How to Prevent Diabetes...and Should You Care? | Bad Medicine Podcast Ep. 2

Well, this was a great episode. We talked about a topic that is so important to me, type 2 diabetes and insulin resistance. We talked about the importance of exercise, diet, all the different lifestyle things. But we also paid attention to why it's important to educate yourself about type 2 diabetes and insulin resistance. So I hope you enjoy it. And our next episode is going to be about CGMs. So I'm looking forward to that. Dr. C. It's in your wheelhouse. I think we're going to really have fun talking about CGMs.

I had a blast with this one. We didn't anticipate it, but we ended up talking a lot about how these conversations go in practice. So with social media, Instagram, et cetera, you do see a lot of things like fear tactics, black and white thinking. And I think it was useful to talk about as a practicing physician. What are these conversations, how they can look different depending on the patient, depending on other factors. And I think that is not content I've seen, so hopefully people find it valuable. Welcome to Bad Medicine Healing Medicine. One episode at a time.

I'm Anusim board certified functional health coach.

And this is Dr. Nicholas Cannell, board certified family medicine physician.

We believe in the importance of lifestyle factors, evidence based medicine, and moving beyond symptomatic treatment to true healing.

Our mission is to empower you on your journey to optimal health by demystifying healthcare and guiding you through the vast sea of wellness information.

We help you ask the right questions, become more knowledgeable about medicine and build a good relationship with your medical team.

The Bad Medicine podcast is for informational purposes only and should not be considered as professional medical advice. The views expressed are solely those of the hosts and guests. Enjoy. All right, where shall we start? Let's recap our last episode.

So, last episode we talked about alkaline diets, the good, bad and ugly. And we really went into quite a bit of detail there and we talked about sarcopenia, probiotics and sarcopenia. What else did we talk about? That was a good episode.

Yeah, yeah, the probiotic stuff was super cool. I was just looking. One of my favorite probiotics is discontinued. The market is just getting totally shifted and yeah, you find one and then it's gone. It's interesting where it's going to go. Our probiotics, have we seen the heyday and they're now on the decline. And is it prebiotic, postbiotic and psychobiotics? And yeah, there's a whole. Are we in a post post prebiotic world?

I'll tell you Just having done the research for my book the past two years, the one thing I will say the takeaway for me has been look for all of your probiotics through food, as the food is a supplement. Because there are so many variabilities with probiotics and I have a very hard time telling my clients, this one's going to work for sure.

Companies are not going to very much like this advice.

No.

They've got other supplements to sell.

Yeah. But I think for, for me, what I like telling my clients is it's not about the brand, it's not about the probiotic itself, it is about the strain. So you really have to kind of educate yourself about which train is going to work for you. Let's say BB lactose, you know, 12. That is a fabulous one. It's got a lot of research behind it for constipation. So my clients with constipation, I say, hey, why don't you try Nancy's yogurt, Greek yogurt, that has that, you know, as a baby lactose, that's a good starting point. So in other words, I'm saying don't go grab the first supplement, but try food. And then if you need some extra support, then there's so many things that are important, like how is it going to colonize? How are you storing it? What kind of strain are you looking at? Is it single strain or multi strain? There's so many things to think about when you're telling a client or a patient about probiotics. That's the tricky part about probiotics. I prefer to say, let's just start with prebiotics. Let them do the job of feeding your bacteria so much.

So we shouldn't just recommend patients buy the flashiest, most expensive probiotic with the highest number of strains and the highest colony counts.

I mean, it's not that I haven't done it, I have, because we're all kind, we all buy into that. Right. Like someone's shouting on just, wow, this is the best thing. And your blood sugar is going to be perfect if you did take this particular strain, especially like a keystone species, of course you want to believe that and you want to try it, but so far it hasn't been like, wow, this is a game changer with psychobiotics. And I've seen that certain things like Lactobacillus plantarum, I think it's 299v certain things. I've seen quite a few of my clients with anxiety and when they take it, along with whatever it is that their doctor prescribes. They feel very differently on it. So again, it's really not a. I've.

Seen those studies like anxiety and probiotics.

But there are new ones coming out all the time.

I didn't know this new name. This is amazing. Psychobiotics. Is that gonna stick? I don't know.

Maybe. You know, we'll come up with a.

Better one, I think.

Yeah.

