Podcast Episode 32 Transcript – Exploring Non-Traditional Approaches to Type 2 Diabetes Management Part 1

Leah

00:00:09 – 00:00:22

Welcome to the Ideal Nutrition podcast. This is Episode 32, I am Leah Higl, and I’m here with my co-host Aidan Muir. And today we’re going to be exploring nontraditional approaches to type 2 diabetes management. 

Aidan

00:00:23 – 00:01:13

So as like effective background, I suppose we need to know what is type two diabetes, and I guess just the relevant background info for the rest of everything we’re going to go through with management and stuff like that. I’m going to try and, like, do explain this as simply as possible, but basically probably a better way to phrase this. It is an inability to effectively remove glucose from the blood due to either or both insulin resistance or the capacity of the pancreas to produce enough insulin. Usually it’s a combination of both of those things, and the reason this matters is because Type two diabetes, if not managed well, can increase the risk of conditions such as cardiovascular disease, chronic kidney disease, eye problems and peripheral neuropathy. 

Aidan

00:01:14 – 00:01:54

All carbs break down to glucose in the blood. A lot of people will link diabetes with sugar because it is blood sugars or blood glucose. But all carbohydrates break down to glucose in the blood. Sugar is a form of carbohydrate and sugar or other high gi carbohydrates just get to becoming glucose quicker. They raise glucose levels quicker, but all carbs break down to glucose in the blood. Adding another variable, protein can be converted to glucose, so that can also raise blood glucose levels. And fat doesn’t directly raise glucose usually, but it can indirectly raise glucose. 

Aidan

00:01:55 – 00:02:32

In terms of, say, you had a meal that had a certain amount of protein and carbs and you compare that to a meal had the same amount of protein carbs, but it had fat added to it. It would raise glucose more arguably because it can do some of the functions that the protein and carbs we’re going to do. So it takes over some of those roles, and then there’ll be more of the protein and carbs available to be converted to glucose that were not used for other functions, and the final kind of piece of background in terms of when we’re looking at management stuff like that, because one of it is obviously how do we get less glucose into the blood to need to be taken out by insulin and stuff like that. Um, the other kind of variable is like the insulin resistance side of things. 

Aidan

00:02:33 – 00:02:52

If somebody had excess body fat, decreasing body fat could reduce insulin resistance and might also improve the ability of the pancreas to put out insulin as well. So these kind of factors to be considered, that was a very brief summary for a very complex condition. But I feel like that’s a little bit of background before we go further. 

Leah

00:02:52 – 00:03:34

Yeah, Type two diabetes. It’s a very complex condition. I remember even being in university and just really struggling with that that topic, and I had to go over it so many times before I really got a good handle on it. Um, but usually the big question that comes up with the management of diabetes is “Do you chase remission”, or do you just manage that condition? So remission is defined as blood glucose markers staying in the non-diabetic range for six months without any medication. So a caveat to this is that if you would have followed a low carb diet to achieve that, but it hadn’t addressed the actual disease, like the insulin resistance and the pancreas aspect of things. 

Leah

00:03:34 – 00:03:51

Is it really remission? So you have good blood glucose markers because you’re on a low carb diet and therefore don’t require that insulin to work. Um, so all your blood markers are good, but is that really remission? Probably not, I wouldn’t think it would be. 

Aidan

00:03:51 – 00:04:25

Yeah, it is a complex thing because it’s like the condition is better managed and everything like that. But, like what if you did have a high carb meal and your blood glucose levels weren’t high? What if you took the oral glucose tolerance test and your body still had this inability to clear glucose and an effective rate? That’s the thing that’s not necessarily being like, Oh, well, low carb diets are bad way of managing. It’s not saying that at all. It’s just like if we’re defining remission, you could be meeting the criteria by that technical deficient, that technical definition. 

Aidan

00:04:25 – 00:04:41

But really, it’s probably not building on that caveat, though. What if you did follow a low carb diet and you got to the point that your insulin sensitivity had improved to the loss of body fat and everything like that. And then you could have higher carb meals down the line without it going too high and stuff like that. Blood glucose levels that would be that would be both at he same time, you can manage the condition through having low carbohydrate diet, but also be working on the things that put you into actual remission and treat that condition.

