Dr Oscar Duke

0:04Hello and welcome to The Midpoint. My guest today is Dr. Oscar Duke. He's a regular on the BBC's Morning Live and has a string of TV appearances under his belt. He first featured in the hit Channel 4 series 24 Hours in A &E and then went on to present his own award-winning primetime documentary for BBC Two, Born Too White, an immersive expose of the mutilation and murder of people living with albinism in East Africa. Oscar was born with the condition and understands only too well the challenges that brings. So he's got plenty of media experience and his own podcast as well, Bedside Manners. And today I really want to find out more about GLP-1s.

0:44So let's speak to Oscar.

0:49Dr. Oscar Duke, great to have you on The Midpoint. And when I said your name then, it's just got such gravitas. I mean, doctors should have good, strong names, but that is one. I feel they should. I mean, Oscar used to be quite unique. And now if you go to the park, every child and every dog is called Oscar. When I was Oscar, there were originally as a young Oscar. The Duke. The Dr. Duke is all right. Yeah. In your introduction, you said you're quite a kind of old hand now at TV and media, aren't you? So this should pose no problems. Approaching the midpoint thereof, maybe. This should pose no problems.

1:24One of the things I want to get into is something that comes up quite a bit in terms of feedback from people when we ask them for ideas. And we haven't discussed it at all, actually, on the podcast. and nobody who's been on has said they're on them is GLP1s, which is the generic name or the medical name for the drugs that we know as WeGoV and as Zempik. Yeah, those sort of weight loss jabs, if you like. Yes, yeah. There are others, obviously, on the market. In fact, an increasing amount on the market. So I have a lot of questions on them. First of all, let's get going with, at the moment, if you had to kind of guess, or do you know what percentage of people in this country or how many people in this country are currently on these drugs?

2:03Well, I think maybe, as you said, no one who's come on has said they're on them. It probably gives you a good idea. It's difficult for us to know exactly how many people are on them because people aren't always very honest about them. There's obviously a lot of prescribing that goes on in the private sector. More difficult to get through the NHS, but through specialist weight loss management services, you can get access to them. And I think ever-increasing numbers of people. We've had issues in the past where there have been supply problems, and obviously there's that concern that people who are using them for diabetes as well as perhaps weight loss are not able to get access to that sort of diabetic treatment that they really need.

2:37I think we seem to be in quite a good sort of supply place at the moment, but the prices have gone up recently as well. Was that to do with Donald Trump or not? Well, certainly the manufacturers of Manjaro, Terazapide, Eli Lilly, they have sort of increased their list price. I think some suggestions to put us in line with other countries around the world. I think Trump may have been involved in that. And the reason I ask about the numbers is because I don't know what's going on with the NHS, but certainly privately and anecdotally, there doesn't seem to have been a week lately where I haven't met somebody who's had dramatic weight loss or talked about somebody else that, you know, we know through a social who's had dramatic weight loss.

3:18And it feels the last few months, it's blown up. It's become almost like commonplace to be meeting people. And quite a lot of people are open about it. Some aren't. What's your take as a doctor who's sitting in a surgery and people coming in in terms of the interest and asking for them? So I do a combination of NHS and private work and I would say across the board there's massive interest and exactly that kind of from friends. Somebody's recommended it, somebody knows somebody who's had a good result from it. More difficult to get in the NHS privately, I think ever increasing uptake of it. People are always a bit nervous when they first start thinking about taking new medication and going through the potential side effects.

4:01Are there any harms? What's that kind of long-term data? Lots of which, of course, we don't have people who are using it simply for weight loss because lots of these drugs are either quite new or even though the class has been around for a while, using them without diabetes is a relatively new thing over the last few years anyway. So it's difficult to give a exact sense of what people are thinking, but people are just hearing good news stories about it. And I see that all the time in the clinic. And you prescribing. Yeah, I do. Yeah. So privately in the NHS, it's, as I said, the sort of specialist weight loss services that do it.

