Shireen: Podcasting from Dallas, Texas, I am Shireen and this is the Yumlish podcast. Yumlish Is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.

Dr. Aleem Kanj. is a board-certified endocrinologist and obesity medicine physician, and the founder of Ethos Endocrinology in Houston, Texas. Dr. Kanji’s passion is improving metabolic health through increased time and attention made possible by the direct care model of Ethos Endocrinology. Welcome Dr. Kanji.

Kanji: Thank you for having me.

It's a pleasure to be here.

Shireen: An absolute pleasure having you on. So Dr. Kanji, will you tell our listeners a little bit more about your background and why you decided to specialize in diabetes and obesity in particular? 

Kanji:  Yeah, absolutely. So I attended Texas Tech University Health Sciences Center, School of Medicine in Lubbock, Texas.

I came back home to Houston where I completed my internal medicine residency and endocrinology fellowship at Baylor College of Medicine in the Texas Medical Center. After fellowship, I founded Ethos Endocrinology to practice medicine in a way that preserves and strengthens the patient physician relationship and is my passion for improving metabolic health through, I obtained board certification in obesity medicine.

So I take care of individuals with diabetes, other hormone, lung disorders as well.  I'm particularly passionate about the intersection of obesity with these endocrine conditions.

Shireen:  So that is interesting. According to the American Diabetes Association, there are three specific criteria someone has to meet in order to be considered prediabetic.

Can you talk a little bit about that?

Kanji: Yes, absolutely. And I think it may be helpful for us to kind of define prediabetes to begin with as well. So this is according to the American Diabetes Association. We're, I'll refer to them as the ADA, as we move forward. So prediabetes refers to blood glucose or blood sugar levels that are higher than normal, but don't meet the criteria for diabetes.

And I, I like to explain it as a spectrum rather than a diagnosis in its own silo. So as you move along the prediabetes spectrum, there's an increased risk for progression to, to diabetes. Regarding the three criteria. So the ADA does define three criteria for the diagnosis of prediabetes and each of the three criteria is based on a specific laboratory test.

So I think it'd be helpful to discuss the, the three tests and the, the criteria that go along with it. The first one is one of the more familiar ones. So this is called a fasting plasma glucose, or a fasting blood sugar. A normal fasting blood sugar is below 100 milligrams per deciliter, whereas a fasting blood sugar that's between 100 and 125 milligrams per deciliter meets the criteria for prediabetes.

And some people may hear the term impaired fasting glucose to refer to this. In other words, a fasting blood sugar in this prediabetes range. Second test is called a hemoglobin A1C. And I think many people have heard of this lab test before, but I think it'd be helpful to, to break down what it is. So first the term hemoglobin refers to this iron containing protein inside of the red blood cells and as glucose or blood sugar rises, they attach to this hemoglobin protein in the red blood.

So this hemoglobin A1C test reflects the average blood sugar levels over the life of the red blood cells. And so red blood cells circulate for about four months before they're removed from the circulation. And so going back to the criteria for hemoglobin A1C, less than 5.7% is considered normal 5.7% to 6.4% meets the criteria for prediabetes.

And for reference a hemoglobin A1C of 6.5% or higher meets the criteria for diabetes, the last test or the third criteria that we were discussing is called an oral glucose tolerance test or OG TT. This test is done fasting and essentially you are given a drink, a liquid to drink which contains 75 grams of glucose or sugar.

Then your blood sugar or glucose is checked two hours after completing the drink and a two hour blood glucose that's between 140 milligrams per deciliter to 199 milligrams per deciliter meets the criteria for prediabetes.

Shireen:  So let's talk about some of the symptoms associated, cuz we always hear about diabetes.

I do wanna talk about how does someone understand if they're prediabetic. 

Kanji: Absolutely. So regarding symptoms this is the, the challenging part. So prediabetes usually presents with no symptoms and that's what allows it to escape detection if it's not looked for sometimes for years. And so I think that annual annual exam or, or, or checkup is so valuable because it can detect prediabetes or even other conditions that usually may not present with symptom.

There are some individuals that can experience symptoms that are associated with a rising blood sugar level. So that can include frequent urination, increased thirst, fatigue, blurred vision, or numbness or tingling in the hands or feet. 

And by the time those symptoms happen, though, is that more headed toward diabetes?

Is that when some of the symptoms start showing more obviously?

That's a great question. I would say. I would say that's likely the case because we, we mentioned that prediabetes is a spectrum. So as that sugar level rises along the spectrum, there is a higher tendency for those symptoms to appear.

Shireen:  Now this question this next one, have you seen individuals reverse their prediabetes? First,

tell us what that even means, but then help us understand if individuals are able to reverse out of that. And if so, was it through changes in diet, exercise, medication? You know, can you walk us through that a little bit? The work that we do at Yumlish focuses a lot on that, and I would like love to get your perspective on sort of what you see.

Kanji:  Absolutely. I think there's, there's a lot of information to, to unpack in this question and to answer it simply I absolutely have seen people reverse prediabetes, and that is what makes me so passionate about practicing at this intersection of endocrinology and obesity medicine. But I think to answer this question more concretely we can look at some great data from a clinical trial called the diabetes prevention program or the DPP.