Leah

00:04:43 – 00:05:27

So that’s a good point as well. Um, I think the big thing to note here is that remission is, unfortunately, incredibly rare and a very difficult thing to achieve even before the disease has progressed to the point of medication. Um, so the direct trial we will definitely touch on an affair. Better detail later. Um, but they had 149 non-insulin dependent people with diabetes go through the standard model of care for diabetes management in the UK, and just 4% went into remission over 12 months. That’s a pretty dire statistic, 4%.

Aidan

00:05:27 – 00:05:55

For sure, and like the fact that in that trial they weren’t really far progressed, they weren’t on insulin. They usually had not a super fresh diagnosis, but they hadn’t had had Type two diabetes. Typically, they hadn’t had it for a long period of time. If anything, they’re probably the most likely people to be going into remission and only 4% winter mission in 12 months. As you said, like the reason we’ve kind of picked that is it’s kind of like the easiest way we can kind of like find statistics showing how hard it is to get remission, how unlikely it is.

Aidan

00:05:56 – 00:06:34

A lot of people talk about it being a progressive condition. This is hard because a lot of people on one side of the fence just call it a disease that’s not curable. It’s a progressive condition, curable. That’s that’s another conversation, but like the remission thing, whereas like there, other people like criticising people in charge for not necessarily aiming for remission. But when you look at 4% that kind of number, it’s quite rare to happen. And if every single person of diabetes was chasing remission like based on that statistic, 96% of people are probably going to be disappointed. 

Leah

00:06:34 – 00:07:00

Yeah, and I think remission is one of those things that is It’s a very difficult thing to achieve. So I think you need to be the kind of person that is really gun ho and, like, ready to adapt your whole lifestyle to getting that remission. But it’s a very deep rabbit hole to go down. But I think it’s important to just differentiate managing versus treating this condition. And whilst they can be one and the same, they’re often separate and we’ll come back to like Is it worth chasing a second?

Aidan

00:07:00 – 00:07:40

Because I suppose we would go through what needs to be achieved for remission, to put that in context. So typically for remission to occur, they’re often needs to be two aspects kind of factored in. So one of them is a pretty significant decrease in body fat, which can help increase insulin sensitivity and maybe again, and muscle, which also can help the increase in insulin sensitivity. The gain in muscles a bit of a rare case like I don’t actually see that very much in a lot of people who do achieve remission, but like I have seen that a little bit, some people have definitely noticed the benefit in terms that they’ve lost a lot of body fat. 

Aidan

00:07:41 – 00:08:14

They’ve been around the border of being in remission. Or maybe they have been in remission or whatever. And then they have, like, taking up CrossFit or something like that. And I’ve gained a little bit muscle and, like, oh, my blood because I was managed a little bit more easily, um, so that that’s the key for managing the insulin sensitivity aspect of it and potentially increase in the pancreas ability to put out insulin. But another factor is just like also managing blood glucose levels in the HbA1c so HbA1c is basically like a long term measurement of your average blood glucose levels. It’s based on your red blood cells, which have like an average lifespan of three months. 

Aidan

00:08:14 – 00:08:47

Which is why it’s a three month test, um, and to manage blood glucose levels like if there is a reduction in calories and carbohydrates, potentially or lower glycemic carbohydrates, and say you’re exercising and exercising burns through some of the glucose as well. That will also help in the management of HbA1c and blood glucose levels in the short term, which would also contribute to meeting this criteria for remission. Um, another factor that I wanted to touch on, though that that makes it a bit more of an interesting discussion as well is Metformin.

Aidan

00:08:47 – 00:09:28

It’s not as popular in the bio hacking space now, but it definitely like 5 to 10 years ago. It still does exist, but like in that space. But like 5 to 10 years ago, healthy people were taking that form in in the pursuit of longevity. Because there’s minimal downsides. There is arguably some downsides, but there’s minimal downsides, and improving insulin sensitivity is usually a good thing. It also improves the ability of the pancreas to put out insulin as well. It does a lot of good things, particularly for somebody with diabetes or who is at risk of diabetes with minimal downsides. There is some downsides. It’s minimal. And to achieve for a mission, you need to be on no medication. So you’d have to come off all medications, including metformin, which is an interesting kind of discussion, because that’s just to mee the definition.

Aidan

00:09:29 – 00:10:08

So it’s kind of like if you’re chasing the definition, you’d have to do that. So like most people, probably don’t care about the definition, but that is something to consider as well. But like taking the metformin aspect out of it, just going back to the significant decreases in body fat and all the other things that would probably be required to achieve permission. Is it worth chasing like that? Also comes back to our hustle kind of discussion that we had a few weeks back. Um, what is the likelihood of somebody losing quite a large amount of body fat and maintaining that weight loss for multiple years? Is that something that is likely to happen? 

