A conversation between Dr Sheela Nambiar, MD Obgyn (SN) &
Dr Jayshree Gopal Endocrinologist (JG)
Date – 1/6/19 at the TFL Fitness Studio, Chennai
SN – A big warm welcome to Dr Jayashree Gopal, Senior consultant in Diabetes and Endocrinology at Apollo hospitals, and Seethapathi Clinic. Founder of DiabIndia and recipient of many, many awards. She’s also a very dear friend from way back in medical college and we’ve known each other for over thirty years now!! For those of you who don’t know her, I am really glad you came today because her knowledge & the understanding of diabetes as a disease as well as well as its progression is so well-rounded that I hope we can have an interesting discussion.
One of the reasons I chose Diabetes is, as we all may be aware, we in India have the proud privilege of being the Diabetic capital of the world!!
So my first question is to you Jayshree is, why is our country in such a position today?
JG –That’s actually a fascinating question. A lot of people have propounded theories why so many Indians are at risk of being diabetic.
There are 3 main reasons –
One – our carb intake. We eat a lot of carbs and are unable to burn off the carbs we eat.
Two – we have less muscle mass than the Caucasians.
Three – it is also believed that we inherently also have less pancreatic insulin secreting cells, that is the beta cells.
So it is a combination of genetic factors and the food that we eat.
SN– When you say ‘Carbs’, you mean the bread/cerea/ grain group that is the rice, rotis, poha etc.? Just to be clear, since vegetables also contain mainly carbs.
JG – Yes. A typical Indian diet is about 80 to 90% carbs. Every time we eat carbs, our insulin level tends to spike. Not so much with proteins. There is also some difference between animal protein and vegetable protein like lentils which make your body produce little more insulin. With animal protein like eggs, fish & chicken, the insulin spike is slightly less.
If you load your body, with easily digestible carbs like rice without enough fibre or protein to compensate for it from a very young age, you tire the working of the the beta cells. By the time you discover you have diabetes, you have lost 50% of the pancreatic function. The pancreas has been overworked for years. If your fasting blood sugar crosses100, you are already compromised.
Question from audience –So it has been proven that carb overload is affects your pancreas?
Question from audience – Why are we then not changing our dietary pattern?
SN –It is a very difficult (but not impossible) to change something so deeply ingrained and cultural. If you look at the whole of India, our main food is a carbohydrate, usually reifned.
JG – Thats a good question!!If you can go off carbs, that would be wonderful. I myself have been trying to go low carb for a while. The worst diet to try low carb is a south Indian diet. If you go sit in woodlands for breakfast, you realise that other than the chutney, everything else is high in carbs, be it the dosa, idli or pongal!
The usual question is, we have been eating like this for so many years, how is it that we have changed? If you look at a person working in a construction site they dont have any fat on them, yet they eat a carb rich diet. So physical activity is important. In studies done with people on a low carb diet, those who want to include carb, understand when to include it. They include it just before or after an intense work out. In other words, if you are going for a carb heavy meal, make sure you burn it off.
SN – So you were talking about the Indian pheno type, wherein we Indians are inherently born with less muscle mass. Since that’s the problem, do you think even the way we exercise is really not apt for our body, because most people do a lot of cardio and very few actually train with weights to increase muscle mass. The objective should ideally be to increase the muscle mass as that’s where the problem lies. So, would you say the very approach to exercise could be the reason for this problem?
JG – I think you are the right person to answer your own question!
SN – I think it is, isn’t it?
JG – In fact I will be interested to know what you do in your out-patient clinic. You get women from a wide spectrum of society to exercise in your practice.
SN –Yes I do insist on weight training even for women who are from backgrounds that are not traditionally used to the concept of weight training.
JG – How do you do that?
SN – We start with own-body-weight training and then progress. The interesting thing is, once they start to appreciate the strength of their own body, they are happy to include external weights. Regarding their diet, they are also able to change from the mainly high refined carb diet to a diet rich in vegetables, (which are also carbs but water based like gourds etc). I manage my Gestational Diabeteics with just diet and exercise.
Do you think Diabetes is reversible?
JG – I think it depends if you pick it up early enough! Like I said, by the time diabetes is actually diagnosed, fasting sugars are at 140mm/dl -150mm/dl and Post prandial is over 200mm/dl. By then you have already lost a chunk of your pancreas.
When I say lost, I mean, its just not working and how much of it is reversible varies between individuals. Studies have shown that a person with good insulin sensitivity would probably have a fasting sugar of 80/85mg/dl. 100mg/dl is just a arbitrary number for us. Anything over 100 is impaired fasting glucose. Warning bells go off for me when the levels reach 95mg/dl.
SN – What is the current upper limit for postprandial sugars?
