Latest / Clearly Hormonal / Type 2 Diabetes Isn't a Moral Failing: Genetics, Hormones, Stigma, and the Truth About Insulin

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Type 2 Diabetes Isn't a Moral Failing: Genetics, Hormones, Stigma, and the Truth About Insulin · Clearly Hormonal

• 0:00
  Dr. Komal Patil-Sisodia: Welcome to Clearly Hormonal, the podcast where we stop googling our symptoms at midnight and actually start understanding what's going on in our bodies.
• 0:08
  Dr. Komal Patil-Sisodia: I'm Dr.
• 0:09
  Dr. Komal Patil-Sisodia: Komal Patil-Sisodia, an endocrinologist, internist, obesity medicine specialist, and a Menopause Society certified practitioner, which is really just a whole lot of words to say hormones are kind of my jam.
• 0:20
  Dr. Komal Patil-Sisodia: I've spent 17 years watching women try to navigate their hormonal health without ever having been taught the language for what's happening in their own bodies, and then meeting clinicians who want nothing more than to help them figure it out, but are up against 10-minute appointments and a system that just wasn't built for it.
• 0:36
  Dr. Komal Patil-Sisodia: This podcast is my answer to that gap.
• 0:39
  Dr. Komal Patil-Sisodia: We'll cover menopause, metabolism, hormones, and everything in between with real evidence, not trends, and without the overwhelm.
• 0:47
  Dr. Komal Patil-Sisodia: A quick disclaimer.
• 0:48
  Dr. Komal Patil-Sisodia: I'm a physician, but this is education, not personalized medical advice.
• 0:52
  Dr. Komal Patil-Sisodia: Take what resonates and discuss it with your own healthcare team.
• 0:55
  Dr. Komal Patil-Sisodia: Now, let's get into it and talk about what's clearly hormonal and what's not.
• 1:01
  Dr. Komal Patil-Sisodia: This episode is really personal for me.
• 1:03
  Dr. Komal Patil-Sisodia: I've been treating diabetes for 17 years, and I have family members who live with it.
• 1:09
  Dr. Komal Patil-Sisodia: I'm at risk for it, given my family history.
• 1:12
  Dr. Komal Patil-Sisodia: And the story we tell about type 2 diabetes, that it's caused by bad choices, that it's reversible if you just try hard enough, that needing insulin means you failed, is not just scientifically inaccurate, it has a lot of consequences for patients who hear that messaging.
• 1:34
  Dr. Komal Patil-Sisodia: It delays care.
• 1:36
  Dr. Komal Patil-Sisodia: It causes shame.
• 1:37
  Dr. Komal Patil-Sisodia: It keeps people from the medications that they need.
• 1:41
  Dr. Komal Patil-Sisodia: And the point of this episode is to take that story apart piece by piece with the data to back it up.
• 1:48
  Dr. Komal Patil-Sisodia: The biggest Myth that I see about type 2 diabetes is that it's a lifestyle disease, that you caused it, you can reverse it, and if you need insulin, well, you really let things get out of hand.
• 2:01
  Dr. Komal Patil-Sisodia: And I'm here to tell you that that is a bunch of BS.
• 2:04
  Dr. Komal Patil-Sisodia: There are real numbers to back up the harm that happens when we push these narratives about type two diabetes.
• 2:11
  Dr. Komal Patil-Sisodia: Fifty-two percent of people with type two diabetes report experiencing stigma related to their disease.
• 2:18
  Dr. Komal Patil-Sisodia: And it's not just uncomfortable, it's actually associated with worse hemoglobin A1Cs, higher rates of depression, and being less engaged in their own care.
• 2:28
  Dr. Komal Patil-Sisodia: They're less motivated to take care of themselves because of all of this stuff that they're hearing.
• 2:33
  Dr. Komal Patil-Sisodia: People who are afraid of insulin actually delay starting it by an average of three years after their A1C has gone high, despite being on all of the oral meds and maybe GLP-1s.
