Diabetology (BLOOD SUGAR) Part 1 Encore with Mike Natter

"Hey, it's me. You're broken, pancreas." Not Ali Ward, unfortunately, but it's me, Dr. Mike Natter here. So why is Ali not here today? Well unfortunately, Ali's feeling under the weather. We think she may have had a relapse of her pneumonia and under doctor's orders, including mine, she needs to rest. And we really want her to feel better soon and we want her to take some time away from work. Ali, we hope you feel better. So instead, we're going to be kicking off a series of encore episodes starting with mine, Diapetology. Ali and I cut this up in 2019. We had a ball. And since that time, a lot has changed to my life. I finished my medical residency. I went on and finished my endocrine fellowship. And now I am a fully fledged endocrinologist in New York City, where I get to treat all the things like adrenal problems and pituitary problems and thyroid problems. But primarily, I'm doing a lot of diabetes, all different flavors. I still have dreams of making my graphic novel, but time's been tight. And I will have it happen, but just not right now. Oh, I also started on a new insulin pump called the beta-bionic eyelid pump. And it's super novel because I no longer need to carve count, which is really, really cool. So all that being said, I hope you enjoy this encore episode of Diapetology with me and Ali Ward. Ali, we miss you. We love you. Get well soon. I'll see you. Oh, hey, it's your friend who looks at listings of houses. She has no intention of buying Ali Ward back with another episode of The Allegies. So this is a real sweet one. It's got everything, everything that you crave. There's a personal connection to The Allegy, a very surprising backstory. My copious sweating. There's human cyborgs. And there's reasons to drink pee. So first, a quick thank you to everyone who's supporting on Patreon and who tells friends and co-workers and fam. This week, Ali, there's number three on the science charts up there with the NPR giants. So thanks to everyone who listens and subscribes and rates. And of course, reviews. Old dad word on podcast reads them all. And because talking into a microphone in your closet toward a pile of laundry can be kind of a weird kind of loansome. Your review has always keep me going. So I read a new one each week. This week, this one's from Dermal Denticole. Who says, "Capt my ADHD attention." I thought podcasts might just not be for me, but I'm so glad I gave Ali, listen, thanks for making everything from my college commute to shoveling a crap ton of snow off the driveway. A little joyful. I hope to listen to these as anologist one day. Well, thank you, Dermal Denticole, for spending time in the freezing cold with me. Speaking of Ali, let's meet this week's "Diabetes" which, as I say often, it's a real fricking word. But what is it? What is "Diabetes"? First off, it is not "Diabetes" as I thought, so I was wrong. Oops. "Diabetes" is the science of diabetes diagnosis and its treatment. So it's a term it's used in medicine, but just not super formally. So it might refer to a doctor who has like an interest or special skills with diabetic patients, which thisologist very certainly does. He has been studying the disease for over 25 years, and he's only in his mid 30s. So we became internet pals in 2013. He makes these really great science drawings. And I have watched his journey from med students to MD, and I have never met a doctor so passionate about his work or his patients or the cause of diabetes. He has a vested, deep and gloopy interest in the hormones that regulate our blood sugar, which I am so excited to talk about. He was in LA from New York City over the summer, and so we sat down in my living room. We had a cab, even though it was blazing hot, and his Friday afternoon lift across town had him arriving. An hour late, he was so stressed out he didn't realize that in LA, showing up in our late is pretty punctual. So we cleaved this episode into. In this first one, you're going to learn of his staggering, very heartwarming journey to being a doc. What blood sugar does, how it affects your mood, and energy, and every cell in your body. Keto diet versus veganism, how many people have diabetes, what could cause it, and why I fall asleep and pants a lot. Also how to handle the emotional aspects of a busted pancreas. So we're about to spill some unsweetened tea on the topic of your blood sugar with wonderful person and diabetologist Dr. Mike Natter MD. Dr. Mike Natter. Dr. Ali Ward. Dr. You are Dr. Natter. You are a doctor. I am. You have been a doctor for Helen. Three years, let's see. So I started, I finished med school in 2017. So I've been a doctor for almost three years. Well, let's talk about your shitty pancreas. I have a shitty pancreas. Let's talk about it. It's busted. You've been a diabetic, longer than you've been a diabetic, a doctor. So Dr. Natter is in his final year of internal medicine residency and he will soon be a board-certified internist, which then leads to your end-recognology fellowship, but he sees and treats patients with diabetes and again has been studying diabetes for decades. At what point did you realize that you're not only the president, you're also a customer? What point did you realize I am baby Mike Natter and I've got a busted shitty pancreas? At what point did I realize I was diabetic? Yeah. Oh, the origin of the story. Yeah. We're going to dig in. Yeah, we're going to dig in because as long as I've known you, I've known your diabetic, type one. Yeah, we've known each other for five years. I know. Oh, Dr. Ward, we go back. I know. I've known your pancreas this long and it's still that worth it. It's a lazy piece of shit. Yeah, it's terrible. I can hear you. So, okay. So, I was, this was two weeks after my ninth birthday. I remember very well. It was pretty traumatic, unfortunately. I was super lethargic. I was really tired and I would wake up at night, three, four or five times to urinate, but also to, you know, chug water. I was like the, I was parched beyond belief. You would chug and then you'd need to chug more. You would be thirsty like you wouldn't believe. Everything would say she ate it and then you'd be peeing constantly. Wow, that's a lot. So those were kind of the symptoms initially. This went on for maybe a week or two. And then it just got to the point where I was losing weight. I looked very ill and there was one day when in mid September when I started to get ill, it was vomiting and couldn't, I couldn't move and I just looked awful and my dad scooped me up. I'll never forget. He actually scooped me up in his arms and carried me to the ER at Mount Sin in New York City. It was kind of in and out and ended up kind of falling into a coma. Yeah, it was very traumatic. But I had the, from what they tell me at the time, the highest blood sugar on history at Mount Sin at the time. So 94, yeah. What were we talking? It was up there. So if the normal range of glucose is like, blood glucose, yours right now is probably like a hundred, you know, you run in that range. And high glucose, it's typically like 200, 300, 400. My glucose was 1600. What? Yeah. Oh. It was really bad. That's so bad. It was bad. It wasn't good. It was not good. And a baby nine-year-old, how long did you think you had had type one diabetes before you were diagnosed? Probably a few months. It's, I would have probably died if it was more than that. I don't think anyone can live with type one undiagnosed for more than a few months. No, probably, probably less, maybe like a month. Oh my god. But let's dig straight into what is diabetes. Yeah. Let's do it. Okay. So, so