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Diabetes is a well-known medical condition that affects roughly 30 per cent of Canadians, some of whom are yet to be diagnosed. The majority of people with diabetes have Type 2, and on this episode of the DocTalks Podcast, host Ian Gillespie interviews St. Joseph's Health Care London endocrinologist Dr. Tamara Spaic, Medical Director of St. Joseph's Diabetes Education Centre to learn of the latest treatments to help those affected.
Welcome to the DocTalks Podcast, a conversation on what’s new and relevant in the world of Canadian medicine and hospital health care. Join us for each episode, as we interview physicians, patients and caregivers to dive deep into what it’s like to treat and live with some of today’s most common health challenges. Hosted by Ian Gillespie.
Note: The content of St. Joseph's DocTalks Podcasts is for informational purposes only. The material is not intended for and should not be used as a substitute for direct medical advice from a licensed health care practitioner.
The DocTalks Podcast - Can type 2 diabetes go into remittion? With Dr. Tamara Spaic
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[00:00:00] Ian Gillespie: Hello. I'm Ian Gillespie. Welcome to The Doc Talks Podcast, brought to you by St. Joseph's Healthcare London. Today, we're discussing a well known medical condition that affects roughly 30% of Canadians, some of whom are yet to be diagnosed. I'm talking about diabetes. And St. Joseph's is the regional leader in diabetes treatment and education in Southwestern, Ontario, and with me today to discuss the latest in diabetes care is endocrinologist Dr. Tamara Spaic. Dr. Spaic is the medical director of the Diabetes Education Center at St Joseph's and an assistant professor in the division of Endocrinology and Metabolism at Western University. She trained in internal medicine and endocrinology at Western, where she also received her master of science degree in clinical epidemiology and biostatistics.
Dr. Spaic, welcome, and thanks for joining us today.
[00:01:51] Dr. Tamara Spaic: Oh, hello, Ian. Thank you so much for having me. This is really exciting.
[00:01:56] Ian Gillespie: Yeah. So I think, I, I mean, a lot of us, we probably think we know a little bit about diabetes, as I said, at the start there that, uh, about 30% of Canadians are affected either with diabetes or prediabetes and that diabetes apparently can reduce your lifespan by five to 10 years. And I think a lot of us are somewhat familiar that there is a type one and type two.
So can you just take us through the very basics here? What is type one diabetes?
[00:02:24] Dr. Tamara Spaic: That's great. Yes. the most common two types of diabetes are type one and type two diabetes. Type one diabetes refers to an autoimmune condition where the beta cells, which are the cells of the pancreas, which is the organ that produces insulin are destroyed by this autoimmune process. So a person is unable to produce sufficient insulin to keep their blood sugars in a normal level.
We do not know exact cause of type one diabetes. We know that it is an autoimmune condition. We do not know exactly what triggers type one diabetes. It's a probably combination of some kind of environmental and genetic, factors. this type of diabetes usually develops early in life. Uh, you can see it as early as children, age one and two, and there is no cure.
People are dependent on insulin as a life sustaining treatment throughout, their life. But as of late, we have found out that the type one diabetes is more and more diagnosed in older people, people above of age 30 or 40, which, uh, it used to be less, common. So that would be type one diabetes,
[00:03:46] Ian Gillespie: And sorry, I just wanna check a fact with you here. It says that approximately 10% of people with diabetes have type one. Does that sound accurate?
[00:03:53] Dr. Tamara Spaic: Probably around that number. Uh, we usually
say 90% of people that have diabetes will have type two
diabetes. Some of the numbers may be slightly underestimated because people that are diagnosed later on in life are assumed to have type two while they may have some type one. But the, that breakdown on 90 to 10% is roughly correct.
[00:04:16] Ian Gillespie: Hmm. And, um, maybe we should mention some of the symptoms of type one, are and correct me if I've got this wrong, but blurred vision, decreased mental sharpness and awareness, extreme thirst and hunger, fatigue, uh, frequent need to urinate, uh, skin infections. weight loss and, are those, does that make sense? Those are all symptoms of type one?
[00:04:37] Dr. Tamara Spaic: Yeah. So a type one has a very discreet onset. So most people remember exact date when they were diagnosed. They will tell you it was April 13th, 1989 when I was diagnosed. It presents very typically with a significant thirst. So increased thirst, increased urination, patients who are diagnosed with type one diabetes, have to go to the bathroom all the time.