I also have to ask you, is higher colony counts just generally where you go or is too much? I worked with. This is a long time ago, an attending who said that whenever he used probiotics, he just looked at the serving size on the label and then he took four times as much as it said on there. That was like his advice, which I thought was hilarious. Yeah, I think he was factoring in that a lot of it gets killed in the stomach acid. And this is a long time ago before they were like that. Aware. Maybe they were aware, but not as good at trying to regulate.

I don't know if that's changed because even now we're thinking about colony. How many are there? All of that? Because you're right, it's going through the gut. It's going through. How many of it is going to get killed? How is this preserved? Is it refrigerated versus shelf life? All of that makes a huge difference.

Shall we proceed along news of the week? All right, well, this news of the week is that Dexcom has released an over the counter, the first in the United States continuous glucose monitor, or cgm. It's a big deal. They said it wasn't going to get done by end of summer, but I guess technically they just got it done. I'm getting ads for it already. I'm watching the US Open tennis and I'm getting lots and lots of ads for it. And what's the big news other than the CGM itself is the pronunciation. So it's Stello. And I thought it was stylo this whole time, as I, I know the, the rep comes to our office and brings us G7 samples. And she said it was Stello. I don't know. What do you think of this?

You know, I, I met a Dexcom rep at the airport and so I said, and I said stylo. She said, no, stilo. So now.

Oh, they said Ste. Yeah, they said stilo.

Stilo.

No, it's Stello. My grandmother's name was Stella. So now it's. I'm like having this weird, like Stello. What is. It's like a male version of the name Stella. I don'. And then Abbott is going to come out with lingo. So that's what we think it might end up being Lango. We don't know.

We have to be prepared as long as it's doing what it's supposed to do.

And then there's Rio, which could be Rao or. All right, that's the news of the week. Interesting clients, patients from the week. Lessons learned.

So I had a client struggling with constipation. And one of the things I'm big on is gut motility that got the transit time. So. So I was really curious about hers because of all the symptoms. I said, let's just do an easy test. Let's see. Let's have you take some sweet corn and see how long it takes for you to pass it. And I didn't hear for her from her for some time. And then I said, hey, what's going on? How I still haven't seen it. So that was like day 10 or 12, and I was like, getting a little nervous. I said, where the hell is the corn?

You know?

And finally she texts me on day 27. I saw it finally. So I'm like. I had never had that happen to me. It's like, usually either like, malabsorption, it passes very quickly, or maybe a little late, like maybe four or five days. And usually it's 24 hours that functional doctors say, okay, that's a good time. I don't know what the. What. What it is in your world when you look about, look at.

It's very broad. Yeah. It's. There's not a. You have to do something.

Yeah.

Cut off.

As I'm aware of, motility really fascinates me from a micro. Microbiome perspective. Dysbiosis. Just so many things. Right. So this is just completely flummox me. I don't know where to go with it.

You know, I'm gonna throw something at you that maybe will get your juices and your wheels spinning.

Yeah.

It's a story from residency at A child ate a. It was a glass or a light bulb or something like this. And they came into the hospital on my pediatrics rotation, and at no time was the kid anything but completely fine. Like, outward appearing in the hospital, admitted playing, and like, totally fine. But we had to check X rays every so often and watch the glass because it showed up move through the intestines. But here's what was interesting, is that when the glass hit the cecum, which is a part of our intestines, it's kind of like a bulbous large area. It kind of stopped. It kind of stayed there. And the kid kept having bowel movements. So. Yeah. So it made me think this. It may have just been like, on the wall in the corner. And technically, yes, it is a motility issue. The cecum wasn't getting a good flush. Or maybe it was more dieter. Maybe the hospital food and no fiber. I'm sure it didn't. But that got me thinking tangentially. Biofilms, right. You can think of. Can things almost trap. Yeah, Things in the. In the wall and make things just less able to come out. And it was days. I think we actually discharged the patient with glass. I could be wrong with the glass still, because it was like. It was absurd. You were putting the kid at risk of infection. Just being in the hospital, encountering us.

Corn is a lot safer corn.

That would be.

Yeah. I've done beets, but I don't have too many clients who really like beets, so it's a really tough one. Oh, I don't want to eat beets since. So beats is easy. You see the red? You know, it. You know, it's okay.