diabetes, so there's, there's flavors of diabetes. So we're talking about diabetes mellitus, you and I. Okay. If we look at the, the etiology and the etymology, I'll let you dig into that. But my understanding is, I think it translates diabetes itself translates into siphon. And the idea is that it's a siphon because you're ingesting so much fluid and you're just peeing it out. And so back in the day, the doctors who were observing this were like, oh, they're like a siphon. They're just fluid going in, fluid coming out. Melitus translates to something like sweet or honey codate or something like that. So back in the day, physicians would actually kind of do a little bit of, take a little, little taste test. Really? That's how you could tell if there was urine, there was sugar in the urine. And so siphon of fluid coming in and going out and it's sweet, sweet urine diabetes mellitus. Oh my god. You're a sugar calendar. I'm a sugar. You're a honey calendar. That's right. PS, if you haven't heard the melatology episode, it's about bees and honey. Also if your name is Melissa and you have a bad pancreas, your name means bee, which is sweet, like maybe your pee. Oh no. Is it hygienic to drink urine? No, it's not a good thing. Yeah, I wouldn't recommend it. Although if there's no infection, technically, I guess it's sterile, but no, we're not going to, yeah. Okay. Now they're disclaimer on this whole deal. I have an MD. There is no medical advice being given on this show. Don't drink your pee. I'm sure there are so many people out there right now just toasting to a glass of their own room temperature urine. So many people right now. Oh my god. With the healthcare industry, what it is? What else are you going to do? Cheers. Cheers. Okay. not on pee drinking. As long as we're here, do people do this? - I mean, I did draw the line the other day. Apparently there's an ancient Ayurvedic practice where you drink your own urine. - Not even Gwen with polteroidusis. And though it has roots in ancient medicine according to one published study I read titled, "The Golden Fountain is urine the miracle drug no one told you about? They say it's a big no." No scientific benefit. Even the army is like, if you're in a survival sitch, it's not worth it. The army also says not to drink booze, seawater, or blood, just no matter how parched you are. It's got a lot of salt. And though it's sterile when it leaves your kidneys, that is true. It can pick up up to 85 different kinds of bacteria on its merry way out of your body tubes. And I want you to know as I was researching this, I was sipping a really large beaker of lukewarm green tea. - Big mistake, big, huge. - So what is diabetes? I know that there's two flavors, there's type one, there's type two, there's probably more. So is that just the name for when your pancreas stops working? - No, so there's more than two flavors actually. There's a handful. There's something called Lada or latent autoimmune diabetes of adults that sometimes called 1.5, which is strange. There's just stational diabetes. So there's different flavors of the sugar diabetes. But there's also something called diabetes insipidus, which also kind of has that siphon quality, where your body for either central reasons, meaning from the brain or the pituitary or nephrogenic reasons, meaning from the kidney itself, you're unable to kind of concentrate urine. And so it's really an issue with water and sodium. That's a whole other can of worms. It's not really at all related to type one, type two, or just stational diabetes. - Okay, this is the foundation of what diabetes is. So I'm gonna reiterate it because it's complicated and important, we're gonna go through that once again, so we feel like we really know what's up. Okay, so once again, type one, an autoimmune issue causes your pancreas to stop making insulin. And your pancreas, buy the buy, if you're like, what is that? It's a large, dong-shaped organ that's hiding behind kind of like your liver and stomach area. And most medical illustrators seem to draw it kind of like if a corn on the cob had matching nards or a lumpy butter sack. Once again, I'm not a doctor. Okay, type two, according to the American Diabetes Association is the most common form of diabetes. So type two means that your body doesn't use insulin properly and 90 to 95% of diagnosed cases of diabetes are type two. Now between the two, there's a type 1.5 and we are not clowning you, this is a real thing. It's called latent autoimmune diabetes and adults or lata and it shares characteristics of both type one and type two diabetes. Okay, Dr. Natter also mentioned gestational diabetes. That happens at about 10% of pregnancies in otherwise non-diabetic folks and it's caused by hormones in the placenta messing with how your body responds to insulin. So gestational diabetes, it's usually diagnosed about the 24th week of pregnancy and it can lead to preeclampsia, which is high blood pressure, depression or having a large baby. As I like to call them real lungors, which is a fishing term. I just applied to your big baby. Okay, there are also a few rare types like monogenic diabetes. That's caused by just a single gene. There are cystic fibrosis caused diabetes. There's brittle diabetes and something called wolfram syndrome, which sounds kind of like the backstory of a hairy superhero. And finally, there's diabetes in sypitus, which Dr. Natter mentioned. It is a hormonal issue that makes you unable to make concentrated pee. So you're just thirsty and you pee up to 20 liters a day. And in sypitus, by the way, it means bland or lacking flavor. So you're a siphon with flavorless pee, which is a sick burn. And how huge a health issue is diabetes. So the CDC says it's a seventh leading cause of death in the US and in the last 20 years cases have doubled. Almost 10% of Americans, more than 30 million people have diabetes and one in four of them does not know they have it. So if you are listening to this on the subway or at a rave or like a crowded gym, there's a good chance someone near you has the beat us and may or may not even know it. You can tell them about this episode if you want, but you don't have to. When did you decide that you weren't just going to be a patient but you were going to be a doctor? That's a really good question. So I grew up as an art kid. So I used to draw my whole life and I still do. But there was no medicine in my family. I never really thought that I was smart. What? Yeah, no. So apt. I didn't excel academically my whole life. So I was really bad at math and science. I did pretty well in history and English and art obviously. And so I never really thought that a career in medicine or anything that people considered intelligent people would go into is something in the cards for me. Obviously, I'm appalled by this. When I was diagnosed with diabetes, I gained this kind of appreciation or this awe of our physiology. Cause if you think about it, the pancreas is doing so many things and it would do it automatically. It was autonomously regulating a homeostasis of blood sugar. And now at nine years old, this is like crazy responsibility. It's thrust on my shoulders. And it gave me this appreciation for holy crap. This is really cool, really intense, really beautiful. And so I said, it would be really interesting to be a doctor. But I never thought of it seriously. It was almost like if a kid was like, saw an astronaut and they would be, oh wow, that would be cool to be an astronaut, but they knew they never really could actually become an astronaut. That's what I thought about as being a doctor. And then here you are. Yeah, it was