They cannot go on the long road trips, . They. cannot sleep throughout the night.
They constantly go to the bathroom and there is a significant weight loss. so they present feeling thirsty, drinking water all the time, losing weight. And it, it, that does not
usually hopefully last for a long time.
They are. if they have a access to the healthcare, they are diagnosed fairly quickly and it's a very discrete event in their life, which they remember very well.
[00:05:30] Ian Gillespie: Wow. And so let's, uh, jump before we get into treatment and so forth. Um, let's get into type two, the most common form of diabetes, as you said, about 90% of individuals, have type
[00:05:41] Dr. Tamara Spaic: The,
[00:05:41] Ian Gillespie: Can you tell us a
little bit about Type
[00:05:43] Dr. Tamara Spaic: The type two is a much more common, presents in adulthood. Although as you know, with the rise of the obesity, now we are seeing more children presenting with type two diabetes. Type two diabetes, as a chronic metabolic, illness is a result of either insulin resistance, but insulin resistance means that patients produces enough insulin, but that insulin, which is the hormone that maintains blood sugar in a normal range does not work. It's like a key, uh, that does not fit in a proper, key hole. And then it's a combination of insulin resistance as well as with time, usually,
lack of insulin. With the time the pancreas cannot produce enough insulin to keep up with this insulin resistance and then results in elevated blood sugar. So type two, is, as I said, usually diagnosed, in adulthood, uh, in old increases the risk of type two increases with older age. And there are, significant risk factors, which primarily involves high BMI or, uh, obesity, certain ethnic groups like our First Nations in Canada have a much higher incidence of type two
diabetes, diabetes in pregnancies, so called gestational diabetes, having a large baby increases the risk of type two diabetes. And as the
rise of obesity in the Western world, is, significant, uh, the type two diabetes parallels that rise as you know, about 60% of Canadians are overweight or obese.
Uh, and that significantly increases the risk of type two diabetes.
[00:07:23] Ian Gillespie: Wow. so we're seeing more type two is more prevalent. Can you, is there a number you can attach to that or are we seeing a certain percentage increase
in type two diabetes?
[00:07:33] Dr. Tamara Spaic: Yeah. So right now, let's say in Ontario, one or out of every 10 adults in Ontario have diabetes and in age about 75, that number goes even to one to five. The prediction is that the number of Canadians that will develop type two diabetes by, I believe 2040 is 40% increase. So
really.
[00:07:56] Ian Gillespie: 40% increase?
[00:07:58] Dr. Tamara Spaic: By, I believe 2040
So, and the International Diabetes Federation, which is the , worldwide sort of a diabetes, uh, organization just calls type two diabetes, a tsunami.
So with the rises of the obesity and the population that is aging, the prevalence rates of type two diabetes are significantly on the increase, and the cost and the burden on the healthcare system is humongous. So everything that we can do to prevent diabetes from developing should be our focus, at the moment.
[00:08:35] Ian Gillespie: Mm-hmm . And then again, obviously the, some of the consequences of type two diabetes are obviously quite serious. again, I'm looking here that, uh, people with diabetes are three times more likely to hospitalized with cardiovascular disease. 12 times more likely to be hospitalized with end stage renal disease.
And, um, well, this is a strange one, almost 20 times more likely to be hospitalized for a non-traumatic lower limb amputation.
Those are
serious, obviously.
[00:09:07] Dr. Tamara Spaic: Absolutely so people that have diabetes, will not die from high blood sugars itself. It's the consequences of that high, uh, blood sugars over time that cause all these health issues. So we know that people with type two diabetes are two to four times more likely to develop cardiovascular disease.
As you mentioned, they live five to 10 years shorter. And the primary cause of, death and dying is cardiovascular. So strokes and, uh, heart attacks. We know that traditionally diabetes has been the leading cause of blindness, leading cause of end stage renal disease, so dialysis, uh, as well as amputations. So we call those structural complications, those high sugars of a time affect the nerves and blood vessels.
And as a consequence affects other organs, however, over the past five to 10 years, a bit longer, the research has shown that there are many other consequences and that other organs are affected as well. For example, people with diabetes have a higher rates of certain cancers.
there is a significant involvement and the risk of
developing liver
disease.
