Denise 0:01
Myth, Magic, Medicine, and everything in between - 2 doctors talking.
Hello again and welcome to Myth, Magic, Medicine, with me, Denise Billen-Mejia, and my guest today is the lovely Heba Ismail, who is a pediatric endocrinologist specializing in type one diabetes. And she also has a research interest in the microbiome. So welcome habba thank you so much.
Heba 0:30
Thank you for having me. I appreciate it. Good to be here.
Denise 0:36
What what is your main message to the world about the microbiome, we hear an awful lot about it but mostly from the lay press.
Heba 0:46
Yeah, so there's, there's a lot to learn it is such a huge field. In such an area that's evolving very rapidly, you know, it's hard to keep up with even. But my main message is that, you know, you can almost think of the microbiome, which means the bugs that live inside us and on us and by bugs, I mean microbes not, you know, yeah. I suppose. Yeah,
Denise 1:16
yes, they,
Heba 1:18
they, you can almost think of them as a separate, or not a separate but an organ of the body. So they're almost like a part of the body. Because that when you count the numbers, that it's almost more than the numbers of cells we have in our body. And so they have a function, and in different parts of our body, they do produce a function, and they can affect our health. So I think that's, that's the main message.
Denise 1:44
In your work with kids with diabetes, how much? How much influence can you have with clients and patients, so I have to train myself, so clients, patients and parents to, I assume that most of the changes that you can make to the microbiome is going to be through dietary changes. And unfortunately, some of the medicines that we use for so knock them out, so how, how receptive are they to this information?
Heba 2:15
Yeah, so it's interesting. They're very receptive, they're very open to it. One of the studies that I'm doing involves taking this prebiotic which is a supplement. So the biotic basically, is this indigestible fibers. So we know fibers and fruit and vegetables. And those are more digestible fibers, meaning us as humans can digest them our intestines. But the indigestible ones are the ones that we can't utilize or use. But the bugs the bacteria, the viruses, the different microbes in our intestines can use and, and, and utilize them to produce these good chemicals that have this good effect on our body and more anti inflammatory effects so so that when I approached people about that prebiotic supplement, a lot of people are very excited about it. And they're like, oh, yeah, we will take that. Sure. And that's primarily for research. It's not something that I can recommend clinically, although I do get people asking about probiotics, and would you recommend that I'd say, you know, it doesn't hurt to take, right. And the difference just to clarify between a prebiotic and probiotic is the probiotic you are giving specific and select bacteria, right, that have been shown in studies to be beneficial, and
Denise 3:42
basically seeding the gut. Right?
Heba 3:45
The prebiotic, more of a broad spectrum because a lot of the good bacteria that are available in probiotics and not available and probiotics can benefit from that and grow and flourish in our intestines. So yeah.
Denise 4:04
So have you seen any have I watched stages your research? Is it very preliminary? Do you have you heard it yet?
Heba 4:11
Yes. It's it's early. We don't have yet the full number of people more in depth. But we we have looked at some of the preliminary data and it's it's exciting. We're seeing that there's this improvement in glucose control. That happens in those if we give it to those individuals specifically who were just recently diagnosed, right. And that, you know, if they took it properly, and it's only for four weeks, we're seeing that glucose control in some of them not all of them continue to be near normal up two years from diagnosis up to four years now is Yeah, did find, do you have
Denise 4:57
to manipulate their diet do they have have to be more careful about the diet. No, no,
Heba 5:02
no, actually, it's a very simple study where we say, Hey, you follow this diabetic diet and take the prebiotic for four weeks or follow your diabetic diet without the prebiotic for four weeks. So just
Denise 5:15
Okay, no, I meant to get the results if they've they've been on this diet plus the prebiotic. You're saying that the effect will last for four years afterwards. So what what are they? Of course, it depends if they're teenagers, they might leave. We were talking about that before we actually officially recorded here, but working from what I remember when I was milling years ago, when I was a pediatrician working with young diabetics, kind of heartbreaking sometimes, but but doable. But adolescent diabetics were honestly a nightmare. So
Heba 5:53
it depends. Yeah, absolutely. I don't know, I think Yeah. So the question is, are we manipulating their diet? Also? Yes. Yeah. So no, we're not, we're not changing anything they just take it with, with some kind of food because it's not something that can dissolve in water. But no, there's there's no specific at least for this pilot study. We're not doing any specific manipulation of the diet. But back to your point about adolescence. I mean, I don't know I'm, I'm a rare person who enjoys working with that. Because you know, you you see in front of your eyes, those, those beautiful kids like just their personality evolving in front of your eyes.
