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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP Programme 2. - type 2 Diabetes
RADIO 4
THURSDAY 6TH MARCH 2008
PRESENTER: BARBARA MYERS
CONTRIBUTORS: NICK OLIVER
PRODUCER: BETH EASTWOODÌý
NOT CHECKED AS BROADCAST
MYERS
Hello. Diabetes in middle age often seems to come out of the blue, with few obvious symptoms to speak of it's often only picked up only on a routine test. But we may be missing the obvious clue. Carrying a lot of extra weight, especially if you have a big waist, is a key risk factor for late onset or type 2 diabetes. And weight loss is the key to controlling it. Diet and exercise are often enough to stabilise blood sugar levels and to reduce the complications that may arise such as heart disease and kidney failure. Though medication may in the end be needed, drugs to start perhaps insulin injections in due course. If you would like advice about prevention and control of type 2 diabetes which is thought to be affecting up to three million adults in this country well you've come to the right place because here in the Check Up studio today to answer your questions is Dr Nick Oliver. He is a diabetologist - a diabetics expert - at St. Mary's Hospital in Paddington.
And the first caller, I think, is on the line now. Who shall we go to first? Caroline Kerley is there and she's in Somerset. Caroline, have you got a question about diabetes?
KERLEY
Yes. I've recently been told that I am borderline diabetic and I have been given a leaflet to read about diet. And I took it home and found in fact that it's very much the diet I follow. The other thing is - so I really don't know what I can change in that respect - the other thing is that the symptoms that took me to the doctor were extreme tiredness and blurred eyesight. And so the exercise is a problem because I find it so difficult to motivate myself because I'm so tired all the time.
MYERS
Well let me hand you straight over to Nick to talk about diet and exercise and the part that they might play in reducing symptoms that Caroline's described and the diagnosis that she's been given of borderline diabetes.
OLIVER
Hello Caroline.
KERLEY
Hello.
OLIVER
Could you just give me a little bit of information? The borderline diabetes diagnosis - did you have a blood test for that?
KERLEY
I had two glucose tolerance tests, yes.
OLIVER
So you had that done twice, is that right?
KERLEY
Yes.
OLIVER
Okay. And you had some blurred vision and tiredness before that?
KERLEY
Yes.
OLIVER
Well both of those symptoms are very common in type 2 diabetes, particularly when you're developing the problem and I understand that you're borderline, which suggests that the way your body handles glucose isn't quite normal but isn't quite in the range that we would define as diabetes. Now you've been given diet information and that's absolutely the right thing to do, though you tell us that you have been already on a diet, which is very similar to the diabetes diet, so very well done for that. There have been several studies done over the past decade or so that have shown that exercise is absolutely crucial at this stage, where you have a pre-diabetic state and if you exercise a lot what you can actually do is prevent the progression to type 2 diabetes by around 30-40%. So the advice you've been given to do exercise is absolutely the right thing to do as well, though it is very difficult when you're feeling tired and particularly with blurred vision to do these things. What sort of exercise have you been trying?
KERLEY
Well I like to go walking, I used to go swimming but I've kind of given up on that and I do go to an aerobics class on Thursday evenings.
OLIVER
Well that all sounds excellent. When we say exercise it doesn't have to be aggressive, you don't have to get on an exercise bike and cycle at full pelt for an hour, you don't have to go and run marathons. Walking down to the shops instead of getting the bus, doing some gardening - mowing the lawn - these all count as exercise. If you're a little bit our of puff doing something then that's exercise enough. So it doesn't have to be - it doesn't have to be playing football once a week.
MYERS
Is it possible, I'm wondering, from what you're saying, if it is borderline or pre-diabetes that you can possibly reverse things if you do all the right things - get the weight down, take plenty of exercise and so on?
OLIVER
Yeah absolutely, these studies done over the last decade have really prevented people developing type 2 diabetes. And whilst the way your body handles glucose may not go completely back to normal you certainly don't get the problems associated with type 2 diabetes and that makes a massive difference.
MYERS
Caroline, thank you very much for the call. We'll move to another one also in the West Country, we've got Mrs Harding waiting to speak to us, again with a question about type 2 diabetes and weight, what's the question for our expert today Mrs Harding?
