CRF 'LIFESTYLE MANAGEMENT AND TYPE 2 DIABETES' - JUDY DOWNEY
CRF 'LIFESTYLE MANAGEMENT AND TYPE 2 DIABETES' - JUDY DOWNEY (08.11.22 - Term 2, 2022)
Summary
This on-demand teaching session is aimed at medical professionals and covers the lifestyle management of type two diabetes. It will cover topics such as the importance of glycemic management, the DCCT and UKPDS trial results, how to use blood glucose monitoring, continuous glucose monitoring, metabolic surgery and behavioral approaches to weight reduction. This session will provide medical professionals with the insights and guidance to help their patients understand and successfully manage the effects of type two diabetes.
Description
Learning objectives
Learning Objectives:
- Understand why lifestyle management is the key to successful diabetes management
- Describe the legacy effect of lower HbA1C
- Explain the benefits of blood glucose monitoring for making lifestyle changes
- Identify the importance of weight reduction in diabetes management
- Analyze the need for small and achievable goals in behavior changes for successful diabetes management
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Computer generated transcript
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
um, it's big. We're recording an American accent now. So, um so, guys, if you if you keep your, um, mix off at the moment, Um, but I would like to speak to you all towards the end. It's really nice to hear your voice is, um So, um, and then put any any questions in chat and repeat a will keep an eye on them, because sometimes you might think, What is she talking about? So So this is the second in in my in my series, and I don't know how many of you managed to listen to the first one I did last week, which was about passive physiology. Um, classification of diabetes. But today I'm actually covering lifestyle management of type two diabetes in specifically, and we've got 16 people. That's lovely. Thank you for joining me. Um, and Tatiana, your professor there. I hope you find this interesting. Thank you for joining us. So that's me. I've been I've actually worked in diabetes for over 20 years. So? So I might have been doing it longer than some of you've been alive, which is a funny thought. Um, but I believe the lifestyle management of type two diabetes is the key and most important thing of diabetes management. I don't just believe it. I know it. And, uh, evidence is starting to show this to us more and more. Um, that that, uh, we can use all these different drugs, and I'm going to be covering the drugs in another session. We can use insulin. But if If a person is not able or can't or won't make lifestyle changes to underpin this, then it's actually really difficult to actually, um, achieve the goals. And these goals are to prevent long term complications, aren't they? The long term complications that we all know about retinopathy nephropathy neuropathy cut an in specifically cardiovascular disease is the is the key. Um, if I miss one out anyway, there's loads of complications of diabetes, and we want to prevent these long term complications, which obviously affects someone's quality of life in a big way. And what can we do to to help someone prevent it, other than giving medication an insulin? So, um, we all know it's about controlling blood, sugars, glycemic management, and, uh, that's very important. Um, but weight management, I'm going to talk about quite a lot, actually, in this session. Weight management. Um, we we also have cardio renal protection with glucose lowering agents that will be in another session, not today. And we also have cardiovascular risk factor management, which includes, um, lifestyle measures as well as some of the newer therapies, which, as I say, the therapies are going to be covered on another session. But we want to to Obviously, if people do have symptomatic high blood sugars or hyperglycemia, one would hope that they don't because, um, the whole point of this is to get the education, the support, the the the information a person might need in order to to make lifestyle changes, which isn't easy because you don't only it's not like, Oh, it's just for 12 weeks. And it's not like you go on a diet for 12 weeks and then you can go back to how you were before. This is actually making long term lifestyle changes, and the idea is that this should happen at diagnosis or even before diagnosis, where someone has prediabetes so within. Hopefully, that person would not have symptoms of hypoglycemia are thirsty going to the we we ain't lot. Uh, polyuria polydipsia um very tired. Most people at this stage do not have these symptoms, But if they did, if they did and sometimes they do a diagnosis because they've they've they've left it so long that their HBA one C is already very high, even at diagnosis. And I've seen it many times. Then they will have symptoms. But if they can make these lifestyle star changes even then, it will reduce a lot. The the symptoms of hypoglycemia, if not actually make them go away completely. Um, so the D. C. C. T. Was a diabetes control and complication trial, which is quite an old one now, Um, and that was that was actually with people with type one diabetes. Um and, um that they they found where the HBA one c was reduced, that the 22 arms of the trial were intensive control what they call intensive management, whether they were in for HB a one C's of 7% versus Standard Management, where they were aiming for HB a one C's of 9%. So you can see this is old can't because we would now aim for lower than 7%. To be honest, at 6.5 or even 6%. But even so, the people who had the lower HB a one CS had quite a huge reduction in microvascular complications. So that should retinopathy and and your nephropathy in particular. But