• 2:48
  Dr. Komal Patil-Sisodia: Three years.
• 2:49
  Dr. Komal Patil-Sisodia: And during that time, all of the complications they're afraid of, are being created by the uncontrolled blood sugars.
• 2:58
  Dr. Komal Patil-Sisodia: Additionally, 64% of patients believe that they can feel when their blood sugar is high.
• 3:03
  Dr. Komal Patil-Sisodia: Most of the time, they can't, and that is why we call diabetes the silent killer because you don't feel it until things get really bad, and it can take several years for complications of diabetes to develop.
• 3:18
  Dr. Komal Patil-Sisodia: So I want to set the scene for you all.
• 3:20
  Dr. Komal Patil-Sisodia: Imagine a woman who has done everything right.
• 3:23
  Dr. Komal Patil-Sisodia: She walks every day.
• 3:25
  Dr. Komal Patil-Sisodia: She started cutting carbs when she noticed her blood sugars were going up.
• 3:29
  Dr. Komal Patil-Sisodia: She's lost thirty pounds.
• 3:31
  Dr. Komal Patil-Sisodia: Her hemoglobin A1C came down.
• 3:34
  Dr. Komal Patil-Sisodia: And for a while, things were better, but then life happened.
• 3:37
  Dr. Komal Patil-Sisodia: There was a brutal year at work, less sleep, more stress.
• 3:42
  Dr. Komal Patil-Sisodia: And then out of nowhere, perimenopause comes in, which, as I'll explain in a few minutes, is not just a small hormonal blip.
• 3:51
  Dr. Komal Patil-Sisodia: The patient's A1C actually starts climbing again.
• 3:54
  Dr. Komal Patil-Sisodia: And when she saw her new doctor, the first thing out of his mouth was,"What happened?
• 3:58
  Dr. Komal Patil-Sisodia: Did you stop trying?" She hadn't stopped trying.
• 4:01
  Dr. Komal Patil-Sisodia: She's been trying for more than fifteen years.
• 4:05
  Dr. Komal Patil-Sisodia: But she sits in that exam room and thinks,"Gosh, maybe he's right.
• 4:09
  Dr. Komal Patil-Sisodia: Maybe this is my fault." It's not, and today we're going to talk about why.
• 4:15
  Dr. Komal Patil-Sisodia: Let's talk a bit about what type 2 diabetes actually is, because I think most people have been given a very incomplete picture.
• 4:23
  Dr. Komal Patil-Sisodia: It's a complex, progressive metabolic disease, and two things are happening at once.
• 4:28
  Dr. Komal Patil-Sisodia: Number one, your cells are becoming resistant to insulin, and that means that they need more insulin to do the job that they would normally do.
• 4:39
  Dr. Komal Patil-Sisodia: Your beta cells in your pancreas, the cells that produce insulin, start to decline and die.
• 4:47
  Dr. Komal Patil-Sisodia: That beta cell loss starts around the time of diagnosis and continues over time.
• 4:52
  Dr. Komal Patil-Sisodia: It's not something lifestyle alone can stop because it's not something that lifestyle choices were the only cause for.
• 5:00
  Dr. Komal Patil-Sisodia: Genetics plays a big role in type 2 diabetes risk.
• 5:05
  Dr. Komal Patil-Sisodia: It's estimated that forty to eighty percent of your type 2 diabetes risk is actually from your genetics.
• 5:12
  Dr. Komal Patil-Sisodia: Scientists have identified over four hundred locations in the genes that are associated with diabetes.
• 5:20
  Dr. Komal Patil-Sisodia: That is not a small number.
• 5:22
  Dr. Komal Patil-Sisodia: That's a disease that has deep biological roots that we've decided as a culture is a personal failing, and that's wrong.
• 5:31
  Dr. Komal Patil-Sisodia: There are also hormonal and lifestyle factors that never really get discussed, especially with women.