crazy. Dr. Natter. Thank you. Well, when, at what point did you decide that you were going to pursue medicine? Like, did you have a moment where you said, I can be an artist and a doctor? What did you do? Yeah, so I went to undergrad. I started studying studio art and then in my end of my junior year, I had been taking some classes in neuroscience because I found neuroscience interesting. But I was doing it kind of like as an aside. And to my surprise, I did well. I was getting really good grades in neuroscience. And so this was the first time I was 20 years old in my life that I had good grades in a science-based class. So I thought, oh, I have some academic confidence. And I had this epiphany of like, I need to go to medical school. This is what I need to do. So Dr. Natter graduated with an art degree without taking organic chemistry or calculus because he was afraid he wouldn't be good at it. So he moved back home to New York City and got at the courage to go back to school and tackle those pre-rex. How did he deal? I moved back home to New York and I did a post-back pre-med program where you kind of do all those pre-rex. And I struggled. I didn't do so hot. I did very mediocre. I mean, I did well for myself, but to get into medical school, it's like very competitive. So I did decent. And then you take the MCAT, which is the entrance exam. I did also very, very mediocre, not so fantastic. And I got essentially rejected from almost every school I applied to except one. And that one offered me an interview solely based on the fact that at the time I had created and was making a comic book about a diabetic superhero. (laughing) Very nerdy. Super nerdy. - Super nerdy, I love it. - Oh, it's the nerdiest. - Oh my god, so based on that they said, how clearly you have a passion, you have a background to let this guy in, let's see what we can do. - I think that was part of it. I think the admissions dean said, your numbers aren't a touch low, but they're not horrible. But you seem to have something that sets you apart. Let's give you an interview. And I was very, very fortunate. But it also did stoke a lot of the imposter syndrome, like, "Oh, I kind of got in through this back door." I remember sitting in my interview day, there's big board table, I've already swept through my shirt and my suit at this point. And everyone goes around to say what med school, what undergrad they're from, and sit next to some kid from Harvard and someone from Princeton and Yale, and they ask what they did the summer before they came there and a lot of them would say, "Oh, I was curing AIDS in Africa, and I was curing cancer in this lab." Oh, I created a comic book. It was like, what am I doing here? - But clearly you need passion, you need drive in order to get through medical school. - You do, you do. What I found is that you don't have to be crazy brilliant. You have to be very motivated because it just takes time. The volume of information is very vast, but the depth of the intellectual difficulty is not, like the rigor is not that bad. It's just taking the time to kind of comprehend the concepts. And I found that using art actually helped me to do so. - Right, because I've found you, because you have all these medical illustrations where you were drawing comics to remember certain medical concepts. - Yeah. - Are those being used as study guides for a lot of people? - So that's the hope. I mean, so I put a lot of that stuff on social media and initially it was very didactic in nature. It would be stuff to kind of help me remember medical concepts for tests and exams and so on. And that seems to help a lot of other medical students. But as I've kind of evolved into being a resident and a lot of the emotional struggles I've kind of utilized and kind of poke fun out with some humor. So kind of all those things, I think hopefully are offering some solace and some help for other people going through the journey. So his Instagram handle by the by is mic.natter and he has all kinds of illustrations and comics based on his life as a doctor. It's Hell of Sweet. Okay, speaking of which, yes, that was sugar-related. So let's talk a little bit about blood sugar. I have a very overactive pancreas, overachiever, workaholic pancreas. So I have reactive hyperinsulinemia. post-pran deal. - Oh, look at you with the big words. - I know, I've read them off of a lab report and then I've ignored the advice the doctors have given me. I have a bad system going on, but explain kind of what blood sugar is and what the pancreas does and why that's important. - Absolutely, okay, so let's start with the pancreas. The pancreas is freaking awesome. - Okay. - It is the coolest. - Okay. - So I mean, clearly I'm a little biased, but you. (laughing) - You always want what you can. - It wears two hats in general. - Okay. - It wears an exocrine hat and an endocrine hat. - Okay. - The bulk of the pancreas is made up like more or less like 90% of the cells are like assing our cells and they make exocrine enzymes to help you digest foods. Things like trips in and light pays and stuff and helps you break down fats and carbs and all this stuff. So that's kind of one hat and that's the bulk of what it does. Then a handful of cells are in these little islands called the eyelids of linger hands and there's alpha cells and beta cells and delta cells and all these cells and they make hormones and the beta cells in particular are making insulin. Okay, so put that on the shelf. Ali, what did you have for lunch today? - Oh God. Y'all, okay. Here's the deal. I have great days where I feed my microbiome a literal shit load of veggies and then sometimes I'm just the worst and I'm traveling and I'll just have like hotel coffee for breakfast and some airport cheetos and then I'll try to consume a packet of peanut butter with a Q-tip as a spoon. I'm not part of this. I know that I have reactive fibroglosemia. I find that I will get to bed, you know, with my contacts out, lights out when I have a low carb diet and I tend not to do it because I just don't want to seem fussy. - Okay. - Which is a horrible reason to get diabetes. Oh, on a normal day, it's a, it's a, I'm a dumpster fire. On a normal day, I would have like an almond milk latte that probably had sugar in the milk and then I add a little bit of more raw sugar. - Sure, sure. - Yeah, 'cause I like to crochet it and then I would probably eat like some sort of pastry and like one PM for breakfast. - I love it. Okay, so that pastry, which sounds delicious, is made up primarily of carbohydrate. So that carbohydrate, it initially starts breaking down in your mouth with some mechanical digestion with your teeth, but there's also a little bit of chemical with the salivary amylase, right? So you're breaking this carbohydrate, which is a complex macromoleculedown. It eventually goes down the food tube. (crickets chirping) You saw if you guys into the stomach and then into the small intestine where more of that digestion is taking place. Once those enzymes really break down that carb, it finally gets small enough into a form called glucose. The glucose can then get in through these little finger-like projections that are absorbing all of that goodness from your food into your bloodstream. Bloodstream is kind of like the subway system. It just like transports all the shit to all the things that needs to go, you know, you know what I'm talking about. So where does it need to go? Essentially, is it needs to go to the trillions of cells that make up your body. And once that glucose can get into those trillions of cells, the cells can then break that glucose down into ATP and energy and do what those