but there there's also other manifestations of microvascular. But those are the two big ones the UKPDS was going on when I started doing diabetes very long time ago. That's a United Kingdom Perspective diabetes study, and that was with people with Type two diabetes. And they have very similar arms of the study and 7% versus 7.9%. And and that also showed particular reduction in microvascular complications. But it's it goes without saying that if someone started off with a higher HBA one C to begin with and they would, they would have a greater benefit. It didn't show such a such, uh, what's the word? Um, results for macrovascular benefit with better blood glucose control. So that's cardiovascular disease. Mainly, um, it didn't show such benefit. But saying that there is still a benefit, so it's you can't say that it doesn't have any benefit. Um, so and another thing about especially the UKPDS which was followed up 10 years later. 20 years like I mean, it's over 20 years old that the people that had the lower HBA one c is 7% for example, at at that time, even 20 years later, we're doing better. It's called the legacy effect. They call it the legacy effects. So those people, even 20 years later were still doing better as regards long term complications than those that had the higher HB a one CS. I remember they were mainly looking for people that were had not been diagnosed very long. So not people who've been diagnosed 10 or 15 years who already had complications. So they were they were choosing, uh, people in the trials that hadn't been diagnosed very long. So, um, obviously, just very quickly, because I'm I'm conscious of the time I get a good time. Yeah, um, so you know about the HBA one c test? If you if you listen last time, it's the venous sample that that shows if you like an averaging out of blood glucose over a three month period. Because it's where the glucose in the bloodstream attaches to the red blood cells. Um, and it's usually reliable for most people unless they've got, um, some form of humor globe in opathy. So, um, where, in other words, where the red blood glucose cells are not normal or if someone has severe anemia or in pregnancy. But for most of our patient's, it's a reliable test. But do bear in mind that it isn't reliable. So if someone has thalassemia sickle cell anemia, uh, anemia pregnancy, then you would have to use, uh, fasting, blood glucose samples, or even do an oral glucose tolerance test. A lot of our patient's the Type two diabetes I don't know about in the Ukraine, but probably not because in the UK, people with Type two diabetes are not encouraged to do blood glucose monitoring because they reckon it's a cost. Too much money, basically. So I'm a cynic, I don't mind saying. Actually, it can be very beneficial because if someone is trying to make lifestyle changes, particularly with their diet, they can actually see what's happening to their blood glucoses after they've eaten. So post prandial. So we're talking about 1.5 to 2 hours after they've eaten, not immediately after they've eaten 1.5 to 2 hours after they've eaten, and they can see the difference. It makes depending on what they've eaten Particular carbohydrates. So, um, so where where I've worked with groups of people who've been trying to, uh, do do much better with their glycemic control. In some cases, they've actually put their diabetes into remission. Then we did provide them with blood glucose meters. In fact, some people brought them themselves or families on, actually, Um and the idea was to see to see how their blood glucose is responded depending on what they had to eat, and it and it was meant to be for a say 23 month period, not for the rest of their lives. Because once you've learned what how the food affect your blood glucose, you don't need to keep doing blood. Uh, you know, blood sugars postprandials for indefinitely and in fact, their blood sugars improved so much that they wouldn't have needed to anyway, This continuous glucose monitoring it's there is a matter of interest when we were in in in the UK uh, see GM is is meant to be, um, available to most people with type one diabetes. not type two. Although some people type two diabetes do pay for it themselves. It's quite expensive, but But it is a you you are able to to pay for it yourself directly from the companies. So and of course, that means you can look at your blood sugars numerous times a day. You don't have to break your finger every time you you do it because you you actually have an app on your phone and, uh, a little little sense so that you just wave across the the thing that's in your arm and I have tried it, so I know it works. I'm not diabetic myself, but I was interested to see the effects of the what I had to eat on my blood sugars. So today I'm talking about behavioral approaches in particular, But obviously med medications is another topic. Metabolic surgery. I'm not really going to cover at all. We sometimes call it bariatric surgery in the UK. Don't know what you call it. Um, it's a sort of a last resort. Um, and people do do need to have a very high b m i in order to qualify to have this done and Obviously, it's a very It's an invasive thing. So someone, psychologically they need to to really be in the right. Um, what's the word? You know, uh, really positive that they are going to to succeed with this, So, um, but I'm talking about behavioral approaches now. Um, it's a tarp. Weight reduction should be a targeted intervention. It's it's it's It's as more important than the medications for most people with type two diabetes who are obese and and if they can lose some weight, then they they will. Their blood sugars will improve. Their lipids will improve, their blood sugars will improve. Seen it many times. Um, weight