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Lifestyle Intervention and Its Impact on Diabetes Treatment & Outcomes

Tim Arakawa

Description

Type 2 diabetes is an epidemic of staggering proportions and threatens the quality of life for millions of individuals. However, the prevalence of this chronic disease also provides opportunities for the Adventist physician to guide their patients back to optimum wellness through health principles. We will explore the underlying pathophysiologic mechanisms for diabetes and how lifestyle intervention can make a difference.


Objectives:


  • Discuss the recent scientific literature from peer reviewed literature that identifies the impact of lifestyle intervention on diabetes

  • Review the pathophysiologic principles that influence the prognosis of lifestyle intervention.

  • Outline specific interventions that are effective in prolonging lifestyle changes. 

Presenter

Tim Arakawa

Endocrinologist in Tamuning, Guam

Conference

Recorded

  • October 30, 2015
    2:00 PM
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All right we gave you just a little time to finish lunch and then come in so I think it worked out OK. But we do have a lot to cover so. Just I we have an introduction though. We're going to be talking a little bit about diabetes. Lifestyle intervention how many of you watched the Republican debates this week. And he want to watch those parts parts of it. Well do you watch the beginning choir or. I'll let ME was partly the middle they did mention diabetes notice that I found interesting that it was the. The non-physicians that actually brought up the fact that if we really want to address the health care crisis in this country. We need to address the health crisis that we're facing. We're going to talking about that today. I think that there's something to that. But I miss a little bit in its introduction here. So I haven't been here for a couple years say Mensa some of you may not know me as well. So we briefly. Introduce who I am. I know Dr Knabb may have I have mentioned as well. I'm currently in a chronology is working on the island of Guam there's an S.T.D. mission clinic there. And I practice there. I would say seventy eight percent of my practice is diabetes type two. There's very little type one actually in Guam. Because that's a lot of it is in a Caucasian. Demographic. But we also have a wellness center there we have lifestyle classes and all the whole the whole bit there so it's a nice place to practice. And our family enjoys it. You may have seen. My wife and kids running around here that we're all privileged to be here. From Guam my wife sonny. And this is my older son Enoch. He's now four years old he was three years old at the time this picture. And this is no of our two year old so. There are other friendly guys you can stop and stop them if you see them in the hall and say hi. Notice closures. Before we go into learning objectives let's start as word of prayer. Defraud or haven't we thank you for the privilege we have of knowing so much about about healthy living. And we pray that. As we now go over the the evidence in the medical literature as we apply it to our situation is advantageous Mia give us a special portion of your spirit to both understand. And to learn how we can be a part of spreading this important message in Jesus name we pray Amen. All right so today we're going to have three main objectives. The first one is sue a look at some of the recent the medical literature that really has has proven that diabetes can be prevented and treated. And that can be done through last honor vention. And then the second part of it is going to be looking at how life under vention works or potentially How it to work. And how to facts. The progression of diabetes and then the final part. We're going to touch briefly on some things perhaps that we can do to help people sustain their healthy lifestyle choices and that is a a big dilemma. Nowadays. So before we begin that you probably are aware of the current diabetes epidemic. But just to review and to reinforce our own mines where we're at now. The most current statistics. As a two thousand and fifteen. So that over fifty percent of the American public. Either has pre-diabetes or diabetes S twelve to fourteen percent with diabetes. And about forty percent with pre-diabetes So you'd walk out on the street. One out of two people. Has pre-diabetes or diabetes and I include pre-diabetes because that's almost as important as I.V. especially talk about last honor vention. One hundred fifteen million people in the United States with either with diabetes and three hundred eighty seven million. Currently worldwide. And just to underscore how quickly. This is growing. Realize that in one hundred eighty five there are only thirty million diagnosed cases of diabetes. At that time. Since then of course we know we're in the three hundred three hundred millions. Currently. And it's projected that it by twenty thirty. Will have about five hundred fifty two million people diagnosed with diabetes. The latest number that I've seen is a projection for teeth. For twenty thirty five. And they're estimating almost six hundred million people with diabetes that's a command of. Amount of course of morbidity and mortality. As well as health care costs. However V A lot of the medical societies now are. Are recommending life on adventure and for pre-diabetes and diabetes. And in fact just a three days ago. The United States Preventive Services Task Force recommended diabetes screening for certain groups of people. And you can see here this is this just came out a few days ago that it says that the that they recommend screening for abnormal blood glucose as part of a cardiovascular risk assessment in adults between forty to seventy years. Who are overweight or obese. I as an endocrinologist. And as a diet