As part of our 8-Week Habit Reset program, our participants had the opportunity to have a round table discussion about Diabetes and Insulin Resistance with Dr Wael Berro. We have summarized the key points of the discussion and Dr Wael’s answers to our participants’ questions. 

“My main message today and one that I share with all my patients is “keep it simple”. We have access to so much data and we don’t realize how deep we need to go so understanding the basics is enough to manage our health.”

Let’s start with the basics. Diabetes is a chronic health condition that affects how your body turns food into energy. When we eat, the body digests and breaks down most of the food into sugar (glucose). This sugar then enters into your blood stream where it is moved around the whole body. Every cell in your body uses glucose as fuel, and when sugar levels rise in the blood stream the pancreas secretes a hormone called insulin. Insulin acts like a “key” that opens the cells and allows sugar to go in and be used for energy. If your pancreas is not creating enough insulin, or if your body has developed insulin insensitivity, there will be an issue with sugar control.

There are two types of diabetes

Type 1 Diabetes, is when your pancreas does not make insulin. This is mostly an autoimmune condition where the cells in your pancreas are attacked by your own immune cells. Without insulin, the sugar in your bloodstream raises to dangerously high levels and can be fatal. This type of diabetes is diagnosed mostly in childhood and the only treatment available is insulin. Today insulin delivery is advancing and hopefully we will one day have a mechanisim to transplant a pancreas or create an artificial one that mimics the biological function in real time.

Type one diabetes typically comes at an early age and presents with acute setting. Today, it makes up 5 to 10% of all diabetes cases and that is because of the steady rise in Type 2 diabetes. I predict these numbers will continue to change as more people are diagnosed with Type 2.

The only treatment is insulin for life from the time of diagnosis. Unfortunately, and this is the sad reality of life, because only 5 to 10% of cases are Type 1, most funding for research goes into Type 2.

There are no preventive measures and it typically tends to be genetic, but that doesn’t mean everyone who has Type 1 diabetes will give it to their kids – as it’s not an autosomal recessive / autosomal dominant condition. However, you are more likely to have it if it runs in your family. It is also common for people who have an autoimmune disease, to have other autoimmune diseases. So autoimmune diseases such as thyroid disease, Hashimoto, Graves disease, etc generally come under one umbrella. So, if you have one, we expect you might have more. I also advise checking your Vitamin B12 as B12 deficiency could be autoimmune as well.

Type 2 Diabetes is when the pancreas is functioning fine and creating insulin but the body does not respond to this insulin. Now, even though type 2 is not an insulin related issue, one way of treatment is insulin because increasing the insulin can create the desired response. So when the body doesnt respond to the proper dose of insulin increasing the amount helps. This was the treatment mode before other medications came on the market. Now we probably have four or five options before we talk about insulin.

That’s why it breaks my heart when I see type two diabetics on insulin because either their doctor was too afraid to explore the new options, or they’ve been on insulin for too long and they’re afraid of stopping it.

One of my favorites things to do is to help my patients stop or reduce their medications, including insulin for type 2 diabeties. Because insulin is a difficult medication to handle.

So when you have diabetes your body does not manage sugar and the amount of sugar will increase in your bloodstream. And because blood flows everywhere in your body from your head to your toe, diabetes affects every single part of your body.

Type Two is caused by insulin resistance or ineffecient use of insulin. So the pancreas is secreting insulin, but our body is not sensitive to it. So there’s something not working well in terms of that relationship. Here is where we try medication such as Glucophage/Metformin, which is one of the cheapest, most effective medications that has been around for more than 30 years and is still going strong. It makes your body more sensitive to insulin. So it recognizes the insulin signal and starts taking the sugar out of the blood stream.

The main difference between type 1 and type 2 diabetes is that type 2 is preventable or at least it is possible to delay it’s onset and slow down it’s progression. When we say that weight loss helps to improve type 2 diabetes it is usually due to the healthy lifestyle choices that led to that weight loss such as increased physical activity and an improved diet.

Why do we become insulin resistant?

We don’t really now how or why it develops. There are some insulin resistance theories but nothing definative. We just know that this happens and we work to increase sensitivity. As long as the pancreas can increase its insulin production it can stabilize blood sugar.

What are the symptoms of Type 2 diabetes?

There are many symptoms that are associated with Type 2 diabetes but they are all very vague and they could be due to any reason. Unexplained weight loss for example – I have never had a patient come to me and say I’ve lost weight without trying and their concern was diabetes.

The reality is Type 2 diabetes is asymptomatic in the early stages of the disease. That means there are no symptoms.