4:36Some GP practices were able to do it on sort of trial bases. But I think privately it's this sort of this benefit that people, you know, I might have seen somebody for a sort of regular checkup every year. And we've talked about their weight, what they can do with their diet, their exercise, all of those sorts of things that everybody knows, to be honest, in terms of things that can help them. And actually, we're going around in circles. We're having the same conversation again and again. And finally, for a lot of those people, a change can be made with these medications. And yes, it's a medicine.

5:04You have to think about the side effects of doing this. But I've had patients who were going to have a knee replacement whose knee no longer hurts because they've lost a significant amount of weight. Perhaps there's an anti-inflammatory benefit on your joints as well. And they've canceled their operation, which is fantastic if they can then sustain that weight loss. Of course, the knee has still probably got all that wear and tear in it. That's not gone away. but the symptoms and the side effects of God which is fantastic. How long can people this is the one question that people keep in discussions that I seem to be having people say how long can you be on for them and nobody really seems to have an answer certainly in the non-medical community in the anecdotal community there doesn't seem to be an answer.

5:44No and I think what's interesting now is we're getting up to the kind of two years. Yes there's sort of two years that's mentioned in the government guidelines and everyone says oh no I won't be on you know lots of patients will say well I didn't want to be on it for more than six months and if they're coming up to a year or maybe even two years and you suggest coming off, people are getting quite reluctant. I think people feel good on these medicines and patients don't really want to come off them. Some do, of course, you know, it's variable. Some people are keen to be without medicines. And for me, you know, you should always only be on any medicine, I think, for the minimum amount of time needed to get the maximum benefit.

6:17Because there is now also this kind of micro dosing chatter that's coming from, I would call them the kind of, you know, the worried or the very concerned well you know those people who are on the edge of what is usually coming out technologically you know the kind of the health pioneers that want to adopt everything who are already seemingly i would say a good weight or you know they're not overweight but they're they're hearing about the benefits of micro dosing with glp ones what's important is to remember that the studies so far are really in people who were classified as obese and you can talk about body mass index and how accurate that is but that's where they set the cutoffs for lots of these studies and many of the studies earlier on were from people with diabetes as well so I think you have to be really careful when you look at scientific evidence to make sure that the population in the studies is the same population that you're looking at when you want to put those results into the real life and that's not necessarily always the case so if you are of a normal BMI and using it more for aesthetic I suppose than the health benefits then we don't quite know how significantly beneficial that's going to be for you.

7:28That said, when we started giving patients these drugs, you're cautious that we don't have long-term data for lots of these medicines. And actually, as studies have followed the drugs initially, mainly looking at weight loss and seeing how effective they were there, they've started to find other significant health benefits as well. So people have a significant reduction in their risk of cardiovascular disease. But is that not because the weight's going down? Well, interestingly, independently in lots of the studies from how much weight they lost. So it doesn't directly seem to link to, yes, you lost loads of weight, which, of course, is helpful for all of those things and reducing those risks as well.

8:04But there's an independent factor. And again, nobody knows. A bit like statins that we take for cholesterol, lots of people take. We know that lowering your cholesterol is helpful to reducing those risks. But also there's probably something else in the statin that we don't fully understand that has a sort of anti-inflammatory effect in your blood vessels. And I think the thinking now is that the GLP-1s and that sort of group of drugs have maybe a similar effect and there's a potential benefit to the brain, the kidney, the heart. is otherwise very healthy. So they were scanned within an inch of their life and you said this person's got good cholesterol, they've got good blood pressure, they're not overweight, they seem to have very good cognitive function.

8:44Could they still be beneficial? Potentially, I think long term. But what would they do? How much better can that person get? You've got to be careful, haven't you? Because we don't have studies to say that. And I guess potentially if that sort of study is done, we're looking at the long term side. long-term benefits of, as you say, someone who's entirely healthy, then there may be a benefit there. And it may become one of those sort of wonder drugs in that sense, if it hasn't already for many people, I think. But then if you think of even something like a statin, which we know has a significant impact on people's life expectancy, if they have high cholesterol, if they've had a stroke, if they've had a heart attack, we don't put statins in the water yet.

