Dr Sameer Sighakoli

Yeah. So that's a very important question because the incidence of prediabetes is also increasing.

People with prediabetes may not necessarily have symptoms.

There is a small possibility that they might have minor symptoms like, for example, they may notice some numbness or tingling, or they could have some change in frequency. Sorry they could. They could be feeling excessively thirsty, but that's less likely with prediabetes is more common with diabetes.

So prediabetes is usually picked up when there is a routine screening test done, or a routine clinical review done, or a blood test, or sometimes when somebody's having some medical procedure and they're having a glucose check or a HbA1c test as part of their assessment for the surgery, for example.

So it's more about being aware of the condition and also having regular reviews.

Damien

Yeah, no, fantastic. Thank you. So we've got George asking. So George is a Type 2 diabetic and asking whether this can be reversed with change of diet and lifestyle alone. George is 47 years old and he has an HbA1c of 98.

But he's not keen on using medications if he can avoid it.

Dr Sameer Sighakoli

Yeah. So short answer is yes. In Type 2 diabetes, we use this term called remission, where if identified early on, and the appropriate changes are made with lifestyle changes where this significant calorie restriction is done, then one can achieve remission in Type 2 diabetes.

But If You have symptoms, if you're not feeling well, then you may have to start treatment first, and once it's controlled, you could consider weaning down the treatment.

So to kickstart the process of achieving good control, you may have to take some medications.

But it's proven in studies, and there's been research on this, so severe calorie restriction can help with remission of Type 2 diabetes, especially in the first few years after diagnosis of Type 2 diabetes.

Damien

Lovely. Well, that actually moves on quite nicely to this next question from an anonymous attendee. If a Type 2 patient reaches the stage where insulin is used, is there any way back from that treatment?

Dr Sameer Sighakoli

Yes, so it's a good question. So if a person with Type 2 diabetes has been on oral medications handle.

Has been on a combination of different class of medications, and if the control is not adequate or suboptimal.

We start insulin and, generally speaking, as we age, as the duration of diabetes increases, the chances of requiring insulin also increases.

But there are situations where, for example, somebody is obese or overweight and diabetes control is poor or inadequate. We might advise starting insulin to make sure the control is good.

But if the person manages to lose weight, then there are situations where we have to cut down on insulin or even stop insulin.

So short answer is yes, we can do that. But it's again depends on the individual circumstance.

Damien

Okay, yeah, grand, thank you.

Next question was, what's your advice for young adults, especially with Type 1 diabetes, regarding diabetes and pregnancy? And typically, is this discussed in primary care or perhaps further consultations, family planning, et cetera?

Dr Sameer Sighakoli

It's very important. So for a person with Type 1 diabetes who's planning pregnancy, it's important to have a review in the secondary care. I mean, obviously, primary care physician needs to be informed as well, but, we have antenatal diabetes service in every hospital in the NHS and in secondary care.

We have dedicated multidisciplinary teams and you'll be eligible for the sensor. You could also be potentially eligible for an insulin pump.

And we have what we call a pre consumption service and before planning pregnancy, the appropriate advice will be given in terms of achieving the target, safe target ranges from a pregnancy perspective.

Damien

Yeah, okay, lovely. Thank you. Yeah, so we've got another anonymous question here, and this is how does insulin resistance present and, I guess, be investigated? This person's struggling with weight. They have gestational, excuse me, diabetes managed with metformin.

And I think their weight was really good, probably the best it's been for a long time.

Alongside sorry, this one's quite a long one.

So yeah, weight's been the best it's been for a long time, and lots of energy, but since weight gone up, really struggling to lose it despite dietary changes and activity alongside fatigue, inflammation, and other conditions.

It sounds like she's tried Wegovy as well.

Dr Sameer Sighakoli

Okay, so you mentioned about insulin resistance, so the risk of insulin resistance is higher in people who are overweight or obese.

There is no specific blood test to measure insulin resistance, but we can calculate insulin resistance by formula, by measuring different parameters.

But if changes in diet and lifestyle modifications have not helped with weight loss.

One might be eligible for the weight loss medications depending upon the criteria that's recommended nationally.

But they're not licensed for the management of Type 1 diabetes. I'm talking about the weight loss medications. But if you had a gestational diabetes, and then, that has and then followed by weight gain.

As I said, if you fulfil the criteria, one could benefit from the weight loss medications and losing weight will help in reducing in managing insulin assistance as well.

Damien

Yeah, lovely, thank you. Janet's got a question here, and, how bad are spikes in glucose readings after eating certain foods? Let me scroll down and see if there's any more to that.

No, that was it. Perhaps maybe, I guess we can interpret that how you wish, but maybe particular foods.

Dr Sameer Sighakoli

Yes. So that's a very good point. So certain food items can lead to glucose spikes. I mean, even in people who don't have diabetes, we can sometimes see what we call as physiological changes after eating certain food items. So that depends on the glucose content or what we call as the glycaemic index.