Hala just. I would say we probably aren't going far enough. With this you're missing a lot of potential diabetes cases by. By not going lower than forty. By not a Pay attention to high risk populations and women would just say show diabetes always have other other categories. But it's a step in the right direction. But notice the second sentence here. It says clinicians should offer or refer patients with abnormal blood glucose. To intensive behavioral clan counseling interventions to promote a healthy diet and physical activity. So this is the most recent recommend recommendations out there and. If you look at the other medical societies. You'll see a similar. Recommendation So here's the American Diabetes Association. One of the preeminent medical societies for diabetes. And in their guidelines this is what they say. Patients with impaired glucose tolerance. Impaired fasting glucose. Or in A one C. between five point seven and six point four. All those groups would be considered pre-diabetes correct. Should be referred to an intensive diet and physical activity behavioral counseling program. Targeting loss of seven percent of body weight and increasing moderate intensity physical activity. Brisk walking. To at least hundred fifty minutes per week. So that is the current guidelines from the American Diabetes Association. And then of course there is the American Association of Clinical Endocrinologists. Which is the society that I belong to and they also have the recommendations for pre-diabetes and diabetes. This is the algorithm for pre-diabetes. And you can see here that my cell modification is the first line treatment and. If you look at the algorithm for diabetes treatment again. We all know this lifestyle modification is the first thing that we should recommend to our patients. So why is that why are these record. These recommendations in place. There were three. Landmark clinical trials that were done around the turn of the millennium. That really proved. Eloquently and convincingly that last on eventually in is very important in the progression of diabetes and we're going to go through each one of those now. The first one was done in one thousand nine hundred seventy was called the DOT Hsing I.C.T. and diabetes study. The second one was published about four years later in two thousand and one and it was called the Finnish diabetes prevention study. And the last one that we're going to talk about was published just a year later in two thousand to call the Diabetes Prevention Program. It's maybe the most famous one and it was done in the United States. So let's start with adopting study. This study. Look at one hundred and they screen one hundred ten thousand six hundred sixty adults from thirty three clinics in dodging. China is back in ninety six probably before. China was as Westernized as it is now. But they were looking for individuals with I.T.T. or impaired glucose tolerance or diabetes type two and of those one hundred ten thousand people. They were her only able to find five hundred seventy seven people with pre-diabetes. That's pretty amazing actually finished up. If you were to do that same. Screening process in the United States right now. OK with the known rates of pre-diabetes. You'd probably find about forty four thousand people with pre-diabetes that if you feel old a little idea of where China was it may be that that demographic at that time in one hundred eighty six. That was prior to the boom in diabetes at least on the early stages of it especially in China. Anyway they randomised these five hundred seventy seven people to either control. Or three different intervention arms. One was a died only arm. One was an exercise only and then one was combined together and I'll show you what they did for each of those in a moment. They fall these individuals at two year intervals for six years. And they were trying to identify those who develop diabetes. And here's what the different. Interventions were of course control was just a general advice brochures. Things of that nature that you would normally give in a primary care setting. The die only arm had several. Targets. There they had dietitians that helped advise patients on a diet. That was supposed to consist of fifty five to sixty five percent carbs. Ten to fifty percent. Ten to fifteen percent protein and twenty five to thirty percent fat. And if you can. If you kind of know these these proportions. Wasn't that aggressive OK. You know the fat levels are pretty high and. You know there's a there's a lot of things that we could do probably to make a stricter. But that's what they chose to use for their study. They were encouraging more vegetables. Drink less alcohol and less simple sugars. There was a calorie restriction for those who are overweight or obese. And that was to encourage them to lose weight. And then in terms of the actual counseling there was individual counseling as with physicians. As well small group sessions that continued throughout the active intervention. What the exercise. Only are. It's a little bit more complicated but they basically were asked to increase their exercise level from whatever they were at baseline. By one or two levels or so and so it wasn't specifically. There wasn't a goal for sort of not a minutes or a certain level of intensity. The result of the study did show a decreased. Incidence of diabetes. In the intervention arms whether it was diet exercise or the combined. Diet and exercise you can see that the cumulus incidence of diabetes dropped from about sixty percent down to. In the forty's. And that correlated to a risk reduction. Specially for the combined arms of about forty two percent. So there. Those who had the lifestyle intervention the full life center vention had their risk of diabetes. Reduced by forty two percent after six years. That was the first study in one thousand nine hundred