• 5:37
  Dr. Komal Patil-Sisodia: Estrogen is what we call an insulin sensitizer.
• 5:40
  Dr. Komal Patil-Sisodia: It makes your body more sensitive to insulin.
• 5:42
  Dr. Komal Patil-Sisodia: And when women hit perimenopause and estrogen drops, the insulin resistance gets worse.
• 5:48
  Dr. Komal Patil-Sisodia: And in women who were previously able to compensate and doing fine, this can be the thing that tips the balance.
• 5:56
  Dr. Komal Patil-Sisodia: That's not a failure of willpower.
• 5:57
  Dr. Komal Patil-Sisodia: That is a shift in your physiology that is not your fault.
• 6:03
  Dr. Komal Patil-Sisodia: Another hormone that's a big contributor is cortisol.
• 6:06
  Dr. Komal Patil-Sisodia: Chronic stress raises cortisol, and I think it's safe to say that we currently live in a society that is chronically stressed all the time, and we are on all the time because of our jobs, because of our responsibilities to friends and family, due to technology, because it's everywhere and it keeps us plugged in all the time.
• 6:28
  Dr. Komal Patil-Sisodia: When cortisol goes up, it raises your blood glucose, and it promotes the buildup of visceral fat, which is the fat that is around your abdomen and actually inside your abdominal cavity.
• 6:41
  Dr. Komal Patil-Sisodia: And telling a chronically stressed-out woman to exercise more is not a treatment plan Next on the list is sleep.
• 6:49
  Dr. Komal Patil-Sisodia: One night of partial sleep deprivation can cause insulin resistance equivalent to eating a high-fat diet for six months.
• 7:01
  Dr. Komal Patil-Sisodia: Let me say that again.
• 7:02
  Dr. Komal Patil-Sisodia: One night of partial sleep deprivation can cause insulin resistance that's equivalent to six months of eating a high-fat diet.
• 7:13
  Dr. Komal Patil-Sisodia: Sleep is really important in maintaining your metabolism.
• 7:17
  Dr. Komal Patil-Sisodia: It's metabolic medicine, and we absolutely don't treat it that way.
• 7:21
  Dr. Komal Patil-Sisodia: Sleep becomes something that we're proud to say that we're lasting on, four to five to six hours of sleep a night, when in reality, we probably all need between seven to nine hours to keep our metabolisms healthy.
• 7:35
  Dr. Komal Patil-Sisodia: And finally, we have PMOS, previously known as PCOS.
• 7:41
  Dr. Komal Patil-Sisodia: Eight to 13% of women of reproductive age have polyendocrine metabolic ovarian syndrome, and insulin resistance is a key part of PMOS.
• 7:52
  Dr. Komal Patil-Sisodia: these women are biologically predisposed to developing type 2 diabetes.
• 7:59
  Dr. Komal Patil-Sisodia: The risk of type 2 diabetes in these women is three to four times that of the average population before they even make a single dietary choice And that is a really tough thing to deal with because the same lifestyle advice that would work for somebody who does not have PMOS is not going to work for somebody with PMOS And these four things don't even cover the number of medications that can contribute to insulin resistance, and I think this doesn't get talked about enough.
• 8:31
  Dr. Komal Patil-Sisodia: Steroids, atypical antipsychotics, certain HIV medications, certain medications that suppress your immune system, all of these can cause or worsen diabetes.
• 8:43
  Dr. Komal Patil-Sisodia: That is a side effect of medications, but the story we tell about it is all the same.
• 8:48
  Dr. Komal Patil-Sisodia: "Oh, this person just didn't take care of themselves." A quick note before we go any further in this episode, I'm talking only about type 2 diabetes today.
• 8:57
  Dr. Komal Patil-Sisodia: Type 1 diabetes is a separate disease.
• 8:59
  Dr. Komal Patil-Sisodia: It's autoimmune.
• 9:00
  Dr. Komal Patil-Sisodia: It's not caused by lifestyle or weight, and it deserves its own episode, which it's getting.
