In this episode we hear from NAPC Council Member, Dr Donal Collins, as he speaks to us about Metabolic Health.
Transcript
Introduction
Katrina Percy
Hello everyone and welcome to this edition of the NAPC podcast. I’m Katrina Percy and I am absolutely delighted today to be talking to Dr Donald Collins. You’re gonna hear from an incredibly inspiring individual and one who’s changed my life over the last decade and a half in many ways. But he has particularly educated me in the area we’re going to talk about today around metabolic health, and that has changed my life as much as the work side. So without further ado, I’m going to ask you, Donal, if you could introduce yourself. Welcome to the podcast and just tell us a little bit about you and your background.
Donal Collins
Hello, everyone. I’m Donal Collins, I was a GP in Hampshire for 27 years and was in Ireland for five years before that, so 32 years of clinical practice. And was involved in some of the Vanguard work, probably about 10 years ago now in trying to improve what we were doing at the time because we could see the tsunami that is coming and probably on our doorstep right now and we’re trying to improve efficiencies and flow earlier diagnosis, earlier treatment. Looking back on it now, we probably could have done it a bit differently.
From GP to Patient
Katrina Percy
Such a good point to make, because that’s something I was going to ask you about, having known you for quite a period of time. Of course, you were always interested in populations, holistic, proactive care, but something change that made you really dig into the field of metabolic health. And it wasn’t just leaving your practice, I think. So I’m just wondering what it was because I see a slightly different version on where you’re coming from now.
Donal Collins
I think we learn best from personal experiences and we learn best when we have skin in the game so I was always a firm believer that if you bring in changes to any system, you should feel the pain of those changes. So then you’ll understand why people are resisting what you think is a great idea. But back in in the Vanguard years, which was really a great time because we got to well, I got to know you, Katrina, as a person. But around that time, personally I was working. I was probably working the hardest that I ever had putting in nearly full-time hours as a GP, clinical lead with the Vanguard, was chair of a GP Federation and I was chair of another GP company delivering community services.
And the reality is, I didn’t have much time for me, which at the time I remember thinking that’s kind of selfish. ‘You shouldn’t be thinking about time for me. You’re supposed to be thinking about time for others and the poor patients who were not really serving as well as we should be.’ So basically, I was grazing all day long, I was grazing bigger and I can remember towards the end of the Vanguard years I was getting really, really tired, couldn’t wait to get to bed, but constantly hungry, despite being massively overweight.
And then eventually got some bloods done, which confirmed I had developed Type 2 diabetes. And so I decided right now is my time to be a patient and let’s feel the pain of our patients who go along and say, please help me. Saw my GP who put me on a medication called Metformin, which is entirely appropriate. He also used an expletive word, telling me how fat I was and that I needed to lose weight, which was actually spot on.
And so, I took his Metformin and there was a weight national weight loss company with two letters that was funded by the NHS at the time, so I brought them into the surgery. I queued up with the patients and after three months I’d lost about 5 1/2 kilos and I was on the Metformin for 3 1/2 months I thought right, all the papers are saying I should be better. I wasn’t really feeling better, but the weight had gone down and everything is about the weight because the weight causes all the other problems, so I tell. We redid my bloods and my diabetes had gotten worse, even though I’d lost the weight and the weight causes this. So how’s that possible?
Learning from Patients
Donal Collins
And then what was interesting was I looked at the group of patients I was queuing up with and those who had what we call metabolic syndrome were losing weight, but they weren’t improving. And the people, let’s say, who didn’t have abnormal metabolic markers, were losing the weight and they were the ones who are getting the benefit.
Around the same time, 2 patients came to see me, and this is where I was in an arrogant phase of my career, you know where I know best. And these two had southeastern heritage. They both had HBA 1C’s, which is a measure of how sugary your blood is over 100. But when they turned sideways, they had no belly, right? So they were not overweight, right?
So the traditional model would be, even though they’re not overweight, you’d be shouting at them to lose weight, but they hadn’t weight to lose. And I said to them, you need drugs. Your diabetes is really bad and out of control, and we need to get it under control. Both of them happen to be engineers and they said can we fix root cause right. I didn’t really understand what they were talking about. But I just nodded, as if I did and said yeah, of course, but come back in three or four months and we’ll put you on those drugs that I know you need and you think they don’t.