Denise 6:39
I must have been I had in my continuity clinic. remember way back when you didn't? Yeah, I had some kids. My long term kids weren't I didn't have any diabetics, we had a very strong endocrine program, and they siphoned off, but I had some kids with lupus. And that was I really had a bond with some of those kids. I met them. So often, I imagine that's a similar bond you have with them, which is also of course, how you can help them stick to the rules because they've got a connection. And that's part of part of what drives me crazy at the moment about what's happening with health care. It's like, oh, you change the insurance, stuff, go find another doctor.
Heba 7:17
It's at the cost of insulin. It's
Denise 7:21
absolutely ridiculous. Yeah.
Heba 7:23
And so yeah, absolutely. And, you know, it depends on when I met them in their life if, if they were diagnosed very young or older, but, you know, the relationship will differ that way. But I think the, the way that I found the most success with is, you know, I tell them, This is how it is, this is what you need to do, you are capable of doing it. This is called tough love. You got to do this. Right. And so they understand better that it's coming from a good place rather than me dictating your kind of the hard part for them, I think is they see, they're, you know, we download their their meter or their continuous glucose monitor. There's all these numbers there. And so they feel like they're being graded. In a way. It's all numbers, right. So they, they have almost the sense of a teacher student relationship, and we try to change I at least I tried to change that. Oh, yeah.
Denise 8:25
What made you what made you interested in endocrinology initially?
Heba 8:28
Okay. So interestingly, I, I was always interested in working with children. So pediatrics was my initial interest. I, at first was actually very interested in becoming an intensivist and pediatric intensivist. And where I had trained my initial training, it was a quaternary center. So meaning we get referrals even from other countries, surrounding area. And so there were a lot of pre terminal cases, like really sad cases. And so it became very depressing for me to continue in that specialty. And I was trying to avoid being a diabetologists and an endocrinologist because I have type one diabetes, I was like, Oh, I don't know if I can do this. But it gives you
Denise 9:20
such insight.
Heba 9:22
It just had to it just didn't work. I had to get to there. It didn't click right away. So then by default, I thought well, what other areas would I be interested in and where I feel like I could, you know, be helpful. And by Yeah, of course, it made sense to become a pediatric endocrinologist and diabetes specialist firm. Yeah. So
Denise 9:47
I admitted when I was introducing you that you are actually from Egypt originally, and that's where you trained. I'm fascinated by the differences in the approach to medicine, obviously anatomy for Geology is the same everywhere. And we either get our drugs from here or Germany, but what What differences do you see in the approach, perhaps to diabetes in the two countries?
Heba 10:11
Oh, that's so it's a very limited resource country and unless you know you, so everything is subsidized research, you know, where I worked and trained in an academic center. And oftentimes, we we actually, as physicians donated money to the patient, so they can go buy the medication. But, but it's so so there's, there's, there's a few differences, like I love how things are very clear cuts, systematic approach here in the US. And, you know, there's, there's clear guidelines of the downside to the guidelines is you don't use your judgment, as as much as you you're just used to following it almost becomes rules, right. So the other form of training, which is actually really, it's very strict, it's, it's, you know, we were a former British colony. So it's a very British, you know, strict six years of medical school, you know, one year of being, and then three years of residency training. So it was, it was very, very strict and very dogmatic. But But there wasn't as much. Maybe because of the volume of patients and the limited resources, used your judgment a lot more. And so I think that the difference between a physician from that area who has never been here and a physician here is that they they might be in that region a bit more resourceful. And they have to come up with solutions on their own rather than maybe have the habit of let's order a ton of lab and imaging, right. Something hits, right. So
Denise 12:04
yeah, and that's, it's certainly not universal. But there are a lot of I watch, when I was still working clinically. You see a lot of younger doctors who are like skip the labs aren't back yet. I can't think
Heba 12:19
down the pipe to that. Definitely having guidelines and standardizing as much as possible is important. But also we forget the personalization piece and and using your judgment. I mean, you you've invested so much time into learning and training, you are capable of using your judgment, there's like there's little lack of confidence there.