So the DPP was a trial that was conducted at 27 centers in the United States from 1996 to 2001 that included a little over 3,200 individuals with prediabetes. Now these individuals were randomly assigned to three groups. The first group assignment was standard lifestyle recommendations, plus a medicine called Metformin given twice daily.

The second group was also standard lifestyle recommendations, but they were given a placebo pill twice daily. And then the third group was an intensive program of lifestyle modification. Now, what did the standard lifestyle recommendation include? This. For the Metformin group and for the placebo group.

So this included following the food guide pyramid, reducing weight and increased physical activity general lifestyle recommendations. Whereas the intensive program of lifestyle modification included a specific goal of weight loss of 7% of initial body weight. And this, this was done by following a low calorie, low fat diet.

Paired with moderate intensity physical activity, such as brisk walking for at least 150 minutes per week. And I, I think before we get to reversing prediabetes, let's find out how much participants lowered their chance of developing type two diabetes. And so I think this is interesting data for participants in the intensive lifestyle program.

They lowered their chance of developing type two diabetes. By 58% compared to placebo placebo whereas participants in the Metformin group, they lower their chance of Del developing type two diabetes by 31% compared to placebo. I think those are pretty substantial numbers, particularly for the intensive program group, but to circle back to perhaps even more interesting question, which is what percentage of participants reversed prediabetes at the one year.

So to, to answer this question, we have to define reverse prediabetes. And we'll say that this is a normal fasting glucose or normal fasting, blood sugar, and a normal glucose at the two hour mark of the oral glucose tolerance test which we discussed previously. And I think it's important to note that this study did not define reversal of prediabetes.

We're just using this as a definition to answer this. So looking at the data, approximately 25% of participants in the placebo group, reversed prediabetes with standard lifestyle changes at the one year mark, about 30% in the Metformin group, reversed prediabetes with the standard lifestyle changes at the one year mark.

Whereas in the intensive lifestyle group, over 40% achieved a reversal of prediabetes at the one year mark. So to answer the question precisely. We absolutely have seen reversal of prediabetes at a larger scale through both diet and exercise and medication. And that's something that, that I see and definitely our work to achieve in my personal practice as well.

Shireen:  And so, you know, with, with that data, Dr. Kanji, I wonder then why is there so much emphasis to Metformin in that case? Right. If we're looking at the data, lifestyle change is the way to go. Where do you see some of those barriers that, that exist today, whereby it's not all about lifestyle change?

Metformin is still being added as part of that standard of care. Where, where do, why do you think that exists.

Kanji: I think there's a, a few different reasons for this one is lifestyle changes. They can be difficult right. And so taking the time to develop a plan which which can change eating pattern as well as incorporating or changing physical activity.

It's a, it's a difficult, it can be a difficult task. And I think the other issue is a bit more systemic to our healthcare system, which is for the physician on the other end to take the time to go through that is also restrictive in the current healthcare system. So I think there's some of these barriers and oftentimes it can appear that it, it may be easier to give Metformin though

i, I will say, that again, we do have great data for Metformin and for some individuals having the addition of Metformin and, and the way that it works. So for example, by decreasing insulin resistance, it it's an additional tool that can actually facilitate those lifestyle changes. So I certainly agree that I, I think lifestyle find changes are the foundation of treatment.

Those certainly Metformin can be an adjunct. But I, I think those are a few of the challenges that I. When let's say lifestyle changes are are skipped over not given, given enough emphasis.

Shireen:  What would you take? What would you say to someone who's worried about the lifestyle changes that it would take to make an impact?

Kanji:  Absolutely. It can seem intimidating or appear drastic, but I recommend taking it in small steps.  Let's take the diabetes prevention program, physical activity goal, for example. All right. So 150 minutes of brisk walking per week can be quite a change for, for some people. But I, I think these, these small steps so initiating a walk for five to 10 minutes, three times per week, that's a, that's a great start and slowly building on that from.

And I think there are some wonderful resources for people, right? Including Yumlish that support people in their journeys whether it's eating pattern changes, physical activity over time. And I think that over time part is, is key in, in making actual change. 

Shireen:  What is the misconception that people have about the, about prediabetes or even diabetes for that matter?

What would, would you normally end up telling your patients about this? 

Kanji: Absolutely. That's a great question. So one misconception is that prediabetes just refers to a slightly higher than normal blood sugar. And as we discussed before prediabetes, it's a spectrum along with along which there's an increased risk for progression to diabetes, but I think more significantly.

Is that prediabetes is associated with increased risk for the development of cardiovascular disease. Cardiovascular diseases are the leading cause of death globally. And so the diagnosis of prediabetes is actually quite significant and meaningful. And so this is one of the reasons why I discuss reversing prediabetes and ideally preventing prediabetes.

Shireen:  Can you talk a little bit more about that overlap with cardiovascular disease? Seems like they shouldn't have much in common and yet they do. Why do, why does like comorbidity exist? 

Kanji: Yeah, absolutely. I mean, this is this is a pretty, pretty well, I would say, well developed association, right?