9:25So I think you have to be very careful, you know, in some of the early studies of these drugs in rodents, then there was an increased risk of thyroid cancer. We haven't seen that bear out in humans yet using them. But there is always a potential, even drugs like paracetamol that we think of as completely inert. Recent studies have shown actually it might have similar gastric side effects with ulcers and things like that as drugs like aspirin. So you never quite know, and I would always caution against using a drug unless you need it and it's medically indicated. So let's go down to the chemical makeup of what they are and how they work.

10:02What are they doing when they go inside the body? Why are people losing weight? So GLP-1 receptor agonist, so it's glucagon-like peptide. So this is a chemical that travels around in your body and it travels to these particular receptors. and it's these GLP-1 receptors that are being stimulated by the drug. So rather than GLP coming along, which is something that comes along when you've eaten a meal to tell you that you're feeling more full, to modulate your glucose responses, you're using the drug to stimulate those receptors. And it doesn't stimulate them quite as much as your natural GLP-1 might do, but it does give them that stimulation.

10:38So you're effectively just feeling fuller for longer? Fuller, quicker. Slowing down, in the case of drugs like Manjaro, probably the most recently added to the list. You're slowing down the gastric emptying as well, modulating how you control your glucose levels, so hopefully lowering those glucose levels, which makes it fantastic for people with diabetes as well. And yet what patients tell you is that they don't feel as hungry. And when they have a whole plate of food in front of them, whereas before they would have had the whole lot, they're often only able to eat half. And in terms of what they're eating, obviously some people I've seen on these drugs seem to be really conscious about trying to eat well other people just seem to be eating less of the bad stuff yeah I think that's what's so important is that when you're eating less and hopefully losing weight the aim of it you need to make sure that the less that you are eating is still nutritionally balanced because you don't want to just be eating less cardboard or less bad stuff and that's really important And I often talk to patients about how you keep an eye on your diet.

11:47And you still want, you know, it's still the same rules, but your proportions are just different. Which is fine if you've got a doctor who's leading you through this. But the amount of people who are able to get these drugs just through websites and, you know, online facilities, there's nothing there tracking them if they're doing it that way. No, it's tricky. And I think the people who've been successful in these studies are people who have done three things. They've taken the medications, they've modified their diet, which obviously the medications help to do, and they've been exercising as well.

12:15Because muscle wastage is one of the side effects. Yeah, and particularly as you get older, in the older age group who might be using these, then muscle wastage is a potential problem. And of course, your muscle weighs a lot, so you can be losing muscle. I'm thinking you're losing loads of fat, but actually it's your muscle that's going down rather than the fat. Stupid question, Lurt. There's no such thing. No such thing, Gabby. So it is purely you're eating less. There is nothing else the drug is doing in terms of eating away, you know, if that is even possible, at fat on the body. It is just about you consuming fewer calories.

12:49So, yes, you're feeling less hungry is the main mechanism. So, yes, you're eating less, but your metabolism is also affected. So there is that change in the metabolism, which is also helping. What, the metabolism is speeding up? Yeah, exactly. Right. And that's the GLP one, is speeding that up while making you feel sated. Exactly. Right, it's the kind of magic combination. You get this double effect, particularly with terazipi, which is manjaro. There's another molecule, a receptor that's also impacted as well as the GLP-1. So they've sort of increased that to try and get that slightly stronger effect.

13:20And on the exercise front, obviously, some people who are attracted to the idea of taking a drug for miracle weight loss might not be into exercise. How important is it that you exercise while taking these? for me it's important for two reasons one for the muscle wasting that we've talked about and to try and prevent that and you don't have to be going down the gym and lifting weights you know you just anything that's really carrying your own body weight is going to be really helpful so you can you know be doing that at home good walking jogging running anything like that but you're right for some people that that's really tricky the muscle element is is the first thing the second thing is that if and when you come off these medicines you're going to see and we've seen already in the early studies, you're going to see your weight starting to go back up again, almost inevitably, unless you've changed your lifestyle whilst you've been on them.