Denise 12:41
We rely on. We're not quite at the AI doctor yet part.
Heba 12:45
You're so used to the guidelines. But that's that's the main difference.
Denise 12:50
How about AMA? The culturally, is that there's differences obviously, within the US, but a different attitude towards health in general in Egypt on in here.
Heba 13:01
Oh, yeah. Yeah, I agree. I think I think it's so interesting. So I think the way it's portrayed in movies, and classically in the media there is that you go to the doctor, as you know, your life savior, it's the last resort, right? You go there and everything like this doctors God almost right. So they
Denise 13:27
show a strong placebo effect. That's good. Yeah.
Heba 13:31
But it tells you how anxious they are, first of all, but they're also like very believing and trusting of you, you know, because you are the person they go to when it's really necessary, right? There's not as much practice of the preventative medicine, and I'm talking about the general population. Of course, obviously, there are people who do, you know, practice preventative medicine, and socially, economically can afford that. But, um, you know, the majority of the general population, you know, it's, it's, it's that Plus, there's also this passive approach to recommendations, you know, you, you wish you could educate them more, and you try to educate them. But as we were just talking before the recording started, you know, some people may be wanting to, but they're not ready for it. And so they shut down and like, Well, I tell you, you know, so we can have a two way conversation. So there's definitely less of that. Yeah.
Denise 14:29
Yeah. Do you think you'd ever go back and practice?
Heba 14:33
I don't know. It's hard. It's, I would love to help. Yeah,
Denise 14:39
yeah. Yeah. Yeah. I think it's very interesting. Okay. So now let's pivot again, to talk about your isn't a blog or is it a newsletter that you use?
Heba 14:52
Oh, yeah, it's very, it's very new. Very much in its infancy. Yeah. Yeah, but I'd
Denise 14:59
love to chat I call also having boiled my share of green bananas in order to use them as substitute eggs because I'm vegan. So, good. Talk about that, please. Why did you choose that apart from being a snappy name?
Heba 15:16
So, um, so what I read when I was researching the microbiome and trying to learn more about the microbiome is that our ancestors, and especially people in Europe, used to eat more of Europe and other countries used to eat raw potatoes in green bananas. And that that is actually that has more of that indigestible fiber that we were referring to earlier. And that helps your your biome or the the good bugs in your intestines to flourish and grow. And so I thought, well, you know, we've always sort of shifted towards the more ripe bananas that are sweeter. Yeah, they are sweeter. And you know what, you have to be careful if you're going to try green bananas, because they can cause an indigestion because our intestines aren't used to that right now, it seems to do it in small increments. But it came to mind that, you know, hey, let's just say instead of eat your apple a day,
Denise 16:16
or green banana,
Heba 16:19
so yeah, so I started this blog just to educate the public a little bit about the microbiome and the effects of that. The health of the microbiome on our health as well.
Denise 16:31
Yeah, that information will be in the show notes, so people can go and hopefully we'll increase your your circulation.
Heba 16:40
Rate, that'd be great. That'd be awesome. I just want to educate people really? Yeah. That's the whole point. So yeah.
Denise 16:48
Is there anything else you would like to say to our listeners, if you're talking about absolutely anything you like, you can talk about Egyptian food and how it's fabulous.
