 To the latest edition of Tell Health in Hawaii, I'm your host, Vikram Acharya. I'm the Chief Executive Officer of Cloudwell Health, an all-virtual telemedicine provider based in Hawaii. We have a great show for you today, a very important show for you today. This month is Diabetes Awareness Month, and on the show with me today is Dr. Martin Abramson. He is an Associate Professor of Medicine at Harvard Medical School. He is the author of the great book, Conquer Your Diabetes, Prevention, Control, and Remission. Dr. Abramson, how are you today? Hi, Vikram. Thank you so much for having me on the show. Delighted to be here. All is good. And as you say, it's a very important month, Diabetes Awareness Month. Absolutely. Very important month. Let's get right into it. Dr. Abramson, you're a diabetes specialist. I am. Physician, physician leader. Tell us a little bit about yourself, your background, and your role, specifically when it comes to diabetes education, patient care, and research. Sure. So I actually got my medical degree at the University of Cape Town in South Africa and did all my training there and my subspecialty training in diabetes and endocrinology. And then in 1992, I was recruited to what was the Beth Israel Hospital in Boston, which is a Harvard teaching affiliate. And the major focus of my role there was to set up and run a diabetes program for patients. Then subsequently, there was a merger with the Deaconess Hospital forming Beth Israel Deaconess Medical Center, which forged a relationship with Jocelyn Diabetes Center. And I had the good fortune to then head up the section on adult diabetes at Jocelyn for about four years and then became the chief medical officer at Jocelyn for almost 10 more years before becoming a senior vice president for health and awareness initiatives at Jocelyn. And then I transitioned back to Beth Israel Deaconess Medical Center because I wanted to pursue more of an educational role which I had already been doing in the form of continuing medical education at Beth Israel Deaconess Medical Center, where my co-author and colleague, Sanjeev Chopra, and I have been running continuing medical education programs for more than 25 years. But there was also an opportunity for me to engage in some international continuing medical education initiatives around the world, teaching primary care physicians more about managing diabetes and hopefully disseminating the information to physicians in the front of the line to manage people with diabetes. So as you know, diabetes is really something that needs to be managed right by the primary care physician. 80 plus percent of people with diabetes are gonna be managed by primary care physicians. And so what we established was a program where endocrinologists and other key opinion leaders would teach primary care physicians in these countries, China, India, Malaysia, Saudi Arabia to name a few, better management strategies for people with diabetes in the hope that we can help people with diabetes live better lives. Our goal as educators has always been a number of eyes, inform people, inspire people to do a better job, get people to include their new knowledge in day-to-day management of people with diabetes. And in the end, the big goal, improve the lives of people with diabetes. Absolutely, you know, many people, especially due to the COVID-19 pandemic have gone at least one to two years, maybe more without seeing a primary care physician, and which raises the possibilities of obtaining something like diabetes. For our audience, what is diabetes? What happens to the body? And what kind of symptoms per se can you check for when it comes to diabetes? Yeah, diabetes is a disorder where the body cannot metabolize glucose efficiently. As you know, glucose is the key source of energy for cells, but it needs to get into the cells in order for the cells to use the glucose as energy. And in diabetes, glucose does not get into the cells of the body for a variety of reasons. Now, the commonest form of diabetes is what we call type two diabetes. In this scenario, there are a number of things that go wrong. Number one, there's a condition called insulin resistance, which develops over time. Insulin resistance does go hand in hand with obesity, although there's a genetic predisposition as well to insulin resistance. But as we've seen society gain weight over the years, so too have we seen this epidemic of diabetes reach magnitude numbers, such that they're in the United States over 37 million people today with this disorder. So to get back to the causation, insulin resistance on the one hand, what does that mean? That means that insulin, which is the key hormone that drives glucose into the cells of the body is not working efficiently, cannot do its job. And then on top of that, the cells that produce insulin in the pancreas, the so-called beta cells of the pancreas, become less able to make enough insulin to overcome the resistance. So the beta cells begin to fail and as a consequence of that, we have rising glucose levels in the blood. Now type two diabetes accounts for probably 95%, more than 90% of people with diabetes today. There's also type one diabetes. Type one diabetes is a different disease completely, although the end result is the same, glucose rises in the blood. In type one diabetes, there is destruction of the cells that make insulin, almost 90 plus percent of the time by what we call an autoimmune process, where for some reason, the immune system of one's own body turns on the cells that produce insulin to kill them, destroy them. And so ultimately people with type one diabetes produce no insulin. They need insulin to survive. Without insulin, they cannot survive. In type two diabetes, there are other medications outside of of course diet and exercise that are fundamentally important as management strategies