• 9:05
  Dr. Komal Patil-Sisodia: But I want to point that out now because making them seem equivalent causes a real harm in both directions.
• 9:15
  Dr. Komal Patil-Sisodia: Now let's go back to the numbers I was talking about at the start of the episode, because when we talk about diabetes myths, it can sound a little abstract, like we're correcting misinformation in some theoretical sense.
• 9:28
  Dr. Komal Patil-Sisodia: But these are actually documented, studied beliefs that are held by real patients and can have a tremendous impact on their outcomes and how they're able to manage their diabetes and manage their health.
• 9:41
  Dr. Komal Patil-Sisodia: 64% of patients with Type 2 diabetes believe that they can always tell when their blood sugar is high.
• 9:47
  Dr. Komal Patil-Sisodia: The reality is that high blood sugars, unlike low blood sugars, typically come without any early warning symptoms.
• 9:55
  Dr. Komal Patil-Sisodia: They're quiet, they're insidious, and relying on how you feel instead of a monitor is genuinely dangerous.
• 10:02
  Dr. Komal Patil-Sisodia: A lot of my patients will start to feel thirsty.
• 10:05
  Dr. Komal Patil-Sisodia: They may feel more tired than usual.
• 10:07
  Dr. Komal Patil-Sisodia: They may have some mild numbness, tingling in their feet, but outside of that, they're actually able to go on with their lives.
• 10:14
  Dr. Komal Patil-Sisodia: For years, my dad felt like he could feel his blood sugars, and he didn't like using a glucometer.
• 10:21
  Dr. Komal Patil-Sisodia: He didn't like checking his blood sugars because poking his fingers hurt, and I get that.
• 10:27
  Dr. Komal Patil-Sisodia: It is not a comfortable thing to do, and I've tried all the monitors and all the different techniques to see what makes it hurt less so I can counsel my patients better.
• 10:36
  Dr. Komal Patil-Sisodia: And at the end of the day, it just kinda hurts.
• 10:38
  Dr. Komal Patil-Sisodia: So there are a lot of people who will shy away, either because they're needle-phobic, or they don't want to do it, or they're afraid of the pain, and it just seems like a hassle, and my dad fell into that category.
• 10:49
  Dr. Komal Patil-Sisodia: A few years ago, he was letting me take a look at his labs, and his A1C was not at a level that I thought was good for him.
• 11:00
  Dr. Komal Patil-Sisodia: We had a discussion about why he wasn't using his glucometer, and he told me,"I just-- I can feel when I'm high." So I bet my dad that if I put him on a continuous glucose monitor, he would not be able to tell when his blood sugars were high and that he wouldn't be able to correlate those symptoms.
• 11:17
  Dr. Komal Patil-Sisodia: Now, continuous glucose monitors, in my opinion, should be the standard of care for all diabetes patients.
• 11:23
  Dr. Komal Patil-Sisodia: The sensor sites are great now, and they'll last anywhere from 10 to 15 days, depending on the continuous glucose monitor that you're using.
• 11:32
  Dr. Komal Patil-Sisodia: They give real-time data about how your body is reacting to the food that you're eating, the stress that you're under, the exercise that you're doing in order to keep yourself healthy.
• 11:43
  Dr. Komal Patil-Sisodia: And I find that a lot of patients will automatically take that information, and start adjusting their diet and their activity to make sure that their blood sugars are staying within a certain range.
• 11:57
  Dr. Komal Patil-Sisodia: And my dad was no different.
• 11:59
  Dr. Komal Patil-Sisodia: Once he started wearing the continuous glucose monitor and he saw how certain foods impacted his blood sugars in certain ways, things that he did not believe were high in carbs or could have that type of an impact, it was really eye-opening for him.
• 12:13
  Dr. Komal Patil-Sisodia: And he was able to make diet changes and lifestyle changes just by watching his data on this continuous glucose monitor and bring his A1C down into a really good control range.