They came back probably six months later, but you know, one had put his HbA1c into the 30s, right, which is well below the pre diabetic range. And the other had put his into the mid 40s so into the pre diabetic range. So from being wildly out of control to being very good control. And none of it was done with my magic drugs. And I was saying, what did you do?
And they were saying that we just fixed root cause we just because they had a type of a South Indian diet. They stopped eating, chapatis stopped eating rice and they said we had a lot more ghee. Ghee is clarified butter. So that’s kind of the opposite to the device we’d be giving you because we all know fat is bad, and so you should have gotten worse, but yet you got better. And then I looked for papers to confirm whether this was a good or bad idea, there’s loads of research out there.
A New Approach: Food as Medicine
Donal Collins
There was loads of papers published, but for some reason we weren’t encouraging that way of thinking. Because I now had skin in the game, I was struggling to control my own Type 2 diabetes, despite losing weight. I did, but they did so reduced my sugar intake, reduced my rapidly absorbing carbohydrate, focused on trying to block food getting absorbed from the front 1/3 of my gut few things happened.
1 is I rapidly lost about another 20 to 25 kilogrammes fairly easily without hunger and that was the critical thing. The hunger disappeared and suddenly instead of food driving me, I was in charge of what do we eat and when I was going to eat, whereas previously when I woke up in the morning first thing in my mind is when’s breakfast, where do we gonna have elevenses, when’s lunch? And now I was getting to a stage where I don’t eat breakfast. I’m actually not really hungry. And then when I got the lunch time, I might be hungry, might not be hungry and then you can skip that as well or eat. Which was amazingly liberating.
And so then I started doing it with patients who happened to come into my consulting room. And again the same effect. It was repeatable over and over and over again. And then I was thinking how can you do this at scale? How can I reach the people who don’t happen to come into my consulting room, which is where I’ve come to now and work with a digital tech company. Where we go into primary care, we invite people who we identify as metabolically unwell and then ask them if they’d like to reverse their chronic disease. Which in my career I was told wasn’t possible. You know, once you get type 2 diabetes, it’s a chronic progressive condition. Don’t tell anyone they might be able to put this into a mission because you can’t give false hope. And looking back at it, you know, it was horrendous advice.
The Rising Demand in Primary Care
Katrina Percy
So, Donal, how have you noticed things change over the years and why do you think that demand is worse today? Why have we got people ringing off the hook and can’t get clinics and everyone’s demanding an appointment?
Donal Collins
I look back in my career, went on the data. So when I started in primary care back in the early 90s, we had empty appointments in our surgeries, right? You just need to say that slowly and listen again. We had empty appointments in our surgeries and these were surgeries that whenever a patient wrong reception can I have an appointment with the doctor? Sure you can come in and have to. There was no multidisciplinary team. There was no pharmacists, you know, a wide range of diabetic nurses. And all these other people that existed in Birmingham. To now where, you know, the demand despite the increase in workforce is it just can’t be dealt with.
What we’re currently trying to do is improve the efficiency of the flow of the patient phoning in to get to the right patient first. There doesn’t seem to be much thinking about why are all these people falling that weren’t falling before. So back in the 90s, we had about 100 type 2 diabetics, when I finished my career, we had 1200 diabetics. Very rarely do I have a conversation with anyone around ‘Why’. Right, it’s just like an acceptance. It’s a bit like, you know, frogs in a warm, tepid water that’s gradually increased in temperature until it boils. And you just stay sitting there saying this is the new norm. There’s nothing I can do about it.
And you know, my firm belief is if you go back and say, well, how did we live in the 60s and 70s to compared to now? You know, there was there was you had breakfast. You would have had a packed lunch at school and you’d had an evening meal. There was no snacking in between. Right now, it’s continuous grazing.
What is Metabolic Health?