for diabetes. But there are other medications that can be used other than insulin to help lower the glucose levels. But ultimately, many people with type two diabetes may also need insulin, but not necessarily insulin dependent, insulin requiring. Those are the two common causes of diabetes. Now you asked about symptoms. When blood glucose levels rise really high, there are a number of symptoms that can occur. First of all, there's excessive thirst because what's happening is the glucose is being filtered through the kidneys and glucose is an osmotic substance that takes water with it. So people pee a lot. They have excessive urination. They tend to become dehydrated. They get very thirsty. They may lose weight because all the calories that they ingest are not being metabolized properly. They're not being taken into the cells of the body. And so they may lose weight. They become tired because the cells are not producing enough energy. They may get blurred vision. They may have urine or vaginal or penile infections. They may get skin infections. Those are the sort of common symptoms that can occur. In type 2 diabetes, many people are asymptomatic. And unless they are screened and diagnosed, they can go on for years without being diagnosed with diabetes. In fact, we know this from studies that have been done many years ago, over 40 years ago started showing that there's a percentage of people with type 2 diabetes when they are diagnosed, so-called newly diagnosed, they already have some complications of the diabetes present. So in some cases, people could be having type 2 diabetes for maybe a year or two, possibly more and may not even know. Maybe longer, maybe longer. That's why it's very important to follow guidelines that recommend regular screening for diabetes in adults. And if there are risk factors for type 2 diabetes, that screening should begin in young adults and even potentially adolescents. At the moment, the screening recommendation started about 40. But if you have risk factors, family history, overweight, high blood pressure, high cholesterol levels, if you have a history of, if you're a woman who has a history of diabetes developing during pregnancy, something we call gestational diabetes, if you have a condition called polycystic ovarian syndrome, all of these things, if you're overweight with one or more of these risk factors, you should be screened at any age for diabetes, starting in your teens, twenties if necessary. What takes place during the screening? So if I'm concerned, what exactly happens? It's a simple blood test. So to screen for diabetes, now the simplest test to do is what we call a hemoglobin A1C. A hemoglobin A1C is a test that originally was developed to assess how well controlled your diabetes is. But because it's such a accurate, defined standardized test, we now know that A1C levels between 5.7 and 6.5% are consistent with a diagnosis called pre-diabetes. And anything 6.5 or higher is considered diagnostic of diabetes if confirmed on a second occasion. You can also test the fasting glucose level, which also have a simple blood test, and there are definitions, what is normal? What is pre-diabetes? What is diabetes? And then if you do a test at any time of the day, if your blood glucose is in excess of 200 milligrams per deciliter and repeated again on a second occasion, that's considered diabetes too. So it's a simple test. The A1C test does not need to be fasting. You can do it at any time of the day because it's a test that measures previous glucose levels in your blood for the previous three months. That's very interesting. Now, are there certain populations that are more at risk for acquiring type two diabetes? Yeah, I'm pleased you brought that up. There are certain population groups, excuse me, where diabetes is more prevalent. African Americans, Native Americans, Hispanics, Asian Americans, those population groups, there's a higher prevalence of diabetes. And so we recommend, again, more vigilant screening, sooner more screening, screen at younger ages, especially if people are overweight and have other risk factors because these people in these population groups are at higher risk for the development of diabetes. The thing about diabetes is it's, A, it's easy to diagnose. B, it can be prevented, type two. C, even if you have it, you can control it and with significant weight loss, you can even get your diabetes into remission. And by remission, we mean glucose levels that are normal without the need for any medications. It can be done. How? Let me talk about a lot about that in our book. Yeah, yeah. Now, if I go to a primary care doctor and I'm diagnosed as concerns around being pre-diabetic, for example, what type of steps could I take to prevent becoming full onset of diabetes? So there has been, there've been a number of well done studies around the world showing that diet and exercise with some weight loss, and we're not talking about a lot of weight loss to about 5% to 7% of body weight loss with regular exercise, regular exercise, 30 minutes of aerobic exercise a day, five days a week, what we call moderate intensity. That doesn't mean going on a treadmill and running at full speed. It's going for a brisk walk. And that though, that can reduce the risk for development of diabetes by 58%. Staggering, almost 60% reduction in risk for the development of diabetes by just 5% to 7% of body weight loss and regular exercise. That is not... Better than any pull. Yeah, I mean, that is relatively not a lot of physical work to get your body into remission. That's really impressive. That's prevention of diabetes. Now, if you have diabetes, you probably have to lose more than 10% of your body weight, probably closer to 15% to have a chance of getting the diabetes into remission. But that can be done too. That can be done with diet and exercise and