August 21, 2024 • 31 mins
Welcome to another enlightening episode of Think Like a Pancreas! Join host Gary Scheiner as he engages in a comprehensive discussion with Dr. Paula Diab, a physician and diabetologist from South Africa. Together, they explore the complexities of weight management for individuals who take insulin, offering practical insights and expert advice.
Subscribe now to Think Like a Pancreas for more episodes packed with expert advice and practical tips. Share this episode with fellow diabetes warriors, and leave a review to let us know your thoughts.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:05):
Welcome to Think Like a Pancreas, the podcast.
Our goal is to keep you informed, inspired,
and a little entertained on all things diabetes.
The information contained in the program is based on the
experience and opinions of the Integrated Diabetes Services
Clinical Team.
Since this is a very individualized condition,
(00:25):
please check with your healthcare provider before
implementing any of the weird stuff we may happen to share
with you today.
I'm your host, Gary Scheiner,
owner and clinical director of Integrated Diabetes
Services.
I've lived with type 1 diabetes for 39 years.
And today we're going to be discussing weight management
for people who take insulin.
(00:46):
I'm delighted to be joined today by somebody who is
completely on the other side of the globe.
I mean, if we drilled a hole through,
we would find South Africa.
And that's where our special guest is from, Dr.
Paula Diab.
Paula is a physician and diabetologist in South Africa.
(01:07):
And she runs an accredited diabetes center of excellence.
So Paula, welcome to the program.
Tell us a little more about yourself.
Thank you, Gary.
Yeah, I suppose, as you said,
the most important thing to note about me is that I'm not
in the US.
So while we're chatting,
the sun might set and it might get a bit dark.
(01:27):
I do get very passionate about things and I talk very fast.
So if I do that,
then hopefully I will calm myself down and talk a bit
slower.
That's where my accent comes from.
But yeah,
I've been working in the field of diabetes for about 20
years.
I graduated with my basic medical degree at the University
of Cape Town in the year 2000.
(01:47):
And I specialized in diabetes.
I did my PhD.
I've recently qualified as a diabetes care and education
specialist.
But I think my real passion is just translating what I
know.
know about diabetes into very simple and usable and user
friendly form for the everyday person.
Because I think, Gary, you'll agree with me as clinicians,
(02:09):
we especially these days,
we can get information really at our fingertips all the
time.
And almost on a daily basis, there's new information,
new research, new evidence coming out.
But the flip side of that is that it's also available to
the everyday person on social media and on the internet.
But from experience,
I often find that people tend to get the wrong end of the
(02:33):
stick sometimes,
sometimes that message is a little tarnished,
and quite a lot gets lost in translation.
So I really enjoy translating that for people and putting
it into a user friendly form.
Yeah.
And one of the bigger challenges any of us has who lives
with diabetes is in trying to manage our weight.
(02:56):
Insulin is a it's a growth hormone.
Insulin not only causes our cells to absorb glucose,
but it causes fat cells to absorb fuel and enlarge.
So the more insulin we take,
the more fat we're going to store,
the heavier we tend to get.
So on one end of this,
we're trying to manage our glucose levels,
(03:17):
and we have to take insulin to do that,
knowing that that insulin is also promoting weight gain.
The first rule is we've got to manage our diabetes.
We've got to manage the glucose levels.
But doing that at the same time as we're trying to lose
weight is really challenging.
You want to talk a little bit about that?
Yeah, I mean,
(03:38):
certainly diabetes is one of those hormonal diseases that
affects our ability to lose and gain weight.
Thyroid disease is another one where you're having to take
hormones in order to make your thyroid operate at the right
level.
Menopause is another one that affects women when their
hormones go upside down.
And these are what we call environmental influences on our
(04:00):
weights.
But I think there's a lot more to weight,
and certainly the latest research is showing that weights
and obesity management, in fact,
weights is now classified as a disease.
And I can expand on that in a bit of detail just now.
But it's a disease that is able to be treated.
(04:20):
It's largely genetically motivated,
but influenced by these hormonal and environmental issues.
So absolutely correct.
We need to monitor how much insulin you're taking or what
level of thyroid hormone you're taking or your reproductive
hormones that you might need to replace.
But when they're not in the right balance,
(04:42):
then that is certainly going to make you gain weight.
When I was in grad school,
endocrinology to me was so appealing and so interesting
because of the interplay.
One thing affects another thing,
which affects another thing, which affects another thing.
thing and then it cycles all over again.
The hormone balances in the body are just incredibly
(05:05):
fascinating.
And the hormones that affect weight in particular,
things like leptin and ghrelin,
and then insulin and thyroid hormone and growth hormone.
These hormones have an interplay.
It's like a ballet going on in the background all the time.
What motivates me to keep my weight under control is
(05:28):
cheapness and laziness.
It's not really a vanity thing and it's not a health thing.
What motivates me is I don't want to have to go out and buy
new clothes that are bigger than the ones I've got.
So everyone out there I think has their own motivation for
why they want to keep their weight under control.
(05:49):
What motivates you to...
keep your weight down.
I've got a very strong family history of diabetes and I've
often said to you I feel like a little bit of a pariah in
IDS because I don't have type 1 diabetes I'm the outsider.
We're thinking for the holidays this year we might give you
diabetes as present.
Thanks.
(06:10):
But yeah I mean I have a very strong family history of type
2 diabetes and I had gestational diabetes and my mum had
gestational diabetes.
So I think for me it's an intellectual knowledge of the
complications and the potential things that can go wrong.
I'm perhaps hit more into that category of working mums who
(06:32):
don't really have a huge amount of time to spend at the gym
and doing a lot of exercise.
But at the same time I also don't restrict myself with what
I'm eating.
I obviously make food for the family and I try and make it
well balanced.
But if it's a Friday night and we want to go out and have
pizza, I'm going to go and have a pizza.
(06:54):
It's just not every night and every Friday night that you
go.
I think again one of the things that I find that people can
really relate to is that I have a very practical way of
approaching life.
I don't spend hours and hours at the gym.
I don't spend hours and hours cooking these beautiful
homemade vegetable soups and never eating pizza.
(07:14):
It's just simple.
Look after yourself 80% of the time and 20% of the time you
can go.
Our colleague and our team Jenny Smith taught me that.
The four out of five rule she calls it.
It's like four out of five dentists surveyed recommend
sugarless gum.
I always wanted to know who was the one dentist that didn't
(07:35):
recommend sugarless gum for his patients.
She said you know four out of five of your meals you should
try to eat reasonably healthy.
One out of five don't worry about it.
Enjoy yourself and I really take solace in that.
We don't have to be perfect all the time.