cells need to do whatever that may be. - Oh wow. - The problem, or not the problem for my problem, but yours is not a problem. But the problem is that the cells, particularly the adipose tissue, which is the fat and the skeletal muscle, have locks on the doors of their cells. And so for that sugar or that glucose to get into those cells, something needs to unlock that. And that's insulin. So insulin's kind of like a key. This is a very oversimplified metaphor, but I think it works well for people who don't necessarily have a background in science or in medicine. And so this is the way in which your pancreas says, I'm gonna dip my toe into that stream of blood, taste it, and say, oh, it's a little bit sweet. Let's pump out some insulin in the right proportion to allow that glucose to get into the cells. You wanna maintain some glucose in the blood at all times. For whatever reason, Dr. Ward. - Once again, not a doctor. - Your pancreas gets very excited. And so when you eat something with carb, and if you don't have anything with fiber, fat, and protein to kind of help that carb, yeah, to help that carb get kind of slowly digested, then your pancreas sees that sugar and it's a spike and it goes, oh my god. And it just pisses out all of this insulin into the blood. - It's an asshole. - It's such an asshole. It just kind of like squee-like a sponge. It squeezes it in there. And then post-prandially, which means like maybe like two to four hours after you eat, you'll notice that there's still insulin hanging around so that too much of that sugar gets out of your blood stream and into your cells. And what does that feel like? What do you feel like when you have that? - I feel like it makes mono seem like I've had a red ball. Like I feel so tired. My limbs feel like lead and it just feels like the energy that would be needed to take out my contacts is massive. But I just have to fall asleep with sometimes wearing shoes. I have fallen asleep with my car in the driveway. I fall asleep on the bathroom floor. - This is dangerous. - Oh yeah, I know. - So that's like that's one way that someone might experience, hypoglycemic also known as low blood sugar. And it's miserable. - Okay, quick aside. Well, researching this, I came across a 2016 paper called generalized anxiety disorder and hypoglycemia, symptoms improved with diet modification. One passage read, quote, "increasing odds of depression and anxiety have been associated with a consumption of foods that have a progressively higher glycemic index, or more sugary and spike your blood sugar faster." So doctors and lay folks alike know too much sugar can lead to like sadness and irritability and mood swings. So much so that after the assassination of Harvey Milk, the defense attorneys cited his murderer's love of coke and hostess. And this is now known as the Twinkie defense. It did not work. But perhaps we need a neuropsychobiology episode. Anyone? Yes? Also, at this point in the interview, a fluffy indoor raccoon interrupted and my dog, Grammy, was a great way to deflect from my bad pancreas and hypoglycemia or low blood sugar to his. - Where did she get that? Oh, from over there. Okay, she brought me in street. I know my blood sugar's fine right now. - She tensed it. - She's like, "Shall we drink your juice?" Did you ever see steel magnolias? - Of course. - Julie Roberts in the hairdresser. - Has that ever happened to you? Has anyone been Shelby drink your juice? - Shelby, Shelby, you need some juice. You need some juice. - Drink the juice. - Excuse me, should I call the doctor or something? - No, no, she's a dog, baby. - She just has a little too much insulin. That's all. We just get a little more energy. All right. - I mean, when I have hypoglycemia, which unfortunately happens here and there, so my symptoms are a little bit different than yours. I don't get the exhaustion as much as I get this kind of cold sweats, weakening these, like, "Oh man, I'm gonna pass the hell out." Kind of tunnel vision, just feeling like just true death. And then you get these weird cravings. Like anything and everything looks delicious. You just shovel into your mouth. Like, what I imagine being pregnant feels like, like peanut butter and ice cream and pizza all at once and then you immediately feel ill afterwards. But yeah, that's essentially my hypoglycemia. - And so, now a type one diabetic has to monitor their blood glucose and then inject or have a pump for insulin because your pancreas is checked out, right? - That's exactly right. So you're worried about high blood sugar, which means you don't have enough insulin. You're also worried about low blood sugar, which means maybe you took too much insulin or blood sugar can also be lowered by exercise. There's a lot of factors. Blood sugar can be elevated by times of stress. - I'm so stressed out. - How is, well, how does that happen? - It's a good question. So the thought is that there are a lot of stress hormones, particularly things like cortisol and epinephrine that when secreted into your bloodstream are this a good one, gluconeogenic. Oh, let's say it again, gluconeogenic. - Gluconeogenic. (laughing) - Let's break it down. So like glucose sugar, neo like the beginning of ingenesis, like the beginning of as well. So like you're basically making new sugar and breaking things down of storage. So things in the liver, your bodies are super smart and so those store things into forms of glycogen. So glycogen is a storage form of sugar, mostly in the liver. And so it'll kind of basically coop out all of that extra sugar because your body's like, oh, fight or flight, we need this energy immediately. Let's get this out there. - So the type of diabetes Dr. Netter has is the more rare form, type one, which is typically, but not always diagnosed in childhood. And Mike found out that he had it one late September day in 1994. And also weird, type one may be related to colder weather. So it tends to be more prevalent in chillier climates and it's diagnosed more often during winter months, which is just cold, man. - That is kind of type one. Now does that happen with an autoimmune problem? Does your immune system attack your pancreas? - It's exactly right. So I mean, that's the theory. Most of the time it's thought to be autoimmune related and autoimmune means autoimmune itself and immune meaning your immune system. And I think of the immune system kind of like this little army of dudes. And they had these little like spears. And at the end of the spears is little Y, little prong. And at the end of those prongs are very specific shapes. So our immune system is kind of dumb. Like you have like all these pre-made antibodies, which is what these spears are. And they're like every, as many combinations as they can in case they encounter an invader that looks like one of them so they can clip it and so on. But then you also have, memory of that, and so you can pump out more. So the theory is something called molecular mimicry, and it's a very clever theory, and it basically states that you have both a genetic and an environmental kind of dual trigger. So you have a genetic propensity to having some sort of autoimmune disease. It's not well understood, but you have some predilection for autoimmunity, and then in the environment you come into contact with some common virus. So I think Caksacky B virus is thought to be one of the leading molecular mimicry theories for type 1 diabetes. Really? So you may have come upon a virus that you've got, and that is what triggered your immune system too. So that's a ham on your pancreas? That's the thought. And if the idea is that the epitope or like the small