100M prediabetics in US. Most clueless. Don't die from ignorance. This video could save your life!

This is Dr. Tom Refai and we are going to be talking about the pandemic, certainly an epidemic in the United States of so called pre diabetes. And I'll discuss why I think that term is a bit misleading in terms of its already established risks of early disease and early death. But first, a little bit about me. I am a double board certified internal medicine and lifestyle medicine specialist. I have spent two terms on the board of directors for the National Board of Physician Nutrition Specialists as well as its president for a time during that board of Director service. And I have also been the regional medical director for metabolic health and weight management management for the Henry Ford Health System. And I am the architect of the methodology, the longevity lifestyle methodology called the Flex 5, which has been licensed now to Henry Ford for eight years to great success. So I have over 20,000 hours of clinical experience. One of my areas of specialty is a reversal or remission, if you will, of what is driving the diabetes epidemic in the United States, in the world, which is not pre diabetes, that's just a stage 2 type 2 diabetes. It is insulin resistance. So let's get into this a little bit, shall we? I'm going to share a screen and we shall get the show on the road. All right, now we have 100 million, almost 100 million. The last that I checked it was 96 million physicians, excuse me people, and many physicians, by the way, that have so called pre diabetes which we'll define in the United States and 9 out of 10 don't even know they have it. This is a real problem in primary care because screening is very easy and we're going to teach you how to know whether you do or don't have it and what to do about it in this webinar. Okay, so if you already know you have prediabetes, great, good for you. You're already acting upon it. Fantastic. Maybe you could just skip this webinar. But most of you are not going to know and we're talking on the order of well over one third of Americans having prediabetes, let alone far more who have insulin resistance. So let's focus now if I've got your interest, turn off all the distractions and let's get into this. We're going to learn about what causes most diabetes and the lab tests and the questions you need to know so that in the seven to at most ten minute visit for the average primary care physician, you're going to be able to ask what helps you to serve your health and your why, as we call it in this case, why you want to be healthy when you're with your primary care physician on those rare moments that you can get in. And if you don't have a primary care physician, I would suggest that it's probably a good idea. Maybe you have a screening fair that you can do these tests or a annual physical that your company pays for. It's a physician, but it's not your primary care doctor. I'm a realist. However you get these things done. I'm trained in primary care. I have a slight bias towards having a primary care physician without pretending that it's magic. Right. We've already discussed myself and specifically, I'm also the founding president and CEO of Reality Meets Science. We are a executive health coaching and digital health solution company. I myself am not just professionally experienced when it comes to metabolic health and lifestyle medicine. I have my own issues with binge eating disorder. I almost lost my life to binge eating disorder back around 2007. And sadly, in 2017, 10 years later, I did lose my youngest brother to binge eating disorder. But there's hope. I don't care how severe it is. If you are motivated, as you can see from my picture, and well over £200 at 19 versus a shot of me at 51. Now, I'm actually. I should do another one of those. I'm actually 55 now. Closer to 60 than 50. So you have hope. Trust me, can do it. You can do it. Right? The preterm. I said I was going to discuss pre diabetes. The term implies that the problem is not there yet. That is not correct. The fact is, and we'll talk about this a little later, that prediabetes really means chronic insulin resistance to the point that the pancreas that makes insulin has burned out, starting to burn out, and cannot control all of the insulin calories coming in mismatched versus the relatively low physical activity we get in the United States. Maybe I should just stand up for a moment out of the respect to avoid excessive sitting time. All right? A little squat every two, three minutes, you'll do 50, 60 a day. You won't even notice. Okay? So we're keeping our integrity here. Our accountability, one of the keys of the Flex 5. Right. What's really driving the insulin resistance, though, of course, is the food environment we live in. We live in a, as we call it in the Flex 5 crap that stands for, as you can see at the bottom, calorie rich, refined and highly processed food saturated environment. It's. It's unbelievable. I mean, it's it's such a mismatch with our human genetics, which are