Katrina Percy
One thing very basic, I just wanted to dig into is you often talk about type 2 diabetes and measurement of that and then in a way, I hear it interchangeably with metabolic health. And I think one of the issues we have with the health service is we sit there and say right, let’s design a diabetes pathway, let’s design a hypertension pathway for example, we don’t talk about metabolic health. So firstly, I was thinking, can you just explain what metabolic health is in a real simple phrase and why it’s sort of almost interchangeable then with a range of long term conditions. And then let’s talk about why this is overlooked in mainstream healthcare.
Donal Collins
If you have good metabolic health, that means your body is in the homeostasis, which means everything is in balance. OK, so if you chuck in an occasional insult into your body, your body will remain in balance. It can deal with it. If you’re in good metabolic health, and let’s say you have a nice milkshake, right, so loads of ice cream, loads of milk, added sugar, and you knock that back, you’ll see a short spike in your glucose, and it’ll rapidly come down again because you have space to put away in that. Excess sugar that you don’t normally eat.
If you’re in poor metabolic health, your reserves are full, so your liver glycogen stores are full. And because they’re full, it will have converted the excess sugars into fat. So you have most of us now have fatty liver and there’s nowhere for that excess sugar to go. So it flows into the bloodstream trying to find a home to exist. And then you stay with perpetually high blood sugar readings. Not just blood sugar, you’ll also get the surge is then called triglycerides that we rarely talk about, but we can come on to why they might be in.
So most of us are in poor metabolic health, so we will get a persistent rise in glucose, a persistent rise in triglycerides that will last beyond 2, 3, 4 hours, which then causes damage to blood vessels, which then allows the abnormal lipids to get into the blood vessels and cause atheroma. It also affects, you know, your brain, so you end up with what’s called an inflamed brain. And then you have all the mental health illnesses from that. Because in in the traditional model what we do is we subdivide all these into individual diseases. So oh, you’ve got type 2 diabetes, you’ve got prediabetes, you’ve got fatty liver, they’re all different clinics, nobody is looking at what might be, what’s the fuel that’s driving all these things and making them worse. With relatively simple advice, people will choose to live this way.
And initially it can be hard you know, if you’ve been having chocolate croissants for breakfast sandwiches and toast for lunch and you know, chocolate bars 3-4 times a day to suddenly say, oh, that sounds like a very restrictive fad diet you’re talking about.
Why Isn’t This Mainstream?
Katrina Percy
The question that’s coming to mind for me is it is so compelling when I hear you talk about this, and others, you know, this is a movement now like you’ve talked about. I find it so hard to fathom why sort of mainstream NHS discussions don’t pick this up. I say to people I know through working with Dr Donal Collins and others; you can put Type 2 diabetes into remission within less than six months. And people look at me, doctors look at me, ‘Ohh no let’s go on and put a diabetes pathway’.
How do we shift the diabetes care out the hospital into primary care? Let’s not just go into that bit. But why is this? I just don’t understand why mainstream primary care, secondary care, NHS have not got this.
Donal Collins
So I think there’s probably several reasons that probably the most important one is incentives. All the incentives in the wrong place. OK, so if you if you look at quaff, which I think was a was a really good idea 10, 12 years ago. Most practices are getting 98, 99% of the crop points and that was all about preventing chronic disease. You know, if we get blood pressure correct, if we get lipids correct, outcomes would improve. So the practices have been really good at improving those individual targets. But the outcomes were not achieving them.
So as in reduction in the amount of people being diagnosed with type 2 diabetes, reduction in the prevalence of type 2 diabetes, reduction in cardiovascular disease, despite everyone nearly being on statins. I’m old enough to be around from the first statin trial when the 4S trial came out. And it was like put everyone on this and cardiovascular disease will reduce by 30%. We’ll be able to reduce the amount of coronary care.
You know, departments that exist and the exact opposite has happened. So we haven’t got incentives in place for outcomes. We’ve got incentive in place for transactions seeing people and doing stuff. And what’s interesting is if you put a Type 2 diabetic patient into remission, you stop seeing them. There’s no transactions, you know, cause they’re now better and they don’t have a chronic disease and suddenly they gotten well. So they’re saying ‘Do you know what, Doc? I don’t need to see you anymore because actually you’re quite boring and I’ve got a lot more interesting stuff to do with my life’.