seven. The second study was the Finnish diabetes prevention study four years later. And they looked at five hundred twenty two adults that were between the ages of forty and sixty five. And they had to have a B.M.I. greater than twenty five In other words they had to be overweight or obese. And they had to have impaired glucose tolerance. They were randomized to a control group. And to a lifestyle intervention group so they did not distinguish between diet and exercise. Individually. The control group of course got the general. Written and oral advice. And then the intervention groups. Had a little bit more Or. of a rigorous or some goals that were set for them that are individualized to the to the to each patient. They were to reduce their weight by at least five percent. They were to decrease their fat intake by thirty percent and saturated fat by ten percent increase their fiber and the exercises was me moderate. At least thirty minutes per day. So this was a little bit more of a goal goal oriented. Intervention. And they were followed annually for four years to defy those that develop diabetes. What do they find here. One thing I should mention before I go over these results is that the dodging Chinese study. This because they did not target weight loss as a goal. They actually did not achieve much when they didn't achieve any weight loss actually. And so all the risk reduction that you see from that first study was due to was not related to weight loss. That makes sense. So there was something else going on with the diet in the exercise. Or even those individually. That was reducing their risk of diabetes. Now in this study. The we have now. Some weight loss and you can see after your two. While the control group last less than a kilogram. The intervention group lost about three point five kilograms and. After four years. The risk reduction was fifty eight percent. Probably due to partially that a more aggressive goal setting. And also probably partly due to the fact that they had some weight loss associated with this program. Fifty eight almost sixty percent. And finally we were getting to the diabetes proof. Prevention Program. This was one that was done in the United States. It in rolled a lot more people over three thousand. Subjects in this study. Separate they were over twenty seven clinical centers. Their B.M.I. had to be greater than twenty four. And in Asians greater than twenty two keep in mind that the B.M.I. cutoff Asians lowered you know that they usually we say twenty three in this case it's a twenty two. But Asian have a different phenotype. And so B.M.I. cutoff was lower for them. And of course they had to have impaired glucose tolerance. They were randomized to either that standard lifestyle advise them placebo. Standard lifestyle with metformin and they could be on metformin up to eight hundred fifty milligrams twice a day which is near maximal doses for metformin and. Or they could be on intensive lifestyle intervention. And we'll talk a bit more about what that was in a moment. They interested in think about this particular study was that they had to stop at one year early because their preliminary results were so good. So they were they were planning to do a four year study. It ended up being closer to three years. And that's because after this well we'll talk about this and all that will go over the results in a moment but they had excellent results. So their goal for their lifestyle. Program was seven percent weight loss. Which is the most aggressive that we've seen so far. Although I would argue that we could be more aggressive. If we really wanted to. But this again was the way they set up. There study their dietary fat goal was twenty five percent of calories from fat. And they had a caloric intake goal between twelve hundred to eight hundred kilo calories per day. Based on their initial body weight. They were also asked to engage in at least one hundred fifty minutes of exercise. A week. It had to be a brisk walking or or higher intensity and the goal was to burn at least seven hundred kilo calories per week. The interesting thing about this program was that it was actually quite a bit more intense in the ones we've seen before. There was a sixteen lesson curriculum. And there were a lot of group sessions. Involving exercise and diet etc. So there's a lot of support. And there was a. There were fairly aggressive. Goals that were set. So the end result of this study after only three years it was stopped early because they found that the risk reduction in the intensive lifestyle group was fifty eight percent. The same as the Finnish diabetes prevention. Study. And that was only after three years. After that they thought the study. They put everyone in the. The diocese prevention program. Ethically. You need to do that right because it was so effective. How could you keep the others from from that important. Ology. Also look at the best woman are and you can see that metformin also is able to cause a risk reduction in that. As metformin. Metformin monotherapy. There have been other studies since. Looking at the life on or vention. In other populations as well as want to bring the spirit tension. For instance there's been a study in a four hundred fifty Japanese males that had impaired glucose tolerance. They were randomizer to control my center vention. The Law Center vention for this one was was really a B.M.I. goal. So a weight loss target and lifestyle instructions that were every three to four months the not very intense. On the lifestyle. Instructions. But they were able to show a risk reduction of sixty seven percent over four years. Though it is very possible that life and eventually maybe especially effective in the Asian population or certain Asian populations. In this other study here though in Indian adults they look at five hundred thirty one Indian adults with impaired