essentially the same as 10,000 years ago when there was such a lack of food availability that the design of a human to be impulsive in terms of eating anything calorie dense when available is totally normal. It's our environment that's all messed up. It is something you can control to some degree, though. We'll talk about this when it comes to the environment's key, particularly home environment, and we'll discuss a little bit about outside of the home environment, but skills and knowledge and environments and managing willpower, not trying to grow willpower, which, you know, can grow a little bit. I mean, once you identify your why and you really work at it, you know, it's like a muscle willpower can improve a bit, but it's really people who learn to manage their willpower and their energy that are perceived as having great willpower. You know, whether it's, you know, Steve Jobs or Senor Zuckerberg wearing the same black shirt every day, not wasting energy on that and conserving their willpower in a way that it looks like they have great willpower, but it's just they're managing what they have better. And you can learn those skills too. Okay? And remember that insulin resistance isn't just about diabetes. Insulin resistance, well before diabetes, well before pre diabetes, okay, can lead to full blown metabolic syndrome and increased risk of death. And we're going to talk about that. Many people just simmer in in insulin resistance and metabolic syndrome, a more advanced version of insulin resistance. We could say it could be potentially before even pre diabetes, you know, insulin resistance, metabolic syndrome, prediabetes and type 2 diabetes, for instance, and just at the level of insulin resistance, let alone metabolic syndrome, where you have issues of blood pressure and lipid or cholesterol issues and some abdominal weight that in and of itself increases risk of heart attack, stroke, cancer and dementia. The blood sugar issues come when you get to the point of pre, and particularly type 2 diabetes and ADD some other risks, and we'll talk about those a little later. All right, so what can be prevented, I've already implied it, By a lifestyle that has a low type 2 diabetes risk. Right? Low risk. Remember genetics? They load the gun, but lifestyle pulls the trigger. You know, and even epigenetics can be adjusted over time. So believe me, the issue that's driving the epidemic of metabolic disease is our environment. We can't just rip every, you know, golden arches or whatever else it is out of its roots and try to save Ourselves from the environment that's outside of our home. But there are things that we can definitely do inside the home, even in our work, in our car, and when we travel. But atrial fibrillation improved with lifestyle change. Chronic kidney disease. Just going to mention the things I haven't already. Multiple cancers, certainly breast and colon cancer, among others. Depression can improve with healthy lifestyle. You got to be careful not to be an extremist and have zero tolerance. So I'll never eat. Fill in the blank again. Doesn't work. You know, brownies, pizza, this and that. Now how often and how much. It's a different story. That balance, what we call the 5% fun zone, not the guilty pleasure zone or the cheat day zone, can be very much an excellent pressure valve release on the pressure cooker. You cook in a pressure cooker without a release valve, it blows up in your face. Fatty liver. Guess what about fatty liver? Something very important. Along with hepatitis C and alcohol, fatty liver is one of the leading three. And I think it may be taking the lead over hepatitis C, alcohol. The pandemic threw us for a loop. So probably the two in the lead for liver cancer and liver failure, cirrhosis. Liver transplant surgery is fatty liver, which is excess calories on the liver. We see this on ultrasound, on other imaging, on blood tests, before you even get to any blood sugar elevation. It's part and parcel. It's a part of the calorie overload syndrome, if you will, of metabolic syndrome and insulin resistance. It's almost majority of the time there when somebody has type 2 diabetes. Good news is, is that healthy lifestyle change and some healthy weight reduction evacuates fat from the liver pretty darn quick. Even erectile function can improve fertility in general, men and women. And whether it's through polycystic ovarian syndrome or otherwise, a lot of reasons for healthy lifestyle, therapeutic, if you will. Lifestyle, what we call tht transformative. A total health transformation. Excuse me, tht so prediabetes is reversible, if you want to say, put in remission. But we don't want to rely on any approach that just has a quick fix and that's it. There's actually nothing wrong with changing things radically and quickly in the beginning, as long as it's kind of staged like Star wars was followed by Empire Strikes Back, was followed by Return of the Jedi and then all the other ones. But to me, those three episodes, the only ones that matter, with that being said, it's if you