The T2D podcast - Prof. Diarmuid Smith - Consultant Endocrinologist, Beaumont Hospital, Dublin

This is the  second episode in the patient-led type two diabetes (T2D) podcast which aims to give you the answers to the questions that you want to know about type two diabetes.
 
 Thank you for all the responses to the initial questionnaire that was sent out to see what questions you had about the condition. Sinead Powell, Senior Dietitian with Diabetes Ireland answered some of your nutrition and diet ones and in this episode Prof. Diarmuid Smith Consultant Endocrinologist in Beaumont Hospital, Dublin, Ireland will answer some of the more clinical ones.
 If you could please take the time to answer the very short survey afterwards and let me know what you think of the information contained in the podcast, I would be very grateful. 

You can leave a comment here - https://www.surveymonkey.com/r/NQNSQ7X  all responses are completely anonymous.

 You can also get in touch with me via the following email address: olivia.crinion2@mail.dcu.ie.

If you have any questions about the information contained in podcast or would like a transcript of any of the episodes, please get in touch with me via the following email address: olivia.crinion2@mail.dcu.ie.

Ethics approval has been granted by DCU for this study.

If participants have concerns about this study and wish to contact an independent person, please contact:

The Chair, DCU Humanities & Social Science Faculty Research Ethics Committee, c/o Dublin City University, Dublin 9. Tel 01-7008000, e-mail hss-frec@dcu.ie

Transcript

Transcript: Interview - Prof. Diarmuid Smith - consultant endocrinologist, Beaumont Hospital, Dublin, Ireland

Interview – 10th August 2023

SPEAKERS

Prof. Diarmuid Smith, Olivia Crinion

Olivia C  00:00

Hello and welcome to the second episode in Ireland's first patient-led type two diabetes podcast. And thank you to everyone who has completed questionnaires, volunteered for interviews and is listening now. Hopefully this will be a source of information for you. And of course, one that can be updated as the science evolves and your questions change. My name is Olivia Crinion and this podcast is part of a dissertation to complete a master's degree in science and health communication in Dublin City University. But it's more than that, I would like to produce something that would make a difference in the lives of people who are living with type two diabetes, and try to ensure that you have the most up to date information you need to take charge of your own health and well-being. To start off an anonymous questionnaire was sent out via the Diabetes, Ireland Facebook page, personal social media and through friends and family, for anybody over 18, who has been diagnosed with prediabetes or type two diabetes. Thank you to everyone who took the time to reply to the questionnaire your responses  to the questions. will now form the basis of this interview. So this is the second interview. The first was with Sinead Powell, senior dietitian with diabetes, Ireland, and hopefully a lot of your nutrition and diet questions were answered then.  The medical professional today is Professor Diarmuid Smith, a consultant endocrinologist in Beaumont Hospital in Dublin, Ireland. I'm going to ask Diarmuid  some of the more clinical questions that you've asked. Please remember to consult with your healthcare professional before acting on any of the information that you may hear in this podcast, as general advice may not apply to specific individual cases.  Good morning Diarmuid, how are you? 

Prof. Diarmuid Smith  01:49

Good. Thank you. Good. 

Olivia C  01:50

You're very good. Thank you so much for talking to us today. First of all, could I ask you please, what is an endocrinologist? And why would somebody with type two diabetes....why might they need to go and see one?