I don't think on this.
No, I think that's what makes us different as humans.
You know,
one thing when I'm explaining how our bodies react to
(07:57):
weight loss and weight gain is I always paint the picture
of a lion in the bush.
Now,
I know there's not a whole bunch of lions roaming around
the States, but I think everyone knows what lions are like.
Africa, you got lions to deal with.
I get it.
We've got lions to deal with.
Not roaming around in our back gardens,
but they're all lions.
When a lion is hungry,
it goes and it looks for a buck and it catches the buck,
(08:19):
and it's going to carry on going until it catches the buck.
And then it's going to sit down or lie down and it's going
to tear that buck apart until it's no longer hungry.
And then when it's no longer hungry,
it's going to go lie in the shade under a tree and it's
going to sit there.
And if another buck comes running past,
that buck is safe because the lions now fall.
The difference with humans is that we eat for socialization
(08:41):
purposes.
We eat for pleasure.
We eat for all sorts of different reasons.
We don't just eat because we are.
homeostatically hungry.
And in fact,
we've now found that appetite is controlled in our brains
in three different places.
One is that homeostatic eating,
or what drives our homeostatic eating,
when we say I'm hungry, I haven't eaten for three days,
I need to get something to eat.
(09:03):
And that's where the lion comes in.
And humans have got a hedonistic side of their brain as
well, which is controlled in the frontal cortex,
that animals don't have developed.
And that is when you've decided that you just want to have
a quiet night at home, for whatever reason,
and then your friend finds you and says, Oh,
we're all going out for pizza,
do you want to come and join us?
(09:24):
99% of the time, you're not going to say no,
unless you've got too much work to do,
or you don't have the money, or there'll be another reason,
but it won't be because you don't want to partake in eating
a pizza.
And so that is the difference as to why you get overweight
humans.
I don't know if the Facebook meme made it across to the
States,
but there's this lovely one going around with all my
(09:45):
friends that shows a big fat hippopotamus eating grass.
And it says proof that you can't lose weight by eating
vegetables.
And that hippopotamus is not overweight.
That is the hippopotamus size.
We've got part of our brain driving us to eat out of
hunger,
we got part of our brain driving us to eat just for pleasure,
hedonistic, whatever.
(10:06):
Here's here's the wrinkle.
In people with diabetes, the hunger part is not normal.
You know,
I learned about 20 years ago about a hormone called amylin.
It's normally produced along with insulin, you know,
the beta cells put out insulin and this amylin hormone at
the same time.
And you know, we can survive and live without amylin.
(10:28):
But amylin plays a pretty important role in regulating
hunger and rate of digestion.
Without it, food digests much faster than it's supposed to.
And we're hungrier than we should be.
So people with diabetes type twos and type ones,
type twos will produce very little amyl.
(10:48):
Type 1s produce none.
Without that hormone,
without that amyl and hormone present,
we're hungrier than we should be.
Our food digests much faster than it should.
Our stomach empties very quickly.
How unfair is that?
I mean,
you think about a disease state where food intake is
central to managing it.
(11:09):
And now you're going to make these people hungry
constantly.
That's not fair.
Are we really on an unfair playing field here?
Is there anything we can do about it?
So certainly, I mean, absolutely.
And that's why a lot of the new diabetic drugs are targeted
at looking at different pathways and diabetes and not just
the simple, you know,
(11:31):
it gives the scar more insulin and the more food he eats,
the more insulin he needs.
I think when I finished university,
we were still talking about three pathways that affected
your your glucose levels in your body.
But we now know about 11 different pathways that influence
your glucose levels.
(11:51):
And only one or two of those is in the pancreas and one is
in the guts.
And the rest are all in all the other organs,
including the brain.
And what's really nice is that we now are starting to be
able to offer people medication that can target all these
different pathways and adapt the hormones that are
influencing your hunger levels in your society and your
ability to metabolize and your gastric emptying and how
(12:14):
slowly or fast you metabolize food.
You see on TV and in the news, you know,
these these new weight loss medications on the market,
they belong to a category called GLP1 receptor agonist.
But you know, things like Ozempic, Trulicity, Munjaro,
Victosa,
I guess these are meds that they do similar things as that
(12:36):
amylin hormone,
but they're a little longer lasting side effects aren't
quite as substantial.
So they become very popular for people trying to lose
weight.
In my case, I use one not because I need to lose weight,
but because it helps me control my appetite,
like still enjoy food,
but I'm not constantly like a lion with an empty stomach
(12:58):
all the time.
You mentioned a bit earlier about the hormone leptin.
So one of the key things that these GLP1s do is,
as soon as you stop eating, whether it's overnight,
whether it's for three days, whether it's for, you know,
you're going on a month long or faster, whatever it is,
your leptin levels start dropping,
and your brain reacts to that drop in leptin by saying,
(13:19):
I'm hungry.
And that's why we often wake up in the morning and before
we even thought what's happening, we hungry,
it's because those leptin levels have dropped.
And that all happens in our subconscious brain.
That's that homeostatic part of the brain.
And so it's an area of our brain that we can't access.
So no matter how much you tell yourself, I'm not hungry,
(13:39):
I'm not hungry, I'm not hungry.
Your brain is still programmed to say you are hungry,
you are hungry, you are hungry.
But what the GLP1s do is they can break that cycle at that
feedback to your brain at that subconscious level.
And it allows you then to differentiate,
do I want to eat this?
Or do I need to eat this and make that differentiation
(13:59):
between those two things?
So sleep is,
I've read a lot about sleep study effects of sleep.
And it certainly affects glucose management,
but it also affects appetite and affects metabolism.
Can you expand a little bit on the role of sleep in weight
management?
Certainly, as you said, it affects diabetes management,
(14:21):
because lack of sleep,
your cortisol levels are going to go up because of the
stress response.
And cortisol obviously is an anti -insulin hormone,
so your glucose levels go up.
And exactly the same way in obesity or in weight
management,
that cortisol level that rises as you don't sleep properly.
affects the way in which you store glucose.
(14:42):
And I think we're seeing this more and more in management
these days with people leading very stressful lives,
not sleeping very well, having unbroken sleep,
people who do shift work.
You know, in the old days,
you never had a cell phone that people could call you on
and message you on that beeped all night long.
And all of those things are playing into our ability to
have a solid eight -hour sleep every night.
(15:04):
And that is certainly affecting the way that we can lose
weight or gain weight.
Yeah,
I read about the leptin -grelin balance while we sleep and
interrupted sleep, poor quality, short duration sleep.
It seems that those leptin levels that help us control our
appetite go down and the ghrelin levels that stimulate
(15:24):
appetite go up.