14:10And what I say to a lot of patients now is you need to write down what you're doing and what you're eating for a week whilst you're taking these medicines. And then you can look back once you're not on them and remember what it is that enabled you to be at that weight that you were happy with. And that's obviously more difficult if you haven't got your hunger and the food noise being switched off by the medicines. Yeah, let's talk about that noise because a lot of people have talked, I've heard talking about the noise inside that is this constant. In fact, actually, Oprah Winfrey articulated it really well because she's had great success on GLP ones and she's talked about this constant noise that was there in the background, which if you haven't got that, you probably don't relate to and you don't understand.

14:52But she articulated, as I say, very well about feeling that food was at the forefront of everything for her And the drugs quietened that down. How? So it's this sensation of satiety, you know, that feeling full that the drugs are able to give you. But even when those people were full before, they'd still be thinking about the next meal. And it is all related to the pathways in the brain. I think we don't fully understand yet. But what... It seems like there's a lot we don't understand yet about these drugs. No, there still is, I think. And that's what always slightly worries me when you take a drug, if you're a patient taking it.

15:30We don't know. But that class has been around for a long time. So why do we not prescribe it to alcoholics then? Because that would quieten the noise for alcohol, would it not? And quieten the noise for that kind of feeling that they're never sated when they want another drink. Would it not work in the same way for them? I think the alcohol receptors are probably slightly different, but you're not wrong in that a lot of patients say one of the things they really notice is that they don't want alcohol. It's not that you can't drink alcohol, you don't have a nasty reaction if you do have alcohol, but people just don't feel like alcohol and don't enjoy drinking alcohol.

16:03So I'm not sure whether in terms of alcohol dependence, you've got an increased amount of alcohol receptors, which probably won't be affected in the same way by the medicine. But I guess it's another sort of potential avenue. All the time, these drugs are now being... You start off with the endocrinologists and the diabetes specialists, who are loving new thronging. Now the cardiologists are talking about them, the renal physicians are talking about them. So they are becoming more and more widespread and the benefits are being seen to be huge. It's not an area I know that would be your area of expertise, but I've also heard conversations in the sporting world about how they would be used for certain sports where people have to have a very lean body mass and how you would use them there, which then it kind of does it cross the line of being an illegal drug for sport.

16:50The advantage of being your own. Yeah, the advantage, yeah. I mean, there's a whole kind of moral debate to be had there, isn't there? Because certain countries would have greater access to those drugs than others if you're looking at a global kind of... Yeah, and the expenses, you know, not insignificant. You're looking at, you know, a couple of hundred pounds a month, probably maybe more for depending on the dose that you're on now. So they're quite expensive medicines. But the benefits for people who really need to lose a lot of weight and, you know, going forwards would save the NHS a lot of money if they're losing that weight in the first place.

17:19And that's why I think the sort of higher tier weight loss services have embraced them because that long term, you know, the cost calculations have been done by the people who do that stuff. And yes, the reduction, if you can stop somebody having a heart attack or reduce their chances of having heart failure or a stroke or even perhaps dementia, according to some studies, then you're... How do we know? If there are no long term studies, how do we know about dementia then? So all of these things are over relatively short periods of time. But I suppose a lot of these things come from a similar underlying vascular process.

17:53So things like vascular dementia, your heart disease, your stroke, irritation, inflammation in the arteries, then the narrowing of the arteries, then little bits of blood supply being blocked off. And they seem to be having some sort of benefit in that area, probably related to inflammation. so the downsides some of them we don't we won't know necessarily for a few years because long long-term studies will come out but in terms of the immediate kind of impact of putting the drugs in your body what what kind of things do people complain of as being something that they potentially can't continue on the glp ones because of the number one is sort of gastrointestinal side effects so feeling a bit sick nausea often people say they feel a bit like they're a bit hung over a bit like morning sickness if they've been pregnant before.

18:37That kind of feeling is the sort of number one side effect that people get. Upset tummy, constipation. Those tend to be the things. For some patients, it's resulted in them stopping. Often they settle down after a couple of weeks of using them. Remember, there tend to be a weekly injection. So, I mean, that's a slight drawback in these sort of things is that, you know, once it's in, it's kind of in for the week. So if you're having bad side effects from it, then you may well be suffering for a few days, if not a bit longer. But most people are finding that they get some of those side effects and some people have no notice at all.