loss of 5 to 15% should be the primary target in management for many people. And you might think to yourself or 5% not a not a lot if you weigh 100 and 50 kg. But, you know, start small and then build confidence, and then you can often find you carry on losing more and more weight. But if someone thinks oh, God, I've got to lose, uh, you know, 50 kg. Oh, my God. They give sort of give up almost immediately. So start small and build on it as someone's confidence and motivation increases. And obviously the more weight you lose, the better the outcomes. But even the 5% confers metabolic improvement. So I just said that even 5% and obviously if you lose more and this is what happened in my remission groups, people lost more 10 or 15%. It did have a disease modifying effect, and some of them did actually go into remission of their diabetes. And I'm sure you've heard of this. That's the ideal thing, isn't it? So even people that are already on medications occasionally even take an insulin, not type one. Remember, always type two there came off their their medications came off their insulin, reduced their anti hypertensives, reduce their statins. It's just amazing. But you do need to have a very motivated uh, you know, person understands what's going on. And of course we were fortunate we could run groups where we could give them a lot of education. Um, although I have known people saying that that have done it on their own by looking online just online, um, facilities, um, websites and I didn't put it in resources, but there is a very good one. If you're interested in this called diet Doctor, you heard of it? It's it's These guys are in Sweden and they've got so much information on on what you can do to help yourself with your diet. So if you're interested or you want to speak to anyone, you know that's got Type two diabetes. Have a look at diet Doctor. I've I've learned so much from them myself. So this was from this is from, um, the a d a e a. STDs. So American Diabetes Association, European Association with the study of diabetes. This is a recent, um, presentation, which is in the public domain. So I didn't steal it. It's in the public domain. They want people to use it. And there's the reference at the bottom there, Um, but basically it's it's goals of care, and we work around this. We assess the key patient, key person characteristics. What factors will impact on their choice of treatment. So we're thinking now about behavioral changes, obviously shared decision making what the management plan, how to put it into Axion. This is important, though, providing ongoing support and monitoring, and then every so often looking at what's been agreed and is it working? And what changes need to be made? This I know is in an ideal world. So, you know, I do know this it might be difficult, especially at the moment. But in an ideal world, we would work through through this. You can see this whole presentation yourselves by just going into Google and, uh, searching for it, cause that's how I found it. Um, shared decision making really important. Um, we do try very hard here. Um, I do find sometimes with my patient's, they find it difficult to to want to share decision making with me. I don't know if I frighten them or what, but especially with older people, younger people, it's much easier. But with older people, they they still feel they want me to tell them what to do and that they're doing it for me. So that I I guess the bottom line is, um, that someone goes away and feels that this is what they want to do, and they're doing it for themselves. This is what they want to do. So So, yeah, giving them the the the confidence that they can that they can do something. They can make some changes giving, helping them to gain that confidence and a lot of our very overweight patient's. And most of them are very overweight. Don't have the confidence that they can do things because they've tried in the past to lose weight. They've been to slimming clubs. They've tried very hard. People have told them off, I'm afraid, you know it does happen and they've come out of after seeing their doctor or their nurse really upset and crying because they feel they failed so they don't have the confidence. So this is one thing I really try very hard to, to show that even if it hasn't worked in the past, you still can make changes. These this is about diabetes group education. Um, I guess at the moment, I I ideally you, of course, you'll have been having diabetes group education, won't you in the Ukraine and probably not happening at the moment. But the idea is that where people have newly diagnosed, this is the idea they're newly diagnosed the type two diabetes that that then, in these groups, they learn all of these things that are on this slide. They may not even learn about the medication taking behavior if they're not on medication, although to be honest, most people will be taking metformin at this point, um, and and the whole thing should be a good 10 hours duration, so it's usually four visits. We're hopeful at the end of it that these are the outcomes. You can see them there, the the in the UK, the uptake for these this group education, diabetes, self management, education and support or they shortly to D. SMEs is very poor, is very poor. So although all of our tattoo patient's are referred in primary care to group education, the percentage that actually go to it or stick it it go to all four is really quite low, actually disappointed. It always has been this. It's something ridiculous, like 12 or 14%. I've probably got that wrong, but I can tell you that most people don't don't go. A lot of it is because it's often times where they should be at work. Um, all they they turn up and that the rest of the group they don't