now we have medications that can facilitate weight loss as well. Are there certain types of foods that can put you on, so to speak, on the track to diabetes? Certain things that definitely can trigger. Obviously, there's probably things like chocolate and candy, but what kinds of other foods can put you on that? So the big thing I think that has sort of funneled, flamed this thing has obviously is obesity in this country. And I do think that processed carbohydrates do play a role in that whole development. So processed carbohydrates, simple sugars, sugar, sweetened beverages, they're not the cause, but I think they contribute to this obesity epidemic. So there's no single one food that one can say that causes diabetes. I think it's a constellation, it's a general lifestyle situation. Now, one of the things we tell patients with diabetes who need to lose weight, when they ask us, so what diet should I follow? And then at the end of the day, there's one very, very important statement that I think people need to hear. And that's the diet that you can stick to, the diet that can help you lose weight, notwithstanding the fact that we obviously do discourage excessive amount of sugar, sweetened beverages, simple sugars, highly processed carbohydrates. The principles of a healthy diet are really in the Mediterranean type of diet, all summarized in there. So what we call low glycemic index carbohydrates, carbohydrates that have fiber that are more natural, but not excessive amounts. Healthy fats, what we call polyunsaturated fats, things like avocados, nuts. And then healthy proteins, mostly chicken and fish type of things, but if you wanna have an occasional bit of red meat, and that's part of your lifestyle, that's fine. So the diet that works for you, lowering your caloric intake so that you can lose weight, maintaining an active lifestyle, and that can go a long way towards controlling your diabetes and if you lose enough weight, remission of diabetes. How about areas like, things like rice, in a very prevalent in many cultures to eat rice? Yeah. What are your thoughts on those two? So this is a challenge because we do know that, especially white rice, which has been stripped of all the sort of the fiber, is more likely to cause spikes in your blood glucose. And so, yes it is, in many cultures, rice is a very important part of the diet. Unfortunately, rice is something that is gonna cause an elevation in your glucose. So what we do is we counsel people about maybe limiting the rice intake, cutting it down because portion control is very important. There's a big difference between a bowl of rice and a cup of rice, in terms of the amount of carbohydrate. Now, just to give you an example, a cup of rice contains 45 grams of carbohydrate. That's probably enough for a meal. But a bowl of rice is probably twice or three times that amount. Well, that's difficult, that's difficult. So again, if people feel they have to have rice, it's not, A, if you can have rice, that's got less stripping of the healthy stuff, the brown rice maybe. It may be better, it is better, but having less of it is also important. Putting it in a meal that's got some protein and fat as well, so you're not having just all carbohydrate at one meal is important too, because that helps prevent the carbohydrates being absorbed more rapidly into the blood system from the GI tract. And I'm sure the same, much of the same themes around bread, certain types of bread perhaps. Bread, pasta, rice, potatoes. Those are, you know, the staple diet of many people, you know, and that's something that people need to try and limit their intake of, to be honest with you, if they can, if they're gonna achieve better outcomes with their diabetes. Now, there's a lot of discussion just in general about the importance of mental health. Now, do many of your patients or patients with pre-diabetes or type 2 diabetes, is it helpful for them to also have mental health services with them as they go through the journey of trying to manage it or try and get it into admission? You know, diabetes is challenging. And that's why in our book, we've sort of said conquer your diabetes. And we've got a picture of somebody climbing a mountain and I'll come back to that story about the mountain in a minute. It can be challenging, because it's something that you live with 24 hours a day, seven days a week, 52 weeks a year. And especially type 1 diabetes, where you have to take multiple shots of insulin or be on an insulin pump, and you really have to learn how to match the insulin with the food that you're eating, because otherwise your sugars are going all over the place. A lot of people with diabetes do suffer from depression, feeling down at times, sometimes feeling a bit burnt out because they're dealing with us on a day-to-day basis. So we do encourage people to get support where necessary, but there's also part of the reason, one of the main reasons why we wrote this book was to really tell people with diabetes that A, diabetes does not define who you are. B, there's nothing you cannot do if you have diabetes, pretty much nothing. Let me give you a few stories. In the preface, we talk about a man called Will Cross. He's a man who actually we reached out to when we heard his story and he read the book and he was very kind enough to write an endorsement about the book. Will developed type 1 diabetes when he was nine years old. And that was in 1976. In the early 2000s, Will decided that he wanted to climb Mount Everest. And he climbed Mount Everest. Now, type 1 diabetes, you have to do multiple shots of insulin every day and you have to measure your blood sugar multiple times a day. At the time that he was doing this, there was no such thing as automatic insulin pumps. There was no such thing as continuous glucose monitoring which we now have available. And you