19:15I think the other thing is that the dose is very variable for different people. And some patients will have a very small sort of starting dose where we tend to start people. And they then find that actually then, you know, they're not affected by it at all. they've said they still feel as hungry as they ever did and it's only when you increase that dose that they get the benefit and we see a lot of patients who need to get up on the dose because over time your body becomes used to that medication so you need to have a slightly higher dose so thereby there is a sort of top dose of sort of seeding you can't have more than that at the moment anyway new drugs may come out which have stronger effects I'm sure because everybody's working hard on this to get into this race but the and of course people who have been on similar monoclasses of drugs for their diabetes for maybe many years and not necessarily people who have got a low BMI.

20:06So that at some point that people do start to eat through and eat through that medication. So the lifestyle change around it is the critical element, I think. And if it can be a crutch to that, then that's brilliant. And if you can be on it, you know, we're talking about how long you should be on it. If you can be on it long enough to change some habits, then for me, that seems like the best way to use it. So are we at the stage where there is a tablet yet or are they all still jabs? Because I heard a tablet was coming down the track. Yeah, so there are some versions. So you can, semaglutide you can have in a tablet form.

20:37That's a daily tablet. So patients, it's a patient's choice, I guess, as to whether they, some of the tablets, you have to be a bit more careful with how you take them on an empty stomach and you shouldn't have anything else. So it's a slightly more restrictive practice. Slightly more restrictive in that sense. It's interesting with injections because people who are initially quite hesitant about it, normally once they've done the injections, I think I've had nobody, whenever I've prescribed it, who's come back and said they simply can't do the injections. If they're kind of up for doing it, it's very, very easy to give yourself an injection.

21:08Is there an age limit at either end, do you think? Or is there, or should there be? So officially, I don't think there is. Whether there should be or not, I suppose it depends on what you're doing and what function. I mean, can you foresee a world in 10 years' time where primary school children are being given these jabs? Yeah, at lower age, I suppose. I was thinking upper. I suppose it's very possible, yeah. I think in terms of licensing for children, then you've got to have some of that long-term data to really see. And of course, giving any drug to children is more difficult because you've got to first have the approvals to do the trial in that age group in the first place.

21:50But I think potentially either the drugs that we have now or similar versions that come down the line, if we can manage the sort of obesity epidemic that we have in a better way, that has to be of benefit to the NHS, the cost, the health primarily of the nation. And at the other end, because you're about to start at the other end. And on the other end, I think like anything, in sort of elderly care, and I look after a lot of elderly patients as well, I think it very much depends on that individual's function. There aren't restrictions on the drugs in terms of things like poor kidney function or poor liver function, which are things that often limit what we can give people as they perhaps get older and their kidneys aren't working so well.

22:35So there's potential there. Of course, things like muscle wasting may be more likely to cause problems as they get older. and any sort of any side effects can be worse as you get older as well and we so we have to sort of balance that and then also there's the kind of prognostic benefit as well you know a bit like taking a cholesterol tablet if you're if you're 94 is it worth starting a statin to reduce your cholesterol well then maybe not so and and and the other thing that anecdotally because so much of this stuff is you know what you read or you hear and this was quite early on actually i remember hearing people talking about the feeling of kind of being a bit and not having much enthusiasm and it kind of zapping a little bit of that joy almost in life now whether that was just psychosomatically related to the fact that they previously got a lot of joy out of food and maybe that connection had gone or whether the same thing that sates your your hunger is sating your desire to go and do things and go out i don't know but have you heard about that it's not something that i hear a lot about from patients that I speak to.