get on with or, you know, there's lots of reasons Group work can be very difficult. And this is going back to this one here. So, um, and it's filling in filling in, um, what wasn't filled in before? Remember it? So we look at the individuals, priorities, their lifestyle. Have they got any co morbidities? Obviously, one hopes they don't at this stage. But have they? How old are they? And obviously up there with urgency and weight and then so so working around, um, this management plan Have you heard of smart goals? Specific, measurable, achievable, realistic and time limited? Really, really important. And but I believe that ongoing support in and and monitoring of emotional well being lifestyle, health behaviors and then feedback. So so checking the HBA one c for example, after three months of the lifestyle changes, not a year later, but three months because if especially if they're not doing blood blood glucose monitoring, they need the to see the HBO and see coming down. And you can see it very well after any three months in order to to say look wow, look at this. Your HBA one C is dropped, you know, by from, uh, for example, 60 millimoles per per mole down to, um, it could It could have dropped down to 50 or even lower. Um, I don't I I know someone who's HBA one c dropped from over 100 to below 48 in three months. I actually know someone. Who who who that happened to? So his HBA one c was over 100 and three months later it was under 48. That just shows you this guy actually did it all on his own as well. It wasn't. It was nothing to do with me. But it just shows you He he basically cut right down on his carbohydrates. So he didn't go. He didn't go. Keto. He didn't go. He didn't go Keto. But we don't. We don't encourage people to completely cut carbohydrates. But he was eating so many carbohydrates that when he did cut them down, it made such a difference to everything about him. He he was amazing. So, um, this this Yeah, because at the moment I can't see the top of my slide because the banners over it. But this is basically showing, um, that this this might be worth having a look at lean. It'll that lancet diabetes and endocrinology 2019. But basically it's a study that he did, Um, which just showed, um, what a massive difference it made to outcomes, where people, um, lost weight and the more weight they lost the the more the the the, uh greater the outcomes. And also to show that it was it was sustainable. Because sometimes people say, Oh, well, you can't. It's not sustainable. What's the point? You can't keep this going. It's called the direct Study, and I'm afraid I can't see it because I've got the annoying banner over the over the thing. But it's called the direct study. Have a look at it. Lean at Al, the Lancet, diabetes and endocrinology. You get these slides anyway, so you'll be able to see um, and this came from the a D a S. D. And there's the reference at the bottom. So So they were. They talked about setting individualized weight management goals, giving generalized general lifestyle advice, medical nutrition. That's what you can tell It's America because, well, I wouldn't call it that, but call me an old cynic. But basically it's healthy eating that we should all be doing to be frank you know, that's That's the way I always see. I I would like to think I eat like this most of the time myself. So and I don't call it medical nutrition, so because that's so so, but it's it's actually healthy eating. Um, but looking at their eating patterns and also, of course, physical activity encouraging increase in physical activity. Um, consider medication for weight loss potentially, um, but only after spending some time three months or so or even six months trying very hard with lifestyle measures. But there are medications which will be in another session that that can help with weight loss. Um, the the the weight management program. Um, in a minute. This is American again. We, on the whole we don't have intensive evidence based structured weight management programs in the UK I don't know if you did. Apart from the groups that I I ran which were unusual, we did them in our own time and again, This is the metabolic surgery. This is for people bariatric surgery that are really extremely overweight. So they b m i is over 40 45. You know, I've even seen people bms of 50 so So when? When we when we look at glucose lowering therapies, you you'll see that some of them, uh, encourage weight gain. Um, and some encourage weight loss. So one would normally these days go for ones that encourage weight loss because you don't really want to be putting on even more weight, right? This is a real person. This is from, um you might want to look this guy up. I didn't reference him, which is really bad of me, I'll admit. But if you write down Doctor David Unwin at U N w i n Doctor David Unwin, he he's a He's a G P in the UK who's actually been running, um, weight loss programs for people with tattoo diabetes for years now. And he does a lot of talks and this is one of his patient's. And I've seen him do this talk loads of times, actually. But he's so interesting. Doctor David Unwin. You can see him on YouTube. He does lots of talks on YouTube and you'll see him do this one. Um, it's work. If you're interested, check him out. So this this this this is one of his patient's, um, it's really powerful. This guy Chris was 40 years old and he for him, Type two diabetes was a chronic deteriorating condition. Needing more meds over the years and possibly insulin eventually. That's what he thought. Well, you know, for God say, you know, what can I do about it? You know, I've got type two diabetes. I'm you know, that's it. I might as well just carry on eating these foods because it won't make any difference, you know? And then he met Doctor David Unwin, who gave him. And this is the P word. Hope. See that hope? Give someone hope that they can do something about it. And the main thing is cutting out the sugar and that sugar is also included in carbohydrates. And look at him on the right hand side. He's now 60. I mean, he looks he looks almost younger. Doesn't he look at the difference in him because he followed Doctor David Onions programme in primary care, not hospital. He went into into into diabetes remission and no longer takes any medications. And this has been going on for five years. So anyone who says that it's not sustainable Well, it obviously is that just to show you there are studies about this, Um, which you can look this one up. But this is a food based, low energy, low carbohydrate diet for people with type two diabetes in primary care and a randomized controlled trial. And it's basically saying there is evidence of clinically significant short term improvements in weight and glycemic control. Now there's controversy about that, because some people say there isn't enough evidence to show that this can be sustained. And you know what's the point sort of thing? Well, you saw the previous slide with his particular patient. And believe me, David Unwin has got loads. Patient's who've who've been in diabetes remission for well over two years. Um, but there does need to be more evidence to to to To what's the word to, um, persuade some a lot of the medical, um, medical community. Although I've been persuaded years ago, this is one of David's slides, which I like so dietary sources of glucose such as sugar, rice, potatoes, et cetera. And, of course, the more more you eat, the more glucose is in your blood. You can lose some of it by exercise by taking insulin by taking the drug liquor side or even using the S g o t t two inhibitor drugs that can help. It can help. You can do that. But at the end of the day, why not just turn off the supply of sugar? Not not completely Turn it off. But why not reduce it so you can do that? V. L C D stands for very low, low carbohydrate diet. My patient's, um, follow the low carbohydrate diet not very low, although if they wanted to, I wouldn't say you can't. Some people use the Mediterranean diet. By the way. That's really good Mediterranean diet, and it shows low carb diet. Yeah, of course, if you have bariatric surgery, it's going to turn it off. But that's that's the way to do it. And, uh, it's a balance of sugar in and sugar out. This is this under underpins all of the lifestyle changes. This comes from the a D a a E s. D. You can look at this in more detail if you're interested. I really like it. It's showing all the different things one can do around lifestyle change seriously. They talk about sweating, so which means moderate to vigorous exercise it. There's another slide that goes into detail, and obviously you might think some of our patient's couldn't do that. But basically a lot of them could could, or for them they could increase their exercise, um, to to, you know, over a whole week, 100 and 50 minutes a week, ideally doing some resistance training as well. So so some body weight exercises, something like squats or lunges. You know, whatever a person can do, we can't. You know, everybody is different as to what they can do, but that they call that they're all beginning with s. You notice that and then the and apparently as little as 30 minutes per week, though if they can only do 30 minutes per week, even that's enough to improve metabolic function. But one does need to consider frailty. That's what that one is. That's meant to be a little old person with a stick. So obviously, of course we would on the stepping, the stepping, um, talks about the okay, 10,000 steps a day. But you know that for a lot of people would be ridiculously, you know, you're lucky if they do UM, 2000 steps a day. So gradually increase the steps. Um, and even if you did, 5 to 6 minutes of what for them is brisk intensity. Walk a day, even if that doesn't sound much. Does a bit. Apparently even that if a person can do that every day, 5 to 6 minutes of brisk intensity walk for them because what's risk for one person is not for another. Even that should be able to add on another four years of life, which is incredibly credible. Strengthening. I mentioned using, um, body weight exercises mainly, um, so there's a lot online, um, that that you can do and there's a I don't know who does what online in the UK is regarding body where exercises. But there's a brilliant guy in the UK, um called Joe Wicks. So it's J O E. Wicks. Now he's he does loads and loads and loads of YouTube videos, and they're all free. And I know he does them for elderly people and people that are new to exercising as well as some of you guys might want to do his hardcore stuff. But he does do stuff, even armchair, if you can't stand up. So you might want to check out Joe Wicks and see if there's anything there that as long as obviously a person needs to be able to understand English. I suppose that's the only thing. But have a look. See what you think and you may have. I'm sure you've probably got people in the in the Ukraine that do do similar, haven't you? So that so The YouTube can be really useful because if you know there's probably not any classes going on at the moment. Sleeping, apparently sleep is so important, and they say, um, if you sleep too much, it's not good. We all know if you sleep too little, it's not good. But apparently, if you if you sleep over eight hours all the time, that's actually not great, either, unless than six hours isn't great. Um, some of our obese patient's with Type two diabetes do struggle with sleeping. Keep an eye on the time because they may, because if they're very overweight, they may, for