Yeah. So it makes me think is if she kept having normal bowel movements, perhaps the corn just sort of get sludged up in one area they seek them or another area and it's just not passing. And is that maybe where, you know, that's the problem rather than. Or did she not have a bowel movement for like.

Well, no, she didn't have a bowel movement that was really, I would deem as satisfactory. Yeah, it was like she was really backed up and like goat pellets. That's really straining. So. Yeah. And all the other symptoms. So that's what kind of made me feel like, oh, I really have to dig deeper into this, you know, so.

Cool.

Cool.

All right, what are we talking about today?

Our favorite topic.

All right, let's do it. Okay. So the topic of the day is going to be about type 2 diabetes and prediabetes, because that's really the best time, in my opinion, where you can intervene and make a big difference for people. So I believe Anew has a couple or some numbers on prediabetes that kind of shocked me when I heard them tell us this.

Yeah, I mean, you know, a lot of my clients come to me because of either diabetes, type 2 or pre diabetes, and I'm thrilled that the doctors have even identified that it is time to take action because so many people don't even know that they're pre diabetic. One in three Americans are pre diabetic. I want to say that again. One in three Americans are pre diabetic.

Wow.

And I wonder how many know that they are pre diabetic. That's, I think, the bigger question. If we could somehow get awareness, education, empower them with knowledge on how this is a lifestyle disease and we can change things so they don't have to be full blown diabetics. Imagine, I mean, that whole scenario is going to completely change in the States.

In my practice, there are some people who have extra weight diabetes in the family. You tell them they have an elevated hemoglobin A1c, which is the most common test we use, and that it's consistent with the prediabetes. They're not really surprised. Shocked you didn't just drop a huge bomb in their life. I have patients who are normal weight, no family history, who have this. Patients who have normal blood pressure, normal cholesterol, pass their checkups every year, normal fasting glucose. And it really is missed quite a bit. And obviously we can talk about the reasons why it's missed or whatever, but that's really the big thing. I have patients in mind right now. They're in the gym and they're working on their diet. They're, they've been told, have your glass of orange juice and oatmeal every morning, American Heart Association. And I feel like they feel feelings of betrayal, feelings of. It can carry a lot of emotional weight as well. Because that word diabetes, some people is like, what is that? What is diabetes? But to some people, the word diabetes is like itself. They think of their friend losing a toe or a foot or having to go to dialysis. Dialysis can be so emotionally heavy to even think about it.

That's how it is for me. I just have largely, almost everyone on my mom's side is diabetic. I feel like it's a huge win for me just not being diabetic. So I just put a lot of, I pay a lot of attention to that. Like the CGM that we're going to be talking about, Nutraceuticals to help me kind of balance the blood sugar really constantly in search of the next study that's going to tell me something different other than saying stop eating all carbs. Not happening to this Indian. So, and which really by from studies that even just a study that came out a few days ago, they compared low fat versus low carbohydrate diet. First of all, I think in pertaining to obesity, but Then again, obesity is connected to type 2 and they didn't see a huge difference.

I saw the line, I haven't read it yet. I'm very curious.

So that was like. Immediately I was like, okay, let me greet my beans. Let me. Yeah, it's a tough one. And you're so right. There are people who are just too paranoid about it. That's all they talk about is blood sugar, as if it's the only thing that matters. Like you said, going to the gym, like insulin resistance, talk about that all the time and forgetting about everything else that makes up our health. Then there are others who live in blissful ignorance. Like there was a construction guy who came to a house and he looked like he could be type 2. The obesity, the sweating. And it was summer. Who's wearing like a tank? I saw dark armpits. I said, I'm always thinking, could that be the insulin resistance? And the sad thing was he dropped dead, like one week later. He was just out with his friends, he had a massive heart attack and he died. And something like that. I always wondered, what if he had known more? What if he had someone had educated him about his health? So there's both. I'm like, paranoia and also the ignorance. Both play a part, I think.

Yeah. Or at least the opportunity to know more. Being given an informed decision. I do have the utmost respect for the patients who understand that they're receiving bad health information and choose to not make changes. But fully understanding the risks. And you have to really make sure someone really understands and accepts the risks, which a lot of people, people aren't willing to. But you gotta respect that. But yeah, you gotta at least get to the point of having an explanation. To some people, their health isn't that important. And obviously it's really important to me. And it's like what I do for a living. But that's a big part of the picture too. When you think about the burden of disease. Doctors and public health people can think that health is top of mind for everybody, but that's just our bias. The goal is to get them to the point where they can make an informed choice. And hopefully they will make the choice to care about their health. But I'm going to be their doctor. If they. I've got patients and it's not a priority. I'm still going to care for them. I'm not going to abandon them.