have a long arc and you say, okay, I'm ready to Go fast. Great. It can be slow, it can be fast. In the end though, the skills and knowledge in all those five areas of the Flex 5, psychology, nutrition, physical activity environments and accountability are key to maintaining in the long run. Okay, so we're going to learn the truth on how to now reliably detect whether you're at risk and what stage of risk. When it comes to the arc of insulin resistance. It's resistant by itself. Insistence plus metabolic syndrome, insulin resistance, progressed to type to pre diabetes or insulin resistance all the way to the level of type 2 diabetes. Okay, and there are some other distractors. I wouldn't say distractors. Other types of diabetes mellitus that occur, we'll talk about a bit. That can be type 1 type or genetic type, but they're more rare. We already know this. Okay, you know this as well, right? You're going to know what to do and have the basics at least. And know that most diabetes in the world is type 2, 90% at least. We have head studies, randomized controlled trials comparing medicine to lifestyle. The most well known of all called the Diabetes Prevention program. Well over 3,000 people with prediabetes and metabolic syndrome randomized to either taking metformin, a drug that is well known be cheap and safe. Now we know can help reduce the risk of converting from prediabetes to type 2 diabetes versus placebo. But also then a third group, so 1,000 in each of the groups, placebo, metformin and then a lifestyle change group in which they were given support, education, skills and knowledge. And I wouldn't even call it the level of breadth of the Flex 5 pretty basic, but good, right? Maybe not excellent, but good, good lifestyle change support program where they were seen one on one and in groups for an extended period of time, typically like six months and then progressively less over time. But they really learned those skills. And the short term results of the Diabetes Prevention Program were impressive. The lifestyle group over about four years reduced the risk of diabetes by almost 60%, losing only 7% of their body weight. In fact, in that group, if you had lost 10% or more within six months. Here's the case for fast weight loss isn't an issue if it's a healthy form of it and it's part of a tactic built on a strategy. Reduce the risk by 85% if someone with prediabetes loses 10% or more of their body weight within six months of the diagnosis. If it's done in a healthy manner, like was done in the Diabetes Prevention Program or obviously through the the most superior, I would say method of all, methodology of all, which is the Flex 5 lifestyle. Now these are the five keys, if you will, of the Flex 5. And when you see mind matters at the top, just think psychology. Okay. They were talking about obviously mental health issues, trauma, depression, anxiety, binge eating disorder, etc and then mindset and mindfulness. Those three areas are particularly important when it comes to mind matters. You might ask why did you say mind matters instead of psychology? We just wanted to reduce the edge of clinical when it comes to lifestyle methodology. Does it have powerful clinical implications? Of course it does. Just don't want it to sound too medical jargony if you will. And then of course nutrition, which is flexible and individualizable and doesn't have any particular interest in a specific ethnicity. It's, it's not about Mediterranean or, or Latino or, or Asian. It can be any of those. Because the nutrition principles of the Flex 5, those five principles, arguably 8, 7, excuse me, are transcendent to any type of ethnicity. You can put whatever spice you want on it. Of course, physical activity, we'll talk more about that. It's not just exercise, by the way. No, notice I didn't say the word exercise. It's activity, much of it being non exercise activity time. And then of course environments which we mentioned. And then accountability. Now that accountability has a wide range, could be anywhere from faith in God to a Fitbit. Either way, the five here and the skills and knowledge in these five domains are the most distilled domains of achieving long term health and longevity and happiness. Okay, now we've already mentioned all of these, that there are a hundred million Americans with pre diabetes that most are unaware. Well over half of half of Americans have insulin resistance. Just, I mean if you had insulin resistance, we were probably in the 150 million, maybe more zone. And only 1% of Americans have ideal heart health. There's a set of criteria called the simple seven. Even if you go to the essential eight of the American Heart association, which depth doesn't really add anything, they've added sleep, which is great, but it's. The seven are so in depth and they're of course having to do with blood pressure, cholesterol, blood sugar, weight, smoking, exercise and physical exam and food, only 1% of Americans check the box on the ideal for all seven. That means we all have some room to improve. Okay. And