23:41There have been some studies looking at mental health and increased risk of depression and suicide on the drugs. And they haven't borne out any sort of significant reduction in a sort of measurable sense. But I suppose there's that element, isn't there, that you're, I think there's still a stigma attached to these drugs for a lot of people saying, you know, that they don't feel confident in telling people that they're on them, they're at a meal and they feel a bit awkward about the fact that somebody who knows them well might have thought they would normally eat all of that and actually they were only having a little bit of it people worry about their friends as well when they're suddenly losing weight you know rightly so unintentional weight loss is is is something that we worry about as doctors a lot so i think there's still a stigma attached to them i think the increasing health benefits that we're seeing from them are is helping to reduce that though i i think there seems to be a much better understanding now that you can you can take these and have huge benefit from them so that that kind of sense of, oh, you know, I don't feel like doing very much.

24:42It's making me feel a little bit joyless. That's not something that you've heard much of. Not a huge amount. No, no. Would it be fair to say you're a fan? I would say I was a fan. Yeah, I think I'm a fan in the right situation. I think I wouldn't be ever prescribing it to somebody who had a normal body mass index. and you've got to have a good reason to go on to any medicine. And that's the same with these sorts of medicines. And I think that's helping with the stigma. As they become more of a medication, the NHS is recognising them. They move away from being more of the kind of aesthetic, almost like a beauty product, if you like, into being an approved medicine.

25:23And as we see, hopefully, more of the research coming through and of the benefits, I think that will become ever-increasing. So they're not going anywhere, are they? They're just going to get bigger and bigger You're a more pharmaceutical company. I think if I ran a drug company, I would be working hard on the next one. But then, of course, with every kind of new phase of drug that comes along, another drug is not needed anymore. So it's all kind of swings and roundabouts, isn't it? If you're losing a lot of weight, then you no longer need that particular medicine that was helping you with your knee pain.

25:49Yes, it's true. You may, yeah. You know, the knock. That being like a turkey boating for Christmas. It's not called Big Pharma for nothing, is it? No, exactly. No, this is true. So, yeah, I suppose there's always something else for them to be working on. But certainly, you know, I think they're doing pretty well out of them at the moment. OK, well, we've exhausted GLP ones. And certainly you've been very, very generous in sharing your knowledge on that. A couple of little kind of questions that have come through about immunity at this time of year, particularly. It's obviously flu and cold season and Christmas parties and, you know, all of that just breeds germs.

26:23So what are your top tips on making sure you don't catch those seasonal diseases? Well, it's avoid the colds and sneezes, really, the coughs and cold people. Most of these are viral infections, so they're being spread by droplets, airborne, as we all learnt far too much about. Masks on, everybody? Well, I think it's not a bad idea if you're going to... Party? I hate the idea. It's not exactly the ideal party vibe, is it? But if you're going to see somebody particularly who's vulnerable, who's elderly, who's got an issue with their immune system, all those things that we got quite used to thinking about during the pandemic, then yes it is because you know flu particularly can be really nasty got some nasty strains of flu around at the moment um and for more vulnerable people they can end up in hospital you know it can definitely ruin christmas new year celebrations all of the things people have had and and worse you know if people get really unwell with these things so i think it's about sort of being considerate and and you're more you know wearing a mask gives more benefit to other people actually than to yourself so it's it's more useful if you've got symptoms and you want Are you surprised it hasn't become more commonplace for people?

27:25Because I know when we travelled to Japan about eight years ago and we saw people wearing masks and it was explained to us by a guide we were with that this is more about courtesy. The person had a cold and didn't want to spread their germs. And then, of course, Covid comes along and we all start wearing masks. And I thought, well, maybe we'll kind of go the Japanese route and we'll start being, you know, kind of considerate to other people and not spread our germs. But it just doesn't. I mean, I was in a hospital the other day and I saw lots of the doctors and nurses wearing masks. but it generally is a very rare sight to see somebody on the tube in a mask.

27:55Yeah, it's interesting that it sort of culturally hasn't taken off, is it? Yeah, came and went. And, you know, it does put a barrier to communicate. You know, there are lots of problems with wearing masks other than just the sort of fashion nastiness of it or maybe it could become a fashion mask. But I think we don't seem to culturally have fully embraced it. And actually it's almost a sign, isn't it, if somebody's wearing a mask, either yes they're being very considerate or perhaps they are somebody who is themselves at higher risk but is having to travel on the train or take that risk and trying to protect themselves.