But then we have all these clinics and and stuff set up and we want to flow people into the white place first time and as matter if you got your blood pressure raised, let’s put you want blood pressure tablets. If you got your cholesterol raised, let’s put you on cholesterol tablets, and so on. And yet when you look at what we’re measuring, we’re measuring stuff that the Pharmaceutical industry wants us to measure.
Now, I don’t want to go down a conspiracy theory and this is bashing pharma, but LDL, right. We measure LDL and everyone gets really excited about LDL, for good reasons, and it has an odds ratio of 1.4 in terms of cardiovascular disease, so the risk of something happening to you if you have raised LDL is 40% higher. That’s quite significant and yes, we need to be jumping up and down.
But let’s go back to our old friend, triglycerides, the odds ratio of triglycerides are 2.1. We don’t hear anyone talking about a triglyceride clinic because there isn’t a drug for it. Well, actually there is a relatively new drug out now, but it’s not that effective. And then you’ve got chronically raised insulin levels gives you an observe ratio of 6.1. We’re jumping up and down about the. 1.4. race. We’re not even measuring the 6.1 race. Well, why would we? Because we haven’t got a drug for that.
One of my great inspirations is this guy. Get Robert Lustig in the states. He’ll say these things are not druggable, but they are ‘foodable’. So if we use food to fix the underlying root cause. All the magic happens, and sometimes in in our webinars we meet some of our patients who have gotten their type 2 diabetes into remission and it’s quite extraordinary the conversations that they play back that they’ve heard. So they’ve gone from having type 2 diabetes, which you know, if you get a young enough, reduces your life expectancy by anything from 13 to 15 years and has a massive risk on cardiovascular disease.
So they’re now not type 2 diabetic, they’ve lost weight, their blood pressure is down, they’re feeling great their mental health has improved, but the LDL stayed the same or gone up a little bit. And people say, ‘oh my God, you’re in a worse place than you were, we need to put you on these drugs because of the weird fat dietram’ and somehow the system isn’t seeing the bigger holistic picture because we’re incentivised to jump on but known about LDL. We’re not incentivized to jump up and down about Missus Murphy’s feeling a hell of a lot better.
Simple Steps to Remission
Katrina Percy
So let’s just quickly recap then what it is you can do to put type 2 diabetes into remission. But as I understand from what you’re saying, that also reduces hypertension, it’s improves mental health, etcetera. Like, here I’ve come in, I’ve got type 2 diabetes already. I might be thin on the outside. I might be fat on the outside, but I’ve got type 2 diabetes. What are the simple food solutions then, as opposed to drug that I can do to put that into remission in six months?
Donal Collins
Don’t eat sugar. Don’t eat processed foods. Eat food as nature gave it to you. It really is as simple as that. And that’s probably one of the issues that our complex systems have. It can’t be that simple, right? Because complex systems like complex solutions, there isn’t a lot of money to be made in this. So the, you know, the cauliflower farmer and the sheep farmer, they’re not funding any clinical trials.
You know, the bigger question is how can we fund these trials that no one really is going to make any money out of but systems will benefit huge cost savings. And then the other thing that happens is if you’re going to follow that advice about don’t eat sugar, don’t eat processed foods, eat food as nature gave you, it kind of goes against some of the dietary guidelines. And I think the important thing to remember about that is guidelines are guidelines and somehow we’re mixing guidelines up with dogma.
The conversation with a fairly senior dietitian on LinkedIn around my worries and troubles with the dietary guidelines. And I, you know, said to her when I developed Type 2 diabetes, I followed the guidelines very clearly and it made no difference. And she said ‘Ohh, when you develop a chronic illness, you don’t follow the guidelines. You need completely different dietary protocol which somebody like me would need to give you’. And you think oh my God, did this person really say that out loud. Because when you think about what poor metabolic health is, there’s a concept called metabolic syndrome that has five arms. So big belly hypertension, waist triglycerides, low HDL and abnormal glucose. About 85% of adults have at least one of those arms.
Katrina Percy
85% already have one. Do they know they have, or they don’t know because we don’t screen those different things.
Donal Collins
Yeah. And people will know my belly is a bit bigger than it was. Right, they might know well, if until they have their blood glucose measured or they get an annual check done on the lipids or have their blood pressure checked. But sometimes it will be well, the sugar is just up a little bit.
Katrina Percy
Not to worry about it, right?
Donal Collins
Yeah, go away and lose weight.
Carbs, Confusion, and the Mediterranean Diet
Katrina Percy
So just before we move on to I think it’s so interesting that what you do about this because it goes from sort of civic government based interventions to one person in front of the receptionist in a GP surgery. So let’s come on to that. One of the things I was thinking about when you were talking is carbohydrates. So a lot of the diet advice is that you should eat, you know, eat your portioned out bit pasta and bread. And as I understand it from digging deeper, that actually also produces sugar spikes, cause they’re actually quite processed.
The bit that’s challenging is, but don’t those Mediterranean diets, those Italians who are really healthy, they eat loads of pasta. So, you know, it’s confusing I think in that sense, when we talk Mediterranean diet, pasta, rice, bread, all of those things. And you get told just eat a small portion of pasta with tomato sauce.
Donal Collins
And it is very confusing and so there’s a few things to say. So one is the last 8-9 years, every day I spend about 1 1/2 to two hours just reading and learning and listening. And at the beginning, one of the most amazing things I learned because most of the dieticians I had met said you need glucose and you need the rapidly absorbing carbohydrates. And then I met one guy who said, well, what happens if you don’t eat those things? And I said, I don’t know. Well, eventually, once you reduce, you know your lichen stores, and yes, your brain needs glucose. He never just makes it.
There’s a thing called gluconeogenesis. So your blood glucose will always stay between 3 1/2 and six. Whether you eat sugars or rapidly absorbing carbohydrates or not. All right. So if you don’t need it, your body will make it. But the other big constituents in food, we need protein and we need fat. And your body doesn’t make those so we need to get them in from the outside and that’s the critical thing. And so that was a huge light bulb moment for me.
And then the other things, so we’re not empty carbohydrates. So the complex carbohydrates, which you can’t absorb, they feed your gut microbiome. So celery, green leafy veg, they’re great. So the concepts are you need to protect your liver which is don’t eat the sugar and rapidly absorbing stuff from the first one third of your gut. So the 1st one third of your gut; feed your liver. If you can get the food past your front one third of your gut, you’ve protected your liver, which is why bariatric surgery works almost instantly in type 2 diabetes reversal. And then if you feed the gut for your microbiome to live on, then you get all the benefits from that and then you need to sustain your brain by eating the right foods as well.
So it’s the combination of those things. Protect your liver, feed your gut, sustain your brain. That’s how you get really good metabolic health and all the positive effects out of it. Now the big problem I have with the Mediterranean diet is what is it, you know, the Mediterranean is kind of a big place, so you’ve got South of France, you’ve got Italy, they eat different Mediterranean foods, you know, Greece and the North African coast, they’re all Mediterranean people. But, you know, you accept that in general, if you’re going to eat a lot more salads is a good thing. Feed your gut. Olive oil, so that’s a good natural fat that will make you full. That’s good.
I have no problems with meat, you know. Again, this is where the guidelines will come in and out, but meat will be a lot safer than the rapidly processed absorbing carbohydrate food. It’s much better than sugar, ice cream or anything that has a marketing department on it. And most published papers when you look at me, it has an answer ratio of around 1.1 which would be in the big picture; noise. So, on the whole, we are inclusive. Nutrition world is highly divided and almost like religions. All right. So if you’re a vegan, this is the only way to eat. If you’re a carnivore, that’s the only way to eat. We will be inclusive of all spiritual beliefs, all right, as long as you don’t eat the sugar, don’t eat processed foods, eat food as nature gave it to you, you can be a vegan, vegetarian, omnivore, pescatarian, carnivore, whatever you want to be.
Conclusion
Katrina Percy
Thanks for tuning in to this episode of the NAPC Podcast with Dr Donal Collins. This was part 1 of 2. In the next episode, we will be hearing from Donal about how practices can use this approach to improve the health of their population and the resources that are available to them.