So getting quality sleep,
getting a good night's sleep on a consistent basis can make
a big difference.
And the other thing that plays into it is as you get
bigger, you're putting more pressure on your lungs.
So when you're lying flat at night,
you get what's called obstructive sleep apnea.
It's purely from a physical,
(15:44):
this diaphragm pushing up on your, I mean,
pushed up against the lungs.
And that also contributes to not being able to sleep
properly.
So it's a completely vicious cycle that we need to break at
some stage.
Yeah, I guess people, those of us who stress eat,
that would be part of that aspect of the brain that's not
hunger -induced, this is emotionally triggered hunger.
(16:07):
I mean, I think we all have our go -to food.
When you're stressed, what's your fertility?
Chocolate, chocolate, chocolate.
Yeah, chocolate, all right.
I go to the store,
I get this box of things called pop -ums.
You ever heard of these?
They're like little donut holes with a glaze on them.
Just thinking about them, my mouth starts to water.
(16:28):
You know, the whole box is probably like, I don't know,
eight or 10 servings, but I'm eating the whole box,
you know, it's gonna disappear.
And when I'm stressed, it's like, I need a box of pop -ums.
Do you know that the interesting thing about that stress
eating and what you're describing is for so many of us,
I mean,
I know I come home from work every afternoon and just the
(16:49):
way our house is designed,
I have to walk through the kitchen to get anywhere in the
house.
And it's almost become sort of a Pavlovian response that
I'll put my bag and my keys down and I'll go and open the
fridge just to see what's there.
I'm not hungry.
I don't even I don't even know if I'm hungry.
I'll just go and open the fridge just for fun just to see
what's there.
And then once the fridge door is open, you think, well,
(17:11):
now I've got to get something out this fridge.
I heard a very interesting thing.
And I've actually used it for a couple of patients and
myself and it works.
And they say if you can identify when you are snacking or
when you are comfort eating or when you have an emotional
situation that's causing you to eat too much,
you only have to change one or two of those aspects in
order for you to break that whole cycle.
(17:33):
So for example, if you used to after dinner,
as a family going to go and sit in the lounge and watch
some TV and then suddenly you get hungry and you want to
eat something.
If you just don't turn the TV on or if you go and fold the
laundry first and then go and watch TV or if you take the
dog for a walk first before you go and watch TV,
(17:55):
you've broken that entire cycle.
So I now come in a different door in our house so that I
don't walk directly into the kitchen and go through to the
bedroom first to put my clothes,
take my shoes off and do whatever I have to do and then go
into the rest of the house and it completely breaks that
cycle of going directly to the fridge.
(18:15):
That's a brilliant idea.
We've seen it because a lot of the people who have started
working from home also that they're often working in the
dining room, lounge, living in kitchen area.
It's just easy,
it's too easy just to go in and they've got into this habit
of walking into the fridge and walking into the kitchen and
just opening the fridge or opening the cupboard.
So simple behavioral changes can make an enormous
(18:38):
difference.
I mean, speaking of the behavioral changes,
I'm an exercise physiologist by trade and staying in shape
is kind of ingrained in me.
I truly believe that that mindset is essential to long
-term weight management and health.
All the medications in the world will only do so much.
(19:00):
You still have to have a certain amount of willpower.
You still have to adopt healthy habits.
Not many people are farming and working in hard
manufacturing type jobs anymore.
People are service industries and pressing buttons on
machines.
Certainly,
(19:20):
you mentioned not many people are farming anymore.
Our bodies and our brains were designed for that act of
hunting together a type of person.
Hunting lions.
Hunting lions.
I don't know if I'd eat a lion.
way around.
I mean, that's what our bodies were designed for.
(19:42):
And the whole hormonal aspect was designed as an anti
starvation mechanism.
And now what we've done is we've got this fast food,
high fat, high salt, high sugar,
your pizza gets delivered to your door,
just press a few buttons on your phone,
you don't even need to go get up and get your wallets,
money, you know, press a few more buttons on your phone,
and you've paid for the pizza, you know,
(20:03):
all of that stuff has now collided with this way in which
our brains are hardwired.
And yeah,
that that's where this whole conundrum is coming in.
And why people are battling with obesity so much is because
it's a collision of these two worlds.
I think living in suburban and rural areas is dangerous for
one's health.
(20:25):
You know,
when people live in the city and work in the city,
they walk everywhere.
They're on their feet almost constantly.
And I see it when I go downtown,
I don't see nearly as much overweight and obesity as I do
out here because everyone just drives every place here.
There's nearly as much foot traffic.
(20:45):
Well,
just this weekend we had a long weekend in South Africa
where there was a public holiday yesterday and we went away
into what's called the Midlands and it's very similar to
the English Midlands where there's lots of hills and rivers
and farms and everything and immediately I said to my
husband as we drove in I said I just feel so much more
relaxed and and laughter happens at a slower pace and you
(21:07):
go out for a breakfast and you can have the eggs and the
bacon and the tomatoes and onions and all the trimmings on
it because you've had a hard day at work.
You're about to have a hard day on the farm and everyone's
working on their farms and there's beautiful homemade food
and everyone's really relaxed and chilled out.
Nobody's rushing around.
It's wonderful and that's not what our lifestyles are like
(21:28):
these days.
Yeah, all four out of five rule still applies.
So,
I mean there's a few different classes of medications besides
the GLP ones which are mostly injectables.
There are some companies developing oral versions of that
so you could take it in pill form but for now most of those
are once a week injectables and they come in a pen where
(21:51):
the the pen needle is so tiny you don't even feel the
needle stick or the injection.
There's another class of drugs called SGLT2 inhibitors.
These are oral meds that literally turn your kidneys into a
sieve.
You just spill sugar out through the urine constantly and
in doing so you lose fluids as well but when you spill
(22:13):
sugar in the urine you're losing calories and normally when
our glucose levels get above 180 or 10 millimole that
happens naturally but these medications cause you to spill
sugar in the urine all the time no matter what your glucose
level is so people can urinate away a few hundred calories
a day just from taking these pills and that facility weight
(22:37):
loss.
The side effects potentially type ones who take these can
sometimes go into ketoacidosis if they're not careful
because they may not retain as much energy as they're used
to.
Their insulin needs may go down quite a bit.
You have any thoughts about the SGLT2 meds as a weight loss
tool?
(22:58):
Yeah, I think when they initially came out,
that was one of the big marketing messages that was given.
And for reasons that you've explained,
they absolutely do cause weight loss.
But I think for me, I mean,
certainly they're not registered at this stage that I know
of outside of diabetes management.
(23:18):
So if you don't have diabetes, you're quite used to it.