Diabetes is associated possibly with
dementia, depression.
So many other organs, not just traditionally that we always
spoke about blindness, kidney disease, heart attacks, and strokes, but now many other
organs
and other, illnesses are associated, uh, and have a higher risk, if you have diabetes,
[00:10:46] Ian Gillespie: Wow. Now some of the symptoms, of type two are similar, uh, to type one. Now, just again, some of the type two symptoms, thirst or hunger, unusual, uh, unexplained, weight loss, frequent urination, extreme fatigue, blurred vision.
[00:11:02] Dr. Tamara Spaic: These are correct.
Although, I will have to say that we think that most people actually have no symptoms. And then most people are diagnosed couple of years after they've developed diabetes. yes. Traditional symptoms of feeling thirsty, feeling tired, having, uh, to pee more often having record infections, sometimes the yeast infection or urine infections can be the first sign, uh, of diabetes, but a lot of times, and that's why we do the routine screening, people will not have atypical symptoms and we often pick up high blood sugars just on a routine blood work that was not done necessarily for any particular symptoms, hence our recommendations that anyone who is above a age of 40 should have a screening for type two diabetes, because prevalence is so high and people will not necessarily, early on in their career of diabetes, present with symptoms.
[00:12:01] Ian Gillespie: And so, obviously sadly, I guess a lot of people are walking around, with undiagnosed diabetes, correct?
[00:12:07] Dr. Tamara Spaic: Absolutely. Absolutely. And that's why, as a physicians and the medical community, what we are trying to spread the awareness and make sure that everyone knows that they should be screened for diabetes early. For example, screening in pregnancies is important because that signifies the risk people that have obesity, people that have what we call a metabolic syndrome, high blood pressure, high cholesterol, significant family history should be screened
for diabetes, even though they may not have, any symptoms. And sometimes I have to say the first presentation of diabetes could be a heart attack. Sometimes we diagnose diabetes in coronary unit when the patients present with the heart attack.
or with the stroke, and we wanna make sure that we can do this in advance so we can decrease the risk of all these complications, including the cardiovascular disease.
[00:12:56] Ian Gillespie: We've talked about symptoms and so forth. Doctor, how do people get screened? How do they find out that they do suffer from diabetes?
[00:13:06] Dr. Tamara Spaic: Ian, take you for that question. That's a really important and great question. Diabetes, uh, can be diagnosed, by a simple blood test. Most of family physicians, do order those tests, any help as a part of their routine screening, but the patients can remind their, either their nurse practitioners, their family physicians, uh, and it's a simple blood test that can be done.
Uh, we do have a special test where we give you a sugary drink to drink, and then we measure blood sugar at hour zero, one and two, but that test, uh, has been now mostly replaced just by a simple, uh, fasting blood, uh, test at any lab in, uh, Ontario. And important to know is if you have significant family history, if your weight has significantly changed, if you are on a medication such as the steroid medications that are known to increase the blood sugars, then you should be screened earlier.
If you develop symptoms such as feeling thirsty, losing weight, going to the bathroom often, then you should also alert your healthcare provider, to have the, uh, test.
And then at the end, some of our patients, have, uh, relatives or their neighbors who have diabetes, who do their own, blood sugar monitoring by pricking their fingers. And if you think that your blood sugars may be high, then your neighbor can help you test. And if the blood sugar level is, uh, elevated, then you should immediately seek, uh, medical, uh, attention.
[00:14:37] Ian Gillespie: Right. So let's, talk about treatment then. generally, um, I guess, different treatments for type one versus type two. Is that correct?
[00:14:47] Dr. Tamara Spaic: yes. To a certain extent, yes. Uh, type, uh, one diabetes, uh, requires insulin at all the times for as a life sustaining. People that are diagnosed with type two diabetes, initially the cornerstone of any, uh, type two diabetes treatment is lifestyle modifications. So changing diet, uh, minimizing, simple carbohydrates, simple sugars, and, uh, balancing the diet, eating more protein and complex carbohydrates, weight loss and physical activity.
Uh, the recommendations for everyone with type two diabetes. So all our patients with type two diabetes will get the same lifestyle recommendation or similar lifestyle recommendations, which is the dietary changes of following diabetic diet, as well as physical activity and aiming for 5% weight loss, if they are overweight or obese.