So, the people who have, a person who has got Type 1 diabetes and has got a sensor or a person who's got a sensor irrespective of the type of diabetes will be able to easily follow the glucose patterns and the trends.

The dietitian will be able to advise on how to avoid that, but just a few points. Having a balanced diet, by which I mean combination of fibre, protein, fat, along with the high glycaemic index foods can help reduce the glucose spikes but when taken on its own, the risk of glucose spikes post-meal is high.

And if a person is on insulin for Type 1 diabetes, then we may have to adjust the dose of insulin based on the carb content of the food.

Damien

Okay, interesting. Yeah, that reminds me of my girlfriend's black bean brownie recipe. Consume some sugar, but higher fibre in the black beans.

We've got David, asking the question here. It seems the common treatment journey is typically pills followed by insulin.

And then he asked them what or what can the patient do?

Dr Sameer Sighakoli

So what happens in the natural history of diabetes? I'm talking about Type 2 diabetes is that by the time diabetes is diagnosed, the body's ability to produce insulin would have come down.

And with time, the insulin that's produced in the body drops further and that's when after, say, maybe 15 or 20 years down the line, the need to support the treatment with insulin increases.

So this is a common scenario where, as you rightly said, you start on medications, but eventually you end up on insulin and that's because of the nature of the disease. Even in spite of the maximum effort you're putting, you might still require insulin to be added to your treatment regime.

Damien

Yeah, okay, lovely, thank you. this next person's actually asking if you can give more details about H01, what it is and how this influences Type 1. I'm not sure if you recognise that one.

Dr Sameer Sighakoli

What is this?

HO-1.

Dr Sameer Sighakoli

I'm not sure. No. I'm not sure what that abbreviation stands for.

Damien

Malakodi, maybe you could, just, give us a little bit more details, in your next question.

We move on to Sandra. Sandra asks, what food should I avoid in pre-diabetics, and I want to get this under control before I go, before I get to Type 2, please.

Dr Sameer Sighakoli

Yes, so that's very important. In fact, when I come across people with pre-diabetes, I advise this.

But it's important to avoid food items such as gut high glyceric index, and we can get the list of those food items online.

This general advice is that have more frequent meals, small portions, rather than having large portions and less frequently.

Anything that's got added sugar, and fortunately, these days, most of the food items that we purchase from the shelves it depicts how much sugar content is there. So anything that's say, for example, shows the glucose is in red means it's got high glucose in that.

And if you still want to have some kind of, if you want to self-treat yourself, then I would recommend you have this high sugar containing food with some other food items like, you know, fibre or protein based.

The best thing is to avoid that, but if you still want to have it, have smaller portions, but more frequently.

The in pre diabetes, the key is if weight is an issue, the key would be to losing weight in losing weight and reducing the waist circumference.

So again, depending upon ethnicities, the recommended base of circumferences are different.

I hope that answers the question.

I think I can't hear you, Damien.

Damien

Sorry, I had a plane go over, and I So we've got David asking, I have an Hba1c of 52, and I'm just about to be prescribed statins, as my glucose is two. Can I reverse the need for statins?

Dr Sameer Sighakoli

You say glucose is two.

Damien

Yeah, that's what it says, yeah. Yeah, I have HBA1C of 52, and I'm just about to be prescribed statins, as my glucose is two.

Dr Sameer Sighakoli

Okay, because glucose of two is extremely low reading, so one may not, one may be very unwell at that value. But going back to the point about statins, so it again depends on the level of the cholesterol in the blood.

With weight loss, we see positive effect on the cholesterol levels as well.

But having said that, if someone has a high risk of developing heart disease, and that is done based on assessment as a whole, taking into account your history of family history of heart disease, or history of high blood pressure.

And based on that, there's a scoring system, and based on that, if the risk is high, statins are prescribed by physicians. So, in your case, if you have high risk, then statins would be beneficial, but if the risk is low, then I say this, the risk is low, and if there is room for losing weight, then yes, we can improve the cholesterol levels in blood.

Damien

Yeah, yeah, no, okay, fantastic.

I've got Amanda here. I'm on type there's a few, questions that are sort of repeating themselves, so I'll just mention that to some of the attendees.

So look back, and this will be recorded so you can listen back.

But we've got Amanda here. I'm Type 2 on insulin, initially from diagnosed. It's now on now I'm on medication only, metformin, with new diet, now gaining weight.

So her HBA1C is 8.5

So yes, I think that's she's been prescribed metformin, but now she's gaining weight.

Dr Sameer Sighakoli

Okay, alright. So HbA1c of 8.5 percent needs to be treated. And if you've just been prescribed metformin, then please continue that.

In fact if I, if I just been start on metformin, it needs to be assessed within three months whether that has helped.

Now, metformin does not normally cause weight gain. It's considered beneficial from that perspective.