example, have problems with sleep apnea and and getting comfortable in bed and things like that. So, um, but sleep is really important and and it seems that people the morning people. So I'm a morning person. I wake up early, I just do. And then I I get I get up early, naturally, and then I don't want to go to bed early. Whereas some people, um, my husband, for example, he doesn't want to get up to go on nine, and then he stays up till midnight. And apparently, people who are naturally morning people like me are at an advantage. And what can you do about that? Because that's that's what you're like, just so you know. So, um yeah, so that's that's some quite interesting, isn't it? Yeah. So? So at the top, what we can all do and and all of us not just whether you're whether you've got diabetes or not all of us, including me. Don't just sit and sit and sit at your computer. You get up, walk around for a bit every 30 minutes. Now, I used to have a consultant that used to teach for me who who actually was an army consultant, and he got everybody thinking, What's he going on about? Because he used to say, every half an hour, get up, walk around and people used to look, you know, this is doctors and nurses. What? But that's what apparently how they did it in the Army. And this is before we knew. It's so important not to just to be sitting for such a long time. Um, so that goes for all of us. Really? So, um, I've talked about the sweating, haven't I? And I've said that 30 minutes a week, even if you can only do 30 minutes, you know? Yeah. 150 minutes you're talking to. It could be a friend of yours. It could be your mother, your grandmother. You know, it doesn't have to be your patient. You know, obviously saying 100 and 50 minutes a week to someone who hardly does anything is going to really put them off, isn't it? So So it's good to know that even 30 minutes of moderate intensity physical activity improves metabolic profiles, and this could be split into 2 15 minutes or all 3, 10 minutes. Um, sections. I've I've seen quite a lot of evidence that shows, you know, that's why it says, you know, 5 to 6 minutes of brisk walking every day is really really good. So So, Yeah, so it doesn't actually have to be all in one hit. So, um, obviously, um, Frailty, of course. Where people are elderly, frail. So, um, the ability to people attached to diabetes to undertake simple, functional exercises in middle age is similar to those over a decade older. So bear that in mind. But it's, you know, if you don't have diabetes and you're quite slim, basically, it's much easier for you to do it than than someone who's who does have diabetes. And he's overweight. So yeah, ideally, increase your steps again, build up gradually. And we've said about the 5 to 6 minutes of walking every day. And we've said about resistance exercises. Um, see what you can find for your patient's or your family or someone. You know. Um, what can you find on YouTube that they can see to motivate themselves or do it with them, even do it with them? Um, sleep. We've talked about sleep. I've mentioned all of this. I made my notes earlier. Uh, so basically all of these things are going to improve someone's glycemic control. All of them. Forget about the medications. Obviously, they will do. But all of this stuff is so important. So we're preventing complications, aren't we? Hopefully, that's that's the key goal. The long term goal optimizing quality of life. Because if you do start to lose weight and you do start to take a little bit of exercise and your confidence increases and you get more motivated, by definition the quality of your life improves. And and again, in my remission groups, you there were people that came to begin with that were really, really dear, miserable, depressed. They weren't sure that they came anyway. And I can think of one young lady in particular who was like, a transformed. She was absolutely transformed. It was in credible, um, after after she had been about three times and she even started running, which I didn't ask her to do. But I was very pleased for her. She got she got her confidence up, you see that she could do it. So this is stuff we've already covered, Um, and coming towards the end of this presentation, and I bet you guys have all got something else to go on to think about someone's age, because obviously, where people are older, they may be frail. It does vary so much from person to person, doesn't it? So much from person to person? Um and usually, um, it's a genetic thing. Um, it can be a psychological thing as well. You know, someone's not motivated, not confident that they can get out and go walking and things, and they and they sit all the time and don't move very much. They're going to lose muscle mass, aren't they? Um, And then if you lose muscle mass, you're less. You're more like to have a fall. It's often happens with elderly people, and once you start having falls, you then or less, even less likely to do anything. And it's like a vicious circle. It's really difficult. So they say Older, over 65. Which isn't that old and younger adults with diabetes. Yeah, I think not only with diabetes, but in all clinical trials. Older people and younger people are let are underrepresented in clinical trials. And let's be honest in in diabetes, you know, the older the incidence of diabetes goes up with age, so really, we need more trials. That and also people of 65 70 year olds now I certainly know quite a lot of medical people that are 70 or older that are still working and are happy, quite happy working. And I would and probably would like, not like to think of themselves as being too old to be in a in a study. Do you know what I mean? But but this is how it is. Um so be careful, obviously, because of the lack