had to keep the insulin at a temperature where it couldn't freeze. Once the insulin froze, it was no good. With all this adverse situation, he will climb Mount Everest. And since then, he has climbed the tallest peak in every continent of the world. He has led expeditions to the North Pole and the South Pole. We have other examples of people. I have a patient who was a pilot, was diagnosed actually with type 2 diabetes, but his diabetes was such that he needed insulin. And at the time, pilots were not allowed to fly planes. You were not allowed to fly a commercial plane if you needed to take insulin. Well, technology has changed and after many, many years of lobbying and through committees from the American Diabetes Association which I was fortunate enough to be part of and the advent of continuous glucose monitoring devices and so on, the federal aviation administration ultimately relented a couple of years ago and said with appropriate conditions, demonstrating excellent glucose control, your sugars have to be in a certain range and so on and so forth, they allowed this man to fly. His dream was always to fly planes, but nearly 10 years he was grounded and he was acting as a teacher and with the airlines. But literally two days before his license was gonna expire, he was able to take off and fly. So again, another example of somebody who persevered, who despite so-called adversity never gave up, never gave up hope. Lots of stories about people in this book that are inspirational and truly inspire me. When I see some of these patients in the office, I'm truly full of awe because they have taken ownership and they have said, nothing can let get me down. And they're amazing people. It's such an interesting conversation we're having because as much as there's the medical aspects that you've unpacked for us, it really all starts with the mindset. The mind has to believe that it can go through life normally that it can conquer challenges to your book. It all starts mentally first for a medical condition. You're absolutely right. I mean, we put every chapter of the books got some quotes that we think are sort of learning things. And one of the quotes in the book is from Winston Churchill. And he said, attitude is a little thing that makes a big difference. And how right that is because it's all about attitude. You know, I've got a story about a patient here who had type on diabetes for 82 years. She developed it in 1937 when she was eight years old. And she tells her life story in the book. She gave a talk at one of our medical courses that we run for physicians. A 20 minute talk about her life story. She got a standing ovation at the end. She spoke at the American Diabetes Association talking about her experiences. 82 years, she must have taken well over 100,000 injections. She must have pricked her finger well over 100,000 times in all those years. She embraced technology. Every new advance she was on top of, she was embracing. She was using continuous glucose monitoring devices when she turned 88, 89, even 90. She eventually passed in her 91st year but she'd had type on diabetes for 82 years. She traveled the world. She represented the United States in curling. She took up curling at an age, at a slightly older age and she represented the United States in curling. She was a remarkable woman. And there are people like that that really inspire me to want to continue to take care of people with diabetes. Absolutely. You know, any type of, you know, in two days we're gonna have turkey and pie and any type of advice to get through Thursday and Friday before people start to focus on much more of what you've broken down for us today. Well, you know, I say to people this, none of us can be perfect 100% of the time. So if 90% of the time you're watching yourself carefully and you have a day like Thanksgiving, don't go crazy. Turkey's fine. It's a protein. It's not gonna do anything to your blood sugar. As I said to somebody yesterday, leaving the office, I said, just watch it with the stuffing because that's gonna push up your blood sugar. So, you know, but have a spoonful. Have, you know, have a tablespoon, have two tablespoons. If you're gonna have, you know, a bit of sweet potato with your turkey, that's your portion of carbohydrate. Have some sweet potato. Just be careful. Just be careful. And, you know, I think everything in this world, there's a degree of moderation that we have to talk about. And remember, I'll come back to my old comment. The diet that works for you is the one that you can stick to. But that doesn't mean to say that you can't have an occasional small piece of chocolate. Just don't have half a bar of chocolate, but have a small piece of chocolate and preferably dark chocolate because that's got some flavonoids and other things in it that are healthy. So, that's the sort of, the key message is moderation, do something that you can sustain. And if it's working, stick with it. If it's not working, reevaluate. Dr. Abramsen, it's always a pleasure to have you on. You know, your leadership as a physician, as an author and the book is Conquer Your Diabetes, Prevention, Control, Remission, Excellent Book. Contributions to research around diabetes, taking care of patients. You have a lot to do in a given day and especially during this week. We thank you for being on and taking the time to educate all of us. I just really appreciate it. Vikram, thank you for having me. I'd be delighted to come on any time you want. It's been a pleasure. Thank you. Likewise. Thank you for your time. Have a wonderful holiday. And you too. Happy Thanksgiving. Happy Thanksgiving. And to all the listeners too. Absolutely. Absolutely. Happy Thanksgiving to everyone. Mahalo. Mahalo button on Vimeo. You can also follow us on Facebook, Instagram and LinkedIn and donate to us at thinktecawaii.com. Mahalo.