you're going to be one of the few Americans that's really, you're going to advance a lot just by watching this webinar. Okay, we already said don't let the pre fool you. Pre is definitely a risk. It can increase the risk. It definitely increases the risk of heart attack, stroke, dementia and cancer. Once you get elevated blood sugar with the full blown type 2 diabetes, you have the additional risk of blindness. It's type 2 diabetes, the most common cause of working age, blindness. Nerves. The most common cause of peripheral neuropathy. Can't feel your feet or tingly uncomfortable feelings. You step on attack or nail, you can't feel it. Days later there's this infection. Of course, the blood supply to the area is also not good. Amputation. So not to be melodramatic, but these things still happen. Definitely the most common cause of amputation in the United states, uncontrolled type 2 diabetes and kidneys. The most common cause, a close second is hypertension. But the most common cause for kidney failure and dialysis in the United States is diabetes. So I think we have a pretty good idea what it is in general. Let's kind of define it a little bit better. Okay? All of these issues, I want you to know, are related and simple. It starts with insulin resistance, it becomes metabolic syndrome, then pre diabetes, and then ultimately of course, type 2 diabetes. So we know that insulin resistance is what causes type 2, type 2 diabetes. Okay? And we're going to learn what diabetes is and defining it very, very soon. But we know that it's a condition where blood sugar is abnormally high. Right? We've got that most common form is type 2 diabetes. And it's essentially a condition of overall calorie overload, especially from what we've called, and we've defined crap, calorie, rich, refined and highly processed crr, ahp, food and beverages combined with below adequate levels of physical activity. Because we've pretty much engineered physical activity out of our lifestyles. Now there's type two, it is the most common, there's no doubt about it. But there's also type 1 and a subset of type 1 is called LADA, latent autoimmune diabetes of adults. And when we see this, it's usually in someone, not always, you know that, but that's leaner, that still has elevated blood sugar, particularly if they, you know, actually have maybe some weight to lose. And they're, they're losing weight and the blood sugar's still not getting better or maybe going up. This is a form of autoimmune diabetes. It's not flagrant and really aggressive like full blown type 1 diabetes in a young child or so called juvenile, or what we used to call juvenile Diabetes, but it's smoldering and it will eventually result in diabetes even despite lifestyle changes. But doesn't make lifestyle changes unimportant. Even more important now to know whether you have lada, you'd have to ask your doctor for a specific blood test. It's an antibody, it's the best screening test. You should at least know this. And if you go to an endocrinologist they might order some others. But for sure even your primary care doctor can order an anti GAD antibody. Okay, anti gad, anti G, A D. All right, so that stands for glutamic acid decarboxylase. Forget about the mumbo jumbo. It's any doctor will know what an anti GAD antibodies. If not, you know, ask for a referral to an endocrinologist. There's also MODI or maturity onset diabetes of the young. Mody, maturity onset diabetes of the young. That's genetic and that's, that will happen single digit percentages of the time. So these are, you know, bad luck conditions if you will. You know, truly nature, not lifestyle per se, although any, either one of them would be improved by having a therapeutic lifestyle. Because we don't want to add the high risk for throwing type 2 diabetes on top of Modi or on top of Lada. Okay, now almost entirely preventable is type 2 diabetes is entirely preventable? Yeah, in mass majority of people that's true. I'd say 90%. But it's in theory, it's very simple. It's true. But easy and simple are two different things. I'm not going to claim that it's easy, but I will say it's not complicated. It's about getting physically active and getting leaner, period. Now how you do that is requires a bunch of skills because the environment. I'm going to stand up again. Is pushing us to do the opposite. Look at that light. Okay, now the main cause we already know is insulin resistance and it begins years before blood sugar rises. That means you have an opportunity, not a crisis, an opportunity. There are signs other than high insulin levels, which we'll discuss. I'm going to actually mention it right at the end of this here, but you might have signs of fatty liver where your liver enzymes are elevated. That's usually the blood test called alt. On your blood test, AST also elevated, but really ALT is far more specific for fatty liver. If you have an ALT and an AST elevation you and the ALT is higher than the ast. It really suggests it's likely fatty liver. Now if you have elevated AST and alt, but the AST is