And I think you're 100% spot on about that. It's. They may not recognize the importance of either the test or the education. At that same moment that you're sharing it. That does not mean that it's going to become relevant down the road. That's something that I've seen with my clients. Take ldl, for example. I have so many clients with high ldl even just pointing out that ldl along with. And high lpa, family history, all of that, you can only tell them that this is important. But if they're focused on something else, let's say they are focused just on weight loss. Okay. And there's no room for anything else for any other conversation to be had. You could say, this is really important and especially given your other markers, but there's no guarantee they're going to really listen to you. But the time will come when they will. And you just have to be patient, I think, with clients like that and say, okay, yeah, I'll wait.

Exercise and patience. People may not. One year, I may say, this is your hemoglobin. A1C is this. We should check in three or six months. And a year passes, we're having another annual. You're able to see my what? But maybe another year will come. And they'll say, I've heard of that. What is mine? And I'll flip the screen around. I'll be like, yeah, it's been high. We've talked about this gently.

I'll, you know, in my book, we've talked about this. So whole chapter on NCDs. And I do talk about diabetes, and I talk particularly about a client who just did not give up. It was pre diabetic. Then it went to type 2. Then he was on metformin. He didn't care. He continued to be heavy, smoking, all of that. And then finally his doctor said, the only way we can save you is you need to start with insulin shots. There's nothing else I can do for you. Light bulb. That's when all of a sudden he said, okay, I'm gonna listen. So some people need that much before.

Yes.

And there's no right or wrong. It is what it is, and we all have that in our lives. It may be something else that you and I are. Whatever, you know, because we are into health, we feel like we deem this as so important, but other areas we could be doing exactly that.

Use of a CGM or continuous glucose monitor can have that effect. Someone looking at their sugar hitting 300 once a day can sometimes get someone to make those changes on their own terms and say, oh, this is my data. I'm going to take control of my body rather than a Doctor Top down. But my other thing, my other hesitance about all of this, which makes it hard in my job is using fear to motivate people is really dicey. And when you talk about type 2 diabetes, I don't really have many conversations where I go, you're going to end up on dialysis. You're going to. I was trained that's and ineffective. But now we've got the CGM and we're look how high your number. You know, we. So this sort of giving people bad news. Obviously, we do that all the time. And then the line of I'm trying to get you to change. Using fear.

Yeah.

And navigating so you never get really over to that point, which I think is fool's errand usually sometimes works. Family members, actually. I see. That'll work. Like, oh, my. My significant other scared the crap out of me and now I'm.

Somebody else is doing your job.

Yeah. When someone else does the fear thing, I'm like, they're not wrong.

Okay. But you know, that fear thing is usually when they've seen family members, friends who really gone. It's really affected them. So then we don't have to do that. They come in knowing that this is really stuff that I need to take seriously. But if they've never had an exposure to that, I mean, what does diabetes mean anyway?

Abstract concept.

Yeah.

Yeah. Oh, it's not that common.

Yeah.

Oh, there's medication for that. I think in modern medical training, we try not to use fear as a tactic. But you do see it. You see a lot of the older doctors using it and I have used it sparingly on occasion, but only after knowing someone for a long time. And actually I've had several patients say, I like when you, like, talk to me like that. People want. They don't want you to be like, oh, it's like we can manage it and paint a rosier picture if it's bad. Some people want you to say, I'm really worried about you. Yeah, this is not going well. And I don't know, a first visit, a second visit, a third visit, that might be the wrong move. But, you know, your trusted doctor, five years, bit of a different scenario. So never say never on fear tactics. That's a byline.

And I'll tell you, my mom had an older doctor, it's probably in his 70s or 80s. I was on a mission to bring my mom's A1C down, so started having her eat like me, all of that. And her A1C was like, crazy high, like 10.5, something like that. So we were able to bring it down to a decent number. And so we go in to see him and he says, Iman's 91. What does it matter? Let her have fun. Let her eat her ice cream. He painted this picture like, just because she was 91, she could eat anything. And the interesting thing is, of course I didn't say anything out of respect for the doctor. But when I came home, mom said, did you hear the doctor? And to this day, it's been some time now she remembers what he said, said. Do you remember what the doctor said? You know, I don't have to care about it, but it doesn't work like that. You have something like a high A one C and your blood sugar is high. There's so many other ramifications from it that family members have to deal with, even if someone is 91. So somehow that was lost on the doctor. So.