of evidence making informed decisions in these age groups, I have to say that So, um, and again, as as you probably all know, pre diabetes and type two diabetes are increasing in the adolescent and young adult population in concert. That's not a word I use very often, along with increases in obesity. The two things are are very linked. Um, you would hardly ever meet anyone diagnosed with Type two diabetes that wasn't overweight. If they If I need to to, um, always stress that if they're not overweight, um, then you then the diagnosis should be queried because it's very, very unusual. Younger people touched two. Diabetes are very high risk for complications, so one of the reasons for that is if if they develop type two diabetes. It's a mid twenties, about 30 whatever. You never used to see that ever. But now you do. By the time they get to 50 which is still middle age, they've already had diabetes for 20 years. Do you see what I mean? And the more years you've had diabetes, the more likely you are to get complications unless you can get a handle on these lifestyle changes as soon as possible and sustain them. If that were the case, then then the risk of complications will go right down, and they may not have any. And I've known people who've had diabetes for 50 years that have not got complications. So it is possible, and young people also have a more rapid deterioration in glycemic control. And my opinion for that is, a lot of times young people are not. Not very, Um, gosh, I'm not supposed to use the word compliant anymore concordant with, you know, taking their often, um, not willing to make the lifestyle changes. I don't blame them because they don't want to be different to their friends nearly time for questions. They don't want to make changes, they don't they want to do whatever anyone else does. That's a young person. They can't be bothered to take the tablets. It's not just young people or they just forget. And because and because of that, the, you know that will affect their glycemic control, won't it? Um, And because they may not be taking their their diabetes medications regularly, Obviously, that's going to make a difference as well. And obviously, people with with weight related comorbidities they're they are, um it's even more important to to to, um, get the weight loss to get the weight down. Even more important, um, and it really is. I mean, it's important anyway. But if there's any of these problems going on comorbidities that actually increases the urgency, and I expect you know, that non white people are disproportionately disproportionately affected by Type two diabetes and its complications, did you know that women have a greater increase in relative risk of CVD than men do? Uh, it's sort of, um is this is my opinion that that, uh, women that don't have type two diabetes are hard, very, very unlikely to have cardiovascular disease before the menopause, aren't they? It's It can happen. I know it can happen, but it's very unlikely. Whereas if they have type two diabetes, that sort of protection of, uh, hormonal. Whatever it is, you know, that seems to be lost. So So, women with type two diabetes, one does need to be looking out for, uh, cardiovascular disease. Which is why we we check lipids and BP and try to achieve targets and all those things. Um, for everybody, you know, we don't distinguish what age they are anything and again. You know, these groups are underrepresented in clinical trials. Um, available data suggests no significance between in group difference, no significant between group differences in treatment. Response. Yeah. So, basically, the clinical trials looking at differences between the different, uh, ethnic minorities. You know, I don't think there's that many of them, but, uh, you could you could call me wrong on that one and that this is the last slide. I think so. And I can see there's some questions in chat. So this is just filling in this whole thing, what we've covered, um, and it's now 10 to 10. 10 to 5. It seems later than that. Let me There's 18 of you there. I want to say thank you for joining me, and I'm just looking at chat now. So, um, so there are there are, uh, asked what's a shared decision making? Oh, it's the shared decision making Is is, um I guess it's a fancy way of of saying what I've always done, which is which is where I sit with the person. And it does mean you've got to have the time to explain what what the decision is going to be about. And this can often be really difficult because we have very short, you know, 10 minute consultations, and and to give people the information you need to give them the information in order for them to work on a decision with you. So it's shared between the person and with the and and and we and with the patient or the person with diabetes and with the healthcare professional and you met, you agree on, um, we we used, um we we filled in a form where the person set themselves goals. What did they want to achieve? For example, over the next three or four months, um, and you discuss it with the person so you'd share this decision. But it obviously the key where it can go wrong is if the person doesn't really understand, you know? So this is why we talk about sets a small steps at a time. Smart goals, realistic and achievable. Not not setting a goal between you and the person that says, Oh, right. I want to lose 20 kg in three months because that is not smart. And that is not realistic. And that is not achievable. And if you and if you and the person with diabetes came came up with that as a shared decision, that would be ridiculously, you know, because the person would almost certainly not not not achieve that in three months. And then the person would become very demotivated and may say, What's the point? I give up? Does that make any sense? So that's the shared it shared between the perp. Yeah, And you can read articles on shared decision making. Guys, people have written articles on it. Um, can I give you, um, the name of the website to look at if you're interested. Irena, thank you very much. You might want to look at this website that it's called the primary Care Diabetes Society. This is in the UK primary care diabetes society. Now anybody can join it and it costs nothing. It's free, and you can also look at all their journals. And they've got five or six journals, and their website is with all the journals for you to look at is called Diabetes on the Net. Diabetes on the neck. Can I please write it? I can, Can't I? Of course I can. So So thank you. I'm being a bit dim here, Diabetes on the Net. And if if you put that into Google, you will be able to actually join and you will be able to see all of their journals. They are aimed at primary care. It's true. But then there's a lot of stuff that about all the new drugs about lifestyle, all the things I've talked about. There's loads of brilliant articles on there, including loads of references. Um, so, yeah, diabetes on the net and then you've got primary you can join out. I really hope you do. Let me know. Primary care, diabetes society. So I used to be on their committee years ago, so don't think, because it's in the primary care that it's not going to be relevant to you. It will be. There'll be loads. You can you can see. So if any anyone is doing any assignments or work on diabetes Oh, the name of the doctor. He's called Doctor David on when, and then his another website is called. Um oh, I just had a mental block. Uh mm. I'll come to it in a minute. But if you put David Unwin and and look at David Unwin on his YouTube videos and the trainers name, that's him. Did you mean him? Irena? Doctor David Unwin. Yeah. So I'm just going I'm just googling it. The one I just had a mental block about Isn't that funny? Do any of you have have mental blocks about things? It's another website that I'm a member of them and everything, and I've just forgotten their name. So primary care a collaborative. Oh, Anyway, if you David Oh, right. The trainer. Yeah, Yeah. Joe Wicks. Joe Wicks. Have you got any trainers like that? It's Have you got any trainers like that in the UK uh, in in the Ukraine people that you can ask people to watch them Yeah. So Joe Wicks, the trainers name anything else? Oh, Tetiana, you said What? It How is it necessary to reduce calories? Take into account the age of the healthy person, Not a person with diabetes. Well, that's that's now, that's that's quite a tricky question. Um, I guess I guess for me, a Tetyana and everybody, I I don't talk about calories. I'm just writing down a book. Where you an app and a book where you can see loads of information that includes carbohydrate count and calorie camp carbs and cows. Um, World foods foods. Get it on Amazon. Um, that's a book. Now, Tetiana, if you want to find out, we we don't normally too much take into account someone's age. Um, carbs and cows. World Food Book. It's brilliant, and it's called World Foods because it's got sections on different types of diets. Say, for example, from South Asian population or African population. I know I've got to finish in a minute, so but you can see the app on your phone and that it basically these two things are very, very, very visual. They're good to show people. They're good to show your patient's. They're good to show your family anyone You're worried about. How many carbs are in how much food you eat, so showing different sizes of portion's from small to medium to large so it could be pasta. It will show how much carbs is in and how that equates to amounts of sugar in your bloodstream. It's it's actually really brings it home to people. Um, and also it does show the calorie content as well. If you're interesting calories, but basically the smaller the amount of carbs on your plate is lower. The amount of calories isn't it? So So, yeah, Is there anything anyone I've missed? I think, Well, I think I've remembered that last one to give you before you go public health collaboration I remembered it. That's got some great charts about amounts of sugar equivalent to 22 amount of carbs that you eat, and it's it really is shocking. If you didn't know, this is unthinking patience. That's another one that's worth looking at that. So all of these are brand lifestyle changes. So anyway, thank you very much. I know you've got other things to go to. Um, and I just want to say thank you so much for for, um, joining me. I do appreciate our hope. It was helpful. And I'm going to put on another one about the the drug, the drugs. Um, but I always will stress that this underpins everything else. And if people can't or won't, maybe they can't make last are changes. Then we can We we will sometimes use therapies for cardiovascular and renal protection, Not just about the glycemic control. Yeah, Our med was asking about why women have a greater risk of CVD them so that this is went in with type two diabetes that seem to have lost that the protection that we premenopausal women who don't have diabetes, um rarely develop cardiovascular disease where they do have diabetes, they're more likely to. And our med a lot of it is to do with, um, not only their blood sugars, but what's happening with their lipids and what's happening with their with their, um, their BP as well, because cardiovascular disease isn't just about the the um the sugars is a lot more to it than that, and that's going to increase their risk. Plus, they don't seem to have the hormonal protection that that they that that women who don't have diabetes do right. I think that's it. It's like, Oh, this