HARDING
Hello. I'm curious as to whether you can get diabetes without being overweight. I'm one of those lucky people who can eat what they like without putting weight on. In fact I'm underweight according to all the charts. But my diet is admittedly high in sugary foods and refined carbohydrates, so I'm wondering if I'm storing up problems for the future?
OLIVER
Well I certainly hope not. When you're underweight you can still develop type 2 diabetes, though you'll have heard a lot about if you're overweight you're at much higher risk of type 2 diabetes. But certainly we do see some people with a normal body mass index, that's a normal weight, or even slightly underweight developing type 2 diabetes. So your risk isn't zero because of that but your risk will certainly be less. And something else you said there about eating a lot of sugary foods - people often feel that if they eat a lot of sweets they're at higher risk of diabetes and that isn't true, except that obviously if you eat a lot of sweets or if you have a poor diet you may put on weight and that may put you at higher risk of diabetes indirectly.
HARDING
Right, so that the weight and the likelihood of getting diabetes don't automatically go together?
OLIVER
Well there is an association and the more you weigh the higher your risk of diabetes in general. But the risk doesn't go down to zero if you're underweight I'm afraid to say.
HARDING
Right, okay thank you.
MYERS
And just to - so we can be clear because I was talking in one of the trails about the waist size and this is something that concerns me because I don't think I'm overweight but I've never had a trim waist. How important as a sort of proxy measure of your risk is waist size?
OLIVER
Well waist circumference is essentially a measure of how big you are round the middle and it's the central obesity, as we call it - how big you are round the middle - that really confers the greatest risk of type 2 diabetes. Waist alone correlates well or is associated with the rates of type 2 diabetes and the ratio of the waist size to your hip size also associated very well with your likelihood of developing type 2 diabetes in the future. So it's not just about how much you weigh, it's about where that weight is and if it's around the middle then that confers an even higher risk of diabetes.
MYERS
Bad news for those of us with larger waist sizes. Let's move on to another caller, we've got Patricia Payman, and she's phoning us from the Netherlands, she's very welcome, thank you. Patricia?
PAYMAN
Yes, good afternoon. I've always had a thick waist, I was born with a thick waist and even as a youngster my waist was two inches bigger than my normal dress size. So sort at about 20 I had a 28 inch waist, 30 inch and now I'm 68 and I've got a 42 inch waist, my bust size is 42. It just doesn't go - I'm active, I have a dietician and I do some exercise but I don't like it but it's the waist - I can't lose it from the waist.
MYERS
Well I think you're in good company Patricia, it's a story one does hear a lot from friends and colleagues, just even if you feel you're in good shape and look as though you're in good shape but somehow that fat around the middle is just a problem. Exercise obviously is going to help, diet is going to help but in the end if you really can't shift it I guess your risk continues of developing type 2 diabetes, that's a fact is it Nick?
OLIVER
Well it is if you look at populations. And this is a - if you take a thousand people, all of whom have big waists, then you'll see that the rates of diabetes in that population will be much higher. What you can't do so reliably is apply that rule to one single individual. And there are lots of other risk factors that we have to take into consideration for type 2 diabetes. Now it may be that if Patricia's always had a big waist it may be that's partly genetic, partly just the way she is and perhaps other people in your family, Patricia, have big waists.
PAYMAN
Yeah we are thick waisted yes.
OLIVER
So perhaps that doesn't confer any risk of type 2 diabetes. Does anyone else in your family have diabetes?
PAYMAN
Nobody has diabetes but I could be possibly borderline.
OLIVER
You could be possibly borderline. Well look the usual advice applies and exercise, as we keep saying, in developing type 2 diabetes exercise is crucial to prevent that. But if you're doing the exercise, if your diet is good, if you're the size that you are and if you're well then obviously we would encourage you to lose a little bit more weight if possible ...
PAYMAN
I would like to yes.
OLIVER
And I'm sure you'd like to. But your risk perhaps isn't solely down to your waist size, it's also your genes and your family and your diet and sometimes risk can go back as far as how much you weighed when you were born and even the environment you had when you were in the womb. So it's a lot more complicated than just your waist size and we would give you the usual advice of diet and exercise and exercise can be miserable but perhaps mowing the lawn, doing some gardening, doing something that isn't sitting on an exercise bike may be more pleasurable for you.
