Welcome to Zoe science and nutrition, where world leading scientists explain how their research can improve your health. Today, we're tackling a silent killer that's claiming more of us every year. It's a disease so widespread that it touches nearly every family in some way. Type two diabetes. This is not just a health issue, it's a rapidly expanding cris, and many people don't even know they have it. In the US alone, 100 million people have prediabetes, and over 37 million grapple with type two diabetes globally. The last 30 years have seen a fourfold increase in the number of people living with this condition. And this isn't just about high blood sugar. This is a serious, chronic disease that can rob you of your vision, your limbs, and even your life. But there is hope. Professor Naveed Satar joins us today to tell us how to prevent, treat, and even reverse type two diabetes. Naveed is a medical doctor and professor of metabolic medicine at the Institute of Cardiovascular and Medical Sciences at the University of Glasgow in Scotland. He's one of the world's top 1% most cited clinical scientists and has worked on many clinical trials of lifestyle changes and drugs to prevent and manage diabetes.

Naveed has also been a member of Zoe's scientific advisory board and an important contributor to Zoe's science in this area. Naveed, really lovely to see you again. Thank you for joining me today.

Pleasure, Jonathan.

So we have this tradition on the show that we always start with a quick fire round of questions from our listeners. And the rules are really simple. You can say yes or no, or if you absolutely have to, you can have a one sentence to answer it. It's specially designed to be really hard for professors. Are you willing to give it a go?

Cool for it? Yeah, absolutely.

All right. Are there millions of people around the world who don't know they are living with type two diabetes?

Yes.

Does type two diabetes significantly increase my risk of other diseases, like heart disease and cancer?

Yes.

Is it true that almost 100 million Americans have prediabetes?

That seems a high number. It's possible. I think it's probably slightly overestimated, in my opinion.

Okay, let's go and dig into that. That is a quote from the CDC. So I'm intrigued to go into that. If the food I eat leads to big blood sugar spikes day after day after day, can this significantly increase my risk of type two diabetes?

Probably, yes. But it would generally tend to do so through weight gain.

Are women better at controlling their blood sugar than men?

Women have a lower risk of type two diabetes than men for reasons linked to where they store body fat.

I think we'll definitely want to talk about that. And then finally, last question, and you definitely can have a sentence or two for this one. Navid, what's the biggest myth about type two diabetes that you come across as an expert in this area?

Certainly my patient's biggest myth often when I tell them that they may have type two or at risk is that they don't eat much sugar. Type two diabetes predominantly is a disease of excess in most people, excess weight to a level in themselves that leads to too much fat in the wrong places, including within the liver.

Got it. And so they're saying, hey, but I don't eat loads of sugar, so how can I have type two diabetes? And the answer is they still do.

They still do. And it's predominantly, people can put on excess weight for a number of reasons, not necessarily just high sugar, but also, obviously lots of fat.

Well, look, let's start to dive into all of this. And just to start with, I think many listeners to this podcast know I have a personal interest in blood sugar because my own blood sugar control is actually really quite poor. But I actually didn't know this was happening inside me at all until I wore a continuous glucose monitor when I took part in the very first Zoe predict clinical trial, which is about five or six years ago. And it was a complete eye opener for me, understanding that my blood sugar would often be very high for hours after I ate certain foods, and was quite high even when I woke up in the morning fasting, because I didn't feel anything. I had no idea about this. So I'm really fascinated in this topic. Now, before I get carried away, though, and jump to all the things that I'd love to discuss about what I could do to improve my blood sugar control, can we just start right at the beginning and maybe just start with what is blood sugar and why does it matter?

Well, sugar is one of the fuels, one of the key fuels that many body cells require for making energy and for conducting their normal function. So particularly, of course, the brain dependent upon fuel for it to function, and it's its source of fuel for it to work, for the cells to work as well as requiring oxygen. It's also, when we are sick, the body is very good at preserving, trying to preserve sugar for your immune cells, the cells that fight off infection or help repair tissues. And again, they require lots of fuel for those mechanisms to fight off infection or repair tissues. And therefore, when you are sick, it makes sense, the body tries to preserve sugar more for those cells, but it's required. Sugar is required for all body cells, basically, for them to function normally.

And one of the things I think that often gets people often mention when they talk about diabetes, you often hear this word, insulin. What is insulin? And why does it ever come up in a discussion around blood sugar and diabetes?

So insulin is a hormone. So if I was to, and I've just eaten a banana, and my body is breaking down that banana, putting its breakdown products, one of which is sugar, into my blood, but I don't want it to be my blood for very long, I want to be able to store that energy in various tissues. Insulin is a bit like a key that opens up some of my cells to take in that sugar and store it when I don't need it. This also stops my own body making sugar when I don't need it. So I've just had a lot of sugar. Hopefully, my insulin started to go up, put the sugar in the right places, and it's also probably signaling to my liver, stop. You don't need to make any more sugar because there's already lots coming in. So it's like a master regulator of keeping sugar levels within the right levels in the blood, putting it in the places where you need it to store for future needs, and also helping you liberate it when you need it. And that actually happens when the insulin levels go right down, so that perhaps when you're sleeping and you're not having sugar in your body, your sugar levels, your insulin is low down, and the liver keeps making sugar sufficient to feed all the cells in your brain, et cetera, for normal bodily function.