Heba 16:59
I will say, and this is not scientific, that I did notice. So I had not visited Egypt in like, 10 years since I had my kids. I was busy. And then I visited a couple of summers ago. And I noticed that of course, the food is different, right. And it's very Mediterranean, very similar to the Greek cuisine. And I was going by with two meals a day, and didn't my portion sizes are smaller. And I did not feel hungry. And it was it was very strange. I mean, I was there for 10 days. And I lost weight. And it was, you know, feeling lighter, and, you know, feel good. And then I came back, and I swear, soon as the airplane landed something in the air, I was hungry. Hungry. I'm like, could it be like the air the quality of the air is affecting my microbiome so quickly? The water I'm not sure what it was. But I was immediately so hungry. It's very strange. It really is. But ya know, it's not something too scientific. But I wish someone would study it like geographically. How, you know, the environment affects your biome as well. But yeah, no, that's, yeah, that's not not Egyptian recipes, necessarily.
Denise 18:19
Viscous is wonderful. It's a great tears. It's got the blood pressure.
Heba 18:23
Yeah, it's great for blood pressure. And it's also and it's the thing that's been passed down from generation to generation in that region is it's in drink, that that'll help your high blood pressure. And I used it myself. And I found that effect, too. But it's also good for your microbiome. So that's only one thing I mentioned in there in that blog.
Denise 18:46
Yeah, do you do you advise people to eat fermented foods, like sauerkraut and the equivalents from various lessons?
Heba 18:54
That's a great point. I don't I would love to recommend it. I think, you know, I'm limited in what I can suggest in clinic. But I do it myself, you know, sugar and all the fermented foods, you know, are added even to yogurt. The sort of probiotics, yeah, I definitely do that myself and my kids as well. So yeah. Any other tidbits I did you want to talk about adolescents too, and
Denise 19:27
I would love to I would love to adolescence is a terrible time for most people. Having managed to rate raise my my kids are now in their 30s. But I do remember that era that was tough, in many ways. They were reasonably well behaved. But it's not it's hard. It's hard to watch your kids struggle with things that they have to struggle with because you need to learn those things. It's it's a hard time, both for both parties. Yeah, especially if you're dealing with an essentially life threatening disease. Yeah, it is not To be fooled with, yeah,
Heba 20:01
yeah. Yeah, absolutely. So chronic lifelong disease, and, and those, those patients really struggle and they have the worst diabetes control, you know, parents try their best and, and there's a lot of resistance and, you know, fights and meltdowns and. And they, they, they have to make a choice my relationship with my child versus, you know, their diabetes control sometimes. And those are the ones sometimes that often come into the hospital with diabetic coma. And so it's known as diabetic ketoacidosis, or DKA, or severe lows, low blood sugars, because they take they took too much insulin or took insulin and didn't eat. Right. And, and, and so it's it's very, it's hard on us as physicians, it's hard on the patients, it's hard on the parents, and it's a really rough time.
Denise 20:59
The The other thing that occurs to me is that the student athlete has an additional stress on their ability to control things. I think things have come a long way since I was in practice. You've got pumps. Now you've got, yeah, the technology is really helped. But it's still emotionally it's hard for kids.
Heba 21:18
It is it is. I totally agree. And I think, I think helping them and you know, we were saying earlier that they have a higher rate of depression and anxiety, and sometimes eating disorders. And so, you know, trying to help them through that very rough period, trying to reassure them, that things will be okay, but also challenge them and push them to do what's right. Because pretty soon in a few years, they're going to be on their own, and they need to learn the skills to do the right thing. And learn those good habits because it becomes second nature. And so it's always a challenge in clinic. But I would say that I personally enjoy working with adolescents, because they're just personalities are all very different and rich and all hormonal, you know,
Denise 22:08
right. But I can't remember whether it was recorded or not. But earlier, we were saying if you can, if you have a steady relationship with kids, if you can have that you can build that relationship. That's great. Yeah. And for right, now, you're in a major center, though, right?
Heba 22:26
I am. Yes. Yeah. Major Center here at Indiana University. So yeah, yeah.