Yeah, yeah, yeah, you're exactly right. You can end up in the hospital from complications of diabetes, which can be. A day in the hospital is traumatic.

Yeah. And to begin with, someone who's been severely diabetic has kidney issues and that can change your from a stage three to stage four. And sure enough, there are other problems from it.

And then maybe a new doctor or two.

Yeah.

And people who've seen a lot of specialists, it's one of the worst things. They like the specialist just fine. But it's now I got to get their appointments, their labs, their meds, and people really don't want to add more specialists. And that's where we talk about an informed decision. If you're going to give someone a decision like ice cream, no ice cream, when your A1C is 10, I think you need to say, here's a reasonable picture of what things will look like with ice cream, without ice cream. And have people make a decision based on that kind of guidance. Shall we get back on track? Anu, this is your time to shine. You were talking about the lock and key analogy.

Oh, yeah, yeah.

Excited to hear about it.

So insulin resistance is as important, I think, as a first step to learn if you have a propensity to being pre diabetic. So this is usually how I explain to my clients. I say, you eat something, the blood sugar needs to be taken to your cells for energy, and that's where the insulin comes in. It's released by the pancreas, it takes it to the cells. But sometimes think about the insulin as the key and your cells as though as the lock and key mechanism and it doesn't quite work. There's something that's jamming it. And when that happens, the glucose is not able to enter the cells. There's a lot of blood sugar in your bloodstream and causes a lot of problems. So, very simple explanation for insulin resistance. What do you think would be the next step to help someone understand insulin resistance?

Yeah, I think insulin resistance as a concept is generally fairly hard to get. The more I practice, the less technical I get. I see a lot of like blank stares. But many people are interested and they do find it useful to integrate this knowledge when they're thinking about, for example, looking at their numbers on a glucose monitor. So I'll tell them high insulin levels are bad for us. They're implicated in heart disease, cancer, dementia. Boom. You have that right off the bat. Oh, I don't want high insulin.

No fear here.

Yeah, exactly. I say with a smile, makes all the difference. And if the insulin isn't working, there's resistance to the impact, the effect. Then our pancreas has to put out more insulin. That's how we get these high levels.

Yeah.

And often it doesn't even work then.

Yeah.

And so the sugar doesn't stay in the range, the normal healthy range. The sugar starts drifting up and the insulin levels are high. You've got two things going on. People can argue which one's worse. I think I'm camp insulin this year. But who knows next year?

This is where a conversation about exercise could come in. Be very handy. Right. Just think about muscle cells and having that lock and key not quite working because you're sedentary or, you know, something like that. And just saying, hey, just a little walk in the morning, something to get yourselves a little bit more active. Would that be a good way to get them excited about ir?

There is one great way to get your sugar down that is insulin free, doesn't require insulin. So we can go kind of independent of all this insulin resistant stuff. And that is through muscle. So going for a walk, exercise will lower your sugar. Maybe for some people it's quite, quite a bit.

Yeah. You talking about that? Guys, any South Asians listening in? Just that little walk is not doing anything for us, I'll tell you that. I mean, these are based on some of the studies. We need a lot more. We need more strength training, anything to awaken the muscles. Because abdominal adiposity is huge in South Asians. And speaking of abdominal adiposity, that belly fat being metabolically active. Tell us more about why that. And Insulin resistance is such a big problem.

So maybe we should come to bmi. And why it's such a. It's helpful to some extent. But BMI misses where is the weight in your muscles? Most professional athletes are technically overweight. I've. I've heard someone could double check that. Or is the fat subcutaneous fat that you can squeeze? Some people say it actually has some benefits. This is sort of the healthy fat. You need fat, brown fat, and then there's the. Yeah, there's the fats in your abdomen. Think of like a taut beer belly that is surrounding your organs. Your organs need cushioning, but they certainly don't need this degree of cushioning. And this has a negative impact on our whole system. Everything. And it's intricately linked with our sugar, it's linked with the fatty liver. The list goes on. But those are like the two big ones.