So insulin is a master regulator in all of us for our sugar levels.

And. Thank you, Nabi, that's really clear, I think. So you've got this sort of insulin keeping things level. I guess the obvious question is, why doesn't our body just let all the sugar hang around in our blood, like the fridge? You just keep putting more stuff in it. And then my brain, or whatever else could take the sugar out when they want. Why can't I just let it get higher and higher?

Yeah, I know. That's a brilliant question. So, if you think about sugar, if you spill sugar, particularly in the context of water, it becomes very sticky. When sugar becomes. Levels become very high in the blood, it starts to stick to lots of our bodily proteins and changes their function, makes them abnormal. So, for example, some of the damage that happens in the eye is because the sugar, very high levels, starts to stick. So loss of proteins are relevant to aspects of our eye function and disrupts it, and you lead to what's known as retinopathy, a damage to the eyes. The same thing happens in the kidneys, the same things happens to some of the bodily parts, proteins that are relevant to nerve function. So sugar levels, when they're high, effectively disrupts lots of raw materials and proteins in our body and disrupts, therefore, lots of normal function and causes damage.

I think that's both very clear and very. It's quite scary, this analogy with, like, the sugar on the table, sticky. I can see that that's not what you want, sort of causing through your blood.

It's a process partly called glycation, and effectively, it changes the structure of your molecules from what's normal to abnormal. And then that means, if I think about it, if you're building a house and you start to make bricks and the wrong shape, that building is going to be disrupted and will potentially not have the same level of integrity and will be disrupted and fall apart. That's effectively what's happening inside your eyes, your kidneys, your nerve cells. If your sugar levels are high, you're changing the structure of proteins so they no longer do what's healthy, and you're building up tissues in an abnormal way that leads to disease.

Hi. I love that you're listening to this. It means a lot to me and the whole team, who put such a lot of hours into this podcast. Each week, we release this show for free, without ads, to help millions of people improve their health with cutting edge science. In return, all I ask is that you help us on this mission. If you know someone who'd benefit from listening to this episode, please send them a link to this show. And if you haven't already hit follow wherever you're listening right now. Thank you and on with the show. Thank you so much, Nabeed. I think that's both a bit scary, but also really clear. Could you explain, then, what happens when someone gets prediabetes or type two diabetes? What does that actually mean?

Yeah, this is a question that's often happened. People living with prediabetes do have a higher risk of obviously developing diabetes. They don't inevitably develop diabetes, so the term prediabetes doesn't mean that it's always inevitable. People who have prediabetes, some stay in that level for years. Others can actually go back to normal levels of sugar if they prove their lifestyle. But if you do have prediabetes, your risk of developing diabetes is clearly higher. Equally, your risk of heart disease is about double compared to people with normal sugar levels, don't have prediabetes or healthy levels of glucose.

I just want to make sure I got that. You're saying that if you have prediabetes, your risk of heart disease is actually double the level if you don't have prediabetes, roughly speaking.

But here's the rub. At the level of prediabetes, that risk is not necessarily caused by sugar levels, because they're not at the level of diabetes. What is caused by is the processes that have led you to develop prediabetes in the first place. So, for example, for me to develop prediabetes, I would probably need to put another four or 5 weight on that. Excess weight will also mean my blood pressure will go up. It will also mean my blood fats and my cholesterol levels will be disrupted. So then I will have higher weight, higher blood pressure, more abnormal toxic levels of lipids, and possibly also other changes. And those are the things that cause my higher risk for heart disease. They will also, in a sense, they're stressing my sugar levels. I'm able to keep them still within the non diabetes range, but they're being stressed because I've put fat in the wrong places in my body.

And, naveed, I just want to make sure that we all understand what prediabetes and diabetes is, and then I'd love to understand more the way these are linked. So what does it mean for someone to have prediabetes or type two diabetes, and how is that linked to their blood sugar that we were talking about a minute ago?

So let me explain it in the terms of a hemoglobin, a one C level, which is a common test that we use, that gives us an average sugar level for an individual over three months. So our normal hemoglobin, a one C in the UK, it doesn't really matter about the units, is 41 millimoles per mole or under. Hopefully, you and I sitting here have got levels of, I don't know, somewhere between 32 and 41. Okay. Prediabetes within UK and other, you know, in Europe is between 42 and 47. Diabetes is when you get to 48 and above. In America, prediabetes criteria is a bit wider than we use. In the UK, it's from 39 to 47, which is probably why the category, perhaps of 100 million, I don't think is quite as high as that. There's always some interpretation, based on CDC data, that they have to extrapolate and base a few caveats. But nevertheless, that's what it is. In older hemoglobin a one terms, the levels we had in our mind was diabetes is at 6.5%. We use the percentage prediabetes is from six to 6.4 in the UK, or from 5.7 to 6.4 in the US.

And effectively, that's hemoglobin a one C, and it's capturing your average sugar levels, your average exposure to sugar levels for three months. So it's a very good, stable measure that we measure in the clinic all the time, increasingly is used to diagnose diabetes or diagnose prediabetes.

And I've heard doctors often refer to this as HBA one C. Is that right?

HBA one C, hemoglobin a one C.