28:26I think you often see people sort of giving people a slightly wider berth which is probably the right thing to do. And any kind of quick tips to wellness if you are suffering right now listening to this? I think you've got to look after yourself at this time of year. The biggest problem we have is that everybody just go, go, go, go, go is in this time of year. When it's too late though you've already gone right you've gone yeah you've gone so no really there are all of the things that you can buy in the shops are just masking over the symptoms until if it's assuming it's a virus until that virus burns itself out but they do help you know you can feed a cold star of a fever is that rubbish yeah i think so so nutrition yes it's really important good nutrition you know chicken soup people always talk about actually some scientists did some studies looking at the effects on the little hairs that beat the viruses and all the gunk out of your nose and if you put chicken soup on them.

29:13And in the test tubes, they found that there was perhaps a potential improvement. So put chicken soup up your nose? No, no, no, just drinking it. But having it and the effect of some of the chemicals within the chicken soup might be useful to the immune system and to those. Heating your body up? Sort of sweating it out. I think no, not a good idea. Oh, OK. God, I always tell my kids, go sweat it out. Pop on another fleece and go for it. No, hot bath, really hot bath, or get in a sauna. You've got to be careful if you've got a fever because you don't want the fever to get too hot. No, but if you've got a cold?

29:41No, OK. I think not a lot of evidence. It's terrible mothering. There's the sort of old wives tell about going out with wet hair. These are, of course, viruses. So you're having a wet hair. Potentially some studies, if you are cold, then the immune system might be a little bit worse. So trying to keep warm, keeping well hydrated, good nutritious food, all of those things are important. In advance of all of that, at any time of the year, something that's come up quite a bit actually to do with midlife, women particularly, is vitamin D, because they can be quite deficient as they hit menopause and perimenopause.

30:13But vitamin D is something that I think people probably should be taking a lot more of, shouldn't they, in terms of immunity? I think of all the vitamins, and when you go into the supermarket, there's a big aisle, right? The vitamin D is the one that is still recommended by the NHS for all the autumn and winter months. We don't need sunlight on your skin to get that, and we just don't get enough of that here, certainly in the UK. if you're covering your skin a lot, if you've got darker skin, if you've got, like me, really pale skin and then you don't go out in the sun too much. So all of those reasons, many people, and as you say, as you enter into the midlife as well, often people are more deficient.

30:46And that is involved in the immune system. So having normal levels of vitamin D is really important. I don't think, you know, there's a lot of talk if you look on the packaging of various things, of sort of immune boosting with various supplements. Boosting the immune system is not really something you want to do. So you want it to be functioning at its perfect level. You don't want it to go into overdrive because suddenly then it starts. That's when you get this sort of autoimmune type conditions and attacking your own body and causing damage because it's working too hard. So you want to support that immune system.

31:17And you have vitamin D, particularly in the autumn winter, is really important. You mentioned your albinism there. And I imagine you have to take vitamin D to you all the time. Well, I should. Whether I do or not. Oh, OK. And your documentary I mentioned in the introduction that you did in terms of the prejudice towards people with albinism in East Africa. How is our society, if you're a young person who is born with albinism, in terms of how people react to you? What did you find as a kid? It's very different here, obviously, to Africa and lots of places in the world that there is severe discrimination.

31:52And I guess part of that comes from if you are a white Westerner in London where I live, then I haven't had too much discrimination. But over the years I've had people on the road swearing at me and calling me an effing albino. It's not been without. It's certainly not as there are in parts of East Africa. Do people understand the kind of things, the condition, if you like, and the things that you are and other people are living with? No, I think the understanding is a lot less actually here, even perhaps than in parts of East Africa, where there's a big drive on education and actually many more people living with albinism.