piece of virus that gets kind of clicked into your antibody, looks similar to that of the beta cells of the pancreas. That's the theory. And then you have all these antibodies that are going ham and chomping down on them pancreas and genetic tissues. Caksacky? Pardon? Ah yes. This is a group of viruses named for the Hudson Bay Hamlet of Caksacky New York. And if you've ever had hand foot and mouth disease, congrats. You've been a bearer of one type of Caksacky, and also Caksacky. It's just a small town. It's about 100 miles upstate from Manhattan. And its name Caksacky means "owl hoot." And you can buy a three-bedroom log cabin there for just over 100 grand. And then tell your house guests, yes. This is where some viruses were first isolated in 1948 via fecal samples. Let's move on from number two to type two. Shall we? Well, what happens with type two diabetes? And why don't they just call it a different name? Is type two enough of a distinction? Or do you think that that confuses people? It's a really good point. So if you look at the numbers, by a huge amount, type two is much more prevalent. Type one makes up a very small amount. I think it's something like 300,000 in the United States, something like that. Something tiny. Type two is significantly more than if you count pre-diabetic, who are pre-type two, that's also just like a mammoth amount. It's a massive problem in our country. What is pre-diabetic? Yeah, well, let's back up. So type two, that was a really good point. It should be a different name. It used to be called adult onset. Type one used to be called juvenile. But they had to change that because for many reasons, one, you're starting to see people who are adults with type one getting diagnosed as an adult and then you're starting to see younger people including kids with type two, which is a problem. So unlike being able to use TikTok or wearing only polo shirts, type two is not an age thing. But Dr. Netter says, The end result is similar. They both result in high blood sugar or high blood glycemia, but for very, very different reasons and for very different mechanisms. Type one is never ever an issue of someone having a lifestyle choice that might have pretty disposed on. It's never that. Type two is often secondary to some lifestyle choices. That being said, there's genetic components to both. And I want to also preface that they tell us in med school that 50% of what you learn in med school after you graduate is proven wrong and different. Okay, side note, I check this out. And yes, type two has a stronger connection to family history than type one. So much so that they have crunched the numbers on twins and found that yep, twins are more likely to share underpants and all of their birthday parties ever. And also a diabetes diagnosis. So why does type two happen? There's a may have changed, but my understanding was that there's actually a higher genetic component to type two than there is to type one. Oh, wow. And does that happen where you kind of exhaust your pancreas? And so it has put out so much insulin over so much time that it just one day is like fuck all you all in out. So full no amount. I think there's a component of that. It's actually a really exciting time in research very, very recently. People think, oh, you ate too much crap. You know, you ate too much carbs and sugar. But what we're finding more and more is that it's actually the animal products and the fat that we're eating is specifically the long chain fatty acids and the saturated fats. And what's happening is there's fat deposition. So fat is kind of accumulating in things like the liver, your skeletal muscle, and the pancreas. And that is spawning a storm of like pro inflammatory cytokines. So you're getting a lot of inflammation. That inflammation is really detrimental. You're getting like free radicals and oxidation all of that. And that's really gunking up the works of the insulin receptors. So initially it's an issue of insulin insensitivity. The block is broken. The key is there. And so very early on in type, do you actually see a hyper insulin state? Because your pancreas is saying, oh shit, my insulin I'm secreting isn't doing anything. Let's pump out extra. It's falling on death years. And so for that reason, eventually you'll have some of that. And like you said, the pancreas pooping up. And there's also some thought that this is also secondary to the fat deposition and inflammation in the pancreas as well. If you're silently analyzing your diets right now, you are not alone. My friend. You know, the question of like, you know, should I eat paleo, should I keto, should I plant based? Plant based diets have evidence that suggests that they help treat and prevent certain disease processes like type 2 diabetes. And I do think that that is a very healthy way to go. There's good data for other diets that are out there. But the only one that I know that I've seen with empirical data behind it that seems very good is the plant based diet. Yeah. A low plant. Really? Fascinating. And so if you are say pre-diabetic, what exactly does that mean? And what can you do? Like, can you turn this boat around? If you have type 2 diabetes, can you turn the cruise ship around? Like, what are we talking here? What are you turns? With a huge buffet. Yeah. Let's flip this bitch. What do you do? Okay. So, yeah, so let's first get into the definition. So in medicine, we like objective numbers. We like data. So we use something called hemoglobin A1c. Hemoglobin A1c refers to, if you look at your blood, your blood is made up of cells and plasma. And some of those cells are red blood cells. They're just kind of hanging out. They have the carousel and oxygen. They get some iron in there doing their thing. Sugar is sticky. And so sugar ends up sticking to these suckers. And your blood turns over every 90 days. Every three months, your marrow is like, here's some new blood. So if I were to take a sample of your blood every three months or every 90 days and I took a look at how much sugar is stuck on those red cells, I'm going to get a sense of what your average blood sugar is over those three months by looking at that. So a normal hemoglobin A1c is somewhere between 4 and like 5%. A prediabetic is classified as anywhere between 5.7 and 6.4%. And then if you have 6.5 or above, you are classified as diabetic. Oh, wow. And so if someone hears their prediabetic or they just diagnosed this type too, what should they do? Like what is like an emergency tool bag like, oh, here we go. I mean, I think the thing that we have to understand, especially as medical professionals is that it's such a multi-pronged issue. And just that physician alone in that 10 minute visit saying like, you need to lose weight is not going to cut it. There's so much to it. There's culture, there's access, there's availability, there's cost of food and food deserts. There's a lot to talk about. Well, part of the reason I want to go into taking care of folks with diabetes is because I get it. It's so difficult. It is a life altering. You have to think about it constantly and it's never going away. And so for that reason, I think having that connection and that empathy with the patient is first and foremost. But usually prototypically type to diabetics and prediabetics can spare some pounds. So losing weight is key. Exercising is really important because exercising itself, in and of itself, even without the weight loss, is going to help resensitize to insulin and then losing weight with using things like a plant-based diet and cutting out a lot of the carbs and a lot of the refined sugars and stuff as well as staying away