If you're having weight-related issues, it's good to assess your thyroid function, for example and if that is normal, then you'd benefit from a dietitian review.

And again, as I said about the principle of calorie restriction, if, let us say, you're still gaining weight and you've reached the threshold where you might benefit from some weight loss medications, then that's a discussion you will need to have with your physician.

But Hba1c, of 8.5% definitely needs treatment.

Damien

Okay, yeah, thank you. We've got another anonymous one here. In your experience, this is a good one actually, does stress play a significant role in Type 2 diabetes?

I have a stressful job and wonder if this might have played a part. I wear a monitor and do see that glucose levels rise during stressful meetings or days.

Dr Sameer Sighakoli

Short answer is yes. Stress has an impact on the blood glucose readings.

And I have seen few people who for some reason change their jobs and they were less stressed and the doses had to be reduced.

Now, there's a concept called stress hyperglycaemia, which means that in stress situations, in terms of physical stress, it can lead to high glucose during and if you suspect that the stress is causing the high blood glucose, it's important to realize whether that is leading to a need for higher dose of insulin.

So I'm not sure what regime you're on, but if you're on insulin, then that needs to be addressed as well. But the changes and fluctuations related to stress are generally mild to moderate, not severe.

But short answer is yes, stress can lead to high blood glucose.

Damien

Yeah, okay, thank you. This one's following on from, Janet's question. What would be classed as a spike?

My continuous glucose monitor shows that my time in range is 100%, but sometimes I'm right at the top of the green band on my monitor.

Dr Sameer Sighakoli

Well, then I would say you're probably having a physiological spike. I mean, that's probably within the normal limits.

So I would not be worried. If your timing range is 100%, then that spikes are probably post meal, maybe in the first one after a standard meal.

So I will not, I would I would say you don't need any treatment for that.

Damien

Fantastic. Okay, good stuff. And another one, quite simply, how can I improve my fatty liver?

Dr Sameer Sighakoli

Okay, so the fatty liver is basically deposition of fat in the liver, and it's being deposited in the wrong part of the body, and that's because of the excess fat.

So if you have, you're overweight or obese, losing weight will definitely help. It could be either through diet or physical activity or weight loss medications, but it will help.

And we see few people with diabetes in my practice where when they have managed to lose weight, the fatty liver has also improved.

Damien

Okay. Yeah. Fantastic. Fantastic.

Next question. So if there is a strong family history of MODY, I'm not sure if you're familiar with that. Good. Can it actually stop diabetes, prediabetes, or insulin resistance?

Dr Sameer Sighakoli

No, if there's a strong family history of MODY, then there is always a risk of the person developing MODY as well. So say for example, one of the parents has got Modi, the different subtypes of MODY.

So if there is a risk or if you feel that you have or if you have been told that you have borderline high glucose readings or abnormal glucose readings, then you would need to have MODY testing.

But it has no link to insulin resistance. I mean, for example, a person with MODY may also have weight-related issues, and they may be obese or overweight, and they could have insulin resistance because of that, and not necessarily because of MODY.

Damien

Yeah. Okay. Interesting. Now, this is an interesting one. I think this is the last one we've got. Another anonymous question.

Can LDL cholesterol rise after weight loss? I've lost I've lost 12.5 stone over the past 10 years. All bloods are really good, but LDL cholesterol is a little high. I've heard bad things about statins, so reluctant to go on them.

Dr Sameer Sighakoli

So generally speaking, weight loss leads to an improvement in all the parameters of lipid profile.

If, I mean, it's, it's a remarkable achievement that you managed to lose 12. Is it 12.5 stone?

Damien

Yeah, 12.5 stone over 10 years.

Dr Sameer Sighakoli

That's a remarkable achievement. So the indication for starting statin treatment would depend upon whether you have diabetes and whether on the scoring system you still have a higher risk of heart problems.

So if that is the case, statins would be advised. Now, if you don't have diabetes, if you only have a mild rise in LDL cholesterol, then that can be supervised and monitored and addition can be made on further subsequent reviews.

Damien

Okay, yeah, fantastic. Yeah, and in fact, I think, this person has also added, that they're 80 years old, normal weight, normal height.

Lost weight once started taking insulin and they happen to be Southeast Asian or South Asian.

I don't know if that has role to play.

Dr Sameer Sighakoli

Yeah. So, I mean, I would still say, I mean, I don't have the exact values, but if your LDL cholesterol is raised, it's important that we continue to monitor that. But given the information that you are showing a positive response in your health parameters, like the weight loss, etc.

You're likely to notice positive effects in LDL cholesterol values as well. But, as I said, we need to look at the specific measurements.

Damien

Yeah, absolutely. Okay, grand. Well, I think that's our questions for this evening. If we move over to the last slide, Dr Sugakoli, that'd be great.

Dr Sameer Sighakoli

Sure.

Damien

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