MYERS
Nick, I don't suppose there is such a thing as a drug that can help you - help prevent diabetes, I mean clearly there is medication, we may hear more about that, if you have diabetes to help you control your blood sugar but is there anything that can prevent the development of this disease?
OLIVER
Unfortunately not. The big studies that have looked at preventing people at risk developing diabetes have of course looked at drugs but actually drugs were less successful compared with exercise. So exercise remains the holy grail for preventing type 2 diabetes I'm afraid.
MYERS
Okay, let's go to a caller now in London, Miranda Moore. Hello Miranda, your question for Dr Nick Oliver our diabetologist - a hard word to say.
MOORE
Good afternoon. My question's very simple, I really wanted just to know if one developed late onset diabetes if it was purely something that could be controlled by weight, if one is also overweight, or you've already said that exercise is the great thing but can it actually be reversed if one loses weight?
OLIVER
A very good question. As I said earlier the sort of pre-diabetic states, where your glucose metabolism isn't quite normal but isn't quite diabetic, we can prevent people develop type 2 diabetes but these are all sort of a spectrum of disease where you go from normal along a straight line all the way through to diabetes. And you don't suddenly wake up one morning and have type 2 diabetes. So if we say that pre-diabetes is reversible then there's no reason why early onset - sorry I shouldn't say early onset - recently diagnosed type 2 diabetes, where things are well managed, there's no reason why that can't be if not entirely reversible why it can't be well managed and why you can't prevent your glucose levels getting worse.
MYERS
Is there something that perhaps people don't quite appreciate that it is a progressive disease but it will only progress if you continue perhaps to be overweight, eating the wrong sort of diet, not doing the exercise - so there's a great deal we can do to limit the impact of the disease albeit not necessarily get rid of it completely, that predisposition may still be there.
OLIVER
Yeah absolutely. type 2 diabetes is something that once you're labelled with we tend to keep the label but you can certainly prevent this progression and it doesn't have to be by tablets - diet and exercise will help these things to stop progressing. But people get very frustrated with type 2 diabetes because even if they're behaving well with their diet, if they're doing exercise, sometimes the levels of treatment they require continue to go up and people feel that's a personal failing. And it really isn't - type 2 diabetes is a progressive disease, you get a little bit more resistant to the insulin you make and you make a little bit less insulin over time and that needs increased treatment but it's not a personal failing and it's important to reassure people with diabetes that they're doing well, that they have good glucose control, that their exercise and diet are working well.
MYERS
Is it also important though Nick to perhaps remind people of some of the effects and some of them are quite serious health effects if your blood sugars go out of control over a length of time and you really are not able to control them whether with lifestyle changes or with medication?
OLIVER
Yeah absolutely. I mean we really don't like to scaremonger and we don't like to frighten our patients but it is important for the people with type 2 diabetes to understand that if it's poorly controlled and if we don't manage their blood pressure and their cholesterol levels and we don't get them to stop smoking and manage their lifestyle they are at much higher risk of developing heart disease, strokes, vascular disease in their legs, kidney damage, eye damage and nerve damage. And it's a frightening list and we don't want to make people live in fear but it is important to understand that looking after diabetes really can prevent these complications over a long period of time and lead to really no problems with quality of life and diabetes is something we should encourage people to live with and manage well rather than be frightened of.
MYERS
Let's go to Julia Carpenter, who is trying to manage through diet, but has got some questions and haven't we all got questions about dietary advice, a lot of which seems very contradictory, I think that's true. Julie over to you, what's your particular point?
CARPENTER
Hi Nick, hi Barbara. Well I was diagnosed last summer with type 2 diabetes and I'm an ex-nurse and I'm a science technician, so I know a bit about what's going on in your body. And I know that if you eat carbohydrate, any type of carbohydrate, whether it's what's called good carbohydrate or refined carbohydrate, it's going to turn to glucose in your body. And I'm somewhat puzzled by the advice that you get at the diabetic clinic that you have to have carbohydrate with every meal, particularly as in the '70s when I nursed carbohydrate was strictly controlled for diabetics and they only were allowed so many units of it. So I'm slightly puzzled as to why all of a sudden it's perfectly permissible for diabetics to eat carbohydrate and are actively encouraged to do this when years ago you weren't supposed to and as we all know it's turned into glucose in our body?