And so the way I understand, I just want to make sure I'm playing it back right. The way I understand it is your blood sugar is changing all the time. So you ate that banana right now and your blood sugar is probably starting to shoot up. Then you'll put in the insulin you described and it'll come back down. And this HBA one C is sort of like this average measure of your blood sugar, like something on the tank, on the car that's just telling you what the average is over months, rather than this thing that's changing all the time, is.

That's perfectly correct. So if I'm able to, after my banana, keep my sugar levels from going too high and keep them within the normal range, every time I eat food, if I keep it relatively within the normal range, my HBA one C will stay within the normal range, because on average, my sugar levels have been kept normal.

Amazing. And so to make sure that. I just want to make sure that I've got this, you're sort of saying we all have, like, a level of sugar that we would normally have in our blood, we can measure it with this HBA one C. And if somebody's been diagnosed who's listening to this with prediabetes or type two diabetes, this is higher than it should be. And this is the concern, and we'll then talk a bit more about what it means and what you might be able to do about it.

That's broadly correct. The reason I think, clearly we can measure sugar levels, they can also give us an indication, particularly when you're fasting. We think the sugar level should be below seven millimoles per liters. We can do it fasting, but the move, certainly in the UK and also in the US and many other countries in the world to diagnose diabetes. They've increasingly started using HBA one C because of its stability, because it doesn't need to be done fasting, because it can also be measured when people have infections or admitted to hospital, because none of those things are going to change an average for three months. So it's a very good aggregated marker. Now, it's not perfect all the time. There are some circumstances, like people who have very severe anemia, or they have a certain different type of hemoglobin, so called hemoglobinopathy. We have to be slightly careful, but that's a very, very small percentage of the population. So therefore, the vast majority of circumstances, HBA one C is a very good aggregated measure of sugar exposure that your body has been exposed to and gives us an indication of whether you have prediabetes, diabetes, or in anola range.

So I think the obvious follow on question is, why has there been this enormous explosion in people with diabetes and prediabetes? The team was sharing, again, some of these stats, and apparently there's a sort of fourfold increase in the number of people with diabetes around the world to, like, hundreds and hundreds of millions of people. And I know that when we look at our own data of people doing the Zoe study, whose there's hundreds of thousands, you see there's lots of people whose levels are far, far lower than the levels you're describing of people with diabetes. So clearly, there's a big shift, I guess, from, I think, about, like, my children. I don't know what their HBA one C is, but I'm pretty confident it's a long way below these levels. Right. They aren't there. So what's going on? What is causing what I think we could sort of describe as an epidemic of type two diabetes with all the scary implications you're describing, and why is it so much more common now, like, even than when I was a child growing up?

Okay, so I think that's, you know, that's obviously a brilliant question. I'm sure many of the listeners can work out some of the major causes, and one of them, of course, is rising levels of weight and waste girths in society. Because as you put on more weight, as people put on more weight, and as average body mass index levels or whatever waist circumference levels have risen in the communities, that means more people have got to the point where they can no longer store fat peripherally, and that fat, excess fat, gets deposited into some of the key organs in the body that are exquisitely sensitive to too much fat and are relevant to how well you either make or store sugar. And if you put too much fat in some of these organs, you will disrupt their ability to control sugar levels. So, for example, too much fat in the liver means that it will continue to make excess sugar in excess of the body's needs when you don't need it. Too much fat in muscles means that your body will not take up the sugar in response to insulin as well as it normally would do if your fat levels and the muscles were less.

That's a simple example. So weight gain is one of them. Another key factor. It's actually linked to success, in part. Another risk factor for diabetes, actually living longer, older. So as life expectancies have gone up and more and more people living longer, we get more diabetes. And part of that reason happens is that in my simple mind, there's three things that determine diabetes risk. The weight you reach and how much fat you put in your organs, your muscle mass, because that's your engine to burn up sugar, and how well your pancreas works. Now, two of those three things, probably all three things, change with age. As we age, our muscle mass goes down, our pancreas becomes less, which is the organ that makes insulin, becomes less plastic, as it were, I. E. Its capacity to make more insulin, to keep the sugar levels down, becomes less over time. And also, as with age, we tend to put on more weight in our stomachs, and we tend to lose fat from our peripheries and our arms and legs and peripheral reasons. So with people living longer, we're also increasing the likelihood of diabetes. And that's not just in high income countries.

If you think about all the millions of people, billions, in fact, in low income countries, as they've proved their hygiene gradually and industrialization, people are no longer dying in their thirty s and forty s. They're living to the. So they're able to develop diabetes in the when they didn't because they died with infection or something else. So there's multiple reasons. So weight gain, increased life expectancy are probably the two major ones.

And so, Navida, I want to unpack that and make sure that I've understood it and our listeners have understood it fully. So maybe to start with the first one, I think you said something really interesting, which is it's about rising levels of weight in particular places. So it's not just generically whether someone has put on weight. You're saying it's about the fact that that weight is actually being stored. So that fat is actually being stored inside crucial organs in our body, and that that is really what starts to trigger the diabetes. Did I understand that right?