• 12:26
  Dr. Komal Patil-Sisodia: I'm really proud of him because I think that it takes a lot for somebody to embrace that process, especially when they've believed something else for the entire duration of their disease.
• 12:39
  Dr. Komal Patil-Sisodia: I see this often with patients.
• 12:40
  Dr. Komal Patil-Sisodia: I think it's very important to keep reiterating, you cannot feel when your blood sugars are high.
• 12:47
  Dr. Komal Patil-Sisodia: The next stat that I think is really interesting is that 52% of patients believe that insulin causes kidney damage and leads to dialysis.
• 12:56
  Dr. Komal Patil-Sisodia: Another 35% of patients believe that insulin causes blindness, amputations, heart attacks, and again, these are all complications of having very high blood sugars for a long period of time, which is really what insulin treats.
• 13:12
  Dr. Komal Patil-Sisodia: I want to sit with that for a second.
• 13:14
  Dr. Komal Patil-Sisodia: It always takes me back to my time at LA County Hospital when I was doing my residency and fellowship, and we had a high-risk diabetes clinic that we would attend to when we were fellows.
• 13:27
  Dr. Komal Patil-Sisodia: And these were patients who did not have a ton of resources, who had a lot of insulin resistance, who were trying to control their diabetes, but were sometimes on, like, three, four, five hundred units of insulin a day.
• 13:41
  Dr. Komal Patil-Sisodia: And actually getting people to take the insulin was the biggest challenge.
• 13:46
  Dr. Komal Patil-Sisodia: There would be people coming into the clinic who were not willing to start insulin at all because they had seen their grandparents or their aunts or uncles or parents pass from complications of diabetes as soon as they started insulin.
• 14:02
  Dr. Komal Patil-Sisodia: And that can happen if the insulin is started too late.
• 14:07
  Dr. Komal Patil-Sisodia: So think back to the beginning of the episode when I said that complications can take a long time to develop.
• 14:13
  Dr. Komal Patil-Sisodia: For a lot of patients with type 2 diabetes that is not well controlled, it can take up to a decade for a complication to appear.
• 14:20
  Dr. Komal Patil-Sisodia: So if the blood sugars are high, blood sugars are high, blood sugars are high, and then finally you meet a doctor who says,"No, you gotta start on insulin," but you're, like, at that 10-year mark of having had diabetes and you haven't done anything else to control it, it's that 10 years of not being controlled that's going to cause the complications, but it's really easy to draw that association with insulin that's being started at a critical point and say,"The complications are because of the insulin." And that is something that unfortunately there's been, a very deep belief system that has stuck around that concept for a long time.
• 14:56
  Dr. Komal Patil-Sisodia: And because of that, people are getting sick because they're trying to protect themselves from insulin, when it's really probably the best choice for treatment at that point.
• 15:07
  Dr. Komal Patil-Sisodia: Another forty-eight percent of patients believe that a vegetarian diet will control their blood sugar, and there's no consistent evidence that vegetarianism alone will actually improve glycemic control.
• 15:18
  Dr. Komal Patil-Sisodia: And an imbalanced plant-based diet can actually make things worse.
• 15:23
  Dr. Komal Patil-Sisodia: I have met people who are vegetarians who tell me they don't like vegetables, and when we take a hard look at their diet, there is a lot of carbohydrate consumption and not a lot of fiber.
• 15:35
  Dr. Komal Patil-Sisodia: Thirty-five percent of patients believe that only sugar raises blood sugar, so avoiding sweet things is enough.
• 15:42
  Dr. Komal Patil-Sisodia: But all carbohydrates affect blood sugar, so grains, starches, fruit, all of it.
• 15:48
  Dr. Komal Patil-Sisodia: The number of people that I have talked to about their potato chip habit and them telling me it's salty, not sweet, it's such an eye-opener for them when we have a conversation around what those chips are actually made of and how they contribute to higher blood sugars.