Denise 22:32
Which helps, because most mostly they take most people's insurance of the insurance changes, they can still stay with the same doctor, all of those things that drive us nuts. I agree. The hard part
Heba 22:43
is when they they are ready to graduate the turn 19 and 20. And they're like, but we want to stay for a little longer. I'll see you a little longer, but at some point, you gotta go.
Denise 22:53
Yeah, we used to have that was our cardiology, especially kids who had had surgeries that had not been available for, you know, decades before. So adult cardiologist didn't know what to do with them. So they tended to stay 25 was pretty much the cut off, but
Heba 23:10
wow, yeah, no, I bet I bet that's very true. Yeah. But ya know, it's a tough age. And I really feel for them, you know, as someone as a type one diabetes, I went through that, you know, that that period of resistance and not not wanting to have diabetes? And why me and why do I have to do all this? This isn't fair. And you know, life is hard. And all those hormones are working against them. Right? And
Denise 23:37
of course, it's also and this is your life forever. This is not something Oh, yes, we'll find a cure for this or at least we will be lovely. If we do eventually we'll find we find cures for all sorts of things. But the likelihood is that the person who diagnosed today it's lifelong for them. So that sorry, it's hard to hear as an adult that you This is it very, very hard for kids.
Heba 24:02
Yeah. Although again, you can have a very, you know, fruitful and successful life like that,
Denise 24:07
but it but it requires vigilance. It does it does and it
Heba 24:11
requires work and and not everyone can do it. Some people do it on their own and are very motivated and some people need a lot of hand holding and in and challenging and pushing and you know, it's it's it's a tough, it really is what what kind of support are
Denise 24:29
you in your tertiary center coterie said, evil to to offer you have psychiatrists, psychologists available to them? Do you have social workers available to them? We do make
Heba 24:39
referrals of course they as everyone in the country are backed up are psychologists and and so we don't have necessarily a special dedicated person. But we do have social workers who do you have come to him and help them with resources
Denise 24:58
are you able to offer groups so that the kids, the kids can help each other because I think it's really beneficial.
Heba 25:05
Absolutely. You're right. Yes. So there are groups for even transition into college and groups for, as I had mentioned, or earlier, I think is, you know, when they were diagnosed little they didn't receive the education and training for managing diabetes. So when they turn into that adolescent age group, there's classes for them as well.
Denise 25:26
And just you realize they're not the only one in the world, because they're probably the only one in their class.
Heba 25:30
Yeah, yeah. And we do refer them to local support groups, whether it's through JDRF. Or, you know, there's other families that have kids with diabetes, they they're willing to connect. So we do, we do try to support them. I wish there was more support in the community would you know, just like babysitters who know about diabetes, so the parents can take a little break, right? Or no respite, calf? Yeah, yeah. So it's a challenge. But
Denise 26:01
yeah, how do you find how do you find parents obviously have to learn and then you have grandparents who have to learn as well, the other people that my family that's not in this country. So I don't have that. But there's pluses and minuses to grandparents, because they raised us, so they must sort of know what they're doing. But there's always some philosophical difference. Do you find any any pushback from grandparents because that, I don't want to do that, that way, everybody eats this in my house,
Heba 26:27
that resign, sometimes, especially I think, if they had been diagnosed with diabetes, whether type one or more so with type two diabetes, because they think, you know, the, they they think they understand, but we tried to explain that, you know, kids are different, and every person with diabetes is different in their management. So sometimes they are more lacs with following recommendations, and we try to educate, but a lot of times, they're very willing to, you know, they'll come to the appointments or do what we call caregiver virtual classes, so they can learn and help the child. But yeah.
Denise 27:09
What's the youngest type two diabetic, you've seen? Is that a different a different clinic?