glucose tolerance. They actually randomized them within a several groups including life under vention metformin. Or both and they actually were fairly mild in their intervention it was just lifestyle advice. OK. No group sessions no major targets for Weight Loss of cetera. But there still were able to show a risk reduction of twenty percent over just three years. And you have to remember that in the in this Indian population we're talking about South Asia. They have a high genetic prove predisposition to insulin resistance. So there are some genetic components at play here too. But it still was an effective way to reduce the incidence of diabetes. Now. Each of these major studies that we just talked about had to follow up studies as well. So even after each of these studies was done. Dodging study was six years. Finished. Dieties prevents that he was four years and then the. The D.P.P. was three years. Even after the participants finished. That study that active intervention. They. And stopped having that that those fall of sessions and all the active intervention. They followed up with those people. A certain amount of time later and so you can see at the dodging study they actually followed up twenty years after the initial study. And they found that believe it or not the risk reduction. Remain the same twenty years later. Forty two percent. Originally and still had a forty three percent risk reduction. After twenty years. Obviously that's the kind of a special population. There are probably some reasons to explain that. But you can see that it was sustained. The Finnish diabetes prevention study. Originally showed a risk reduction of fifty eight percent. After four years. The risk reduction still was about forty three percent. And after thirteen years thirty eight percent. So there was some. You know you can imagine that some of the people maybe weren't quite of that here and to those lifestyle recommendations. Over the course of those years. But they still had a residual benefit. And for the Diabetes Prevention Program here in the States. Remember it had a fifty eight percent risk reduction the beginning after ten years that was thirty four percent and in fifteen years. That was twenty seven percent that's the latest data that we have. So you can look at this two ways you can look at this and say well. At here in sprawly trailed off and actually the finished. Diabetes French and study actually showed that part of the reason why there was sustained. Risk Reduction. Was related to how out at here and the participants were to lifestyle advice. After they finished the study. So we definitely can say that. That Here it's contributes to the risk reduction. Even ten twenty years down the road. But. But you can also see here that there is in increase. A sustained risk reduction. And that's really what I wanted to pull out of these these studies is that life enter vention can't significantly reduce the onset of diabetes. Somewhere between thirty and seventy percent that may depend on the. Lots of factors. Genetic predisposition of the population. The adherents. How structured your program is the weight loss goals that you have all those things may play a factor. But somewhere between thirty to seventy seventy percent within three to six years of active intervention. And that the risk reduction of that intervention can last for up to twenty years. We don't have data beyond that to might might be interesting to see a thirty year follow for forty or follow up. Especially for the dodging study. So how does this was the intervention work. In order to understand how it works. We need to understand what causes diabetes and what causes diabetes to progress. And this is a a in expanding areas research there's a lot of war going on into it. There's a lot that we still don't understand about about diabetes and the underlying path of his the logic mechanisms. But we're going to cover a few things and that we do know and how lifestyle. May be contributing to that. So first of all let's just review. The natural course of diabetes. Most of you will. Will be familiar with this. This is a chart here. Basically a timeline from a normal. Individual who have normal glucose tolerance to someone who has impaired glucose tolerance or what we call pre-diabetes. All the way down here to the overt diabetes. And so we can see here. That early on even when we are considered normal. That insulin resistance begins to creep up. And that normally correlates with an increase in weight and. But we'll talk a little more about that a moment. As the insulin resistance increases. The beta cells in the pancreas. Compensate by increasing their level of insulin production. And so for a while you can see your insulin production. Production also will increase of Sue keep up with the ins and resistance. But those beta cells can only produce and I should really say over produce insulin for so long before they begin to fail. And it's when you have beta sale failure here. That insulin production begins to trail off. And without insulin. Being produced. The glucose level being as a go up and that's where you get the hyperglycemia. Once you had a certain threshold of hyperglycemia. We call that. Type two diabetes. All right. So we're all familiar with this. So let's talk. So there are many many reasons for type two diabetes progression OK. We now know of defects in in the brain. In the adipose tissue in the kidneys. In the got all over the bodies it seems like there are all these different mechanism play. But the two main ways that we just talked about were the two core. Defects of diabetes. Are insulin resistance. And beta cell dysfunction. OK So those are the two they're going to focus on today. So let's first talk about insulin resistance. And there are a lot of cause of insulin resistance but I have I've taken some of the main ones and I've just categorize