• 16:04
  Dr. Komal Patil-Sisodia: This misconception affects how people make decisions all day, every day, and that can be a really dangerous thing as well.
• 16:12
  Dr. Komal Patil-Sisodia: And here's what the research shows.
• 16:14
  Dr. Komal Patil-Sisodia: The diabetes stigma that people feel and face when they're in a doctor's office or even just out in society will correlate with higher rates of depression, higher diabetes distress, and less self-care.
• 16:28
  Dr. Komal Patil-Sisodia: People who are internalizing shame are more likely to skip appointments, avoid screening, and disengage from their own management, and the shame itself becomes a clinical problem.
• 16:40
  Dr. Komal Patil-Sisodia: I've seen this time and again with my patients.
• 16:43
  Dr. Komal Patil-Sisodia: When I first started seeing some of my patients, a few of them said to me when they would come in for their visits,"Oh, my gosh, you're going to yell at me today." And if you know me at all, I'm not a yeller.
• 16:53
  Dr. Komal Patil-Sisodia: I don't believe that that actually helps them do better in terms of their health.
• 16:58
  Dr. Komal Patil-Sisodia: But they'd had such bad experiences in their prior appointments around their diabetes, around their insulin resistance and their habits, they were just, like, bracing for the next hit or the next tongue-lashing from the next healthcare provider that saw them, and that made me really sad for them.
• 17:17
  Dr. Komal Patil-Sisodia: It is really important to create a supportive setting for patients to be able to talk about the different things that are going on in their lives, because every little thing plays into how your diabetes is being controlled.
• 17:32
  Dr. Komal Patil-Sisodia: Next, I want to touch on the topic of diabetes remission versus reversal.
• 17:37
  Dr. Komal Patil-Sisodia: There are a lot of people who will be out there touting that you can reverse diabetes or cure your diabetes, and unfortunately, that's not the reality for most people.
• 17:48
  Dr. Komal Patil-Sisodia: I think that it is setting up people for failure and for feeling worse about themselves.
• 17:54
  Dr. Komal Patil-Sisodia: The remission part of it is real.
• 17:56
  Dr. Komal Patil-Sisodia: That means we've got your A1C below six and a half for three months or more without medications through diet changes, lifestyle, improving your sleep, improving your stress.
• 18:08
  Dr. Komal Patil-Sisodia: All of those things can bring diabetes into remission.
• 18:11
  Dr. Komal Patil-Sisodia: And then beyond just the lifestyle measures, there are medications like GLP-1s or bariatric surgery that can help bring A1c to less than six point five.
• 18:22
  Dr. Komal Patil-Sisodia: Here's what the data actually shows, though, about how long that remission can last.
• 18:28
  Dr. Komal Patil-Sisodia: Remission rates of around forty-six percent will drop after one year of being in that remission to about thirty-six percent at two years, and then approximately eight percent at five years.
• 18:42
  Dr. Komal Patil-Sisodia: A lot of patients will have their diabetes worsen, but it's because it's a progressive disease, not always because somebody is doing something wrong.
• 18:52
  Dr. Komal Patil-Sisodia: In fact, the majority of the time people are doing all the right things, and their disease is just progressing.
• 18:58
  Dr. Komal Patil-Sisodia: So that's not failure.
• 19:00
  Dr. Komal Patil-Sisodia: That's the beta cells not working properly anymore.
• 19:03
  Dr. Komal Patil-Sisodia: That's the insulin resistance potentially getting worse.
• 19:06
  Dr. Komal Patil-Sisodia: And beta cells will decline in different rates at different people, so the insulin production you have will change over time.
• 19:15
  Dr. Komal Patil-Sisodia: And I don't like the word reversal, because that implies something went away.
• 19:19
  Dr. Komal Patil-Sisodia: And remission is a little bit more accurate of a term because it acknowledges the underlying biology of diabetes, of the need to still be monitored, of needing ongoing care, and we have to continue to push that message.