Pro inflammatory. Right. So metabolically active really means that they're producing hormones and so there's chronic inflammation and that can up your insulin resistance.

Yeah. We took this blood test called a high sensitivity C reactive protein or just a plain old C reactive protein. And sometimes it's normals under 10, but an optimal will be under 1. And I have many patients where it's 2 to 4. So it's not scary scary. And I go through the whole list trying to figure out is it from some sort of infection or whatever. And sometimes after a while we just end up saying it's probably weight related.

Yeah.

And it seems to track with the weight and probably the visceral adiposity.

Yeah.

We don't have a great way of measuring this using insurance dollars.

And try glitching.

A1C. Yeah, yeah. Well, you have the DEXA scans which are.

Yeah, yeah, exactly.

One to 200 bucks. You can find these companies, they're willing to take your money and measure you. And then they've got the smart scales which are very inaccurate.

But it's a linear measurement. So kind of give someone a distance.

Something.

Yeah, something.

Yeah, you track. You can sort of see the trends. The trends are probably fairly accurate, but yeah, the Dex is the gold standard.

Gold standard so far. Yeah. Diet makes a huge difference. You know, when your diet is like a standard American diet with a lot of heavily processed, hyper palatable food foods that could be one of the reasons for insulin resistance. So just eating the wrong kinds of foods because all of these foods have no fiber and fiber is one of the most important things for the slow emptying in your stomach. So we'll talk a lot about fiber in the next episode or two. But our standard American diet, our western diet is so low in fiber. So that could be another reason. And of course, what do you think about stress? Stress? Type 2 diabetes.

And I think there's a big association there.

Yeah.

Cortisol is our main stress hormone and this is released by our adrenal glands. It's absolutely necessary and critical for life. If you don't have it, you are in big trouble. But I see the impact of cortisol all the time on the blood sugar. And I do this when patients are wearing a continuous glucose monitor. You can see it. I think one of the most dramatic examples I had was a patient was usually would wake up, Sugar was around 95, pretty stable, very unremarkable every day. And then there was this one day and it was like 1:15, 1:20 all morning. But I noticed that he wrote in the afternoon. He had a dentist appointment. He hated the dentist the whole day. His sugar was worse the whole day. And although this isn't, this is a one case, the food, the meals were higher. And I also see this maybe to a less dramatic extent, after a poor night's sleep that is a big one, we have higher cortisol the next day.

And I've actually seen that on the Dutch test where my clients have the high morning cortisols. Waking up is like super high. And then when they have, they're either wearing a CGM or they see those numbers are not. The morning numbers are really high. And then the postprandial kind of drops eventually when the cortisol. So this definitely a connection between cortisol and insulin, I think. Yeah, I heard someone call them like the sister hormones.

Oh, interesting.

Yeah. And you're right, sleep is super important because I know like when I'm wearing my cgm, I have a poor night's sleep. The next day, it's a mess. I'm not doing anything differently, but I think I am because poor sleep really makes you reach out to something junky. It's almost like, you know, because you're stressed and so you, you're looking for those hyper palatable foods to kind of ease some of that stress. So it's like the cycle. Yeah.

You can think of. I think probably most people have pulled an all nighter, whether it was for school or whatever situation. And the next day you might not feel completely exhausted. You feel like you're running on adrenaline and maybe your brain is feeling weird or you're craving different foods. And this is sort of the most pure Example I can think of when cortisol is in the driver's seat.

Yeah.

And let's say you only sleep five hours. It might not be as dramatic and obvious, but to an extent, that is occurring.

Yeah.

So I think that's one of the big takeaways for people who wear the glucose monitors is the massive impact of stress. And another example that. That unfortunately makes these consults I do tricky is when we see someone eats a meal and they have a big spike. And so the obvious conclusion to some people would be up, it's the food, whatever I ate that you got to factor in. How did that meal go?

Yeah.

Who was at the dinner table? What was the conversation? We got an election coming up. People don't get along. People are arguing. The food took a while. There was an issue with the bill. You.

Oh, you're watching tv. And I actually saw that attracted. You know, I was watching a cricket match and India was losing. Things were not going well with my cgi. I could tell you that.

Yeah. The glucose monitor doesn't tell you why it's high. It doesn't. So that's where there's some nuance in interpretation.