Yes. That's so called ectopic fat fat, where it normally isn't supposed to be in any sort of high level. So, as an example, all of our liver fat levels should be below 5%. Ideally. Usually if you look at the normal range, under 2%. But when the liver accumulates more fat, because your body has been unable to store the fat in other areas, because your wheat's got to such a level, the body's looking for other places to store that excess fat, one of which then tends to be the liver. As the liver fat levels go up, that disrupts the liver's ability to regulate sugar levels normally. And the liver actually starts to make excess sugar beyond the body's needs, which then keeps the sugar levels high. So that's one of the examples. Topic fat. It's not the only cause. Some people also have, shall we say, pancreases, which make insulin, which are unable to make as much insulin as perhaps a healthy individual. So that for even when they're not very overweight, their pancreas. Pancreas's ability to make insulin becomes diminished with age very quickly. And it's a pancreatic driven type two diabetes. But even there, genetically, if you can't make as much insulin as the other person, it's still usually weight gain that's to trigger for diabetes.

And people then tend to have to put on less weight to get that diabetes. So there's an interaction between how well your increase can make insulin, how much fat you put in the wrong organs, and how good is your muscle mass.

I'm sorry, Naveen, can I just, before you jump on, because I think the weight in your organs affecting the way that they work, that makes sense. And you're describing the pancreas as one of these examples. It's so important, it's making the insulin. Could you just explain the muscle mass for a minute? Why does the muscle mass have any impact on diabetes?

Muscle mass is often measure of how active you are. So activity plus, as an example, my muscle mass used to be not so good. It's actually probably a bit better now. I've got a dog and a psycho and so on.

Congratulations.

And my HDL has gone up and I can see it. I can see it as a biomark. It's gone up really almost doubled, which is a good thing, which is a very good thing, because I have a family history. So I think my pancreas probably genetically being South Asian, a family history has got a lower reserve to keep making insulin to the levels I need to overcome any resistance in my tissues, as it were. So by building up muscle and being more active, I have an engine that burns sugar more. So that means I've got an engine that can burn sugar. That means that sugar is not going to stay as high, if that makes sense. Also will burn fat as well.

So by having more muscle, so it's actually going to pull the sugar out of my blood, it's going to burn it up. So it's improving everything. And if I don't have that, I'm more likely to store it in my liver and my pack.

Exactly. It's like having a very efficient engine and a bigger engine for the amount of fuel. If you overpack the car with fuel, too much oil, the oil will disrupt the engine. And if you keep the engine clean and bigger, it may be easier to cope with more oil. That kind of simple analogy.

And can I follow up on the point about the differences between people? Because I'm really interested in that, and you were just talking about being south asian heritage, and I'd love to understand a bit more about that. But the other thing I was interested in is sort of difference between men and women, because I know that when we've had other conversations to do with other risk factors, we've had this conversation about women, particularly before menopause, sort of storing fat in different places. And is there a difference between men and women in terms of their risks of diabetes as well? So I'm really curious about, for people listening, how these things might be different paternity on who they are.

Yeah, well, let's explain all those risks in the prism of where you store the fat. So women generally have a much greater subcutaneous, so they're able to store fat peripherally. Thighs, legs, and obviously the shape of women is such that they have other stores of fat, shall we say. So women generally, in a sense, have a greater storage capacity for fat in the peripheral area. That means they have to put on more weight overall before that fat starts to seep into the liver and peripheral.

Just to make sure, basically, because anybody who's not seen the video where Navidia is helping to indicate, you're basically saying everywhere that's not sort of in my torso and around my belly that women can store a lot more fat there.

And part of the reason women have to store more fat is partly because women have children. They have to feed the children, they have to breastfeed they have to supply nutrients to the child. One of the things that happens in pregnancy is the placenta can suck lots of nutrients from mom. And if mom doesn't have enough fat storage, they can't often get pregnant. You see that in athletes.

So you need, like, your body is like. We're talking about evolution over millions of years. Not like, necessarily. Doesn't mean you as a person listening to this, have to get pregnant. But the point is, that's how our bodies have evolved.

Yeah, that's exactly right. So if you compare men and women in terms of how much fat they have in their liver, even in healthy levels, men tend to have higher levels of fat within their liver compared to women. And also men. When they generally put on weight, it usually is accompanied by their waist circumference going up straight away because they tend to store it. They're all closer already to the threshold of fat going into the wrong places. So with a little weight gain, men's fat usually goes into the wrong places. Women, however, generally can put more fat in peripheral regions, into their thighs and other areas before it goes into the more harmful places, like the liver and muscle, as it were. So that explains why men in every ethnic group are at a higher risk of diabetes than women for type two diabetes. It probably also explains, in part, why men at higher risk of heart disease than women in all ethnicities, by and large. And with that same prism, if you compare, you and I, Jonathan, you're sitting there, you're caucasian or white, I'm south Asian. We know that South Asians on average have 10%, on average, lower muscle mass and carry more fat mass already.

And we also have higher levels of liver fat even when we're healthy. So me, compared to you, I've got higher liver fat. So I'm closer to where I'm going to put too much fat in my liver sufficient to develop diabetes than you are. You are closer than the average, say, an age comparable woman. So that explains the men versus women risk. It also explains the whites versus non whites. And every non white individual compared to whites are at higher diabetes risk. One of the reasons is where people put their fat. It's not the only other reason. Blacks, I think there's another mechanism we don't fully understand. It's maybe to do with how well your pancreas can make insulin. But certainly for South Asians, in a sense, our body makeup is such that we are for less weight gain. We will start putting fat into the wrong places, and therefore we will develop diabetes at lower average weight. Gains than whites.