them into two groups. The first one to be non-life I related. We know that as. As we move in for the age. The aging process naturally leads to more instant response. We know that ethnicity we talked about some of those ethnicities that have a higher rate of insulin resistance. Inherently. There are also diseases. I tend to think of places to go variance syndrome. But there are different diseases that can have higher rates of insulin resistance. Medications steroids would be a good example of that can cause influenza since but there are many of them. And of course infection we know that during acute infections. The body because we're in some resists invest in natural phenomenon. But there are also lifestyle related causes of insulin resistance. The main one that we all think about is obesity and. Asked why because obesity is one of the main players in this. We know that as the obesity epidemic has grown so has the diabetes epidemic epidemic. But there are other things to the physical inactivity. Has been related to insulin resistance. Sleep apnea. Also has been shown to cause influenza sins as well smoking. But the one that I really want to focus on today is this one called chronic low grade inflammation. And this has the potential to bring together a lot of those mechanisms that we just talked about. Into kind of a cozy. Cohesive picture. We know that chronic low grade inflammation is a risk factor for cardiovascular disease right. That's been pretty well proven. We use. C.R.P. level the cetera to to. To evaluate risk for cardiovascular disease. Well. That is probably also the case for other chronic disease. Diseases including diabetes. And this is kind of how how it works or how we think it may it may play together OK so. So bear with me as we walk through this a little bit it's. There are no molecular sickly pathways in this. And so that's why put it here. So go ahead and look up here at First of all the lifestyle factors. So we're looking at a lot of different last the facts we just talked about some of them. But obviously the things that we're putting into a body are diet. The amount of fiber reading. Physical activity or inactivity and cycle social factors right. You know talk about strict with the other stress. Leave all these other things that go into it. Those different components. Can affect levels of various media isn't a body. Of course if we're talking about diet we're going to talk about things like glucose fatty acids. Fatty acids would become what we call life otaku city. Glucose we would call Gluco talks of toxicity. And a bunch of other different. Different concentrations of differences in our bloodstream. OK. Including and slanted toward mediators we're going to talk about these all these things can induce what we call pro-inflammatory responses. In all parts of the body. And that's a systemic response. But it's a low grade response OK. If you have a acute infection they be some of the Monia or a major skin infection or something. Yes. Your information will go sky high but. Was that heals. It should come back down to normal. But this is a chronic low grade type of of response. And notice over here that there's also all. At the same time. A inflammatory response going on in the fat tissue itself. And I'll explain that a little bit more in a second. Together. Sorry. Went the wrong way here. Together these a localized. Ana systemically inflammatory response. Can cause the sustain this chronic low grade. Inflammation. The problem with low grade inflammation is that it can do two things number one. It can inhibit beta cell function and decrease insulin secretion. It can also also. Trigger. Kept up to sis. In those beta cell. And I want to talk a bit more about that in a moment because that's very important. That's a direct effect that it also can cause. Basically insulin resistance and other metabolic disturbances. Which indirectly are also going to contribute. As we saw before. In beta cell failure. Does that make sense. So basically we have here is lifestyle. Causing a low grade chronic inflammatory response in the body. That will either directly. Affect your beta cells in your pancreas. And it will cause an resistance. Which again affects your beta cells. Because it increases the load on them. All right. So what are some of the lifestyle factors that contribute to inflammation. Well there are many but I've summarize some of them here. We know that saturated fat can actually active A inflammatory pathways in multiple organs. Sometimes it's done through what will be called the. T.L.R. system. A set of receptor. That's saturated fat especially palm Aetate can activate. And those receptor are everywhere in the body including data close to shoot liver muscle. Brain. And even those pancreatic islet cells have these receptors. And can be affected by this high saturated fat. We also know that the gut. Microbiome. This is the the gut flora. That you have in your intestines. Is altered in the city. And it also critters in family to respond in fact that you also have those T.L.R. receptors in your gut. We also know that hyperglycemia acutely. And as well from a more epidemiologic standpoint. A diet in high in refined carbohydrates. Will increase your pro-inflammatory markers and decrease your anti inflammatory markers. There's been some research done in sleep deprivation both acute and chronic and that also is pro-inflammatory. And finally. We talked about those those a localized effect in the in the fat tissue. A defiant high perch or C. which occurs when we have too many calories right. The. The a dip. The the fat cells actually high purchase feet and has a become. Some of them will become hypoxic because the outstrip their blood supply. And if they become hypoxic they want to cross and die. When they do that that attracts. Macrophages and immune cells to clean up that. And those immune cells. Then