MYERS
Okay, well made point, what's the answer Nick?
OLIVER
Yeah a very well made point and absolutely right and you're pointing out something that's changed really in the way that we've managed diabetes from a couple of decades ago to now. And you're right that the old dogma was that we would be very proscriptive and we would tell patients with diabetes they really mustn't eat any carbohydrate because you're absolutely right - any carbohydrate you eat turns into glucose, puts your glucose levels up and can cause these complications that we've talked about.
MYERS
So this is your bread and your pasta and anything with sugar, even fruit with sugar in it and so on, all of this goes in and - goes into the bloodstream as glucose or as sugar?
OLIVER
Absolutely, yeah absolutely. And we used to give our patients very clear advice to avoid as much carbohydrate as possible. We've realised over time that people can't stick to that diet, it's simply not realistic and it's also a monastic sort of lifestyle that's really unfair on people with diabetes. And what we've changed to doing now really is to encourage them to eat as normally as possible. And in doing so we have to obviously cover the amount of glucose they eat and they have to have a sensible balanced diet and when I say cover the amount of glucose they eat, I mean with their treatment or whatever they're using to control their diabetes. You're right when you said Julie about complex carbohydrates and refined carbohydrates - the good and bad ones - and we want people with diabetes to eat complex carbohydrate. It does get broken down into glucose but it happens over a longer period of time and don't forget that carbohydrates are an excellent source of energy and all of the cells in the body need these things - your heart, your liver, your red blood cells - rely on glucose and indeed your nerve cells - rely on glucose as energy. So we have to eat a little bit. The more we can have as complex carbohydrate that's absorbed slowly and gently into the bloodstream the better.
MYERS
And people will have heard perhaps about the GI diet, so called, but eating foods with a low glycaemic index, so that's to do with how quickly the sugars in the food, in the carbohydrates, are released. So would you say then, as a diabetologist, that's a useful diet to follow?
OLIVER
We don't specifically encourage people to follow a low GI diet and I have to say I'm not a dietician at this stage and I would bow to a dietician's superior advice on this. But we don't specifically advise low GI diets, they can be difficult to follow and difficult to understand. We suggest healthy balanced diets with sensible foods, avoiding frying, avoiding lots of fats and avoiding lots of refined sugars but we don't say that people with diabetes have to definitely cut out any particular sort of food.
MYERS
It is quite complex, as you say, and often have to hand over to the dietician but just a final comment perhaps on an e-mail from Hannah who says that since she started a low carb. eating plan a year ago she's fitter than ever, she's lost eight kilos in weight, got rid of most of her tablets that she's been taking for type 2 diabetes and feels that this is the way forward. So it's interesting, you know, the proof of the pudding in that case again is perhaps the fact she's lost the weight is the key to it.
OLIVER
I think that would probably be the most important fact there. And the first thing to say is well done Hannah, that's exactly what we want our patients with diabetes to be doing, we want them to be embracing a healthy lifestyle, improving their overall weight and improving their reaction to insulin, which she's clearly doing and she's managed to come off some tablets which is superb.
MYERS
Okay, let's go to Andy Coleman who's in London with a question, I think on behalf of his mum. Andy over to you.
COLEMAN
Thank you. My question is about managing and monitoring blood sugar for people with type 2 diabetes. My mother was recently diagnosed with type 2 and was put on a regime of tablets and diet. She was told that she would get a blood test every three months at her GP's surgery and would therefore not be given a blood test meter. How can she manage her blood sugar on a daily basis and ensure she's not getting high readings without testing her blood sugar herself?
OLIVER
That's a very good question. Certainly if people have type 1 diabetes or if they have type 2 diabetes treated with insulin injections then they do need to do self monitoring of their blood glucose at home, using a little monitor that will give you a result in a few seconds of what the blood glucose level is. In type 2 diabetes when you're treated with diet or tablets alone is a little bit of a different story. When you're treated with insulin the idea of testing your blood glucose is that you can change your insulin doses, you can look at how your body's responded to a meal and some insulin and you can learn from that and change for the future. It's a little bit more difficult when you're taking tablets to make these self adjustments yourself because the doses are a little bit less easy to tweak. And that's why I think your mother's been advised to have a blood test every three months or so, which I suspect will be called the HBO1C blood test which gives us an idea of the blood glucose over the last three months as a sort of average. And this is pretty informative for us as diabetes specialists and we can look at the result of that and we can make adjustments to the tablets from that. Metformin is a nice tablet, I think your mum's taking Metformin, is that right?