The importance of regular health checkups

Most people are diagnosed during a regular health check. Which is why health checkups are so important. Now, it is hard to convince people to come for these checks. Many complain they don’t have time or worry that it is a commercial ploy to make money.

However, many of these chronic illnesses such as type 2 diabetes are silent diseases. For example, older generations used to wait until they had their first heart attack to be diagnosed with ‘everything’. Then they would be prescribed a cocktail of medications to manage their health. Which would be a shock for them because they felt that they were healthy all their life and suddenly at 65 everything went wrong. In reality, they would have had these conditions 10 to 15 years – at least – before their first serious symptom. As the damage slowly buildups in the body. The beauty of today’s life is that we check more which means we can diagnose early or even predict who is at risk and can therefore work on preventative measures and avoid unnecessary medications.So don’t wait for any of these very vague general symptoms and just get regular checkups.

How is diabetes diagnosed?

Diagnosing diabetes is really very simple, cheap, effective. It can be done  using fasting sugar levels or the A1C test. You can also do a two hour sugar test however it is a very uncomfortable test and is really unessecary in most cases.

I prefer the A1C – Basically this is an average of your three months sugar level and is better than the snapshot picture fasting glucose will give you. Simply put under 5.7 or 5.8% is normal, over 6.5% you’re diabetic, the higher, the worse. I’ve had patients with 13% which is very, very bad, really bad. And the aim once you’re diabetic is to push the numbers back into the normal range. Anything in between 5.8 and 6.4 is prediabetic. It’s a very simple way of classifying people. These numbers don’t change overnight – and that’s important for people to know you will not go from 5.8 to 6.4 in three months time because you were not eating healthy. This takes years and years. It’s a slow process. So this goes back to getting regular health checks so you can detect changes and work on prevention early.

Just remember it is not just about the numbers, it is about reducing the risk of disease. As a doctor, I’m not in the industry of making your numbers better. My aim of treating your diabetes is to reduce your risk of having heart attack, heart disease, arterial disease in the next five to 10 years.

So for diabetes, the highest risk is heart disease?

Remember, diabtetes affects your blood sugar levels and your blood goes everywhere in your body. So, it affects everything in your body. Literally everything! It affects your arteries, small organs, solid organs… it goes to your eyes and may cause blindness, it goes to your brain and may give you a stroke, it will go to your arteries and cause a heart attack, it can also can damage your nerves so you lose sensation – typically we call it the glove and socks attribution because we start losing sensation from the periphery, it goes to your kidneys and causes kidney damage. So we want to stop it before it causes all these issues.

So if you are prediabetic? What does that mean? What lifestyle habits do I need to change? Do I need to eat less sugar?

You need to reduce carbohydrates. The changes you need to make depends on the individual, so if you are someone who doesnt exercise or doesnt eat well then yes changing your lifestyle is the first course of action. Hoever, if you are leading a healthy lifestyle and still your numbers are going uop then there is probably a genetic cause and this is where we explore pharmecuetical therapies. Again remember it takes years for the disease to develop so keep your checkups regular. But also remember that you should not let the fear of developing a disease take over your life.

As you mentioned earlier as soon as someone is diagnosed with diabetes, in addition to the diabetes medication they are also put on medication for cholestrol or high blood pressure? Why is it all connected? Or why do the doctors feel they have to treat all these diseases together?

Risk! What we’re doing is we want to reduce your risk of having a heart attack. So we do that once you have a problem, in addition to primary prevention, we have secondary prevention. So primary prevention is before the problem happens. So eating healthy and exercise to prevent diabetes. But now you are diagnosed with diabetes. The next step is to prevent the disease from getting worse – which is called secondary prevention. So for example I would always advise assessment of arteries using a CT-Scan. If we see early signs that your artery is narrowed by 20 to 30% – which would have no symptoms and would not be detected by a treadmill stress test – we will put you on cholesterol medication, even if your cholesterol is ‘beautiful’. Also if your blood pressure is at the upper levels of normal we prefer it to lower it down, because now what we’re doing is risk control. You may feel you are on too many medications but we just don’t want it to get any worse.

Can you become dependent on these medications?

There is a misconception that you will become dependent on diabetes, blood pressure or cholestrol medications. People think that if they start these medications they will never be able to stop. If you change your lifestyle and you manage to improve your numbers eating healthy and exercising and now your blood pressure is 110 over 60 all the time and your sugar and cholestrol are stable then you can definetly reduce medication dosage or stop them under your doctors supervision.

However, life is unfair! You may do everything right and live a perfectly healthy life and still you will sometimes need medication. So don’t feel that having to take medication is failure, be greateful that it is available to improve your life.

So should we only worry if we are prediabetic? What if our number is 5.4?That’s 2 points away?

So wherever your number is it doesn’t necessarily mean it will go up. Even if you are prediabetic it isn’t inevitable that you will develop prediabetes.You could stay at the same levels for the next 10 years.

Between your 40s and 60s many changes will happen in your body, your lifestyle and genetics will determine how quickly these changes occur. So don’t stress out if you are on the border of prediabetes today, try to improve your number with some managable lifestyle changes and just keep an eye on it. And if you are doing your best and you’re healthy, and the numbers are still going up, we can consider pharmaceutical treatment if we have to. The whole point is to reduce your risk in 10 to 15 years, but not everyone who is prediabetic will need medication.

However, if you’ve been pre diabetic for five plus years, some studies now advise that if your numbers are constantly in the prediabetic range despite your health habits, and you have other factors such as being overweight, higher cholesterol level, age, a bit of family history, then your risk might be a bit higher. So there are some indications that medication would be a good idea.

Do you recommend postponing because there is a risk that once you start you can’t come off?

Honestly, you can be taken off most medications if the underlying problem goes away. However, if you have had a serious problem – for example you had bypass surgery or a stent, this means you have arterial disease. Think of the arteries like a tree, if one branch is diseased it is very likely that the whole tree is affected. So in this case medication is needed for life. However, if you were taking medication to lower your risk of developing a disease and you have now made some drastic changes and the risk factors are gone then there is no issue with coming off the medication. Some people however may become psychologically dependent on the medications and will be to scared to come off them.

The issue with medication is how much risk a doctor and patient are willing to take. A doctors job is to treat the problem and make sure it doesn’t get worse. Medications can do that and lifestyle changes can do that – but a doctor needs to believe that the patient is capable of changing. Medication will always be the easiest option and for most people the easiest thing to stick to.

Is it safe to just stop any medication?

No, I can’t say so. Because I don’t know the medical history of the patient. But any medication depending on your risk and the reason why you’re on it can be stopped or reduced under the right conditions. And this includes weight, age, family history, cholesterol, diabetes, blood pressure, smoking/drinking habits, lifestyle, etc. All of these factors have to weighed and then we decide.

Now lets talk a bit more about treatments.

Lifestyle! Really lifestyle, eating habits and exercise. You can talk to a dietician (I always prefer a clinical dietician to a nutritionist or health coach) and identify ways to improve your diet. Also include physical activity in your life.

Of course there is also pharmacology if needed. Not everyone needs medication but they can prevent the disease from getting worse and affecting your organs. Metformin or Glucophage is a simple, basic medication. It’s effective in lowering your sugar levels however it doesn’t protect your heart and doesn’t reduce your heart attack. Another medication, Jardiance is effective and may reduce risk of heart attacks by 33%. So this is very significant. So now it’s being used as a first step in diabetics. So that is a very good drug for people with a high risk of heart disease.

Then you have the injectables, which I’m sure you’ve all heard about the daily the weekly one and then finally if we have to – and hopefully we never have to – you can use insulin.

What about supplements? For example Berberine? You don’t need a prescription so can it be taken prevetatively?

With supplements it is hard to tell. Because supplements are not studied the same way as drugs. One thing I would always advise someone taking supplements is to make sure to regularly check their kidneys and liver. It becomes more complicated if you are taking both pharmaceutical drugs and supplements because we don’t know how they will interact.

Also, in the market you find different dosages of supplements so it’s hard to tell which to take.

We don’t have the studies and it is very hard to initiate studies for ethical reasons. We can’t take people off pharmaceuticals that we know reduce risks of heart attacks and put them on a supplement and then see who dies of a heart attack 15 years later. So as doctors without the scientific studies it is hard to tell which supplemts are significantly affective.

How do you test for insulin? Is there a specific test?

Ok, remember my first rule – “Keep it Simple“!

Insulin resistance has gained a lot of momentum globally and here in Dubai in particular, especially with gynecologists who use it to study polycystic ovarian syndrome – PCOS. There was some association that people who have PCOS had higher levels of insulin, and we really couldn’t understand the mechanism. However, there was no direct association with diabetes. We started noticing that some people just have slightly higher levels of insulin. Until a few years ago, we didn’t even have a normal range for insulin. So even if we measured insulin, it was hard to interpret it.

Insulin is a hormone produced by your pancreas and it’s regulates your blood glucose levels. Glucose is a nutrient and your body’s preferred energy source. Insulin resistence is a sub-optimal biological response to normal insulin levels. Basically something goes wrong in the relationship between your sugar and insulin.

Your pancreas will usually detect a rise in glucose levels in your bloodstream and will secrete insulin to take the excess sugar our of the blood stream. So if you have insulin resistant for some reason, now you have higher levels of insulin, your body is a bit desensitized. There’s a bit more insulin being secreted because normal levels of insulin won’t get the job done.

So insulin resistance means that there’s too much insulin?

Insulin resistance forces the pancreas to make more insulin to see an appropriate response. So the normal levels of insulin are not enough to control the glucose levels.

Honestly in my practice, I don’t measure insulin much as part of a checkup screening for diabetes. If you’re diabetic, I don’t care what’s your insulin level because it’s not going to affect the management and my treatment plan.There would be no benefit in knowing if your insulin is slightly higher or you have insulin resistance besides making you anxious. The message I will send you home with is that same, eat healthy and exercise – because that’s the treatment.

So, does medications like metformin and glucaphage make you less resistant to insulin?

The way Metformin works is by making your cells more sensitive to insulin. So in theory, your insulin becomes more effective. So then you don’t need as much insulin and insulin secretion decreases.

Is there any benefit of taking slow release metformin?

Don’t worry about the preparation on the formula. So slow release just means that it is processed more slowly by your body. It lasts longer and instead of having to take it twice a day you take it once.

One more thing I want to add about Metformin

It doesn’t make you lose weight. Or at least based on the many studies that have looked at metformin over the past decades you could lose between one to three kilos in a year. This is probably not related to the medication but rather due to lifestyle changes you make by you being told that you have insulin resistance or diabetes.

What are the consequences of obesity related insulin resistance?

The major consequence is impaired sugar tolerance, impaired fasting glucose,Type 2 diabetes, and an increase in insulin resistance in Type 1 diabetes. Second is coronary artery disease. Third is metabolic syndrome. Metabolic syndrome is a cluster of conditions that occur together, increasing your risk of heart disease, stroke and Type 2 diabetes. These conditions include increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. Fourth is Non Alcoholic Fatty Liver Disease (NAFLD). This is a very concerning disease, NAFLD is the new kid in town that no one wants to play with and no one should be playing with. 20 years ago when I was a medical student, we didn’t worry about fatty liver and the only concern was alcoholic liver disease. Now the data is scary. The biggest reason for liver cirrhosis is expected to be NAFLD because we still don’t have any treatment for it. The only treatment we have is lifestyle changes, reducing your cholesterol, losing fat and it is really picking up very quickly it’s scary.

How do you test for NAFLD?

For any organ in the body, there are two things we do – blood tests which test for function and a scan to check for structural abnormalities. So even if your blood tests are ok, it is important to get a scan. If we start seeing that your function is affected and you have high risk for fatty liver, you need something called FibroScan because fatty liver can lead to cirrhosis. Cirrhosis is a condition in which your liver is scarred and permanently damaged. Scar tissue replaces healthy liver tissue and prevents your liver from working normally. As cirrhosis gets worse, your liver begins to fail.

What are the symptoms of NAFLD?

Liver disease, like kidney disease, like diabetes, like high blood pressure to a certain extent is a silent disease. If you wait for symptoms – for example jaundice – then is it too late. Therefore early detection through regular sceening is essential. Which is why I keep pushing and raising awarness – regular health checkups can save your life.

The liver is a beautiful organ and it has the ability to regenerate If we treat it well. Fatty liver takes years to develop and to become cirrhosis, so it’s not really bad news if you’re told you have fatty liver.

The risk of developing a “Sick Person” identity

One thing about getting a diagnosis early on, it’s not really a problem and it can be very beneficial and you get a chance to do someting about it. The problem is if you buy into seeing yourself as “sick” – the sick person identity. This idea gets planted in your mind. So if your doctor tells you “you’re prediabetic, but don’t worry, it’s okay. But be careful” – I promise you will wake up at 1 in the morning remembering an aunt who had diabetes and her kidneys were shutting down!! But the reality is that in most cases if we catch these diseases early – they are reversible.

When you put people on medication, does that make it easier for them to change their lifestyle behaviors or do they think okay, I’m going to take medication so no point in changing?

I think people are becoming a bit more educated about how their behaviors affect their health. We all have busy lives, and people have valid reasons for the way they live – I travel a lot, I don’t have time, I’m stressed, I’m working long hours. So the easy option or lets say the available option is to take the medication, because everything else requires more work. For example, we’re supposed to exercise a minimum of 150 minutes plus per week, over three to five days. That’s a lot of commitment for some people with other responsibilties and they don’y know how to make time. So when the disease gets worse the doctor has no choice but to prescribe more medication.