Prof. Diarmuid Smith  02:02

Well, an endocrinologist? Endocrinology is a specialty of medicine. I'm a physician. So we're not surgeons, we're physicians. And essentially, endocrinology encompasses diabetes mellitus and the management of other endocrine disorders like thyroid disease, ovarian disease, pituitary disease, calcium disorders, etc. So there's a whole wide spectrum of conditions that an endocrinologist would look after endocrinologist also do a lot of general internal medicine. So the workload for an endocrinologist is very busy. Essentially, as regards why somebody with diabetes would need to see an endocrinologist , we have a special interest in managing diabetes mellitus, whether that's type one type two diabetes, or the other types of diabetes. Essentially, the way the services in Ireland are currently organised , you know, there's probably about 300,000 people with diabetes in the country, and probably about 270,000 of those have type two diabetes, roughly, we actually not sure what the exact numbers are, because we don't have a National Diabetes register. And it's recommended that somebody with diabetes will be seen two to three times a year by a medical ,,,either their GP or a specialist within the hospital. So essentially, therefore, if that's two hundred and seventy thousand people in the country, that's maybe somewhere between 600 to 900,000 visits a year. And in the country, there's probably roughly only maybe 60 endocrinologists in the country. So therefore, the way we manage type two diabetes is sort of between primary care with your GP and then with the hospital based services. And for type two diabetes, the hospital based services are really looking after those with complicated type two diabetes. Unfortunately, patients with diabetes can develop complications, whether that's renal disease, foot disease, heart disease, heart failure, liver failure, etc. They're the type of patients we see in the hospital, the uncomplicated type two patients are predominantly managed by the GP in the community.

Olivia C  04:09

So one of the things that doesn't seem to be that people don't really understand the potential long term consequences of type two diabetes, have you found that?

Prof. Diarmuid Smith  04:21

Well type two diabetes, I'm afraid if you look at the complications, and this applies to type one diabetes as well. But if you look at the list of complications, so diabetes is the commonest cause of blindness in the working age adult is the commonest cause of renal failure in the western world is the commonest reason for dialysis requirements in the Western world. It's one of the commonest reasons for foot ulceration separation or lower limb amputation. Diabetes can also be associated with heart disease strokes, liver failure cirrhosis, so I'm afraid diabetes can be associated with a whole constellation of complications. And one of the big challenges we face is maybe 20, 30 years ago, people with diabetes with type two diabetes were typically diagnosed maybe in their seventh or eighth decade of life. So they only had the disease maybe for a few years before they died before the complications arose. But now we're seeing type two diabetes, the average age typically now is about the fifth decade of life. And we're actually seeing type two diabetes a handful of cases in in our teenage population. So that means now that people will have diabetes for 10, 20, 30, 40 years, and so the complications can arise and that time, but those complications are preventable, they can be prevented with good diabetes control.

Olivia C  05:53

There's a lot of interest in reversal of type two diabetes. And I know, I know that it's very, very difficult. But do you think that it should be the aim for a lot of people. And even if it's not the aim, that trying to get there would help the condition?

Prof. Diarmuid Smith  06:12

So I personally don't like the term reversal, diabetes, type two diabetes is a genetic disorder. So people are born with a genetic predisposition to developing it and, and type two diabetes is a very heterogeneous group. So you will have patients with type two diabetes who will have a normal body weight, versus patients with type two diabetes who may have significant weight issues. And there are often two different conditions and the way we manage them can be different. So this idea of reversal, I actually don't I don't use that term, increasingly I use the term remission, that you're trying to get your diabetes into remission. And what remission means is that your diabetes control, your blood glucose control is very good. And you're not on medications. And it is possible to get your diabetes into remission. But that requires significant weight loss for those people who have weight issues. And typically, it's only successful maybe in the early stages of the condition. And then if you follow people long enough, over time, the diabetes or the blood glucose levels can start to rise. So I don't like this idea of reversal, or cure. Diabetes, type two diabetes, we do try and aim for diabetes in remission. But that can be very hard to achieve. For a lot of people.

Olivia C  07:35

You mentioned their genetic link. And I know there are a lot of people who are quite interested in that, from the questionnaires, people have said, well, if I have a genetic predisposition to diabetes, is it, you know, do I just accept it?

Prof. Diarmuid Smith  07:53

Well, to be honest, I suppose the three big risk factors for developing diabetes are obviously your genetics, your age, as you get older, we know diabetes does increase with age. And we will certainly have a cohort of patients, particularly our elderly patients, who may develop it in their eighth or ninth decade of life, and it's nearly age that's caught them out. And then the other big, big risk factor is of course, weight, lifestyle, exercise, etc. So essentially, the only risk factor you can modify in those three factors is the weight lifestyle exercise. So essentially, I would sort of say, there's still a lot a person can do to try and prevent or reduce the risk of the onset of diabetes. And as I mentioned, if you develop diabetes, maybe when you're 90, rather than when you're 50. That's incredibly relevant. That's incredibly important. So yes, it's very important that still a lot can be done to prevent its onset. Absolutely.