And then if those measures are successful and we do know that the lifestyle changes can be successful in reverting or preventing development of, uh, type two diabetes. Then the paradigm was gradual addition of initially pills or what we call oral agents. And then with the time as diabetes progresses and the, blood sugars remain, if they remain elevated, then be add other treatments and insulin is one of those, options.
I have to say that the paradigm of treatment of type two diabetes is changing. So type two diabetes is always seen as inevitably chronic progressive illness. However, over the past five years we have had development of new treatments and our paradigm is now shifting. Now we are thinking, can we put type two diabetes in remission?
So treat quite aggressively early on so we can normalize
those blood sugars and even allow patients to maintain normal blood sugars off treatment. So that's what our goal is. So this so-called remission of type two diabetes is the kind of paradigm shift, in treatment of type two diabetes. Uh, and it's the closest that we actually have to sort of a cure of type two diabetes at the moment.
[00:17:05] Ian Gillespie: And is that, um, the goal of remission is that accomplished mainly through medication then?
[00:17:10] Dr. Tamara Spaic: Yes, through the lifestyle, so weight loss
and medications, and we have new pharmacological agents, a completely new classes of drugs that are really effective in normalizing blood sugars and maintaining, uh, and losing weight, which helps, uh, normalize blood sugars of any treatment remission by definition would be normal blood sugars of any treatment for at least three months.
[00:17:37] Ian Gillespie: now can, can you talk a little bit about the, um, the treatment options and the the, the education and so forth, that's offered at St. Joseph's? I mean, so most people, obviously,
they, they might suspect they have certain, they're showing certain symptoms. They go to a family doctor and then might they come to St Joseph's where, where would they go?
[00:17:53] Dr. Tamara Spaic: Yes. Yes. absolutely. Right. Uh, Ian, thank you for reminding me. We are the leaders in diabetes treatment and management, as I said, the cornerstone of diabetes treatment is lifestyle modifications, dietary changes. Here at St. Joseph's diabetes education center. We have our certified diabetes educators who are nurses and dieticians with a focus on managing diabetes.
Our dieticians are extremely skillful. They help our patients modify their diet, uh, and follow specific recommendations for diabetic, uh, diet as well as help with the physical activity. How to monitor blood sugars, what to look for, how to make those life changes gradually and successfully. We have various programs such as craving change, where we help our patients
minimize the food cravings so they can adjust their diet.
We have programs for the physical activity in conjunction with our cardiac rehab program. And importantly, we are the leaders in use of technology in helping monitor blood sugars, as well as implementing a new treatment for our patients with diabetes, either type phenotype, two.
[00:19:18] Ian Gillespie: excellent. we're talking a lot about the, the medical and the physical aspects of the disease. What about the, the, psychological, aspects of diabetes is, uh, do we offer treatment for those sorts of, aspects?
[00:19:32] Dr. Tamara Spaic: This, this is a, a huge, part of, diabetes, management. This is still a chronic illness. There's a lot of labeling and stigma associated, with diabetes and hence, mental, support. And as I mentioned, previously, diabetes is associated with increased risk of, depression.
Uh, also, increased risk of eating disorders. So we do need to work on much better mental health support for our people, our people with diabetes. We are quite lucky here at, uh, St. Joseph's healthcare that we started a new initiative, for people with chronic illnesses, including diabetes, in supporting, uh, through the work with a psychologist and behavioral change, specialist.
So we are now training all our staff at diabetes education center. And we are training physicians to be able to provide this support to our patients. And we are including psychologists as well as social workers and, uh, educating the rest of the team to help support.
But I have to say the mental health resources are scarce as you know, in Canada.
And this has been a major
challenge. That's
why we have started this new initiative at St. Joe's. We are trying to overcome those barriers and at least provide some initial support for our patients, which is the really, really important we are very proud of the, uh, of those developments here.
[00:21:08] Ian Gillespie: Yeah. Excellent. Well, it sounds like such a critical part of the disease. Yeah.
[00:21:12] Dr. Tamara Spaic: Yes. Yeah, absolutely. I agree.
[00:21:15] Ian Gillespie: Of course you're, you're the medical director of the diabetes education center. how many people would go through the, the education center in a year? Do you have, Uh, any sense of how many patients you'd treat?