So, all of this to me leads to the question, because on the internet, there’s 5000 different answers. What are the lifestyle changes? What is the correct diet? What is the correct amount of exercise and the right kind of exercise?

There is no right answer. What works for one person won’t work for someone else. So even if you live in the same household, eating the same food, and following the same exercise regimin -it will still lead to different results depending on whether you are male or female, your hormones, different stresses, your cortisol level, your body type, your genetics, it’s complicated. Someone might come and tell me I’ve been on this diet, and I’ve lost 10 kilos. I try it and then get more depressed because I was more strict and it didn’t work for me. So the sad reality there’s no perfect method, there’s trial and error.

Now one thing that used to be very popular, and now is public enemy number one, is calorie counting. I think that is making a come back, know your calories. This is like your money, you need to know how much money you have. You don’t need to be obsessed and check your account everyday, but you need to know how much money you have because that’s how you know how much to spend. Now, with our health – the proper action is that we what to spend the extra calories we have in the “bank”.

Enjoy your food but don’t just eat whatever it is good to have guidelines. No food is off ;limits and of course it is ok to indulge in moderation. I am completely completely against restrictive diets, because I am genuinely a very big advocate of mental health. I think it stresses people out and there’s no way you’re going to sustain it. No way! Whatever we do has to be sustainable.

Are there any diets you would recommend?

When it comes to diets, Intermittent Fasting is a good idea if done right. So it really depends on you eating healthy during the eating window. But again it will only work if you can sustain it.

I have used a Continuous Glucose Monitor, and one surprising thing is that it showed a glucose spike during exercise. Why does that happen?

After eating we will usually see a spike in glucose levels and one of the best ways to reduce that spike is through light physical activity – like taking a walk. So, it might feel contradictory that you see a glucose spike during a workout session.

This can depend on the intensity of your workout. During a bout of high intensity workout like HITT, heavy lifting or sports like tennis your body will release stress hormones (cortisol and adrenaline) that tell the liver to release stored glycogen into the bloodstream and to produce new glucose from available sources to provide the necessary fuel for your muscles.

This is a perfectly normal response and means your body is working the way it is supposed. However, if you have diabetes you will need to check with your health provider what exercises you should be doing and check your glucose levels more closely.

How about a gluten free diet? Is that useful in case of diabetes or Hashimoto disease?

Avoiding gluten in the diet may help alleviate some symptoms of Hashimoto’s. Celiac disease, an autoimmune condition that causes the body to react to gluten, is more prevalent in people with other autoimmune conditions, such as Hashimoto’s thyroiditis. If you do not have celiac disease, you may still see an improvement in your Hashimoto’s symptoms by eliminating gluten, though the research is mixed. We recommend discussing methods of treating your Hashimoto’s symptoms with your doctor. If you choose to follow a gluten-free diet, a dietitian can help you implement these changes in a healthy way that works for you.

The link between gluten and diabetes differs according to the type of diabetes:

• Type 1 diabetes has links to celiac disease because they are both autoimmune conditions. People with diabetes and celiac disease should avoid gluten.
• Type 2 diabetes is not an autoimmune condition and has no links with celiac disease.

While gluten itself is typically safe for people with diabetes, many foods that contain gluten, such as white bread and biscuits, also contain sugars and carbohydrates. These types of food can have a significant impact on blood sugar levels, so people with diabetes should limit how much they consume. It is also important to note that gluten free foods contain carbohydrates and calories. These foods can still impact blood glucose and cause weight gain, so people should still monitor their intake.

About Dr. Wael

CONSULTANT FAMILY MEDICINE
BCH NUI MICGP MRCPI (IRELAND)
MSC/DLSHTM HEALTH MANAGEMENT (ENGLAND)

Dr. Wael Berro is an Irish-trained Family Medicine Consultant, originally from Lebanon, who is well-known for his fantastic interpersonal skills, patient centered approach, and evidence-based practice.

Dr. Wael has an honours degree from the Royal College of Surgeons in Ireland and trained in major teaching hospitals there. He has completed dual specialty training in Internal medicine (MRCPI) and Family Medicine (MICGP). Prior to undergoing his medical studies, he completed a Master’s Degree in Health Management from LSE/LSHTM in London.

With more than 16 years of high-level clinical experience both in Dubai and abroad, Dr. Wael has joined our growing team at Circle Care Clinic.

He is available to consult in English, French and Arabic.

You can book appointment with Dr Wael at Dubai Herbal & Treatment Center and Circle Care Clinic in City Walk and Al Thanya.

wael@circlecareclinic.com

wael@dubaihtc.com