Between either prediabetes or more significantly diabetes and cardiovascular disease. We see that there is an there's an increased increased risk. One kind of real world example would be, you know, if, if I'm taking care of an individual with, with diabetes and we're calculating their cardiovascular risk, which is something that,

I like to do, considering that it's the number one cause of death globally. One of the, the questions that we, that we look at is, okay, does this individual have diabetes when calculating a risk. So for example, if you were to look at the American college of cardiology, American heart association, risk calculator, that's one of the questions and someone's risk.

Drastically increases with the presence of that. So certainly that that association is, is, is quite is quite strong. And I think it requires a lot of attention for individuals, either with prediabetes or diabetes for that aspect to be managed in addition to the blood sugar levels. 

And can you help us understand more from the biology side of things.

Shireen:  What does that comorbidity look like? Why, why does it even exist? What, you know, how is it, what is the affiliation there or how are they causal? 

Kanji: Yeah, absolutely. So one one, I think one way to think about it is as we see increased blood glucose circulating. There there's an additional risk for development of inflammation within the vessels as well.

Right. And when you're setting off an inflammatory cascade in a, in a blood vessel that can over time can lead to the development of atherosclerosis. Or another way of saying is the buildup of this plaque that's actually occurring within the vessel, but could could be leading to that vessel being more and more narrowed and eventually leading to an event, right?

Whether it's a blood vessel in the heart, such as a heart attack or a blood vessel in the brain leading to a stroke or minis stroke. So that kind of in inflammatory aspect affecting the vessels is, is I would say one piece to, to keep in mind. 

Shireen:  You know, one of the things Dr. Kanji, you, you mentioned earlier is, is, you know, being able to talk to patients and you know, sort of drive that whole thing to say that lifestyle change is important.

How do you go about doing that? How do you do that and understanding where the patients are, if they're ready to make a change or not? You know, sometimes it's even, like you mentioned, it's just easier to sometimes just here's medication, figure it out. Right. How do you sort of balance that with your patients?

Kanji:  So I, I think the, the words that you used are those they're, they're very significant, right? You mentioned really key points. The first is where is someone right. Meeting them where they are. So every, every individual is kind of in a, in a different point in their life. And that includes regarding eating pattern and physical activity.

So I think meeting someone where they are and understanding where that point is is, is the first step. Certainly. And then the second also, which you mentioned is desire for change. Not everyone may be at that point. Some individuals, you know, may be thinking about it or they're actively ready and then looking for that support.

And so I think those two things, although it may it could be said very easily. Those are, those are very, very important aspects. So that's something that I try and incorporate as well. And again, I think the tough thing is these things take time. So taking the time to really get to know someone.

Understand where they are, whether they're looking for change. And then depending on that latter aspect, if they do want to change, then giving them resources that would allow them to do that. And I, again, always emphasize a more gradual approach. I think taking things to the extreme, whether it's eating pattern or physical activity, that sustainability piece is very difficult.

And so I'm always looking for. Strategies or changes that I can make when I'm partnering with the individuals that I take care of that we can make changes that are sustainable over time, that can increase long term success. 

Shireen:  That is interesting. And so with that, we are nearing the end of the episode, Dr. Kanji, in the last few minutes here, can you tell us how our listeners can connect with you and just learn more about your work.

Kanji: Absolutely so they can connect with me at my website ethos, endo.com. They can also connect with me on LinkedIn. You can find our practice ethos endocrinology on Facebook at ethos endo.

Hopefully all of those are are easy enough to find. 

Shireen:  Absolutely. And we'll link all of those in the show notes then folks can quickly direct over and find find those pages. And so with the Dr. Kanji, thank you so very much for your time. This was a very interesting conversation, you know, I always find it interesting because there's so much work to be done from when someone is diagnosed with something like prediabetes or diabetes.

It's a, it's a life change event because there's so many, like you mentioned, there's core morbidity impact. There's a lot that you can do that is in your control. There's also things that are not so much in your control and trying to balance all of that. And meanwhile, life is also going on and you have to do everything that you do every day.

And so there's, there's a lot to do there, but this is a very interesting conversation. I wanna thank you so much for your time. And to our listeners out there listening, head over to our Facebook, head over to our Instagram and answer this quick question. How does diabetes impact you and your family?

So head over to our Instagram, our Facebook, you can find us at Yumlish on Facebook and at Yumlish_ on Instagram, head over there. Find this podcast post, let's keep the conversation going over there. And with that again, Dr. Kanji, thank you so very much for your time.

Kanji: Thank you. It was, it was a pleasure being here.

Shireen: Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media @Yumlish_ on Instagram and Twitter and @Yumlish on Facebook and LinkedIn. For tips about managing your diabetes and other chronic conditions and to chat and connect with us about your journey and perspectives. You can also visit our website Yumlish.com for more recipes advice and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week's show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we'll see you next time. Remember your health always comes first. Stay well.

Connect with Yumlish!

Website

Instagram

Twitter

Facebook

LinkedIn

YouTube

Connect with Aleem!

Website

Instagram

Facebook

LinkedIn