from some of those saturated fats is going to help significantly lower A1C and get people back on track. So people with diabetes type one and two come in all shapes and sizes. I know beanpulse and even someone who's a world renowned boxing coach who has diabetes in great shape. But doctors agree that higher body fat in some patients can be one aggravator. And part of the environmental factors. So why does lowering body fat seem to help some patients? So it's still not really well understood. So the more recent studies, like I said, are looking at the fat deposition on our organs itself. And so the excess fat that we carry around or waste and so on is kind of an external marker of some visceral fat. Interestingly, if you carry your fat like in your thighs or your butt, it's like considered more healthy than if you were going to carry it in your belly. That's where tires particularly bad. But I think there's also this idea of something called lipotoxicity. And so just having fat in and of itself is very inflammatory and having inflammation kind of cascades. All of these biomarkers in our body to go haywire and kind of gunk up the normal mechanisms and therefore making you less sensitive to the insulin. Are we learning more and more about inflammation? Are we starting to realize like, oh, inflammation. We're really awful. We forgot to look into you before. It's all about balance because inflammation can be good. If we get sick, inflammation is going to bring all of those. the characters of our immune system to where it needs to be and do a really good job. A fever in and of itself is actually potentially a good thing. But then if the fever continues after the infection has been quarantined, after you're feeling better, you're going to cause damage. And so it's all about finding that balance. Okay. Do we have maybe more inflammation than we need these days? Do we have more factors that are contributing to increased inflammation? Absolutely. And I think, unfortunately, a lot of it is diet, smoking, drinking, all the vices that, you know, I wish I could sound more sexy and say like, you have to stay away from this one thing. But it's everything we already kind of know. But we're just learning more and more about how bad some of it really is. And what do you use to manage your diabetes? Your robot. I have some work. That's correct. I have, so I have an insulin pump and I have something called the CGM. And my CGM, it stands for Continuous Glucose Monitor. And my insulin pump basically has a reservoir of insulin that I change out every four to five days. And it automatically will pump in what's called the basal rate into me through a subcutaneous little cannula. So side note, a subcutaneous cannula is just fancy talk for a tiny hose that goes under your skin. And then every time I have something to eat that is carbohydrates, I have an estimation of how many carbs that is. I have an insulin to carb ratio, plug that guy into my pump, and I get a bolus of insulin to hopefully cover that meal. And who is a good candidate for that? Because that seems way better than poking your finger and poking yourself in the needle. Right. No, it does. I mean, it doesn't. It doesn't. So it's interesting. A lot of type ones prefer to not have the pump. So you have to be attached to it all the time. It's kind of annoying. You know, the main question you get asked, you know, like, what are you doing? I'm in sex. You know, oh, yeah, you got this thing dinkle dangles. Like a mic pack or something exactly. Yeah, what do you do? Just kind of floating by the side. I mean, you haven't ever had sex before, but when we, I don't do those things. So I'm not an animal. I feel this is a good plug for your sexuality. But what does a person with type one diabetes do about being an android? I mean, when I was first diagnosed, a lot of these technology didn't exist. So I would use syringes and that would. And so the technology has come to be so that the disease can be very well managed and hopefully kind of fall into the background a little bit. And the pump allows a lot more of that. And so now we have this what's called a closed loop system. So my continuous moct glucose monitor, which I have on my arm, it sits in the what's called the interstitial space. And it's detecting this kind of flux of glucose across cells. Why is that so amazing? It's because it's given me a sense of the direction of where my blood sugar is heading before it gets there. So if I'm on my way down or on my way up, I can kind of take care of that before it actually hits. And my pump has now the ability to say, Oh, you're going up. I'm going to give you a little more insulin without me having to do anything, which is like phenomenal. Yeah. Yeah. Who is not a good candidate for a pump? It's really expensive too. It is. It's crazy expensive. So thankfully, I have insurance, but I think about this often as well as more recently with the, you know, the crazy sky recking price of insulin. It's ridiculous. It's that what is causing it in this insulin search? What's the deal? Who boy? Oh boy, howdy. We're going to get to the cost of insulin in next week's part two. But you can start right now just practicing screaming with rage if you like. Okay. But at this moment, back to the pump. Oh my god. So many things. So, um, so just real quick with the pump. So who's a good candidate for the pump? So if you're type one, um, you know, you have to demonstrate that you have, you still, the pump is not autopilot. You still need to be cognizant of how to take care of yourself and how to troubleshoot. And it's also a machine which can have, you know, its own issues, which I've dealt with as well. And so if you've proven to your, your endocrinologist or your diabetologist that you have a good sense of your disease, you know, how to handle it and you know what to do in case of emergencies and troubleshoot. And you really want to try and fine tune. Then that would be a good thing for you. A CGM on the other hand, I think every diabetic should have. Prior to CGM, it kind of feels like you're flying an airplane with a blindfold on. You test your blood sugar and that's one point in time. You don't know if that's a hundred and it's going up or going down. You have no idea. So the only way to kind of combat that is you test your blood sugar 12 times a day and connect the dots, which is a pain in the ass. Yeah. Right? Yeah. Sucks. Is it hurt to prick your finger? No, I mean, I don't think so. I think anything that you do every day for X amount of years, like you just kind of adapt to, but even when I first was diagnosed with freaking your fingers, like not that's walking the part. Yeah. What advice would you give someone who's just been diagnosed? That's a good question. I think it's important to recognize that it sucks. I think, you know, oftentimes when like bad stuff happens to people and people who have experience with it are like, oh, it's not that bad or whatever. I think it's okay to kind of get down on the level and be like, you know, this sucks. But just because it sucks doesn't mean that your life is over and doesn't mean that you need to alter everything in your life. It means that you're going to have to make some changes and you're going to have to adapt, but it's adaptable and it's doable. So it's adaptable and it's doable, especially with all the diabetologists and charities working to further outreach and research. And for each episode, we donate to a cause of theologists choosing. And for part one of Diabetology Dr. Natter, chose an organization called Beyond Type One. And Beyond Type One is uniting the global diabetes community and providing solutions to improve lives today. It was founded in 2015 and they focus on education, advocacy, and the path to a cure. And their site is awesome. It has everything from equipment information to diet info to dads, aka diabetic alert dogs. And it was a great resource as I was researching this episode. And it has wonderful links for patients and for newly diagnosed folks. So that's Beyond Type One with a numeralone.org. So that donation was made possible by sponsors of the show, which you may hear about now. Okay, so where were we? Yes, okay. We were talking about cyborg pancreases. Do you think we're going to get like robo internal pancreases or is it too many moving parts? I think that there's two flavors of cure. There is, I think if we can get stem cells, the concern would be if it was an autoimmune process that killed off your own cells, then putting your own cells back in will also have the same issue. So I think if we could somehow like hermetically seal them in like a Trojan horse. And then we can implant them in like the omen them or the liver, those beta cells will then kind of act as their own free roaming, you know, endocrine pancreas. And I think that would be a potential cure. The other way would be a mechanical cure, which I think we're very close to doing. And you have kind of a mechanical pancrease is just external. That's exactly right. And I think that the mechanical cure will be an external one. But the thing that we didn't really dive into too much is that there's a gas pedal on there's a break. The gas pedal is insulin insulin is going to drop your blood sugar down. But I right now don't have a break. And the break that our body has physiologically is something called glucagon. So I mentioned that there is the beta cells for insulin, but the alpha cells make glucagon. So it's another hormone. And that hormone just to put very simply basically goes over the liver, knocks on the doors. It's hey liver, let's get some sugar. And so it breaks on the glycogen and pours out some sugar. So it kind of is the Yin to the Yang kind of deal. So a pump that has a dual chamber with some glucagon and some insulin and the closed loop system with the CGM would essentially be that system. And remember CGM stands for continuous glucose monitor. I got you. And can a CGM be a C GGM like glucose and glucagon monitor? Oh, can it be like a duct, can it monitor both glucagon and glucose? So glucose would be the piece that you want to measure because both glucagon and insulin are what's going to be affecting the glucose. Oh, got it. Oh, so then it would be more the pump that had two nozzles. Okay. It would be a double nozzle. Oh my god. Wait a minute. There's two sets of nozzles. Are there any good movies or TV shows about diabetes? Are there good movies? I'm trying to think about other diabetic. Oh, there was so my sister who's a bit older than me used to be a big babysitter's fan. Baby serr's club. Oh my god. Claudia. No, Claudia. I don't know. Of course I look this up. And the babysitter's club character with type 1 diabetes was named. Ready for this? Stacey McGill. So congratulations if you've been in your car alone screaming. It was Stacey. It was Stacey. Come on, word. Okay. Stacey. Yes, sorry. There was an episode that my sister made me watch with her because there was a diabetic and she it was like a Christmas episode. She's eating all them cookies. And then she goes into oh this is such a good segue. Then she goes into something called DKA. Okay. Should we dive? Yeah. We're taking a dive. Oh my god. It's something ketoacidosis. Oh boom. Boom. Right. I'm crushing it. What the D? I mean we're talking about the diabetic ketoacidosis. You're brilliant. So you are a doctor, doctor. I'm pretty much okay. All I need is a lab coat and a really good insurance policy. The best mouth practice. And I'm ready to go. And you're golden. So what is diabetic ketoacidosis? So this is what I was in when I was diagnosed. And often this is what happens with type ones. If you have type 1 diabetes, you have no insulin in your system. With no insulin in your system like we spoke about before, all that sugar, all that glucose can't get out of your bloodstream and it can't get into your cells. Your cells are dying in a sea of plenty. They're like, yo, where's all that delicious sweet, sweet sugar? Oh no, it's all around them. It's all around them. It sucks. And so what does that do to your tissue? So your tissue is like, yo, we need to get some energy now. So they go to alternate forms of energy and that's breaking down your adipose or your fat tissue and sometimes your muscle as well When you break down fat tissue, it's called beta oxidation and you can get some energy from that you actually get things called ketones Which can be used as sources of energy and the major ketones you get are things like beta hydroxy butyrate and acetate and acetone those and So your brain can actually use like neurons can and your heart can use ketones for energy and so on But the problem with ketones is that if there's absolutely no insulin around then these ketone bodies build up in the blood and they're super acidic And your blood is super finicky and it wants to remain very very very neutral like 7.37.4 pH So your pH starts to drop like precipitously and you become Acidemic and then acidotic and then you get very sick coma Brain swelling death kind of kind of deal. That's decay. Yeah. Why does that not happen on the keto diet? So on the keto diet you go into something called ketosis So you're getting more ketones and you kind of shunting that as your fuel source But you still have insulin around in your body and so those ketone bodies don't build up to the point where they're dropping your blood pH Okay, so On the keto diet can you survive without glucose in your blood and glycogen in your liver and your muscles? You need some glucose But they're you're getting some glucose like I think it's almost impossible to eat a diet that has like zero zero glucose like plants and stuff Have a little bit of glucose You can your your body is able to kind of shun to different sources and so on but I really don't think it's the best way to go. I think it does help with epilepsy to some degree The mechanism I don't think is that well under so but it has to do with the idea of neurons utilizing ketones instead of glucose as their source And so it does something with the Excitability of the cells and so if you don't have insulin deficiencies the keto diet won't throw you into ketoacidosis Like it would someone with diabetes and in terms of using the keto diet to control blood sugar Some folks with type 2 say it's allowed them to manage their glucose levels and use less insulin Of course do not use this episode to diagnose or treat a disease consult your doctor before making any changes Do not sue us? How do you think we can change our culture at large to avoid so many people getting type 2 diabetes? Yeah, like obviously there's a lot of things us person can do individually to take responsibility for it and try to look out for themselves But in terms of an epidemic, what should people be doing at higher level? I think that's a really good question It's a really important question because it's really turning into such an issue I think that's to be a multi-pronged approach I think we have to change culture which is a very difficult thing to do and I think the idea of changing culture is really centered around food I think food is a huge driving source and I think we need to make healthy food options more accessible If you think about a single mom raising four kids It's probably really easy and affordable to go to McDonald's and feed everyone We also in our culture, American culture, if you eat dinner I think it's expected that your dinner is going to be filled with a lot of meats and carbs and sugars Our portion sizes are crazy So I think that's huge Having access to health care is important I think those two things in and of themselves would make a huge difference And then outside of that I think we need to be more active I think we need to exercise How does a person stay active when they are doing something really hard Raising a lot of kids or going to medical school or asking people about lizard dicks for too many hours a week How do we prioritize exercise? I know I can fit it in my schedule I know I can touch or sit in there and I'm so bad at it lately It's hard, I'm going to be a hypocrite because I'm a resident, my schedule is awful I wish I could talk about lizard dicks I need more lizards in your clinic I think the idea is being active in exercise doesn't mean you have to carve out an hour and go to the gym You can take the stairs and set the elevator You can park your car a little farther in the parking lot You can take two stairs at a time instead of one step Even if you get 15-20 minutes a day of doing something like that That counts and that makes a difference It adds up Do you ever advise patients to get a fit bit or get a step tracker and just try to hit a goal? Yes, usually what happens is they'll get it in a very excited up front and then it kind of peeters out toward the end But it is nice to have objectives in it And then what I'll try and do is I'll bring them back So I'll say instead of seeing me in six months, come back in a month Let's see how many steps you did, let's see how many pounds you lost And then you kind of work with them and you kind of keep them honest, it's helpful How do you as a doctor approach something like physical fitness and things like that Without making it into like an emotionally shaming issue You know what I mean? Because it's so hard to feel good about your body in a culture that celebrates like Amaciated Instagram models That's correct And so we're fed these two really different messages about we should be stick thin And also you should feel good about your body at any size It's a little confusing It's difficult, you're absolutely right From a clinical or physician point of view, when someone has disease or they're developing disease That it should be the motivating factor, it's not about you don't look good It's about I want you to lose this weight because I'm worried about your diabetes And your metabolic syndrome and your blood pressure And losing weight doesn't necessarily mean that you're gonna. I don't want someone to necessarily look different, I want them to feel better And so I think if you package it like that and say it's about your health And you know it's not necessarily about the physique I think that's important How do you as a doctor and also a patient motivate yourself to do the things you know are good for you? I struggle, Ellie, I really do The things that I can control are control So I try really hard to be careful about what I eat But I also think it's important that. I believe in moderation I think it's important that if you like ice cream, if you like french fries You shouldn't deprive yourself of them all the time I think it's okay being a diabetic or being you know a hypertensive or overweight or to once in a while indole yourself And I think that's. - I once in a while That's the balance, right? That's the balance I, for instance, I try not to eat any red meat But I'll have red meat maybe once a month, once every two months That's not evidence-based, I just made it up I just said, well, you know, and what I do is when I'm at the restaurant, when I'm out with my friends or whatever And everyone's ordering steaks, I think back Okay, when was the last time I had a steak? When was the last time I had red meat? And if it was recently, I'm like, you know what? I'm gonna go for the salad But I try to eat them in the morning, I try to eat eggs Some like avocado, something with like a lot of protein and some fat to kind of keep me going Maybe I'll have like a Greek yogurt, some berries, berries tend to be okay In terms of glycemic index for diabetics Other fruits are a little bit more tricky And then, and a coffee, lots of coffee Numerous amounts of copious coffee And then for lunch, I'll have a salad, usually, if possible, and then maybe I'll have some fruit Like, maybe an apple or something for a snack, a handful of almonds, something like that Another two or three coffees So, what do you eat for dinner? Oh my god, for dinner, what do I eat for dinner? Yeah, so like, I eat at good amounts sushi Sometimes I'll have like some grilled chicken and salad or like quinoa, sweet potato, that kind of stuff I try Have you ever done like a straight up diet like a whole 30 or a South Beach or have you ever, you're like now? No, it's just like, I don't think diets, like those types of diets, I don't think that they work because I don't think they're sustainable And I think the best kind of diet is a diet that allows some moderation So a diet doesn't work, but it's like a fat diet Yeah, like a diet in that, like you know generally what you want to stay away from them, what you want to have And then recognize that there's some room for moderation and moderation means both serving size and frequency of how often you have it Okay, can I ask you some Patreon questions? Hit me Yeah, let's do it Okay, we're going to inject you with Patreon questions So ask nice doctors to be questions and stay tuned for next week's episode which has more of your questions about staying healthy and affording insulin And supporting people you love who have diabetes, how to avoid getting diabetes yourself So to follow Dr. Nath on the meantime, he's Mike.nathor on Instagram or Mike_nathor on Twitter We are allergies at both and I'm alleyward with 1L on Instagram and Twitter Links to beyond type 1 and the sponsors of the show are in the show notes and up at alleyward.com/alegies/diametology Allegies merch is available at allegiesmerch.com or up at alleyward.com. Thank you to sisters, Shannon, Feltess and Bonnie Dutch They are hilarious and they run all that merch and they host a podcast called You Are That, which is so funny Thank you to Erin who admined the Facebook group since the start Emily White organizes all the transcripts and we are catching up fast their links to bleeped episodes and transcripts in the show notes Jared Sleeper and thanks of course to he who is sweet and not insipid Steven Ray Morris for putting all the parts of the episode together and getting it out on time Nick Thorburn wrote and performed theme music, he's in a band called Islands, listen to them And if you stick around until the end of the episode, you know I tell you a secret This week I'm going to share a little hot tip for my fellow folks who have sleep procrastination or fall asleep when they're close a lot So at 8pm, this is a new habit, I make myself get ready for bed even if I have no intention of sleeping for hours That way at like 11.30 when I'm super tired, I don't have to splash cold water water on my face and have it run down my sleeves and essentially look like a possum who's been attacked by a garden hose. So baby stepskids get ready for bed hours early it helps with the sleep procrastination. Okay so next week we get emotional we have more living tips on how to avoid or afford the beat is so meet me back here. Bye bye. Hackadermy College, Homiology, Doseology, Litology, Dose Technology, Mediaology, Dose Technology, Dose Technology, Dose Technology.