Consuming all our listeners have diabetes would also help
facilitate some weight loss.
So it would facilitate weight loss.
You obviously do need to be careful on the side effects.
because it's as you say it's promoting that your kidneys to
become a sieve and sieve out all the glucose and the extra
glucose that you're not using you end up with a bladder
(23:41):
full of glucose.
So if you are a perimenopausal woman or if you have
decreased mobility in some for whatever reason or if you're
not able to avoid your bladder on a regular basis you're
going to end up with a beautiful place to grow a whole
bunch of bacteria in your bladder.
So that's going to become a problem.
I think if I'm prescribing an SGLT2 I still prescribe it
(24:04):
primarily for its cardiovascular benefits or cardiovascular
and renal protective benefits and I tend to use it more as
weight loss as a side effect.
Having said that a number of people who have type 2
diabetes who have got cardiovascular risk factors are often
overweight as well.
(24:24):
So it just becomes a nice added bonus rating.
I tried one of those medications when they first came out
several years ago because I just try everything I think to
see how it actually works and it does what it says.
I was urinating a lot more than usual and it was lowering
my glucose around the clock.
(24:46):
The odd thing about it after 35 years with type 1 when I
had to pee more than usual in my brain that registers as
bad because it means my glucose is too high.
So when I started urinating more than usual taking those
meds all I kept thinking is this is bad this is bad for me
my blood sugar must be high but it could be it could be
(25:09):
perfectly normal it could even be low and I'm still
urinating away glucose.
So to me the big negative side effect was having to run to
the bathroom so much it just got to be a little disruptive.
And you've got to avoid an empty or bladder because of that
high glucose content that sits there.
And what a lot of people do is they see that they're going
to the toilet more often so they automatically reduce their
(25:32):
fluid intake and that's the next worst thing that you can
do because you dehydrate it.
So there's one other weight management technique or
procedure that some people opt for and that's gastric
bypass.
It's not something I have experience with.
I've not tried it myself and I don't know- You haven't
(25:53):
tried that.
I honestly don't know that I've had any patients who have
done it either.
You have any patients who have gone for gastric bypass?
I actually have and it works very nicely in some patients
and I think the nicest way to think about gastric bypass
surgery and sort of medication for obesity in general is to
think of it like a pyramid and right up at the top of the
(26:15):
pyramid you've got surgical options for weight loss
management.
The next layer underneath that is your medical management
so your GLP ones and whatever other medical management you
want to use.
Underneath that you've got diet and exercise,
and underneath that, you've got behavioral management.
So your gastric bypass surgery is not going to work if you
(26:39):
don't have diet and exercise at all the other building
blocks under DCU.
It works very nicely in patients whom it is intended,
and those are generally people with a PMR of over 45 or 50
who've tried all the other levels.
And what it basically does is it just reduces the size of
the stomach and changes some of the metabolism and
(27:00):
absorption of your stomach.
But you need those building blocks at the bottom.
So we've spoken a lot about the medical management,
and you've hinted at the diet and the exercise part of
things.
And I always say to my patients,
if you've got a patient with asthma, for example,
you don't say to their patients,
(27:21):
just breathe more deeply if they're having an acute asthma
attack.
You don't say to them, just take deep breaths,
that's going to help you.
You give them an asthma inhaler,
and you help their lungs to expand and get more oxygen in.
And then you say to them, okay,
now I breathe deeply as well,
and you'll get more oxygen into your lungs.
And I try to encourage people to think of weight loss in
(27:44):
that same way.
Absolutely, calorie intake and output is important.
And what you're eating is important,
and what physical activity you're doing is important.
But you are going to need,
if we agree that this disease is genetically inherited and
it's centered in the brain, and it's hormonally driven,
(28:04):
you are going to need that GLP -1 drug to change that
feedback mechanism into your brain.
But then you can't just sit back and go, okay,
I've taken the medication,
now I can go and eat pizza for breakfast lunch and supper,
and I'm never going to do any exercise.
You still need to have that baseline underneath.
And in the behavioral therapy part of it is the
(28:26):
understanding of you know, when do I snack?
Why do I snack?
The emotional eating?
How do I curb that?
You know, all those behavioral techniques at the bottom.
So if you think of it like a pyramid,
all those specific people,
gastric bypass surgery works wonders.
And I've had people who've even reversed their tattoo
diabetes to a large extent,
(28:46):
who've had gastric bypass surgery.
But if you've only got a BMI of 30,
it's not really going to work to go for gastric bypass
surgery,
and then still going to eat what you want and do what you
want.
I'm sketching something out here.
My hand is not the best that I drew.
Paula's weight loss pyramid.
(29:07):
That's exactly it.
You should copyright this.
I think it's being copyrighted.
I'm just paraphrasing it.
Fundamental stuff at the bottom, the foundation,
the behaviors, good sleep, stress management, attitude.
I mean, just having good attitude.
And then...
some of the caloric balance stuff, the meal planning,
(29:29):
but keeping the four out of the five thing in mind,
it doesn't have to be optimized all the time,
and physical activity.
Physical activity is not just exercise,
it's daily activity, stuff throughout the day also,
how much movement we get.
And then we have the medical options, GLP1s,
SGLT2 inhibitors,
even metformin has been found to help some people with
(29:52):
weight management and up here different surgical options
that people can take.
So Paul's pyramid of weight loss.
This is great.
That's exactly it.
And you've got targets at all those levels in order to get
any weight.
Yeah.
That'd be right.
Paula Diab from South Africa.
(30:13):
What town in South Africa are you from?
Durban.
That's the main city.
You're anywhere near the shore, near the coastline.
About 20 kilometers from the coastline.
It's an extended city and we stay on the suburbs on the
outskirts.
Do you get your kids to the beach at all?
We do.
My kids normally drag me to watch hockey and ballet and
(30:33):
other things,
which prohibits the amount of time that you can go to the
beach.
We nasty sort of halfway between the beach and the
mountains and the bush.
So it's very nice.
All right.
I want a picture of you wrestling with a lion.
That would be cool.
Maybe a baby lion.
And you don't have to be wrestling with it.
You can just be kind of cuddling.
How about that?
Yeah.
It can be a fluffy toy lion rather.
(30:54):
A fluffy toy lion would do.
Because I don't think I'm going to get to the bush to go
and cuddle a lion.
Yeah.
You're important.
Well, thank you, Paula.
I appreciate you joining us today.
Thank you, Gary.
I know it's morning here, but I think it's dinner time,
almost dinner time there for you.
Almost dinner time.
Yeah.
The sun wasn't set yet.
They actually got a beautiful sunset that I can see just
out the window.
(31:15):
So I want to thank everybody for joining us today.
On behalf of Think Like a Pancreas, the podcast,
I'm Gary Scheiner.
Have a great rest of your week.
Thanks, Gary.
Thanks, everyone.
Welcome to Think Like a Pancreas, the podcast.
Our goal is to keep you informed, inspired,
and a little entertained on all things diabetes.
The information contained in the program is based on the
experience and opinions of the Integrated Diabetes Services
Clinical Team.
Since this is a very individualized condition,
(00:25):
please check with your healthcare provider before
implementing any of the weird stuff we may happen to share
with you today.
I'm your host, Gary Scheiner,
owner and clinical director of Integrated Diabetes
Services.
I've lived with type 1 diabetes for 39 years.
And today we're going to be discussing weight management
for people who take insulin.
(00:46):
I'm delighted to be joined today by somebody who is
completely on the other side of the globe.
I mean, if we drilled a hole through,
we would find South Africa.
And that's where our special guest is from, Dr.
Paula Diab.
Paula is a physician and diabetologist in South Africa.
(01:07):
And she runs an accredited diabetes center of excellence.
So Paula, welcome to the program.
Tell us a little more about yourself.
Thank you, Gary.
Yeah, I suppose, as you said,
the most important thing to note about me is that I'm not
in the US.
So while we're chatting,
the sun might set and it might get a bit dark.
(01:27):
I do get very passionate about things and I talk very fast.
So if I do that,
then hopefully I will calm myself down and talk a bit
slower.
That's where my accent comes from.
But yeah,
I've been working in the field of diabetes for about 20
years.
I graduated with my basic medical degree at the University
of Cape Town in the year 2000.
(01:47):
And I specialized in diabetes.
I did my PhD.
I've recently qualified as a diabetes care and education
specialist.
But I think my real passion is just translating what I
know.
know about diabetes into very simple and usable and user
friendly form for the everyday person.
Because I think, Gary, you'll agree with me as clinicians,
(02:09):
we especially these days,
we can get information really at our fingertips all the
time.
And almost on a daily basis, there's new information,
new research, new evidence coming out.
But the flip side of that is that it's also available to
the everyday person on social media and on the internet.
But from experience,
I often find that people tend to get the wrong end of the
(02:33):
stick sometimes,
sometimes that message is a little tarnished,
and quite a lot gets lost in translation.
So I really enjoy translating that for people and putting
it into a user friendly form.
Yeah.
And one of the bigger challenges any of us has who lives
with diabetes is in trying to manage our weight.
(02:56):
Insulin is a it's a growth hormone.
Insulin not only causes our cells to absorb glucose,
but it causes fat cells to absorb fuel and enlarge.
So the more insulin we take,
the more fat we're going to store,
the heavier we tend to get.
So on one end of this,
we're trying to manage our glucose levels,
(03:17):
and we have to take insulin to do that,
knowing that that insulin is also promoting weight gain.
The first rule is we've got to manage our diabetes.
We've got to manage the glucose levels.
But doing that at the same time as we're trying to lose
weight is really challenging.
You want to talk a little bit about that?
Yeah, I mean,
(03:38):
certainly diabetes is one of those hormonal diseases that
affects our ability to lose and gain weight.
Thyroid disease is another one where you're having to take
hormones in order to make your thyroid operate at the right
level.
Menopause is another one that affects women when their
hormones go upside down.
And these are what we call environmental influences on our
(04:00):
weights.
But I think there's a lot more to weight,
and certainly the latest research is showing that weights
and obesity management, in fact,
weights is now classified as a disease.
And I can expand on that in a bit of detail just now.
But it's a disease that is able to be treated.
(04:20):
It's largely genetically motivated,
but influenced by these hormonal and environmental issues.
So absolutely correct.
We need to monitor how much insulin you're taking or what
level of thyroid hormone you're taking or your reproductive
hormones that you might need to replace.
But when they're not in the right balance,
(04:42):
then that is certainly going to make you gain weight.
When I was in grad school,
endocrinology to me was so appealing and so interesting
because of the interplay.
One thing affects another thing,
which affects another thing, which affects another thing.
thing and then it cycles all over again.
The hormone balances in the body are just incredibly
(05:05):
fascinating.
And the hormones that affect weight in particular,
things like leptin and ghrelin,
and then insulin and thyroid hormone and growth hormone.
These hormones have an interplay.
It's like a ballet going on in the background all the time.
What motivates me to keep my weight under control is
(05:28):
cheapness and laziness.
It's not really a vanity thing and it's not a health thing.
What motivates me is I don't want to have to go out and buy
new clothes that are bigger than the ones I've got.
So everyone out there I think has their own motivation for
why they want to keep their weight under control.
(05:49):
What motivates you to...
keep your weight down.
I've got a very strong family history of diabetes and I've
often said to you I feel like a little bit of a pariah in
IDS because I don't have type 1 diabetes I'm the outsider.
We're thinking for the holidays this year we might give you
diabetes as present.
Thanks.
(06:10):
But yeah I mean I have a very strong family history of type
2 diabetes and I had gestational diabetes and my mum had
gestational diabetes.
So I think for me it's an intellectual knowledge of the
complications and the potential things that can go wrong.
I'm perhaps hit more into that category of working mums who
(06:32):
don't really have a huge amount of time to spend at the gym
and doing a lot of exercise.
But at the same time I also don't restrict myself with what
I'm eating.
I obviously make food for the family and I try and make it
well balanced.
But if it's a Friday night and we want to go out and have
pizza, I'm going to go and have a pizza.
(06:54):
It's just not every night and every Friday night that you
go.
I think again one of the things that I find that people can
really relate to is that I have a very practical way of
approaching life.
I don't spend hours and hours at the gym.
I don't spend hours and hours cooking these beautiful
homemade vegetable soups and never eating pizza.
(07:14):
It's just simple.
Look after yourself 80% of the time and 20% of the time you
can go.
Our colleague and our team Jenny Smith taught me that.
The four out of five rule she calls it.
It's like four out of five dentists surveyed recommend
sugarless gum.
I always wanted to know who was the one dentist that didn't
(07:35):
recommend sugarless gum for his patients.
She said you know four out of five of your meals you should
try to eat reasonably healthy.
One out of five don't worry about it.
Enjoy yourself and I really take solace in that.
We don't have to be perfect all the time.
I don't think on this.
No, I think that's what makes us different as humans.
You know,
one thing when I'm explaining how our bodies react to
(07:57):
weight loss and weight gain is I always paint the picture
of a lion in the bush.
Now,
I know there's not a whole bunch of lions roaming around
the States, but I think everyone knows what lions are like.
Africa, you got lions to deal with.
I get it.
We've got lions to deal with.
Not roaming around in our back gardens,
but they're all lions.
When a lion is hungry,
it goes and it looks for a buck and it catches the buck,
(08:19):
and it's going to carry on going until it catches the buck.
And then it's going to sit down or lie down and it's going
to tear that buck apart until it's no longer hungry.
And then when it's no longer hungry,
it's going to go lie in the shade under a tree and it's
going to sit there.
And if another buck comes running past,
that buck is safe because the lions now fall.
The difference with humans is that we eat for socialization
(08:41):
purposes.
We eat for pleasure.
We eat for all sorts of different reasons.
We don't just eat because we are.
homeostatically hungry.
And in fact,
we've now found that appetite is controlled in our brains
in three different places.
One is that homeostatic eating,
or what drives our homeostatic eating,
when we say I'm hungry, I haven't eaten for three days,
I need to get something to eat.
(09:03):
And that's where the lion comes in.
And humans have got a hedonistic side of their brain as
well, which is controlled in the frontal cortex,
that animals don't have developed.
And that is when you've decided that you just want to have
a quiet night at home, for whatever reason,
and then your friend finds you and says, Oh,
we're all going out for pizza,
do you want to come and join us?
(09:24):
99% of the time, you're not going to say no,
unless you've got too much work to do,
or you don't have the money, or there'll be another reason,
but it won't be because you don't want to partake in eating
a pizza.
And so that is the difference as to why you get overweight
humans.
I don't know if the Facebook meme made it across to the
States,
but there's this lovely one going around with all my
(09:45):
friends that shows a big fat hippopotamus eating grass.
And it says proof that you can't lose weight by eating
vegetables.
And that hippopotamus is not overweight.
That is the hippopotamus size.
We've got part of our brain driving us to eat out of
hunger,
we got part of our brain driving us to eat just for pleasure,
hedonistic, whatever.
(10:06):
Here's here's the wrinkle.
In people with diabetes, the hunger part is not normal.
You know,
I learned about 20 years ago about a hormone called amylin.
It's normally produced along with insulin, you know,
the beta cells put out insulin and this amylin hormone at
the same time.
And you know, we can survive and live without amylin.
(10:28):
But amylin plays a pretty important role in regulating
hunger and rate of digestion.
Without it, food digests much faster than it's supposed to.
And we're hungrier than we should be.
So people with diabetes type twos and type ones,
type twos will produce very little amyl.
(10:48):
Type 1s produce none.
Without that hormone,
without that amyl and hormone present,
we're hungrier than we should be.
Our food digests much faster than it should.
Our stomach empties very quickly.
How unfair is that?
I mean,
you think about a disease state where food intake is
central to managing it.
(11:09):
And now you're going to make these people hungry
constantly.
That's not fair.
Are we really on an unfair playing field here?
Is there anything we can do about it?
So certainly, I mean, absolutely.
And that's why a lot of the new diabetic drugs are targeted
at looking at different pathways and diabetes and not just
the simple, you know,
(11:31):
it gives the scar more insulin and the more food he eats,
the more insulin he needs.
I think when I finished university,
we were still talking about three pathways that affected
your your glucose levels in your body.
But we now know about 11 different pathways that influence
your glucose levels.
(11:51):
And only one or two of those is in the pancreas and one is
in the guts.
And the rest are all in all the other organs,
including the brain.
And what's really nice is that we now are starting to be
able to offer people medication that can target all these
different pathways and adapt the hormones that are
influencing your hunger levels in your society and your
ability to metabolize and your gastric emptying and how
(12:14):
slowly or fast you metabolize food.
You see on TV and in the news, you know,
these these new weight loss medications on the market,
they belong to a category called GLP1 receptor agonist.
But you know, things like Ozempic, Trulicity, Munjaro,
Victosa,
I guess these are meds that they do similar things as that
(12:36):
amylin hormone,
but they're a little longer lasting side effects aren't
quite as substantial.
So they become very popular for people trying to lose
weight.
In my case, I use one not because I need to lose weight,
but because it helps me control my appetite,
like still enjoy food,
but I'm not constantly like a lion with an empty stomach
(12:58):
all the time.
You mentioned a bit earlier about the hormone leptin.
So one of the key things that these GLP1s do is,
as soon as you stop eating, whether it's overnight,
whether it's for three days, whether it's for, you know,
you're going on a month long or faster, whatever it is,
your leptin levels start dropping,
and your brain reacts to that drop in leptin by saying,
(13:19):
I'm hungry.
And that's why we often wake up in the morning and before
we even thought what's happening, we hungry,
it's because those leptin levels have dropped.
And that all happens in our subconscious brain.
That's that homeostatic part of the brain.
And so it's an area of our brain that we can't access.
So no matter how much you tell yourself, I'm not hungry,
(13:39):
I'm not hungry, I'm not hungry.
Your brain is still programmed to say you are hungry,
you are hungry, you are hungry.
But what the GLP1s do is they can break that cycle at that
feedback to your brain at that subconscious level.
And it allows you then to differentiate,
do I want to eat this?
Or do I need to eat this and make that differentiation
(13:59):
between those two things?
So sleep is,
I've read a lot about sleep study effects of sleep.
And it certainly affects glucose management,
but it also affects appetite and affects metabolism.
Can you expand a little bit on the role of sleep in weight
management?
Certainly, as you said, it affects diabetes management,
(14:21):
because lack of sleep,
your cortisol levels are going to go up because of the
stress response.
And cortisol obviously is an anti -insulin hormone,
so your glucose levels go up.
And exactly the same way in obesity or in weight
management,
that cortisol level that rises as you don't sleep properly.
affects the way in which you store glucose.
(14:42):
And I think we're seeing this more and more in management
these days with people leading very stressful lives,
not sleeping very well, having unbroken sleep,
people who do shift work.
You know, in the old days,
you never had a cell phone that people could call you on
and message you on that beeped all night long.
And all of those things are playing into our ability to
have a solid eight -hour sleep every night.
(15:04):
And that is certainly affecting the way that we can lose
weight or gain weight.
Yeah,
I read about the leptin -grelin balance while we sleep and
interrupted sleep, poor quality, short duration sleep.
It seems that those leptin levels that help us control our
appetite go down and the ghrelin levels that stimulate
(15:24):
appetite go up.
So getting quality sleep,
getting a good night's sleep on a consistent basis can make
a big difference.
And the other thing that plays into it is as you get
bigger, you're putting more pressure on your lungs.
So when you're lying flat at night,
you get what's called obstructive sleep apnea.
It's purely from a physical,
(15:44):
this diaphragm pushing up on your, I mean,
pushed up against the lungs.
And that also contributes to not being able to sleep
properly.
So it's a completely vicious cycle that we need to break at
some stage.
Yeah, I guess people, those of us who stress eat,
that would be part of that aspect of the brain that's not
hunger -induced, this is emotionally triggered hunger.
(16:07):
I mean, I think we all have our go -to food.
When you're stressed, what's your fertility?
Chocolate, chocolate, chocolate.
Yeah, chocolate, all right.
I go to the store,
I get this box of things called pop -ums.
You ever heard of these?
They're like little donut holes with a glaze on them.
Just thinking about them, my mouth starts to water.
(16:28):
You know, the whole box is probably like, I don't know,
eight or 10 servings, but I'm eating the whole box,
you know, it's gonna disappear.
And when I'm stressed, it's like, I need a box of pop -ums.
Do you know that the interesting thing about that stress
eating and what you're describing is for so many of us,
I mean,
I know I come home from work every afternoon and just the
(16:49):
way our house is designed,
I have to walk through the kitchen to get anywhere in the
house.
And it's almost become sort of a Pavlovian response that
I'll put my bag and my keys down and I'll go and open the
fridge just to see what's there.
I'm not hungry.
I don't even I don't even know if I'm hungry.
I'll just go and open the fridge just for fun just to see
what's there.
And then once the fridge door is open, you think, well,
(17:11):
now I've got to get something out this fridge.
I heard a very interesting thing.
And I've actually used it for a couple of patients and
myself and it works.
And they say if you can identify when you are snacking or
when you are comfort eating or when you have an emotional
situation that's causing you to eat too much,
you only have to change one or two of those aspects in
order for you to break that whole cycle.
(17:33):
So for example, if you used to after dinner,
as a family going to go and sit in the lounge and watch
some TV and then suddenly you get hungry and you want to
eat something.
If you just don't turn the TV on or if you go and fold the
laundry first and then go and watch TV or if you take the
dog for a walk first before you go and watch TV,
(17:55):
you've broken that entire cycle.
So I now come in a different door in our house so that I
don't walk directly into the kitchen and go through to the
bedroom first to put my clothes,
take my shoes off and do whatever I have to do and then go
into the rest of the house and it completely breaks that
cycle of going directly to the fridge.
(18:15):
That's a brilliant idea.
We've seen it because a lot of the people who have started
working from home also that they're often working in the
dining room, lounge, living in kitchen area.
It's just easy,
it's too easy just to go in and they've got into this habit
of walking into the fridge and walking into the kitchen and
just opening the fridge or opening the cupboard.
So simple behavioral changes can make an enormous
(18:38):
difference.
I mean, speaking of the behavioral changes,
I'm an exercise physiologist by trade and staying in shape
is kind of ingrained in me.
I truly believe that that mindset is essential to long
-term weight management and health.
All the medications in the world will only do so much.
(19:00):
You still have to have a certain amount of willpower.
You still have to adopt healthy habits.
Not many people are farming and working in hard
manufacturing type jobs anymore.
People are service industries and pressing buttons on
machines.
Certainly,
(19:20):
you mentioned not many people are farming anymore.
Our bodies and our brains were designed for that act of
hunting together a type of person.
Hunting lions.
Hunting lions.
I don't know if I'd eat a lion.
way around.
I mean, that's what our bodies were designed for.
(19:42):
And the whole hormonal aspect was designed as an anti
starvation mechanism.
And now what we've done is we've got this fast food,
high fat, high salt, high sugar,
your pizza gets delivered to your door,
just press a few buttons on your phone,
you don't even need to go get up and get your wallets,
money, you know, press a few more buttons on your phone,
and you've paid for the pizza, you know,
(20:03):
all of that stuff has now collided with this way in which
our brains are hardwired.
And yeah,
that that's where this whole conundrum is coming in.
And why people are battling with obesity so much is because
it's a collision of these two worlds.
I think living in suburban and rural areas is dangerous for
one's health.
(20:25):
You know,
when people live in the city and work in the city,
they walk everywhere.
They're on their feet almost constantly.
And I see it when I go downtown,
I don't see nearly as much overweight and obesity as I do
out here because everyone just drives every place here.
There's nearly as much foot traffic.
(20:45):
Well,
just this weekend we had a long weekend in South Africa
where there was a public holiday yesterday and we went away
into what's called the Midlands and it's very similar to
the English Midlands where there's lots of hills and rivers
and farms and everything and immediately I said to my
husband as we drove in I said I just feel so much more
relaxed and and laughter happens at a slower pace and you
(21:07):
go out for a breakfast and you can have the eggs and the
bacon and the tomatoes and onions and all the trimmings on
it because you've had a hard day at work.
You're about to have a hard day on the farm and everyone's
working on their farms and there's beautiful homemade food
and everyone's really relaxed and chilled out.
Nobody's rushing around.
It's wonderful and that's not what our lifestyles are like
(21:28):
these days.
Yeah, all four out of five rule still applies.
So,
I mean there's a few different classes of medications besides
the GLP ones which are mostly injectables.
There are some companies developing oral versions of that
so you could take it in pill form but for now most of those
are once a week injectables and they come in a pen where
(21:51):
the the pen needle is so tiny you don't even feel the
needle stick or the injection.
There's another class of drugs called SGLT2 inhibitors.
These are oral meds that literally turn your kidneys into a
sieve.
You just spill sugar out through the urine constantly and
in doing so you lose fluids as well but when you spill
(22:13):
sugar in the urine you're losing calories and normally when
our glucose levels get above 180 or 10 millimole that
happens naturally but these medications cause you to spill
sugar in the urine all the time no matter what your glucose
level is so people can urinate away a few hundred calories
a day just from taking these pills and that facility weight
(22:37):
loss.
The side effects potentially type ones who take these can
sometimes go into ketoacidosis if they're not careful
because they may not retain as much energy as they're used
to.
Their insulin needs may go down quite a bit.
You have any thoughts about the SGLT2 meds as a weight loss
tool?
(22:58):
Yeah, I think when they initially came out,
that was one of the big marketing messages that was given.
And for reasons that you've explained,
they absolutely do cause weight loss.
But I think for me, I mean,
certainly they're not registered at this stage that I know
of outside of diabetes management.
(23:18):
So if you don't have diabetes, you're quite used to it.
Consuming all our listeners have diabetes would also help
facilitate some weight loss.
So it would facilitate weight loss.
You obviously do need to be careful on the side effects.
because it's as you say it's promoting that your kidneys to
become a sieve and sieve out all the glucose and the extra
glucose that you're not using you end up with a bladder
(23:41):
full of glucose.
So if you are a perimenopausal woman or if you have
decreased mobility in some for whatever reason or if you're
not able to avoid your bladder on a regular basis you're
going to end up with a beautiful place to grow a whole
bunch of bacteria in your bladder.
So that's going to become a problem.
I think if I'm prescribing an SGLT2 I still prescribe it
(24:04):
primarily for its cardiovascular benefits or cardiovascular
and renal protective benefits and I tend to use it more as
weight loss as a side effect.
Having said that a number of people who have type 2
diabetes who have got cardiovascular risk factors are often
overweight as well.
(24:24):
So it just becomes a nice added bonus rating.
I tried one of those medications when they first came out
several years ago because I just try everything I think to
see how it actually works and it does what it says.
I was urinating a lot more than usual and it was lowering
my glucose around the clock.
(24:46):
The odd thing about it after 35 years with type 1 when I
had to pee more than usual in my brain that registers as
bad because it means my glucose is too high.
So when I started urinating more than usual taking those
meds all I kept thinking is this is bad this is bad for me
my blood sugar must be high but it could be it could be
(25:09):
perfectly normal it could even be low and I'm still
urinating away glucose.
So to me the big negative side effect was having to run to
the bathroom so much it just got to be a little disruptive.
And you've got to avoid an empty or bladder because of that
high glucose content that sits there.
And what a lot of people do is they see that they're going
to the toilet more often so they automatically reduce their
(25:32):
fluid intake and that's the next worst thing that you can
do because you dehydrate it.
So there's one other weight management technique or
procedure that some people opt for and that's gastric
bypass.
It's not something I have experience with.
I've not tried it myself and I don't know- You haven't
(25:53):
tried that.
I honestly don't know that I've had any patients who have
done it either.
You have any patients who have gone for gastric bypass?
I actually have and it works very nicely in some patients
and I think the nicest way to think about gastric bypass
surgery and sort of medication for obesity in general is to
think of it like a pyramid and right up at the top of the
(26:15):
pyramid you've got surgical options for weight loss
management.
The next layer underneath that is your medical management
so your GLP ones and whatever other medical management you
want to use.
Underneath that you've got diet and exercise,
and underneath that, you've got behavioral management.
So your gastric bypass surgery is not going to work if you
(26:39):
don't have diet and exercise at all the other building
blocks under DCU.
It works very nicely in patients whom it is intended,
and those are generally people with a PMR of over 45 or 50
who've tried all the other levels.
And what it basically does is it just reduces the size of
the stomach and changes some of the metabolism and
(27:00):
absorption of your stomach.
But you need those building blocks at the bottom.
So we've spoken a lot about the medical management,
and you've hinted at the diet and the exercise part of
things.
And I always say to my patients,
if you've got a patient with asthma, for example,
you don't say to their patients,
(27:21):
just breathe more deeply if they're having an acute asthma
attack.
You don't say to them, just take deep breaths,
that's going to help you.
You give them an asthma inhaler,
and you help their lungs to expand and get more oxygen in.
And then you say to them, okay,
now I breathe deeply as well,
and you'll get more oxygen into your lungs.
And I try to encourage people to think of weight loss in
(27:44):
that same way.
Absolutely, calorie intake and output is important.
And what you're eating is important,
and what physical activity you're doing is important.
But you are going to need,
if we agree that this disease is genetically inherited and
it's centered in the brain, and it's hormonally driven,
(28:04):
you are going to need that GLP -1 drug to change that
feedback mechanism into your brain.
But then you can't just sit back and go, okay,
I've taken the medication,
now I can go and eat pizza for breakfast lunch and supper,
and I'm never going to do any exercise.
You still need to have that baseline underneath.
And in the behavioral therapy part of it is the
(28:26):
understanding of you know, when do I snack?
Why do I snack?
The emotional eating?
How do I curb that?
You know, all those behavioral techniques at the bottom.
So if you think of it like a pyramid,
all those specific people,
gastric bypass surgery works wonders.
And I've had people who've even reversed their tattoo
diabetes to a large extent,
(28:46):
who've had gastric bypass surgery.
But if you've only got a BMI of 30,
it's not really going to work to go for gastric bypass
surgery,
and then still going to eat what you want and do what you
want.
I'm sketching something out here.
My hand is not the best that I drew.
Paula's weight loss pyramid.
(29:07):
That's exactly it.
You should copyright this.
I think it's being copyrighted.
I'm just paraphrasing it.
Fundamental stuff at the bottom, the foundation,
the behaviors, good sleep, stress management, attitude.
I mean, just having good attitude.
And then...
some of the caloric balance stuff, the meal planning,
(29:29):
but keeping the four out of the five thing in mind,
it doesn't have to be optimized all the time,
and physical activity.
Physical activity is not just exercise,
it's daily activity, stuff throughout the day also,
how much movement we get.
And then we have the medical options, GLP1s,
SGLT2 inhibitors,
even metformin has been found to help some people with
(29:52):
weight management and up here different surgical options
that people can take.
So Paul's pyramid of weight loss.
This is great.
That's exactly it.
And you've got targets at all those levels in order to get
any weight.
Yeah.
That'd be right.
Paula Diab from South Africa.
(30:13):
What town in South Africa are you from?
Durban.
That's the main city.
You're anywhere near the shore, near the coastline.
About 20 kilometers from the coastline.
It's an extended city and we stay on the suburbs on the
outskirts.
Do you get your kids to the beach at all?
We do.
My kids normally drag me to watch hockey and ballet and
(30:33):
other things,
which prohibits the amount of time that you can go to the
beach.
We nasty sort of halfway between the beach and the
mountains and the bush.
So it's very nice.
All right.
I want a picture of you wrestling with a lion.
That would be cool.
Maybe a baby lion.
And you don't have to be wrestling with it.
You can just be kind of cuddling.
How about that?
Yeah.
It can be a fluffy toy lion rather.
(30:54):
A fluffy toy lion would do.
Because I don't think I'm going to get to the bush to go
and cuddle a lion.
Yeah.
You're important.
Well, thank you, Paula.
I appreciate you joining us today.
Thank you, Gary.
I know it's morning here, but I think it's dinner time,
almost dinner time there for you.
Almost dinner time.
Yeah.
The sun wasn't set yet.
They actually got a beautiful sunset that I can see just
out the window.
(31:15):
So I want to thank everybody for joining us today.
On behalf of Think Like a Pancreas, the podcast,
I'm Gary Scheiner.
Have a great rest of your week.
Thanks, Gary.
Thanks, everyone.
Popular Podcasts
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com