Leah

00:10:09 – 00:10:36

Yeah, and there’s also the people that I mean. I’ve definitely run into people that are just falling into the overweight category but have a lot of abdominal fat. You have been diagnosed with Type two diabetes and our diet resistant. Like I think we had this discussion that Type two diabetes is not something I see a lot in clinic. The two cases that have had smaller women with that really would very diet resistant in their seventies. So for those people, weight reduction, I don’t know that’s a hard thing for them.

Aidan

00:10:36 – 00:11:11

For sure, for sure, like, and there’s a lot of lot of approaches you can take, but it’s definitely something to think about in terms of only a small percentage of people achieving it. And, like there is a downside as we spoke about. Dieting is a contact sport. Just because somebody has diabetes doesn’t reduce that risk. It’s still a risk to go down. Um, so I suppose before we go through nontraditional approaches, we probably have to touch on what is the traditional approach, particularly in Australia. Like, what is the standard model of care in Australia right now? 

Leah

00:11:11 – 00:11:54

So when you I guess you go to see a GP or you go see a dietitian for managing your type two diabetes, the first lifestyle things that we’d usually addresses likely for a lot of people, that modest weight loss that is something that you know in the research has been shown to be quite effective, even like 5 to 10% of your body weight, um, in in improving the outcomes of type two diabetes for patients that are that are overweight, so sometimes that can be a part of it. Um, but the the larger part of it is usually moderating. Carbohydrate intake and glycemic load. So kind of spacing your carbohydrates evenly out of the day, not having too much in one sitting like really high levels of carbohydrates in one sitting that’s going to, um, spike your insulin

Leah

00:11:55 – 00:12:03

Um, so that’s a part of it, Um, and being low GI sources, 

Aidan

00:12:03 – 00:12:16

What would you say when most dietitians are talking about moderating carbohydrate intake, what would you say that that comes out as on a per meal basis on a across the day basis, like What would you say for that? 

Leah

00:12:16 – 00:12:43

So, usually a lot of dietitians would recommend that you have kind of 2 to 3 servings of carbohydrates like 30 to 45 grams for meals and 1 to 2 smaller serves for snacks. So you’re really spreading that quite evenly throughout the day to manage that glucose and that insulin. So that would be the standard model of care. So it’s not particularly like low carb. 

Aidan

00:12:43 – 00:13:22

It’s just moderating and spread your carb intake, and I’ve seen like dietitians put it out there in terms of being like okay, your main meal should have that 30 to 45 then your snacks. You should have two or three snacks per day and should come out as this amount, um, not necessarily putting a limit on which could be a different kind of discussion as well, being like, Okay, that could be the maximum 45 grams in a main meal or something like that. And I’ve seen some patients. Internal clients interpret that as if they were told to increase their carbohydrate intake. But doing the maps on the top end of all of those ranges it comes out as a maximum of about 180 grams of carbohydrate per day. 

Aidan

00:13:23 – 00:14:04

Assuming you went with the top end of that, I believe the average person probably has around 300 grams of carbohydrate per day. Obviously, some go higher. Some go lower. Most people probably wouldn’t necessarily be aware that they have that amount of carbohydrates per day as well. And when we look at that that that is quite literally, a modest reduction in carbohydrates like it is, it is a modest reduction in carbohydrates. Um, and then when you if you framed it slightly differently being like, Okay, let’s put this kind of a maximum number of, say, 45 grams in a main meal or whatever, so that there’s no spikes in blood glucose levels as well. So that’s not just HBO and see the long term that is just inside a day. There’s no particular big spikes in blood glucose levels or whatever. 

Aidan

00:14:04 – 00:14:45

It is a bit of a moderate approach that could probably would improve the management for most people. It’s not as aggressive as a low carb approach, but it is still lower carb than what most people are doing. But it also does rely on adherence to so to speak, like in terms of like it comes back to a bit of a concept of even though, like on average, it’s like Okay, reduce the glycemic index or reduce the glycemic load. It is still a bit of a You can eat anything but not everything approach. Some people would interpret that being like with the snacks or whatever. Maybe you could have a small slice of cake occasionally within that 30 grams of carbohydrates that snacks, but you couldn’t have a large slice. Okay, because that would be more than yeah. 