• 19:38
  Dr. Komal Patil-Sisodia: Controlling diabetes is a lifelong effort, but with the right team on your side, the right lifestyle interventions, the right medications, you can actually have a great quality of life and not develop complications.
• 19:51
  Dr. Komal Patil-Sisodia: But not engaging in any of those things or figuring out what plan is best for you is going to put you at higher risk We've talked about all of the beliefs that hold people back, and here's what I think people with diabetes actually deserve.
• 20:05
  Dr. Komal Patil-Sisodia: I've been treating diabetes for seventeen years.
• 20:08
  Dr. Komal Patil-Sisodia: I have family members who have this disease, and the shame that we've embedded into this diagnosis as a society is that, quote,"you did this to yourself" narrative delays care, worsens outcomes, and costs lives.
• 20:21
  Dr. Komal Patil-Sisodia: And I think that's really important for anybody listening to this episode to recognize.
• 20:26
  Dr. Komal Patil-Sisodia: Every person with Type 2 diabetes deserves an explanation of their biology that doesn't put the blame on them.
• 20:35
  Dr. Komal Patil-Sisodia: They deserve an assessment of all the contributing factors, not just what they ate, but whether their hormones are at play, how their genetics are at play, whether their medications are contributing, their sleep, their stress, their socioeconomic circumstances.
• 20:51
  Dr. Komal Patil-Sisodia: And they deserve access to the full range of tools that we have, metformin, GLP-1s, SGLT2 inhibitors, insulin, without first having to prove they tried hard enough with lifestyle.
• 21:03
  Dr. Komal Patil-Sisodia: We don't make people who have high blood pressure earn their medication.
• 21:07
  Dr. Komal Patil-Sisodia: We see high blood pressure, and we say,"Oh, crap, we don't want you to have a heart attack or stroke, so take this medication, and let's work on it in addition to you making some modifications to your lifestyle and cutting down on the salt in your diet and maybe working on your stress." Why do we not do that with people who have diabetes?
• 21:26
  Dr. Komal Patil-Sisodia: One of the things that I saw most frequently when I first started in practice is people would come in to see me, and they'd have hemoglobin A1C levels of eight, and they would tell me,"Oh, I've never been told I have diabetes," or,"I was just told it was borderline." There's nothing borderline about that.
• 21:41
  Dr. Komal Patil-Sisodia: That's an actual diagnosis.
• 21:43
  Dr. Komal Patil-Sisodia: But for some reason, we tiptoe around this with patients with diabetes, and it's not fair.
• 21:49
  Dr. Komal Patil-Sisodia: So they deserve accurate information about insulin, that insulin does not cause complications, that it can actually help prevent complications, that uncontrolled high blood sugars are actually what cause complications, and that's not the same thing.
• 22:04
  Dr. Komal Patil-Sisodia: By not dispelling that myth, we actually do a lot of harm.
• 22:08
  Dr. Komal Patil-Sisodia: The last thing that we need to drive home is that lifestyle does matter.
• 22:12
  Dr. Komal Patil-Sisodia: A lot of people think that,"Oh, it's not going to help me anyway, so why should I bother?" But there's a lot of evidence out there that you need to do all of the things, lifestyle as well as medication, in order to get the best result for your condition, to get the best result for managing diabetes.
• 22:32
  Dr. Komal Patil-Sisodia: Pointing out how it helps is very different than saying it's the only thing that matters, or if it didn't work, it's your fault.
• 22:38
  Dr. Komal Patil-Sisodia: So we need to be really careful about how we put that together for patients And lastly, here's the thing that I think doesn't get said enough in the diabetes conversation with women.
• 22:48
  Dr. Komal Patil-Sisodia: Women in perimenopause and menopause are at a point that standard diabetes care completely ignores.
• 22:55
  Dr. Komal Patil-Sisodia: The hormone shifts in this transition, so the declining estrogen, the sleep disruptions, the rising cortisol from chronic stress, are the same shifts that worsen insulin resistance and accelerate beta cell stress.