Heba 27:16
No, I. So we do try to have them in separate clinics just to make it easier. But I have seen and manage people with type two diabetes. The youngest I've seen is down at age eight. Yeah. Okay. And unfortunately, you know, the pandemic has caused this problem with a lot of kids. We had this big and it's been published, we've had this big flux of patients who were newly diagnosed with type one, type two diabetes, who were more adolescents. And I think it's because they were sitting at home, easy access to food, they were doing virtual classes. And so a lot of them gained weight, if they were pre diabetic borderline, or had this insulin resistance level, or just even overweight, it threw them off. Right. And so. So we have, we've had a recent increase in the number of people with type two diabetes, and I think we've seen it nationally in talking to
Denise 28:19
do you feel, do you feel that that can be reversed if they have the opportunity to eat properly and exercise properly? Again,
Heba 28:28
that's, that's a hard one. It's so we, from what we've seen, you know, you can and just like adults, and I'm sure you've seen that, too, is, you know, you can sort of, if they start on insulin and they start following recommendations, they sort of get weaned off insulin and we start this oral medication called glucose VAs or metformin and follow diet and exercise recommendations. They can come off insulin, but usually it's not it's just a few years and then eventually, they don't need to go on insulin. So yeah, so it's it's but hey, you know, to buy a few years off of insulin that's that's a win. Are you doing the right thing?
Denise 29:12
Unfortunately, financially it's a big thing too. Because really, it's mind blowing how expensive that is. It is
Heba 29:21
it's really sad. Yeah.
Denise 29:24
So anything else you would like to say to people?
Heba 29:29
See, I don't I'm not sure what you told me. I'm not talking about anything. Yeah,
Denise 29:35
but I just know you're you're working a working doctor with children who are fairly young. How old were you? You can talk about that to affect your mood.
Heba 29:50
Well, I tried to schedule some me time. That's it. That's all is a challenge. But yes, I do have a six year old a six year old daughter who's going on 13 And a nine year old sweet young man who is just the sweetest boy so that helps a little yes it is a challenge with a full time job and as a single parent but yeah, I wouldn't have it otherwise I love my job I love what I do I love helping people and I love spending time with my kids and
Denise 30:26
is your your schedules reasonable you you have debt you don't get called into the ER too often at night.
Heba 30:33
No and then that's something nice about Yeah, that's this specialty specifically and that you know you when you're on call you're on call and you do rounds and see patients on the in the hospital but you don't necessarily have to you can give recommendations overnight. You don't necessarily have to go in unless in very very severe cases that we get called in. You never know but yeah, definitely
yeah yeah, yeah so but
Denise 31:08
so you've achieved certain amount of work life balance whatever the heck
Heba 31:12
yeah, I can't complain. Yeah, it's it's very decent. Yeah.
Denise 31:16
And your your kids don't pull at your heartstrings too often. You're always going to work. Oh, we they do.
Heba 31:25
Especially my daughter. She's like, Oh, mommy, but I'm sick to go to clinic clinic but I'm sick to
Denise 31:34
ASD. I got that from from my eldest when he was two. I feel Mommy has to go back to the hospital because one of the little children got sick. And I have to go help. And he's, but I'm a children too. Thanks, no. Say come pre programmed to say thanks. He's now in his 30s and a doctor too. So now he's getting the other way. That's awesome.
Heba 32:06
Yeah, yeah. No, it's been wonderful.
Denise 32:09
Yeah. Well, I this is said it says the myth of magic medicine and to doctors just talking if people want to listen, that's great. It's been very helpful. I would I did look at your blog. I must admit, I do see a lot of I get way too much email. But I did take a quick look. And I will go look again and I will look for the recipes.
Heba 32:32
Wondering recipe. Yeah. Tell me what you think. I'd love any feedback. So that'd be great.
Denise 32:40
Thank you very much. So nice to see you again. Thank you
Heba 32:45
was lovely talking to you.
Denise 32:46
Thank you for joining us at myth magic medicine. If you have found this episode useful, you can apply for free CME credit through the link provided in the transcript. If you're not a medical professional, please remember, while we're physicians, we're not your physicians, so please consult with your own healthcare professional if you think something you have heard might apply to you or a loved one. Until next time, bye bye
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