And these are quite big differences you're describing, aren't they, Nabi? Because I feel like in general, when you talk to a lot of scientists, then it feels like often they've ended up coming to the conclusion that even genetics in general, never mind ethnic differences, are sort of ending up being quite small versus environment, but here you're talking about quite important differences, it sounds like in terms of risk factors based on sort of your ethnicity. Did I understand that right?

Yeah. No, you're correct. So, roughly speaking, South Asians risk for diabetes. So comparing age by age and sex by sex, somewhere between two to four fold higher risk of type two diabetes.

Two to four times higher. So that is an enormous difference in risk.

And even within the south asian groups, there is a gradient of risk. So the highest groups in the big countries is actually in Bangladesh, then it's Pakistan, then it's India. And a nice potential explanation for why Bangladesh compared to Pakistanis is height and early growth, because height is a proxy for how much muscle you have. Bangladeshis tend to be shorter than Pakistanis, who tend to be shorter than Indians on average.

It's fascinating. The one thing I would say is, of course, these are just averages. And so you can have this huge.

Because.

And listeners will have heard this, I don't want to bore them, but I actually have quite a lot of fat stored around my belly in terrible places and very little anywhere else, which I had no idea of until, as part of that first Zoe clinical study, I actually had a Dexa scan. And I remember the face, I remember the look on the nurse doing it, who was, like, really surprised. And the answer was, I'm apparently what's. I think it's called, like a toffee or something like this. And it turns out that I have fat nicely stored around my liver and elsewhere. And I remember Tim explaining to me that this was really bad news. And so of know there are these ethnic differences, but there's obviously also very big personal variation, which is know, some person, I guess, is much more at risk of diabetes than something else.

And there may be various genes at play as well. The question I would ask if you were one of my patients, Jonathan, is, do you have a family history of type two diabetes? Your BMI is obviously not high. It's pretty good. And it may not be that, actually, this is a BMI factor, clearly, because you're clearly not heavy. It may be that you've got a specific gene that doesn't allow you to export liver fat out of your liver into your circulation, I don't know, but that's something for you to interrogate. But by and large, I'm going to.

Be following this up in detail after this call. Naveen, I'm conscious that I want to move on because I know you had limited time before you had to be back in clinic. I'd love to talk for a minute before we talk about what we do. What are the symptoms? So let's say that somebody's listening to this and they're like, oh, I wonder if I do have diabetes. What are the symptoms that I'm going to be experiencing that are going to answer that question for me?

So most individuals who have type two diabetes, who move into their sugar levels going high, generally have very vague symptoms. And some, lots are completely asymptomatic because that change has been so gradual that they haven't.

So asymptomatic means they're not aware of any symptoms at all?

Yeah. The symptoms come generally when the sugar levels go really high. At that point, when the sugar goes very high, the kidney's ability to reabsorb that sugar, it gets diminished and you push more sugar out into your urine. Sugar cannot go out on its own. It has to carry water with it. So you tend to pee a lot, pee more during the day, pee more during the night, so called polyure. You may then get more infections because you've got higher sugar levels as well. You tend to feel tired and fatigued, partly because if you're starting to pee out sugar, your body's efficiency and how it uses the sugar for optimal function is diminished. So you're fatigued. So fatigue, more infections, passing out more urine, other kind of major kind of symptoms.

And it sounds like those symptoms you're describing, they aren't when you first. It's not like when you get a cold or something. You don't get these symptoms. When you first get prediabetes or even diabetes. This is like when it's already lived with it.

Yeah, exactly. The sugar levels are going up relatively slowly. Most people generally, maybe they have some vague feeling of don't have as much energy as they used to. I'm sleeping a bit more erratically and just some vague symptoms and some may not. It depends how fast that sugar level is rising. It tends over what period it's rising. It depends what age you are. We know that younger people develop diabetes. The sugar levels rises faster than older people. Also, excess weight is a much bigger factor in younger people develop diabetes than older people. So there's lots of different dimensions. The thing I would say. We did a study of 100 asian men and white men. Of those 100 Asians, 13 had diabetes and didn't know about it. Okay. Didn't know they had diabetes.

So you had 100 Asians that you studied. None of them thought they had diabetes.

None of them knew they had.

And 13, one in 713 turned out. Yeah, that's huge. 13% had this and they had no idea that they had this serious disease. Exactly.

Yeah.

I think everybody listening to this is now going to be a little bit scared if they haven't spoken to somebody. Is it all right if you think you have some concern? So maybe. I think you're describing some of the reasons, like you think maybe you have put on more weight around your tummy.

Well, it's more than that, Jonathan. So the things you should do, there are simple scores. You can look, know, what is my risk for diabetes? High, lower, medium. And you can do that. There's the diabetes UK risk score, which you can get online. There's the Leicester diabetes score, there's what's known as Q diabetes online. And the risk scores capture your age, your family history of diabetes, your ethnicity, whether you're a male or female, and generally your weight, and a couple of few other things. And they will give you an idea. And it may be when you put that risk score, it comes up for the vast majority, it's going to be actually low, in which case, don't worry about, it's very unlikely you have diabetes. If it comes up medium or high, then at that point you might want to reach out to your GP and say, look, I've done this score. Could you potentially do my HBA one C test? I would like to know and just get an MOT, as it were. And that's what we.

Just to make sure that makes sense to everybody not in the UK listening, who may not know what an MOT is. What you're saying is, I think if I play that back, right, is, firstly, there's a score, and we will put a link in the show notes for anyone listening to this who can find the right way to score this for their country, which basically gives you an indication of your likelihood of risk. And what you're saying, I think, is if that risk is medium or high, then don't feel bad about going and speaking to your doctor or physician. And that there. Is this very. Is it a very difficult test to do to then find out this HBA one?

No, it's effectively, it's a blood test that the GP or the healthcare professional can take, or a phlebotomist can take any time of the day and it gets costs about, in british terms, one to two pounds. It's not very expensive and probably a bit more expensive in the US than some other places. So it's not very expensive.

The tests are always a lot more expensive in the US. Yes, but we won't go and discuss that right now.

That's a completely different. But anyway, it's relatively easy. It's done, get the result within a day and he comes up with the hemoglobin, a one test.

Because I think sometimes people say, oh, if you're not really sick, are you just like creating all these people worrying for no reason?

No.

Gone.

The vast majority of listeners, when they do this test, the risk will come up as low. Okay, the vast majority. And then they're reassured. Doesn't mean to say everyone has to try and live the best life they can and an enjoyable life in a way as well. But as an example, it would be somebody like myself. I have a family history of diabetes, so I have a risk factor. I'm also getting older. That in itself isn't a risk factor, but because I have a family history and I'm South Asian, then I probably motivate. If I do my diabetes risk score, it comes up as something like 15% chance over the next ten years. So it's a one in six or seven chance that I would. And I have had a hemogobina one test done and it came back as it's actually okay. But it's getting close to the prediabetes range, which fits with my family history. The reason I've met, I've kept it down, is because I've kept my muscle mass up. My father and my mother both developed diabetes in their forty s and fifty.

S. Hi, I want to take a quick break here and tell you about something new. We've created a free guide that will kick start your journey to better gut health. We feed our gut microbiome through the variety of foods we eat, and in return, our microbes give us a wealth of health benefits. They're responsible for so much as we've been learning, from digestion to immune support and even our mental wellbeing. So how can you nurture your gut in the best way? Which food swaps can you try to nourish those good bacteria? What does a high fiber shopping list really look like? Our free gut health guide shares it all. Emails and actionable tips that are designed to put you in control of your gut health. To get yours for free. Simply go to zoe.com gut guide. You'll also find the link in the show notes. Okay, back to the show. You know what, that is a brilliant transition point because I'd love to talk about. So what do you do to avoid getting, hopefully diabetes, pre diabetes in the first place? And it sounds naveed that you're literally living this yourself. So I'm fascinated, and you mentioned I wasn't sure was getting the dog part of this solution.

But tell me, I think you've painted a pretty clear picture that you would really like to avoid this because of all the serious implications. So if someone's listening to this and they're saying they want to make the right actions, could you talk through, I think, based on your own research, but also, I think fascinating to hear what you're doing yourself as an expert.

I mean, it's not even my research. I think it's based on the kind of global evidence that we know from all the randomized trials, all the various studies and around the world. The evidence base is the following is that if you want to reduce your risk of diabetes, the key aspects are keeping as healthy weight as you possibly can. So diets makes a big sense. Probably all the listeners here are well tuned to that and keeping relatively physically active. And those are the two major things we cannot stop aging. The one thing I would also say, and I think I've hinted at this, Jonathan, I'm now 56. If I can delay developing diabetes till I'm 75, I'm far less worried because if my sugar levels start to escape high level, then I don't have many more years for that sugar to cause damage. High sugars immediately do not cause damage. It takes about five to ten to 15 years. And also the older you become to get diabetes, the slower your sugar will elevate because it's less linked to weight gain, the younger you develop diabetes, it's more toxic. It's a more toxic disease because sugar levels rise faster, you tend to have to need more weight.

The reason you tend to need to have more weight to treat a diabetes is because when you're young, you tend to have a bigger muscle because you're young. And your pancreas is healthier because you're young. So in other words, to overcome those, your better buffering capacity because you're younger, you need to stress the system more by putting more fat in the wrong places. But that comes with all the other risk factors. That means your risk is much higher.

So you're saying if I can hold it off till I'm 75, then at that point maybe you could eat chocolate croissant all day. Is that where. There's other reasons not to think about that?

I know that the diabetes then is.

But you're less worried about the diabetes.

It's not going to massively impair my life expectancy, if at all. It's not going to lead me to have raging eye or kidney disease or nerve disease, if at all. If you're in your forty s and fifty s and you're in prediabetes, some small, sustainable lifestyle changes, that means that you either stay the same weight, put on a bit of muscle mass, or else lose three or 4, sustain that and able to keep healthy with a little bit of activity to stop you putting on weight means that you will probably delay developing diabetes for three, four or five or ten years. Up to ten years. And some people can delay this for a long time or even revert back to normal sugar levels. So it's effectively improving your muscle mass, cutting your weight, ectopic fat sufficient to destress your glucose control mechanisms.

And naveed, could we talk a little bit about. I'd love to talk about what you've done yourself and you touched on it, maybe briefly, but I'd love to understand. It sounds like this is a real live risk for you. You described the fact that both your parents developed it when they were very young. And it sounds like this is really on your. And it just reminds me a little bit of Tim when making his own changes for his health. It sounds like this is live for you. How does it affect what you do?

I'm obviously fortunate to live in an area where there's an ability to do more physical activity. I think the dog wasn't an effort necessarily to keep my diabetes away, but the side product of the dog is that I've increased my walking much more than I ever did before and I enjoy it. I've now cycled to work for the last ten years and I love it. So I've almost changed my own identity and who I am by becoming more physically active and finding things that I really enjoy. The side product of that is my muscle mass. I can feel it has gone up. I've probably reduced a little bit of excess fat within my liver. 25 years ago, I was a bit heavier and one of my signals for diabetes was incredibly high. And it's come right down because effectively it built more muscle, got rid of some of that fat mass, and some of those changes have been very gradual. Equally, I've also made some dietary changes as well, cutting out some of the refined sugars, increasing the variety of the foods. I eat more fiber rich, retrain my palate to have different tastes, which takes a bit of time to get used to.

Would you believe I even enjoy shredded wheat now? I love shredded wheat, but that's taking me a few weeks to get used to that taste and texture, but I love it. Okay, add two or three grapes on it for a little bit of sweetness, but that's fine again. So in a sense, I've been on this gradual step by step by step journey to eating a better quality fuel, having a better quality activity. That's in a sense, stop me putting fat in the wrong places, keep my engine better, to stop me pushing into diabetes in my 40s or fifty s. And hopefully I can keep doing that by staying active. Even if I get diabetes in my late 60s, I'm not worried about it because we now have better. I could undergo a weight loss intervention, I could go undergo this metformin. There's some better drugs coming forward as well.

For someone who's listening to this, who already has type two diabetes, or maybe they've been told they have prediabetes, is it possible to actually reverse some of this? Can you actually lower the blood sugars that you were talking about?

Yeah, absolutely. So, in every individual, we all have a different slope between weight gain and the hemoglobin, the HBA one C level. So in a sense, there's almost a straight line between each of us. And my line is steeper than yours, Jonathan, because of my family history. So for a smaller amount of weight gain, my HBA one C will elevate because I'll put fat in the wrong places. So we've shown in the direct trial that if you have a person who's developed diabetes within the last three to four years, if they lose 10 kg, about 46% after one year, or 33% after two years, no longer have diabetes because they've got rid of fat. The liver fat comes right down, then the liver responds far better to insulin, the liver makes less sugar. Your sugar normalizes in loss. So there's a straight line between how much weight people lose and how well their HBA one C improves by and large, and it works the other way as well. There's a straight line between how much weight you put on and just that slope of that line is different for different individuals, based on whether you're male or female, south asian or white, and whatever age you're at, and so on and so on, and so that does.

Mean wherever you are, there is something you can do, and it's not just about taking drugs.

So I had a patient this morning in the clinic who has diabetes, who'd undergone surgery for weight loss. They'd lost a lot of weight, their sugar levels had plummeted. They're still within the diabetes range. And the thing I discussed with them was, and they were starting to worry about mobility, was, can you actually now increase your muscle mass? You've done, you've lost, and they had lost seven stored because of surgery, but they could do some resistance exercise, a bit more physical activity to improve their mobility, to improve the engine side of it. So everyone listening can do something, but what they need to do is find something that they can sustain or enjoy, to reinvent a new version of themselves that they enjoy and they can sustain for better health as well. Whether that's dietary, physical, better sleep, all the things that you've discussed in Zoe, in various podcasts, better sleep gives you better appetite, allows you to control your appetite, better de stress, maybe more physical activity, all those things, and try and do it in a way that either small steps that you can get to slightly better health, to keep some of these diseases away, and also to increase the life expectancy of a healthy life, as it were, and contract unhealthy life.

For later years, which I think everyone listening to this podcast is interested in. Can I ask one final question before we then get to the summary? There are some new drugs that have been in the news, like Azempic, and there's been a lot of discussion. We're really lucky to speak to somebody who's one of the world's experts on diabetes. What's your view about these?

In some respects, I wish we didn't need to have those tools, because I wish we could change the environment, make it easier for people to live easier lives, because it's not easy changing your diet. It's not easy becoming more physically active. We talked about it, and we have to overcome waste, stigma. We have to talk about helping people navigate the environment that they live in.

If you're surrounded by awful food, it's very hard.

Yeah, it's almost impossible. I don't want people to think that. I think it's easy. It's not easy. Some of the changes that we've all had to make, we've had to work at them. But even then, for a lot of people, willpower is not enough. The environment to live is not enough. So I wish we did. Having said all of that, there's millions of people living with obesity and chronic diseases. These drugs are good, powerful tools that will help people control their appetite, lose quite a considerable amount of weight, and therefore reduce and improve and reduce the risk of a number of chronic diseases. Not only diabetes, but more recently, you reduce the risk of heart attacks or strokes, improve symptoms and heart failure, reduce the risk of kidney disease, improve the quality of life. So I'm glad they're there. They're expensive, we don't have great availability, so we need to work out in all healthcare systems, how do we get them to the people who need them the most to get the maximum benefit from those individuals and society? And that's a big ask. And hopefully, over the next ten years, we'll have more of those tools.

The prices will come down, they'll be proven to be long term safe, and the benefits outweigh any potential risks.

But it sounds like you are expecting to be prescribing these to some people.

I've already prescribed them in some people because we have to. But we need to do both prevention and treatment. We can't do just one.

And that is a whole nother podcast that I would like to get you. Indeed it is, Navid. I would love to do a wrap up and for you to make sure whether I've got this right before you shoot off to see another patient, if that's all right.

Sure.

So I think we started by talking about why would you worry about blood sugar at all? And you gave this brilliant analogy of sort of spilling sugar on the table and getting it wet, and that that's this sticky mess and you do not want that in your blood vessels. And what happens is, if you lose this control over your blood sugar, because, for example, you're starting to get all this fat in your liver, in your pancreas and all the rest of it, actually, you're getting this stickiness in these little blood vessels, and this is damaging your eyes and your nerves, and it doesn't sound good. So it's very clear that we don't want that. And then the question is, well, why is this happening? Because it's now happening where there's 100 million people with prediabetes, according to CDC in the US, and this big increase. And you're saying the biggest reason is we're starting to get, number one, that we're getting fat stored in our organs in a way that is really bad for them and didn't really happen in the past. And you particularly talked about it being in your liver and in your pancreas and that, interestingly, one of the reasons why we see so much variation between the risks of diabetes is that different people have very different likelihood to store excess weight in those places.

And so you described that, for example, women before menopause are much, are lower risk for diabetes because they tend to store their weight in almost anywhere other than the liver. But interestingly, as a man, you're saying almost the first place that I'm going to store this excess weight. And in my case in particular, that's obviously very true, is like right in the liver. And then it starts to cause all of these problems that, interestingly, there are big ethnic differences. And I think you described that sort of. Anyone who isn't caucasian, I think you said, actually has significantly higher risk. And then there's further differences between ethnicity, that there's some online tools to look at this, and we will share those links in the show notes so you can understand your own risks, which are averages, because I think what we always see with Zoe is there's a lot of personal variation, but this is a free first step, and that if it looks high, you should go to your doctor and check. And then I think we talked about the fact that, I think one of the things that's quite scary about this is that many people feel no symptoms.

And so you can have diabetes for a long time and this damage is starting to happen and you just don't even realize, which is, again, a reason to really believe in preventive health care. And then we talked about what to do. And I think the main answer is, for many people listening to this, is do what Naveed has done. So firstly, get a dog. Secondly, cycle to work. So basically find ways to be more physically active, you're saying, because it increases your muscles compared to just this very non moving way we tend to be and try and figure out how to control your weight, which is a topic we talk about a lot on other podcasts and we know is hard. But fundamentally, if your weight is just going up year after year after year, then you've got this problem. So physically active, healthy weight, so the right healthy diet, and a lot of.

People need support in that, obviously. Yeah, carry on, Jonathan.

Sorry. Absolutely. And part of what we talk, obviously, a lot on the podcast is about this. And of course, we want people ultimately to decide they'd like to try the postalized program that's really focused for them, which we talk about. And then I thought one thing you said that was really interesting is, in your mind's eye, actually, what you want to do is delay diabetes. In your perspective, if you got diabetes when you're 75, you're actually not too stressed about it because it takes quite a long time for there to be damage to you. So it's not like having a heart attack when you get diabetes. It's more like a risk. And so you're saying you want to push that out because actually maybe you're quite high risk. If you could push it out till 75, you're going to be okay. And then the final thing you said, which I thought was really positive, is you can reverse diabetes. Right? It's not like having cancer or a heart attack. Like, it's not a one way street. Actually, by removing this fat out of your liver, you can actually get to the point where you don't have diabetes or pre diabetes.

And I thought that was a beautiful, positive way to wrap it up.

Perfect. That's a fantastic summary.

Jonathan Naveed, thank you so much. I know that we jumped over a lot of this very big topic, and I know you're doing a lot of research in these areas. I hope that I can tempt you back in the future and we can continue.

We're delighted. Yeah, absolutely. Particularly, whatever the feedback, to try and unpick some of the other, because obviously it's hard to go into very specifics. There are some variations in various things, but I've given you the broad picture for the vast majority of people in terms of type two.

We would love to do that, and we'll talk a lot more about the diet side of it as well, of course, this being Zoe Naveed, thank you so, so much for taking the time.

Pleasure.

Thank you, naveed, for joining me on Zoe science and nutrition today. It's been fascinating to learn so much about blood sugar, how type two diabetes impacts our health, and how we can prevent and even reverse it. If you want to hear more insights from the podcast, you can download our free guide with our ten most impactful findings by going to zoe.com podcast. And if after this conversation you want to understand your own blood sugar levels in more detail and how they respond to the food that you eat, as I have done myself, then you can learn more about becoming a Zoe member and getting personalized advice about how to eat the best foods to reduce your blood sugar spikes. You can also get 10% off your membership again by going to zoe.com podcast. As always, I'm your host, Jonathan Wolf. Zoe Science and nutrition is produced by yellow Huings, Martin, Richard Willen, and Tilly Fulford. See you next time.