become activated to produce side of kinds and inflammatory. Markers. And then that recruits more. Macrophages an immune cells and you get this vicious cycle of of what they call a defeatist or a low grade. Information. Of adipose tissue. So how does information. Cause diabetes Well first of all. If any of this in inflammation happens in either the adipose tissue liver or skeletal muscle. We're going to have insulin resistance. All right. But also adipose tissue. When inflamed releases free fatty acids. And so when those three fatty acids are surgically in the blood. They cause insulin resistance in fact. Research that I did in. When I was in fellowship. We would infuse normal patients like like you and I with free fatty acids in to live it. And within four hours. People are completely an insulin resistant just like a diabetic would be just based on a few hours of increased levels of free fatty acids. So this is a very powerful effect. And also remember that these three fatty acids have a have a why put their life with toxic. And they have a direct effect on beta cells. Now in the hypothalamus. They're all that also can become inflamed. And the hypothalamus is where appetite and. And a caloric intake is controlled. And so those with information the hypothalamus are going to be prone to obesity. They will have central leptin and insulin resistance and cetera. And finally inflammation can actually directly affect the pancreatic beta cells and decrease their insulin secretion. So there you go. Inflammation. Can affect all the different. A lot of the different mechanisms that underlie diabetes. Now if lifestyle. Cause the problem. Can lifestyle. Reverse the problem. Or improve the problem. And there is evidence to that that regard. So let's talk about exercise first. In the large population studies these are observational studies. We see an inverse association between inflammation and inflammatory markers and physical activity. So the more physically active. The less inflammation and vice versa. And that goes for both acute exercise and regular exercise so in acute exercise we actually have found that. That there is an anti-inflammatory effect of acute exercise so after even one. One session of exercise. You will have a decrease in your and anti-inflammatory markers and that's true. Primarily the secretion of interleukin six. So. I also expect multiple roles but in this case it's actually anti-inflammatory. And they also. There's also immunosuppressive effect on certain cytokine producing immune cells. Primarily monocytes. The Remember those ones that are tracked to the to the the fat tissue and they start that cycle of inflammation. Now with regular exercise. There's been some interesting findings their regular exercise can decrease. Inflammation in the body. But. It has to be moderate to vigorous intensity. That means greater than seventy percent of your max. A robot capacity. If it's Miles. Which is typically the slow walking which. If that's all that your patient can do or. Then you've got you have to start somewhere. Don't you. But just realize that it has to be moderate to vigorous in order to impact into an Asian. All right. And there has been some studies also in this. What's called high intensity. Intermittent training. Have you heard of it before. And so. What's called hit. If you do these very intense. Like greater than ninety percent of your macro the capacity for short amounts of time with breaks in between. You actually can get very very strong. Decreases in your info and your inflammation. And they found that even after two weeks of this high intensity intermittent training. The you can have vastly reduced levels of information. When it comes to diet. There is a lot that we could talk about here. I'll just mention a couple things. Most of you familiar with a better training diet and that's just you know more plant based. Healthier oils. Etc. Low red meat etc diet. That has been associated with decrease unsanitary markers in the metabolic syndrome. And we also know that a diet us low refined carbohydrates actually decreases C.R.P. levels which is one of the inflammatory markers and. Keep in mind that motto polyunsaturated fatty acids. Can decrease post-meal inflammatory response as well. So there are there's a bunch more information but this is just what I wanted to to share with you today about how diet also can impact. Inflammation. So we've talked about is no resistance. All right. But how about those beta cells. Because I'll be honest with you. The real the real predictor. Or the real bottom line for diabetes is. Unless you have beta cell failure. Because that's what diabetes is it's if it's a dysfunction of the pancreas. The incinerate system so we talked about is is just a is just causing those beta cells to fail. So if we can. If we can target those beta cells and preserve as those beta sales. We will preserve. We will prevent diabetes is that make sense. So this is a chart here looking at beta cell function and. This here is probably the gold standard for Bates looking at beta cell function. It takes into account. Not only what the glucose level is at the time as measured but it also takes into account the insulin resistance of that individual at that point in time. And you can see here. That as we progress from normal or normal glucose tolerance to id T. impaired glucose tolerance to type two diabetes. We have a slow a steady decline in beta cell function. But there's a couple things that I want to point out here. First of all the blue is considered normal glucose tolerance. But by the time that. Even if your normal glucose tolerance here at the very edge of almost becoming. Impaired glucose tolerance. Notice that you've already lost fifty percent of your beta cell function. Before you even known to have pre-diabetes. All right. And that's primarily related pollies of the influences and the