[00:21:25] Dr. Tamara Spaic: that's a very good question. we do, uh, certainly. I cannot give you exact number per year. Uh, but in our practice, we do have currently, over 6,000 patients with type two diabetes and 2000 patients with type one diabetes, and, and most of our patients will go through diabetes education.
I should mention that the really important part is that we work as a multidisciplinary team. So diabetes specialists uh, work alongside with our certified diabetes educators, our nurses and dieticians. And we work together as a team on a program that is adopted to each patient individually that makes sure that we address their needs and barriers and, different, factors that, uh, will allow us to move ahead with the proper diabetes management.
[00:22:20] Ian Gillespie: And again, patients would come, to experts at St. Joe's from all over Southwestern Ontario, I assume.
[00:22:27] Dr. Tamara Spaic: yes, that is, correct. Uh, we do, primarily cover London and surrounding, area. Uh, however,
we do have patients as far as, uh, Sault Saint Marie, And uh, Down to, all to
the Windsor has their own, but we do cover, uh, wide area. And because we are considered the, that we have an expertise, especially in treatment of type one diabetes and technology, we will see patients wider than, uh, our catchment area.
For sure.
[00:22:57] Ian Gillespie: Right. And I know you've worked, extensively looking into juvenile diabetes, right? In affecting adolescents and so forth. Obviously you've seen big increases there amongst young people.
[00:23:09] Dr. Tamara Spaic: yes. Yeah. Um, my clinical practice and my research focuses on, uh, type one, diabetes used to be called juvenile, diabetes. It's now referred as a type one diabetes and yes, over the past, uh, number of years, there is a slight increase in the incidence of, type one diabetes in, uh, Western world. You know, it's, it's hard to exactly, uh, say what we are seeing much more frequently is the rise of type two diabetes in our young patients.
So we are seeing now 15 and 16, 17 years old that have type two diabetes. And that's really early in your life to have a chronic illness that, uh, may have a significant impact on other organs and shorten one's life. You are right, there has been a shift. Diabetes, including type one and type two affect each age.
I have to say that, uh, we are very proud in this center, to have people that have lived
with type one diabetes for
50 years. So we have a special
ceremony, for the people that have had type one diabetes for 50 years. It's a called, uh, half a century awards. we dedicate a, a day. We bring patients and their families and, uh, healthcare team to celebrate the achievement of living with type one diabetes for 15 years, which is in itself an amazing, uh, achievement.
[00:24:31] Ian Gillespie: And, we were talking about prediabetes. I've been diagnosed as prediabetic. How, does that mean if someone is prediabetic, are they, destined to develop diabetes or am I doomed or is it obviously if I control lifestyle factors and so forth, can I fight it off?
[00:24:49] Dr. Tamara Spaic: Oh, you are absolutely right Ian. Good news. I have a good news, type two diabetes is, uh, preventable so we can keep you, we can help you and, uh, keep you in good shape and you do not have to develop type two diabetes. It's really important to uh, be aware of, pre-diabetes because there's a lot we can do to prevent, type two from developing.
So you are, you are not given that you will, have type two, but you do have to put some effort into it. Uh, so again, lifestyle, maintaining healthy body weight, maintaining a good diet and being physically active, at least 30 minutes, five times a week. We always say to a total about 150 minutes, per week, and you can prevent diabetes.
We know that weight loss of about 5% of the current body weight will decrease your risk of developing diabetes by 60%. That's huge. So that means that that, that it's not, you know, that it's rather preventable, illness with some lifestyle changes. We do have a medications that can also decrease the risk of progressing to type two diabetes, but they are actually less effective than the lifestyle.
So for example, Metformin, which is a common medication we use in treatment of prediabetes and type two diabetes decreases the risk of development by 30% while the lifestyle will do it by 60%. So, that tells us how important is to address, the diet and activity.
you know, I could talk about it. This is a passion of mine to certain, the, the addressing the, uh, lifestyle and exercise, is great on a paper, but the barriers to doing so are actually quite significant. So, you know, this all means like addressing the food security and the, the measures to help people, those changes to decrease the risk of developing type two diabetes should be on a much larger systemic, systemic level.