Looks like this is something our next episode's all going to be about. It's the CGM teaser.

Yeah, I like it. Recap in pearls. So today we talked about prediabetes, insulin resistance, type 2 diabetes, and really delved a lot into the psychology of how people think about their health and some of the different reasons. Some people are really motivated, some people are not motivated. And it's not just telling people the data, telling people about numbers, scaring the crap out of people. That's not how I work. I don't think that's. I would call that bad medicine.

Yeah, I would agree.

Yeah, I worked it in there.

Yeah, definitely. Yeah.

Yeah. And I think that's the pearl is for people may not see eye to eye with you, whether they're patients, maybe other doctors. People bring in their own biases, their own experiences. Some people. It's not the right time. Maybe it is the right person. Not the right time.

Yes.

And having patience with ourselves, patience with others, and being supportive of people whether they're doing well or not.

Yeah.

I think that's just a huge part of the practice.

And whether you're a doctor or a coach, it is a partnership with your patient or client. So it can't be on your terms or on. At your time. It is when it's right for the patient or client. So I think that's something that's really important.

So what to ask your doctor, how conversations should go? That's a loaded question. Let's see. So I think step one is do not assume that your fasting glucose is giving you the full picture. If you have a diet that's not great. High stress, family history. I think it is always reasonable to ask a doctor to order a hemoglobin A1c as a next step. If the hemoglobin A1c is high, I think it's important to not wait a full 12 months to get it rechecked. There are certain cases where that is the right move, but usually you want to do some sort of intervention, however big, however small, and then retest three or six months, and then that conversation is, how much time and willingness do we have to do something? And that could be simple dietary changes, more dietary overhaul, exercise. Maybe it's stress management, maybe it's cgm, yada yada. It goes kind of on and on.

I'm going to throw one at you. I mean, I had a client. I think she got her fasting insulin test did along with glucose and A1C and her insulin fasting insulin was pretty high. So I said, so what are the next steps? What did he say? What did your doctor say? Nothing. I only know that my insulin is high because you pointed out to me that's bad medicine.

Yeah, it's a bit of a mess, the fasting insulin levels. So, one, we cannot guarantee coverage by your insurance company for this test, But I personally have never encountered an issue ordering it. Two, I have been gently chastised by an endocrinologist that it has. It's more of a research tool and has no role. So that's occurred.

Do you agree?

No, I don't either. Yeah, they were nice about it with what they know and what they believe, and that's fine. I welcome that. It made me sort of say, am I doing the right thing?

And no, for me, the bad medicine is ordering a test and not following up on knowing how to not giving it the attention it needed.

Yeah. That leads me to point 3, which is the cutoffs. We put so much faith in these labs. Cutoffs. And they're often so wrong. The insulin one is a big one. So if you go online, go through studies, there's all sorts of different cutoffs that have been used to what's the normal insulin level? The normal insulin level at LabCorp is like really high. So a doctor doesn't order many of these, might say, oh, the cutoff says 25. And the insulin level is 30. That's mild. Something like that. Right, like that. That. That's how an error can be made. The other thing is we're probably the best way to handle the insulin level is to put. Put it in a calculator for homa IR H O M A I R with a paired glucose test.

Yeah. And it's free, guys. If your doctor is not doing it, you can easily find this online and.

Yeah, yeah. And that will give you a number that's a bit more accurate, reliable. There's still different cutoffs, but that you can see around there. And so yeah, I would call it bad medicine. To ever order a test that you don't fully explain for somebody or at least have a plan? Let's say there's a. It could be like, oh, a specialist should take a look at this because I really don't know that's a plan. It's not the best plan, but it's a plan. But yeah, I think you should have some advice. When you see that. And those numbers can be. Come out pretty high. I think I've seen the highest was maybe 50 something.

Oh my gosh. Yeah.

With a normal A1C.

That's when you really have to. What the hell is going on?

Yeah, it was drug from a drug. Yeah, sorry. Spoiler alert. So.

All right, so what's up Next episode.

Next episode we'll be talking about continuous glucose monitors. Why we believe in them. How they're finally entering common practice with the release of STELO from.

Oh, Stello. Yeah, I'm just going to remember your grandma Stella.

That's right. There you go. And I've got mine already ordered. I'm going to test them out so maybe that'll be an interesting thing to share as well. Yeah.