obesity. And the information that's going on. Four Before you cross that threshold that we all know for in for pre-diabetes. Now by the time do you get to the end of v. Pre-diabetes you have lost approximately eighty percent of your beta cell function. All right. If a question of your. That's a that's a good question. It depends on the individual. And so. Remember this is function. It's not necessarily beta cell. Loss itself. So some of this definitely is is beta cell loss in fact. The study shows that by the time you get to this point. You probably lost about fifty percent of your beta cell maths. OK. That's actual beta cells. But some of this is probably do especially during the parable Solomon's to the hyperglycemia causing glucose toxicity and potentially the life of toxicity that we're talking about with the increased fat free fatty acids. They may also be. Be preventing those beta cells from fully producing secreted as much insulin as they could. So in the case of someone who is caught early. There's a much greater chance first of all that they'll have less beta cell loss. And if they are caught. If we reverse some of that life of toxicity some of that glucose toxicity. There's a much greater chance if we do that early. That they can recover. A lot of some of that function back and we've all seen patients that have done this. Typically it's the ones that have had diabetes and less or they may have some some genetic. Different genetic risk profiles. But there are people in these categories. Who can who can easily reverse. But we need to realize that the longer we go along this curve. The harder it's going to be to completely reverse. Why is that. Because once you lose a beta cell. Completely like it. Aptos this cell death. It's gone. You can't get it back when science knows of no way currently to regenerate. A beta cell. Short of cell transplant. So once you lose that beta cell. I'm not talking about the ones that are that are still alive and. And if you. If we do C.P.R. on them they can come back to life and and. And that's we can reverse their diabetes there I'm talking about the ones that have died. Once we lose them they're gone. OK. This is a powerful argument for early early intervention. In fact intervention should be somewhere in this range. In my opinion. Because we want to save those beta cells. Even then. So we need life on invention. And we need it early. So that makes sense. All right let's move to the last part of our talk and that is there is a dilemma isn't there. How do we keep these life style changes. Going. And I. I have to admit I don't feel like I know all the answers to this. I think there are a lot of great minds. Some of them even in this room who have been tackling this and. And I appreciate that. I will tell you that when I was in the fellowship in this. In the University of Texas sent in Tonio. One of the premier diabetes research groups is located there. They do a ton of research and. As I spent time with them doing research along with them. One thing was very clear. As we work together as we talk together about diabetes and that was that. Everyone knows that lifestyle intervention is is significantly. Powerful to reduce dives incidence. No one questions that. What people would produce question is how. How had here and people are going to be to those lifestyle changes. And that is actually what led the research group that I hope that I was a part of to to actually recommend. Pharmacologic therapy it's called triple therapy. To to find some way to get people to treat people early and of preserve those beta cells. But we all know that better than those pharmacologic agents. Is these lifestyle changes. If we can get people to continue to make those healthy lifestyle choices. Over time in the long term. So one more thing before I go into some of the. The programs. The thing that I probably appreciate the most was what our aim and president. Todd got three what he said last night. Right and that is that in order for people to make long term changes in their life. There has to be a change in what our density. Right. We have to. We have to be transformed. At a different level. To gain access to a power that can help sustain change. And I think ultimately that's where we as Adventists have a profound opportunity. And we talk about that in a moment. Let me first just quickly go over. What some of the studies have shown. Are what they did in some of these trials. We talk a little bit about these landmark trials. And the docking study. Had individualized addition counseling and small group sessions. They met once a week for a month. Then once monthly for three months. And finally. Every three months. For the rest of their intervention. The Finnish diabetes prevention study. Had face to face encounters but it was with their nutritionist so they involved a multi-disciplinary team. And they were meeting about every three months after some initial like seven face to face encounters in the first year. They also had voluntary supervised. Exercise sessions at the gym. The diet is prevention program was the most structured and the most aggressive. And they had a sixteen lesson curriculum. Cover diet exercise behavior modification. It was done a one on one. For us six months. And then they had monthly group sessions for reinforcements. When you look at the divers prevention program which is probably been the most successful and the most widely copied. Program out there. This is actually the these are the actual. Components that they felt summarize their program. When they published it. And so let's just go over them briefly goal based intervention remitted weight loss goals other goals. Lifestyle coaches. They did use lifestyle coaching. Frequent contact and structured curriculum. Supervised physical activity. Flexibility including motivational campaigns and restart so they gave the opportunity for patients who kind of felt the wagon to get back into their intensive weight loss program and restart. There was individualisation ethnic sensitivity. Really trying to personalize it to the patient. And they also had a network for training the staff and getting feedback which was important to them. So the problem with this. D.P.P. program was that it was so aggressive. It was difficult for a lot of. You know primary care. Offices or even communities programs to implement. Although some house and there'd been modifications of it. So other mortalities have been looked at too and I don't really we don't really have time to go through a lot of these. But I'll just mention a few things first of all there are there other face to face type. Modelling he's. Some of the popular classes from the Diabetes Prevention Program where resistance training that hearing cooking. And those restart programs to just keep that in mind. Shared Medical point is another way to to address a group setting for less than or vention an interesting component is this what is called Mobile health. And this is basically using mobile phones and mobile technology. To. For health intervention. And one of them of course is phone coaching and the idea behind all of this is that a lot of people have cell phones and even even dumb phones can can do texting right. So so. Everyone has a phone nowadays pretty much. And it. You don't have to all meet in one place. You can call people have sometimes a date of on their schedule. And of course finally it's doesn't cost much and that was. That's the big issue with implementing a large scale and resource intensive programs. So fun coaching has been found to be to be helpful. Texting. Actually there's been a bunch of studies on texting. OK. Yet. On texting. And it works really well at least in some of those I saw in women. They had pair of these they would have these women. Texting. Called texting buddies. And they would exchange tech all the time like a hundred twenty or so techs. A week or so like that they were texting back and forth and supporting one another so texting can work. What all to say about mobile health is that the general gist of the research is showing that it's helpful. But it doesn't take the place of face to face. All right. Internet Web site portals. Not very helpful. Social media. We're just getting into that. But there are a lot of hip. Issues and different type of C. issues that go along with social media. But the last thing I want to just talk about as we close here is spiritual support. I don't have time to really talk about some of the there are Christian diabetes programs that are being implemented in Turkey is. But what we what we really. What we really should be talking about now is what can we as Adventists do this this health care crisis in diabetes. It's huge it's one of the. The crisis of our generation and happen to have known the. The answer to this crisis. Since before there was a crisis. Sit four hundred years we've had we have known the health message that we have. And it's perfectly situated. For the times of reliving it. In reality. I haven't to should have been doing the dieties prevention program. We should have been on the leading edge. Doing those major landmark studies we could have done it. And we should have done it. They've been done. The evidence is out there. I'm glad it's out there. There are a lot of researchers doing research on insulin resistance inflammation and all these beta cell things that will continue to be done where it can ave just contribute the most. I would say. The biggest question mark right now in diabetes prevention and treatment is how to sustain lifestyle change. No one has an answer. And Adventists. We have the answer. In our health message. And the answer in how we can sustain that and that's through a transform life that taps into the power of God to make changes that are lasting. And so that's really what I want to encourage us today. The studies are that the landmark studies are done the research is going on but we need. People and there are some here today. Who are doing it now. We need more. We need more people to step up and say we want to innovate. We want to be on the leading edge we want to publish these studies and show the world. How we can have a program. That's faith based that taps into some things other than meditation or other types of of eastern type. Spiritualities to really show that this can be done. And that this can be done to the power of Christ and we can use as a model to to make a difference in this diabetes epidemic. So keep that in mind of anyone here who's interested in diabetes come talk to me later. I'd love to to network together. But the let's pray A. That we can take advantage of this opportunity the God given us. And then we can apply we know as Adventists. And a special way to to help medical missionary work to be that final push to reach others. Those that need it most. Let's end with a word of prayer. And then we'll have any question you can stay afterward Naslund. All right there. Defied heaven. Thank you for giving us. Knowledge. Special knowledge. For always giving us special knowledge. At critical times in the Earth's history. And now as we live in the most critical time. Of US history. We want to play a role. The role that you have set aside for medical missionary work for lifestyle. Medicine to show the world that not only is the health message true. But that you have the power to change people's lives for ever. Help us to be innovators. Through your grace. We praise and uses the. Amen. Media was brought to you by audio groups a Web site dedicated to spreading God's word through free. Sermon audio. And much more. If you would like to know more about how do you or you would like to listen to more sermon. Leave it there. W W W dot dot.

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