We should not just blame our patients for, their life choices. That's a completely wrong, uh, approach. And we don't do this for, for sure, but sometimes our patients and our people with diabetes may feel that way cuz of the advice they are given. So we say, you know, eat healthier exercise. That's what you hear everywhere in
the, uh, news and on the TV, and so forth.
And, but that's a difficult thing to do. We cannot just say eat healthy, when you don't have food security, you don't have access. The fruit and vegetables are so much more expensive than, buying soft drinks and chips, right?
[00:27:29] Ian Gillespie: Yes. Particularly now as, as we're seeing food prices rising, right?
[00:27:33] Dr. Tamara Spaic: yes, and that's a big concern to us. We know that that's going to affect our patients.
[00:27:38] Ian Gillespie: I was gonna ask you about the future of, treatment and research into diabetes. Is there anything, um, you, you mentioned a few things, but is there anything particularly exciting on the horizon
that, we're moving towards?
[00:27:49] Dr. Tamara Spaic: Well, thank you for asking. Yes. I would say that the future and the road ahead is exciting and the future is bright and we have had over the past couple of years, development of new pharmacological agents that have looked beyond only treating blood sugars, but those agents have made a huge change in decreasing the risk of heart disease and strokes progression of kidney disease.
Uh, and for us, it's a, again, another paradigm shift, and, uh, even newer agents that are still in development have shown such a huge promise. Some of those agents have been able to help people lose up to 50 pounds weight and probably will be significantly implicated in the normalization of blood sugars and diabetes, hopefully in diabetes, uh, remissions. Those studies are, Yet fully done, but initial data that has just been presented this year has shown tremendous improvement, not only in blood sugar, but in weight, significant weight losses, and normalizations complete normalizations of blood sugar. So we are quite excited that we have now, in our toolbox, which used to be only couple of medications, now we have a whole array of very effective agents and the agents that not only normalize the blood sugar, but decrease those complications, those risks of, vascular disease, heart attacks and strokes, kidney, uh, disease. So the, I have to say the future is promising.
I'm very excited. and, uh, I wanna make sure that our
patients know, There
is a hope, uh, and there are
much better treatments. the old memories of uncles and aunts and grandparents that were blind with amputated limbs that were on insulin, that was their own treatment that they had to take insulin four times a day are probably getting slowly behind us,
thanks to those new treatments.
[00:29:59] Ian Gillespie: Well, that's very encouraging. That's uh, and I'm when we finish off here, I'm going outside and I'm going for my half hour walk. Definitely.
[00:30:06] Dr. Tamara Spaic: Please do. And the thing is the new, it's the new illnesses. So, I do try to get, remind myself to get up every 20 minutes and go for a couple of minutes walk. That is a challenge, but we can together be better.
Simple things we can do. I, I
always tell, uh,
my, uh, patients park the furthest in the grocery store parking lot.
So you can walk to the grocery store and always avoid the middle aisles, purchase your, uh, groceries on outside where the veggies and fruits, uh, and the dairy is. So do not go in the middle of the grocery store, if that helps,
[00:30:47] Ian Gillespie: Stay away from those, uh, pretzels and chips. That's what you're saying.
[00:30:52] Dr. Tamara Spaic: Easier said than done, but we can do it together. And I always say we are here to help and we are all humans and we cannot be perfect. And, you know, we all will at times, have some, uh, dietary in discretions. But, uh, if on overall we give our best to eat healthier. And I think we are on a good
road because our children in our schools are doing better job. The schools are, teaching, uh, young ones about healthy diet and hopefully no pop machines and soda machines in schools anymore, more physical activity. I think we have to focus on our young generations. We have to make
sure, that, uh, our youngest
ones
are physically active.
We have to remember that at least an hour of a, physical activity minimal, for a,
young, child each day. and I know that the social media and electronics are posing a, uh, a certain challenge, but we should think of the ways, how to use this to our advantage rather than, disadvantage.
So.
[00:31:52] Ian Gillespie: Excellent. Well, Dr. Spaic this has been, uh, fascinating and formative and, and, uh, I'm, I'm feeling optimistic about things really encouraging at the end there, I think so. thank you so, much for joining us today on doc talks.
[00:32:04] Dr. Tamara Spaic: Yeah, more than welcome. I'm very glad Ian, for sure. The, uh, the, I will finish with saying that the future is, uh, bright.
[00:32:12] Dr. Tamara Spaic: