Key Moments
#41–Jake Kushner, M.D.: How to thrive with T1D and the valuable insights that can benefit anyone
Peter Attia MDKey Moments
Type 1 diabetes management, diet, exercise, and tech like CGMs can improve lives. Low-carb diets and personalized care are key.
Key Insights
Type 1 diabetes has complex autoimmune origins involving both T-cells and B-cells, influenced by genetic and environmental factors.
Effective type 1 diabetes management can significantly reduce complications, with lower average blood glucose (HbA1c) correlating to better long-term health outcomes.
Dietary strategies, particularly carbohydrate restriction (low-carb/ketogenic diets), show promise in stabilizing blood glucose levels and reducing insulin needs, though protein also requires insulin consideration.
Continuous Glucose Monitors (CGMs) are essential tools for real-time glucose monitoring, enabling better management and reducing the 'cognitive load' and distress associated with type 1 diabetes.
Exercise, especially distance running, plays a crucial role in glucose uptake via AMPK pathways, potentially reducing insulin requirements and improving overall metabolic health.
The psychological burden (diabetes distress) of managing type 1 diabetes is significant, impacting mental health, and requires compassionate, patient-centered care that moves beyond blame and non-compliance.
UNDERSTANDING TYPE 1 DIABETES: ORIGINS AND PREVALENCE
Type 1 diabetes (T1D) is an autoimmune condition where the body's immune system attacks and destroys insulin-producing beta cells in the pancreas. This complex disease has both genetic predispositions, particularly involving HLA alleles, and environmental triggers that are not fully understood but contribute to its increasing incidence. While children are often diagnosed, T1D can also manifest in adults with 'cryptic' or late-onset forms. The pathophysiology involves T-cells and B-cells, with detectable antibodies like anti-GAD and anti-IA-2 serving as diagnostic markers.
THE EVOLUTION OF T1D MANAGEMENT AND TARGET GOALS
Historically, before insulin's discovery, T1D was a rapidly fatal disease. The discovery by Banting and Best revolutionized treatment, but early management often involved difficult diets and high insulin doses, leading to significant complications. The Diabetes Control and Complications Trial (DCCT) in the 1990s proved that tighter glycemic control (lower HbA1c) drastically reduced microvascular complications like retinopathy and nephropathy. This trial shifted the paradigm, emphasizing near-normal blood glucose levels, though it also highlighted the challenge of increased hypoglycemia and weight gain.
DIETARY STRATEGIES AND THE BERNSTEIN METHOD
Dr. Richard Bernstein's work and book, 'The Diabetes Solution,' are transformative, advocating for a low-carbohydrate diet to minimize glucose excursions. The core principle is that carbohydrates directly drive blood glucose spikes, requiring more insulin and increasing the risk of errors and hypoglycemia. Bernstein's method, which he adapted for himself over decades, focuses on low carb, moderate protein (which requires covering with insulin due to gluconeogenesis), and moderate fat. This approach aims for blood glucose levels very close to non-diabetic ranges, significantly reducing insulin requirements and volatility.
THE ROLE OF TECHNOLOGY AND EXERCISE IN MANAGEMENT
Continuous Glucose Monitors (CGMs) have become indispensable tools, providing real-time glucose data that allows for more informed adjustments to insulin dosing and dietary choices. CGMs help reduce the 'cognitive load' and distress associated with constant manual monitoring. Exercise, particularly sustained aerobic activity like distance running, also plays a vital role by promoting insulin-independent glucose uptake via AMPK pathways, potentially lowering insulin needs and improving metabolic flexibility. This approach, combined with dietary changes, empowers individuals to gain better control.
MANAGING THE PSYCHOLOGICAL AND EMOTIONAL BURDEN
Living with T1D imposes a significant 'diabetes distress' or psychological burden, often leading to anxiety and depression, with high rates reported among patients. This distress stems from the constant need for vigilance, the fear of complications, and the perceived judgment from healthcare providers. Compassionate, in-depth patient interactions that build rapport, validate struggles, and offer tailored support are crucial. Moving beyond a 'non-compliant' label to understanding patient challenges is key to fostering positive outcomes and improving quality of life.
EXTRAPOLATING T1D LESSONS TO THE GENERAL POPULATION
Insights from T1D management, particularly regarding the detrimental effects of hyperinsulinemia and high carbohydrate intake on weight and cardiovascular health, have broad implications for the non-diabetic population. High insulin levels, driven by diets rich in refined carbohydrates, are linked to increased cardiovascular risk. The success seen in T1D patients adopting low-carb, low-insulin strategies suggests that similar dietary modifications could offer significant health benefits, including improved metabolic health and reduced risk of chronic diseases, for the general population.
Mentioned in This Episode
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Hemoglobin A1c and Average Blood Glucose Equivalents
Data extracted from this episode
| Hemoglobin A1c (%) | Average Blood Glucose (mg/dL) |
|---|---|
| 7.5% | 160 (approximate) |
| 9% | 190-200 (approximate) |
| 5.7-5.9% | Near normal |
Common Questions
Type 1 Diabetes is an autoimmune condition primarily driven by T-cells, where the beta cells in the pancreas are destroyed, leading to insulin dependence. It affects approximately 1 in 300 people in the US, with a typical onset around age nine.
Topics
Mentioned in this video
A device that continuously measures blood glucose levels, initially introduced to Dr. Attia by Dr. Kushner, and later made essential for his and his patients' diabetes management.
A company manufacturing continuous glucose monitors (CGMs). Its early generations were frustrating but later models like G4 made a significant impact.
Nobel Prize-winning biochemist, associated with Genentech and the development of recombinant DNA technology.
A pioneer in Type 1 Diabetes management who champions a low-carbohydrate approach, outlined in his book 'The Diabetes Solution,' achieving near-normal blood glucose levels and reducing complications.
A sales representative for Dexcom who has Type 1 Diabetes and introduced Dr. Kushner to the continuous glucose monitor.
A medical student who collaborated with Banting in the discovery of insulin, sharing the Nobel Prize.
A researcher at Boston Children's whose lab Dr. Kushner worked in, studying insulin signaling.
Author of 'Bright Spots & Landmines,' a manual for living with diabetes, offering practical tips on wellness, exercise, sleep, and low-carb nutrition.
A pediatric endocrinologist and close friend of Dr. Peter Attia, specializing in Type 1 Diabetes management. He advocates for dietary interventions like low-carbohydrate and protein management to improve outcomes.
A Canadian surgeon and Nobel Prize winner, credited with co-discovering insulin in 1922, a monumental achievement in medicine.
A researcher known for experiments on fasting and ketosis, mentioned in the context of a patient's hypoglycemic unawareness while in nutritional ketosis.
A pediatric endocrinologist at Boston Children's Hospital and a friend of Dr. Kushner, whose meticulous carbohydrate avoidance at a restaurant inspired his approach to Type 1 Diabetes management.
A scientist whose work in C. elegans demonstrated that modest alterations in insulin signaling could double lifespan, inspiring insights into hyperinsulinemia and aging.
Pioneer in diabetes care who adopted the 'Allen diet' and advocated for understanding the reduction of long-term complications, supporting the DCCT.
Associated with Dexcom, credited by Dr. Attia for getting him 'fully hooked' on Continuous Glucose Monitors (CGMs).
An anesthesiologist in Melbourne, Australia, and the passionate advocate and founder of Low Carb Down Under.
A radiologist who developed Type 1 Diabetes and learned to manage it using a low-carbohydrate approach, featured in talks by Low Carb Down Under.
A comprehensive guide by Dr. Richard Bernstein, considered a 'Bible' by many, detailing a low-carbohydrate, high-protein diet for managing Type 1 and Type 2 Diabetes and preventing complications.
A book by Adam Brown, provided as a practical manual for managing diabetes, covering various aspects from wellness to low-carb nutrition.
A book by Michael Bliss detailing the remarkable story of how Banting and Best discovered insulin.
A Facebook group for followers of the Bernstein method, providing mutual support and sharing experiences about low-carb management for Type 1 Diabetes.
Where Dr. Kushner completed his pediatric residency.
Where Dr. Attia completed his general surgery residency, noting two co-residents had Type 1 Diabetes, which influenced his early understanding of the disease.
A medical center where Dr. Kushner worked as a research technician after college.
Where Dr. Kushner took his first job as an assistant professor, setting up a lab to study beta cells.
An organization founded by Dr. Rod Taylor, based in Australia, that advocates for low-carbohydrate diets and provides extensive educational content through talks and videos on YouTube.
Where Dr. Kushner pursued his undergraduate studies, working continuously in basic science research labs.
A major pediatric center where Dr. Kushner pursued his endocrine fellowship and later worked, eventually becoming the first clinical fellow in 10 years to specialize in Type 1 Diabetes.
One of the major pediatric centers in North America where Dr. Kushner worked.
A class of drugs that lower glucose by causing its excretion in urine, noted for leading to euglycemic DKA in some Type 1 and Type 2 Diabetes patients, but also for profound cardiovascular benefits.
An SGLT2 inhibitor (referenced as 'epic of flows') that has shown a profound impact on cardiovascular outcomes, reducing complications by 40% in Type 2 Diabetes patients.
A drug that lowers glucose by activating AMPK, used in Type 2 Diabetes, mentioned for its effect on glucose disposal and the potential for lower insulin levels.
A pharmaceutical company for which Dr. Kushner serves on an advisory council, involved in the development of adjuvant therapies for Type 1 Diabetes, like the drug 'sotoglozin'.
A pivotal biotechnology company that first figured out how to produce human insulin inside E. coli in the 1980s.
A pizza restaurant where Dr. Kushner observed his colleague, Dr. Mary Ann, meticulously removing croutons from her salad to manage her Type 1 Diabetes.
An organization that runs a low-carb physician teleconference focused on Type 1 Diabetes, which Dr. Kushner attends.
A gene in C. elegans associated with insulin-like growth factor signaling, whose modulation by Cynthia Kenyon was shown to dramatically extend lifespan in worms.
A nematode worm used as a model organism in genetic and aging research, notably in studies by Dr. Cynthia Kenyon on insulin signaling and lifespan.
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