Olivia C  08:50

And you mentioned one of the things that is important is weight. And can you explain the link between diabetes and obesity? 

Prof. Diarmuid Smith  09:03

Yes, so, so essentially, I suppose there's a number of different reasons why people become diabetic. But probably the main reason is that you're born with this genetic predisposition to a thing called insulin resistance. Now what insulin resistance means is that from birth your your pancreas is having to try and work hard to keep your glucose levels normal. So if your insulin resistance sorry about the seagulls, we have a terrible problem with seagulls in Beaumont Hospital so if you hear seagulls that's that's the reason so apologies about that. But essentially, the function of insulin is to take glucose from your bloodstream and put it in your liver and the muscle as an energy store. And it also suppresses fatty acid breakdown. And if you get a lot of fatty acid breakdown, those materials can be regenerated and turned into glucose. Now, if you're born with a genetic predisposition to insulin resistance, the insulin doesn't work as well. So the problem is you can excess of fatty acid breakdown. And those fatty acids can be turned into glucose. Now, if you're overweight than your fat mass is increased. So you have a greater fat mass, which is increasing the breakdown products of these fatty acids, which is increasing your blood glucose levels. The other reason is your fat is an active tissue, it releases a lot of what we called cytokines or adipokines. And the cytokines can go to the muscle and liver, and make those organs increasingly insulin resistant. And those cytokines can also go to the beta cells of the pancreas and destroy the cells of the pancreas that produce insulin. So the patient then starts to not only have insulin resistance, but now they're not producing enough insulin and they become diabetic.

Olivia C  10:50

It's a very, very complicated process.

Prof. Diarmuid Smith  10:53

Yeah, so there's a lot of different factors. And I suppose important things for patients with type two diabetes is there's a problem. One of our colleagues in the States called Ralph de Fronzo,  he called it the ominous octet. So he described a situation where there's eight different reasons for why your blood sugars are high. There's a problem with the liver, problem with the muscle, problem with the fat cells, a problem with the pancreas, both the cells of the pancreas that produce insulin, and other cells in the pancreas that produce a hormone called glucagon. And there's also then a problem with the gut, a problem with the brain and a problem with the kidney. So you've got these eight different contributory factors to why someone has a high blood sugar level. And when you've got eight different reasons, it means that potentially you've got eight different targets that you could impact on. And so in diabetes, we obviously have diet and exercise, nutrition. And but then we have got multiple drug targets that some of these drugs work on the gut for example, other drugs work on the kidney, for example, other drugs work on the muscle, for example. But those medications actually then can complement each other, they work together to try and improve diabetes control.

Olivia C  12:08

There were some people asking as well, they're, they're on medication. But they said that they would like to know why nutrition and exercise is not discussed before putting people on to medication.

Prof. Diarmuid Smith  12:23

Well no, I'd like to think that nutrition and exercise are discussed, because they're incredibly important. And they're still the cornerstone of management, of type two diabetes, no matter how many medications you're on in diabetes, we know that these medications work better if the patient has a good diet, exercising, trying to stay fit and trying to stay active. I suppose what you're seeing, though, is, recently in the last number of years, we've got new medications that have come onto the market in the field of diabetes. And essentially, for those new medications to come onto the market and be used, they had to undergo quite rigid trials. And the trials were there to show that these medications were safe from a cardiovascular point of view. And the idea for cardiovascular being the main endpoint of these trials is I'm afraid cardiovascular disease is still the biggest killer in type two diabetes. So heart disease, strokes are still is still the biggest killer in type two diabetes. So essentially, when these medications, were under these research trials, their endpoint was to make sure that they were safe from a cardiovascular point of view. And essentially, what these trials showed is not only were these medications safe, but they actually had a cardiovascular benefit. So these medications, reduce cardiovascular deaths, they reduce cardiovascular morbidity, they reduce risk of heart failure, etc. So these medications, therefore, we're not only good at lowering the blood sugar, but they had some benefit, even outside of lowering the blood sugar that they were beneficial. They were doing something else that modified our cardiovascular risk factor. So therefore, I know in the management of type two diabetes, now I have medications that are very good at trying to improve diabetes control, but they have significant other benefits, whether that's for the heart to kidney, etc. So that's why we're often now maybe pushing them a lot earlier than we did before. And in the past, I suppose we had this sort of stepwise algorithm for the management of type two diabetes. In other words, if somebody with type two diabetes came to me, I would give them a trial of diet and exercise, see them down a number of months later, if they fail that trial of diet and exercise, I'd add in one medication, then I'd see them a number of months later. And if they fail, that medication, I'm adding in a second medication. And because of the Irish healthcare system, and because of the waiting lists that few months later is often a year later, and so then you might have a patient who's actually two to three years down the line. They're on medication, but they have had suboptimal diabetes control. So increasingly, we are becoming more aggressive. We are jumping in earlier with medications. And we're often using combinations of medications so that we get good control early on from the start. But diet and exercise is still a key complement to those medications. And we have a number of patients who say, Listen, I think I can do it myself. I would like to see if I can get for example, as you mentioned, Olivia, try and get my diabetes into remission. And you would sort of say, Okay, let's see if you can do that. But to get your diabetes into remission frequently requires quite significant weight loss. You know, you're talking into trials, there is up to maybe 15 kilogramme weight loss, and we know that that's really hard to do,

Olivia C  15:53

there is as well, a lot of interest in bariatric surgery. And do you see bariatric surgery as something in the future that will be more and more used?

Prof. Diarmuid Smith  16:04

Yeah. So I suppose what we're talking about is when we talk about surgery, there's really two types of surgery. And we use the term increasingly bariatric surgery for patients with a body mass index of over 40 kilogrammes per metre squared. So your body mass index is your weight divided by your height and metre squared. And that's typically used for patients who don't have diabetes. Again the term we use is Metabolic Surgery. So for diabetes, we would love to have access to Metabolic Surgery. So this would be surgery for patients with type two diabetes. And so these will be patients who would have a body mass index of over 35 kilogrammes per metre squared. Or you could argue it should be even lower. And we would love to have access to Metabolic Surgery, because there's been very good studies from other countries that Metabolic Surgery can make a difference in diabetes control, blood pressure control, cholesterol control, quality of life, etc. I'm afraid in Ireland, we have, well, in my service, we have no Metabolic Surgery access, to be honest, you know, we have a centre in Loughlinstown on the south side of Dublin that does Metabolic and Bariatric surgery, but the waiting list is, you know, three years or so. So we would love to have access to Metabolic Surgery. But I'm afraid in the current health system in Ireland, we don't. And that is definitely a downside of the service we can provide patients, it's not ideal. Now, increasingly, we do have new medications that are coming along that we have been using in diabetes for years that are injectable therapies that can help people lose weight. And some of these newer injectable treatments that coming along in the future, hopefully will really help people lose a significant amount of weight, but they're still not available to us at the moment.

Olivia C  17:53

Well, thank you so much for talking to us and explaining some of the more clinical aspects of type two diabetes. We already had a podcast from Sinead Powell from Diabetes Ireland talking about sone of the  nutritional aspects. So thank you so much for taking time out of your busy day to talk to us.

Prof. Diarmuid Smith  18:13

No problem. Olivia. Thank you very much.

Olivia C  18:15

Thank you, Diarmuid, for talking to me today and answering the questions that respondents to the questionnaires have had and thank you to everyone who has listened. And if you don't mind, please, filling out a short questionnaire about the podcasts you've listened to even if you've only listened to a little bit. I'd love to hear your opinion. You don't have to have been diagnosed with pre diabetes or type two diabetes, but you do need to be over 18 Also, if you'd like to talk about the treatment of your type two diabetes, or the information that is contained in the podcasts and might be interested in a recorded interview, please get in touch with me, Olivia Crinion via email at the following address Olivia dot Crinion Two at gmail.dcu.ie. That's Olivia dot c r i n i o n the number two@mail.dcu.ie Thank you