COLEMAN
Correct yes.
OLIVER
That makes her more sensitive to the insulin that she's producing, it has a very low incidence of causing low blood sugars, so that's good, and it's a very safe tablet to take. So every three months it would be very acceptable for her to have an HBO1C blood test and she doesn't need to do self monitoring of blood glucose in the meantime, studies have shown that it doesn't make any difference to your HBO1C over time.
MYERS
Hopefully that answers your question Andy.
COLEMAN
Thank you.
MYERS
Thanks for the call. We'll move to Claudia who's again got concerns about type 2 diabetes and wondering about losing weight, are you like the rest of us struggling with that Claudia?
CLAUDIA
I certainly am. I'm very overweight, I've been diabetic since '01 and I have been following the GI principles for quite some time and I have my five a day. I do all that. I also have osteoarthritis in my legs, so I can't walk like I used to, I used to do long walks and I can't do that anymore. And I must say I haven't been doing much exercise. But how can I lose the weight?
MYERS
A plea from the heart there and many people will have the same concerns, particularly if you can't be so active.
OLIVER
No absolutely. With osteoarthritis it is difficult to do exercise and obviously you get into a little bit of a vicious circle there if you're carrying around some extra weight, it gets more difficult to do exercise. And it really can seem very difficult to get out of that. So it sounds like you're doing all the right things in terms of your diet - you're eating fresh fruit and vegetable and you're following a diet that's low in refined in carbohydrates - so well done for that. And I'm sure you're trying to do as much exercise as possible, given the limitations. So why aren't you losing weight? Well one of the answers may be related to your treatment - do you know what tablets or insulin you're taking?
CLAUDIA
Yes I'm taking - oh hang on a sec ...
MYERS
I hope it's handy and you're not having to go upstairs to find it.
CLAUDIA
No it isn't.
OLIVER
Do you take insulin Claudia?
CLAUDIA
No I don't, I don't, I have high blood pressure, I take Glicaside.
OLIVER
You take Glicaside. So how Glicaside works is that it increases the amount of insulin that your own pancreas is producing. Now insulin is a wonderful hormone but it puts glucose and fat and protein into cells, so it builds tissue, and it does that from an evolutionary point in that when we didn't eat for a few days it would put things away in storage for us. Now if you're only taking Glicaside that can make it difficult to lose weight and there's some evidence that it can even make you put on weight because it increases the amount of insulin you've got. So what it may be worth doing is obviously continuing with the diet and exercise as much as possible but having a chat to either your GP or the diabetes specialist that looks after you and have a chat about other tablets and other treatments that may not increase your weight quite so much.
MYERS
Okay. We'll have to leave it at that. I want to put in finally a very quick question, I was hoping to go to Rodney but I know that his question is an interesting one, perhaps I can paraphrase it. He's wondering whether liposuction would help people with type 2 diabetes. Of course liposuction is sucking the fat out, in this case, of the abdomen. It sounds like a very nice quick fix, would it work?
OLIVER
I think the short answer is probably no. The central obesity, the central fat, that puts you at risk of type 2 diabetes is really the fat around the organs, the fat particularly around the liver, so I don't think taking fat from under the skin would help I'm afraid.
MYERS
What a shame. Thank you very much. I hope some of the other advice, however, you will find helpful. Thanks for your calls, for your e-mails and thanks to our expert Dr Nick Oliver for the answers today. If you've missed anything you can of course go to our website where you can listen again to the whole programme, that's at www.bbc.co.uk, follow the prompts to Check Up. You can download this programme and indeed the whole series as a podcast or if you'd actually like to speak to someone about further sources of information then call our help line, that's 0800 044 044.
And join me again next week at the same time, we have answers and questions about chronic obstructive pulmonary disease, otherwise known as a bad chest.
Ends
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