• 23:08
  Dr. Komal Patil-Sisodia: And it means that a woman whose A1C is starting to rise in her late forties, who's not necessarily eating differently or moving less, she's going through a hormonal transition that her metabolic system is responding to exactly as it should, and nobody's really connecting those dots.
• 23:27
  Dr. Komal Patil-Sisodia: Women have Been largely excluded from diabetes prevention trials, and hormonal status is not something we've really documented in metabolic workups.
• 23:36
  Dr. Komal Patil-Sisodia: For women, it's really important not just to ask about lifestyle, but also to ask about where are you in your menopausal transition?
• 23:43
  Dr. Komal Patil-Sisodia: What's been happening with your sleep?
• 23:45
  Dr. Komal Patil-Sisodia: Has anybody talked to you about hormone therapy?
• 23:49
  Dr. Komal Patil-Sisodia: I really hope you found this episode helpful today.
• 23:51
  Dr. Komal Patil-Sisodia: And as we close it out, I want to just go over what we talked about over the last 25 minutes.
• 23:57
  Dr. Komal Patil-Sisodia: Type 2 diabetes is not a moral failing.
• 24:01
  Dr. Komal Patil-Sisodia: It's a complex, progressive metabolic disease that has genetic causes, hormonal contributors, and a social narrative that has caused a lot of harm to a lot of patients.
• 24:12
  Dr. Komal Patil-Sisodia: The biology we talked about today, genetics accounting for 40 to 80% of your risk, estrogen as an insulin sensitizer when it drops in perimenopause and worsens insulin resistance, chronic stress raising cortisol, which raises blood sugar, and how one night of poor sleep can do the same thing as the six months of a high-fat diet.
• 24:36
  Dr. Komal Patil-Sisodia: PMOS contributing to insulin resistance far more than any lifestyle factor ever could, and how some medications can simply cause diabetes.
• 24:49
  Dr. Komal Patil-Sisodia: We also talked about beliefs that are keeping people from care.
• 24:52
  Dr. Komal Patil-Sisodia: You can't feel when your blood sugars are high.
• 24:54
  Dr. Komal Patil-Sisodia: Insulin does not cause kidney disease, blindness, amputations.
• 24:59
  Dr. Komal Patil-Sisodia: Uncontrolled blood sugars do cause those things.
• 25:02
  Dr. Komal Patil-Sisodia: Vegetarian diet is not a substitute for diabetes management, and needing insulin is not a failure, it's treatment.
• 25:10
  Dr. Komal Patil-Sisodia: I want to be clear that remission is real, but reversal is not.
• 25:14
  Dr. Komal Patil-Sisodia: The underlying biology does not disappear for anyone, and relapse is not failure, it's disease progression.
• 25:21
  Dr. Komal Patil-Sisodia: And for women who are in midlife specifically, a rising hemoglobin A1c in your late 40s is not automatically about what you're eating.
• 25:29
  Dr. Komal Patil-Sisodia: It could be that you're in your hormone transition that is contributing to this, and those two things need to be evaluated together.
• 25:37
  Dr. Komal Patil-Sisodia: If this episode shifted something for you, share it.
• 25:39
  Dr. Komal Patil-Sisodia: Share it with someone who's been told they caused their diabetes.
• 25:43
  Dr. Komal Patil-Sisodia: Share it with somebody who's afraid to start insulin.
• 25:45
  Dr. Komal Patil-Sisodia: Share it with a clinician who might need to hear it too.
• 25:48
  Dr. Komal Patil-Sisodia: And if you're avoiding treatment or insulin because of what you think it will do, please bring this conversation to your doctor.
• 25:56
  Dr. Komal Patil-Sisodia: Ask about the evidence.
• 25:57
  Dr. Komal Patil-Sisodia: You deserve accurate information.
• 26:00
  Dr. Komal Patil-Sisodia: Thank you for being here today, and I will see you on the next episode.