32:33In the UK, only about one in 17 ,000, one in 20 ,000 people has albinism. And for most people, albinism will affect both their eyesight and their skin and their hair. So I guess what you see is the white, pale skin and hair. But actually the bit that inhibits me all the time is that I'm severely visually impaired as a result of that. And because you need pigment at the back of your eye, a bit like a sort of old-fashioned camera, to stop the film becoming overexposed, it needs to be dark at the back of your eye so you can get a nice focused image on the retina at the back. And if you don't have pigment there, you have that lack of melanin, then...

33:06But you're not wearing glasses, so you always have contact lenses. But my contact lenses will only bring my eyesight up to a certain level. So I still am very impaired, even in spite of it. But I guess I've been lucky that, in a way, it's a condition that I've had my whole life. So I was born with it. My eyesight's stable from that perspective, aside from the sort of normal ageing bits of eyesight. But it means that I think if you had normal eyesight and then deteriorated to the level that I have, it's much more noticeable and much more difficult. So is everything a little bit out of focus? Yeah, and even that's hard for me to say because I don't have any comparison.

33:47Distance is the most difficult thing for me. And I was always, I can get close to things I can normally manage. But I like to have things sort of nicely enlarged. There was a huge worry when I applied to medical school. In fact, the first time I applied to medical school to become a doctor, I was rejected by all of the medical schools. And I'll never know for certain if that's because I had albinism. But I highly suspected that it was. And, you know, it's a highly competitive environment. And I think perhaps in those days there was less acceptance of people with a disability wanting to be a doctor.

34:17And I was always really clear that I wanted to be a doctor who could do everything in a normal way. You know, I appreciate I'm not going to be a brain surgeon. But, you know, I never wanted it to be something that I even really had to talk to my patients about. And that's just my sort of personal approach. And that's really happened, I think. And so only one in 17 ,000 babies in this country were born. So it really is very rare. Yeah, it is very rare. Is it a recessive gene? Yeah, autosomal recessive. So you get one gene carried by your mother, one gene carried by your father. And that could be generations back?

34:51Yeah, it could do. Because if you just carry one copy of the faulty gene, then you don't have any symptoms at all. So you might have no idea. And neither of my parents had albinism. No one really knows where it came from. It was probably just a mutation at some point. And neither of my children do. I was really keen when we started that sort of process to, my wife doesn't have albinism, so we went to see a geneticist to kind of look through the risks of it. And it's sort of, it's quite fascinating when you start on that sort of journey and thinking about the impact that it might have. And I remember the geneticist saying to me, well, you're telling me you don't want this, but you're also telling me I've just passed this exam to be a doctor.

35:33And it doesn't sort of sit right for some of these people. but I think you know when you have a child you want them to be as healthy as possible and for me yes I've managed with it I think I was really fortunate I had very supportive parents I had the sort of right upbringing to help support me do it for lots of people I've met with albinism in this country abroad you know the story is really different and they feel very stigmatized it's had a huge impact on their mental health physical health might be impacted as well with just the difficulties that they find with living with a relatively invisible disability, I suppose, because people often don't know that you can't see properly.

36:15I'd often be on the ward and reading something closely and a helpful nurse would say, oh, you need to get some glasses. And it might have been somebody that I've worked with for months. And for me, I always wanted it to be kind of lower down the list. I wanted it to be Oscar first and then I'll be... But then you go and make a documentary about it. And then I just, I couldn't not. No, of course. And actually that really helped me because I then had to talk about it. Yeah. To talk about the documentary. And I would regularly, I guess not lie, but maybe a slightly white lie. If people stop you in the street or at a coffee shop and say, oh, are you albino?

36:51I just often felt it was easier just to say, no, I'm just really blonde. And I just would do that. I just don't want to get into this. It's not really your business. You wouldn't walk up to someone and say, oh, are you diabetic? and then I did this documentary and I just talked about it so much I suddenly thought actually this is who I am I can't change it and you're doing such amazing things you know managing and I felt like then actually I should be someone who does talk about it in that position and try and help to break down some of the stigma attached to all sorts of disabilities well thank you for talking to us about it today and GLP ones in particular but also ways to boost our immunity.

37:31So, Dr. Oscar Duke, thanks for coming on The Midpoint. Lovely to see you. Thank you.