JG – 140mm/dl 2 hours after the start of a meal is ideal. When you start eating, the body starts to make insulin. Ideally the lower the post-prandial, the better. You may have noticed that when you have only protein, lets say an omelette, your PP does not rise above 90mm/dl. If you have even one idli or one slice of bread, it can shoot up to 160 or 170mg/dl depending on your insulin sensitivity.
SN – Besides the food and exercise, what are other factors to consider? Can high stress levels trigger diabetes?
JG – Stress, I think acts in a more indirect way. When you don’t have time to eat right or don’t make the effort to exercise it has an impact on your lifestyle. In that way, stress cn lead to diabetes.
SN – How about the abundant intake of sweets? Is that also directly related to the development of diabetes?
JG – It’s not only the glucose in sweets but ultimately all the carbs. Carbs in any form whether as sugar, rice ragi, oats; even millets that are very popular these days! The main difference with the millets is their glycemic index. GI or Glycemic index is the level to which your blood sugar rises after you eat something. Pure sugar is considered to have a GI of 100. Compared to that plain, white, polished rice would have GI of 95 depending on studies. So it’s almost equal to sugar. Something like red rice or hand pounded rice would have a GI of about 70. I think initially when you are trying to control blood sugars, GI does make a difference, but ultimately it all comes to the carb content
When people eat high carb meals, the sugar levels rise and drop very quickly. This is a very common complaint, (particularly among women). Around 11am, or 2 hours after breakfast, their sugar levels drop, they feel they’re getting into “low sugar” as they call it. They start sweating, get palpitations, just don’t feel well and have sit down for a while. This is to do with the rapid drop in sugar following their very high carb breakfast.
Question from audience – Are carbs necessary?
JG – We don’t need it at all.
Question from audience – So what should we should eat when you have a carb craving?
SN – ‘Craving’ for a particular food is more indicative of an ‘addiction’ to that food. Please remember that carbs can be very addictive. Sugar, affects the same parts of the brain as cocaine and heroin.
Comment from audience – But I need to have my sweet after my meal.
SN – So, would you consider that an addiction?
Comment from audience – It makes me feel good and I believe my body really needs it.
SN – Yes, you could interpret it that way. That’s what an addiction is! In a sense you are saying it makes you emotionally comfortable but from a physiological perspective, you don’t ‘need’ it.
JG – You really don’t need it. From a health perspective nothing is going to happen if you don’t eat it.
It is interesting to see how we used to eat 50 to100 years ago. We ate differently, just twice a day. I think that has changed. To answer your question about why diabetes is more common, we are eating 3 to 4 times a day now!
There are other things to consider – Changes occur in our body when it starts to get dark outside. We should try and eat before the sun sets. Now we have artificial light and we tend to eat later and later. Studies have shown that artificial light at night, especially for women, causes more weight gain. Studies on the Eskimo population and light at night indicates that it is one of the reasons for increas in breast cancer.
SN – Speaking of our ancestors, our lives are very different from what theirs used to be. We don’t work like them, our stress levels are different. Like Jayshree said, artificial lighting, our computers, our sleep time, the stressors we have….. everything is different. We need to adapt to our lives today in positive way by eating less refined foods, moving more and so on! What we do however is adapt in the worst possible way by responding to stress with sugary, refined foods for instance.
Jayshree, what do you think about the fad of eating several frequent meals, or snacking every 2 hours?
JG – I think that was the worst fad to come about because every time you eat, you produce Insulin. Insulin is an anabolic hormone. It makes your body store fat. Infact, it is a fascinating hormone because there is no other hormone like insulin. All other hormones are counter regulatory to insulin. One of the reasons a low carb, high protein, keto/ paleo kind of diet works is, your body is not constantly producing insulin. Coming to the question of eating 6 times a day, that’s absolutely the worst thing.
SN – I would also add that there is another drawback to eating frequently – when you eat so often, you stop recognising signals of real hunger. To begin with, right from the time when we were children the hunger instinct is blunted when adults load the plate of the child and force-feed it. Your ability to recognise real hunger is being compromised to the extent you don’t recognise it. You eat a meal because it is 1pm or you perhaps your fear not being able to get food later! We don’t listen to our bodies neither are we mindful of our bodies.
Question from audience – What if you really can’t get food when you are hungry?
SN – The body can use fat as fuel. When you are hungry and there is no glucose available for energy, your body can use fat as fuel and we have lot of it! You don’t have to be worried that your body will completely disintegrate just because you haven’t eaten a meal. In fact it’s a good thing to be hungry sometimes because then, it can tap into your fat stores.
JG – Most of the glucose in our body is stored as something called glygogen, present in the liver and muscle. If you don’t eat all, it takes about 36 hours for your body to get rid of all the glycogen from the liver.
One of the reasons why carbs is preferred as a source of fuel is that it is very easy to digest. If you look at the bio chemistry of it, it takes very few steps to digest the carb and get the energy out. The body has to work harder to digest fat. That is why we store the fat and use it only when needed.
So when people do a low carb diet like keto/ paleo or other versions of it, it takes about 2 weeks, or 10 days to switch from a carb metabolizing physiology to a fat burning one or what we call ketosis where the body is breaking down fat.
Initially people describe the keto flu that you go through where you get muscle aches and pains. Some people find a change in bowel habits and suffer constipation when they switch to a keto diet.
Question from audience – Is it good to stop your carbs completely and have only protein and fat?
JG – I think it depends on what you are trying to achieve.
SN – Is that sustainable is another pertinent question?
JG – For about 2 years now we have been running a low carb clinic. I have been looking at people, even those with diabetes attempting it. I have been encouraging even long standing diabetic to try.
An average Indian diet has about 300 to 350 gms of carb/day. Even if you reduce this by 50%, the sugar levels improve. If you want to actually lose weight, then you will have to go further down. We have estimated you can easily cut it down to 50/70 gms carbs in a south indian diet and maintain it there.
Question from audience – Will your body go into keto-acetosis when you eat a keto diet?
JG – You only go into ketosis. The acid levels do not build up. Acid levels will build up if you have diabetes type 1 that is insulin dependent, where your body doesn’t make insulin. When you go into ketosis however, the ketone levels not the acids, build up. So they are 2 separate things, ketoacidosis and ketosis
Question from audience – What about carb loading for workign out?
SN – Carb loading is a complete myth
JG – What do they do?
SN – This was practiced for long duration endurance sports like marathons. The night before the event, you would carb load, (eat a lot of pasta and the like). Your liver then stores the glycogen. It was believed that glycogen store was required for a long duration sport like a marathon. Prof Tim Noakes who wrote “Lore of running” actually talks about carb loading in the first edition of his book. He was a marathon runner and then became diabetic (for which he blames all the carb loading!). He then went on to revise his advise in the book. He has now gone completely low carb/ hi fat.
So this concept of low carb – how do we do this in the Indian setting, especially if you don’t eat meat?
JG – Keto is when you are restricting your carbs to less than 20 gms a day and for people who are not familiar, one idli has 15 gms of carb. One cup of rice is about 40 to 50 gms depending on the size of the cup, one chapati has15 gms, one dosa -15 gms. Lentils also have carbs. Even almonds and peanuts have carbs. If you are able to achieve 70 gms a day, you can find significant improvement in sugar. You will definitely lose weight but more slowly.
I don’t subscribe to the high fat. I don’t agree to it or recommend it. I don’t think it is right at all. One thing I would say however is, when following a low carb, do not be afraid of fat. I have learnt that often, the craving is not for carb but for fat. It’s very counter intuitive but if at the time of a craving, you have a spoon of almond butter or peanut butter, your craving goes away.
Fat however causes problem when you combine it with carbs. So you have to be very strict about the low carb part of it before you start increasing the fat in your diet.
SN – What about refined seed oils (sunflower and so on)?
JG – Avoid refined oils. There is a community out there debating the usefulness of nut oil vs seed oil. They think seed oil is responsible for all our ills and nut oil is ok. Coconut is ok.
Question from audience – My daughter in law is diabetic. Now she has cut down her food and trains to lose weight.
SN – The weight loss in itself is beneficial for diabetes. A 10 kilo weight loss can lead to the reversal of many of the problems of diabetes depending on how bad they are. Just managing the sugar and staying overweight is not good enough.
JG – the UK has taken it up in a big way. The diabetes association in UK is doing a lot of work in reversal of diabetes. They did a big study and showed that you can reverse and cure idiabetes. They followed up diabetics for 6 months to one year. If you go back to eating the carbs and regaining the weight, the diabetes comes back. If you manage to keep the carbs low and exercise regularly, you are free of the disease. So they actually call that state “post diabetes”.
Question from audience – We have been told that eating whole wheat bread instead of eating white bread makes a difference. Is that true?
SN – Wheat itself may be an issue for many people. You could be allergic to gluten, so if you have a gluten allergy, it is better to avoid it completely. Having said that, both whole wheat and white bread are high in carbs. They belong to the same bread/ cereal/grain group. You still need to restrict that and I have my own suspicion about it being ‘whole wheat’ when made commercially. More like just coloured bread.
JG – Exactly! I don’t think it makes a difference. Both are bad. The glycemic index is probable less with red rice and something like hand pound rice. It’s to do with the fibre content. So eating whole wheat bead is not the answer.
SN – If there are no other questions, we will wind up here. Thank you so very much Jayshree for this very interesting conversation and for giving us your valuable time to chat about this extremely important subject! Thank you all for coming, We will continue to have more such Conversations.