Leah

00:14:45 – 00:15:02

It’s a very middle of the road management strategy that’s probably going to be doable for a lot of people, and I think that’s what a lot of management is. It’s like what’s going to be feasible for people to follow and also quite effective, because you do need both of those things in order to have an impact on someone’s life. 

Aidan

00:15:04 – 00:15:31

And another thing that will briefly touch on is like the Medicare system in Australia. So chronic disease management plans like If you go see a GP and you have a chronic disease such as diabetes or type two diabetes, you would get five sessions per year to split across Allied health professionals. Um, the rebate comes out is about $55. So if an allied health professional was to bulk Bill and you would have the free session, you would they would get paid $55 for that session if that was their business.

Aidan

00:15:32 – 00:15:52

If somebody else is higher than than, the business would get $55 and they’d only get a small cut or a salary or like whatever they’re on. Um, and it’s definitely something to think about in terms of five sessions split between, say, dietitian and exercise physiologist, podiatrist, diabetes educator like if you if you’ve got diabetes, there’s a lot of all of that. 

Aidan

00:15:53 – 00:16:28

Yeah, there’s a lot of things you could benefit from. Um so, like what I typically would say is a diary from when I was doing more of that kind of work in terms of like chronic disease management plans is I’d probably get two sessions per year with somebody with diabetes, and it’s like if I chose to bulk Bill, any business that I was working for probably only would want me to see them for 20 minutes, because it doesn’t really make business sense to send spent in, say, an hour with that person. Because $55 when there’s the medical center taking a cut and the business is taking a cut, then there’d be no money left over for the dietitians. 

Aidan

00:16:28 – 00:16:50

You’ve also got a factor in that. You’ve got to write GP letters you’ve got. There’s admin work. There’s all these other things that need to be done as well. So it’s something to consider that it’s like, okay, if they’re not charging a gap, there’s probably not a lot of time. If they’re charging a gap, it’s an. It’s an expense for the patient, basically, and two sessions. It’s hard to change somebody’s life in two sessions, especially with diabetes.

Leah

00:16:50 – 00:17:09

A lot of people come to a dietitians, and they’ve not even really been given a good explanation of what that condition is and how it affects them. So you think that in itself could take one session or more, um, let alone understanding its actual management or deciding on the best management approach for that person. So it’s a lot. 

Aidan

00:17:09 – 00:17:41

Yeah, exactly. And like, even though we’ve, like, skimmed over it, we’re talking about the weight loss stuff. And we talked about the, um, carbohydrate kind of stuff. Like I I would often struggle in that setting being like, Well, what do I focus on, like if they choose never to come back to see me or another dietitian, whatever. I want to cover the carbohydrate stuff. But like then we talked about like how weight loss could help. And it’s like, well, that that takes many sessions like I’ve got to spend a lot of time on that as well like, and it’s hard to cover everything that somebody needs to know. In 1 to 2 sessions, particularly their short sessions. 

Aidan

00:17:42 – 00:18:08

So the reason why I say that is it’s kind of like that’s another thing to factor in when we’re looking at how the standard model of care performs in terms of overall management and remission rates and stuff like that, because it’s like that’s what typically would happen if somebody wasn’t going out of their way to do a lot more beyond the chronic disease management plans. Like seeing dietitians long term and stuff like that paying out of pocket all those other added expenses, time investments and all these things as well. 

Leah

00:18:08 – 00:18:20

Yes, it’s just from a logistical perspective, the standard model of care probably could use improvement. I don’t like in terms of the direct trial. I don’t know what standard carers in the UK, but I assume it’s probably something what we’ve got here.

Aidan

00:18:20 – 00:18:51

That’s exactly the assumption I made. So what I reckon we’re gonna do is we’re gonna call it here and call this part one of the part, too, because we have a lot we want to cover in the nontraditional approaches. And I just wanted to like, I want to get the background cover to set us up for the next one. Um, so the next one, we’re gonna be talking about very low calorie diet. We’re gonna be talking about that direct trial. We’re going to talk about low carb diets. We’re gonna talk about plant based diets, and we’re going to also touch on, like, broad approaches. And like what I personally think I would do in that kind of situation as well and stuff. We can go through there so we’ll call this part one. So thank you for listening to Episode 32 of the ideal nutrition podcast. And we’ll see you for the next one.