higher. Not necessarily a. Well, it's. It's much more likely that there's alcohol involved. And you would know that, right? I mean, nobody's kind of secretly, you know, making you drink alcohol while you're sleeping. Okay. High blood pressure. In fact, high blood pressure predicts diabetes, and diabetes predicts high blood pressure. But often high blood pressure comes first. As you'll see. One of the criteria for metabolic syndrome is elevated blood pressure. High triglycerides, which are the cousin of high blood sugar, it just means high blood fat. So excess calories in the bloodstream reflected by high blood fats rather than high sugar. Usually they go together. Often they go together. High uric acid. High uric acid may just be asymptomatic, but often is associated with gout, which is crystallization of uric acid. Uric acid crystals in the joint. Usually it's the big toe or kidney stones. More common are calcium oxalate stones, Stones which also can be reduced in risk with healthy lifestyle. But in terms of uric acid, the second most common cause of kidney stones. Uric acid, kidney stones. Obviously, there's a history of gestational diabetes. If you had a diabetes during pregnancy, the odds of you developing type 2 diabetes in the future if you don't do anything about it is on the order of 80 or 90%. It's very high if you don't do anything about it. Obviously excess weight and then their skin changes, such as acanthosis. You may see people who have this condition in a store as you're walking around. They'll have a kind of dark darkening of the back of their neck skin versus this other skin surrounding it. And it's not dirt. They might even think it's dirt. They try to scrub it away. Or you might think it looks like dirt. It's not a dirty neck. It is a condition that results in hyperpigmentation of certain areas of the skin under the influence of high insulin. Behind the neck, under the armpits and the creases of the elbows, sometimes in between the fingers. There's other areas, such as underneath the belly if you've got what we call a panis or a hanging belly. And then into. Inside the. Inside the. The crotch area, if you will, that those areas are commonly going to manifest acanthosis if somebody has a significant insulin resistance. And it's usually not alone. If you look close enough, they've got something there. High blood pressure, high uric acid, fatty liver. Even if they don't have high blood sugar yet, but almost guaranteed they have high insulin. If they don't, it could be cancer. I mean, sometimes acanthosis is also associated with cancer, but I think the most common cause is insulin resistance. Okay, so we know what insulin is. It's made by a organ called the pancreas, which is behind the stomach. The stomach has been reviewed, removed from this view so that you can see the pancreas here in pink. And it makes a lot of things. It makes other hormones. It makes digestive enzymes. We're focusing in on the insulin that it makes. And the pancreas detects elevated blood sugar or carbohydrate, if you will. But it always ends up in terms of blood sugar, whether it came from starch or it came from sugar. Starch is just a long chain of sugars. The pancreas detects it and protein and releases insulin. And the insulin helps get sugar, carbohydrate, if you will, and protein into cells. And insulin tends to slow fat burning. It's definitely not impossible to lose body fat while you have higher insulin levels, especially if they're reducing over time. But when you're eating a significant amount of calories that is obviously spiking insulin, you've turned down dramatically the amount of fat that's being burned versus fat that's being stored. It's almost always a net result. It's not like your body stops burning fat. It's just storing more than it's releasing and burning. Okay, you know what calories increase body fat the most? They all do. I mean, any excess of any type. Now, are there some differences between. Yes, there's some worth pointing out. Refined carbohydrates. That means typically where the fiber has been removed, the water's been removed, and it's been made very light, dry and calorie, concentrated, you know, like a, a Ritz cracker, you know, that very dry, packing a lot of calories and a little thing versus whole fruit, for instance, which would have a lot of water, you know, you'd have to eat, you know, it's about 250 calories a pound for whole fruit, whereas for even a fat free cracker, it would be like 1, 600 calories or so with, with a, you know, dry fat free saltine, for instance, cracker. I think those are relatively low fat. Ritz. Ritz, if you look at it, actually has almost half of its calories from fat. So when we say refined carbohydrates, we're talking about not jelly beans, but, you know, kidney beans. Right. So I'm sorry, when we're talking about refined carbohydrates, we're talking about jelly beans, not kidney beans, things like whole grains, particularly intact whole grains, not necessarily finely milled whole wheat bread, which is, you know, going to be less of an issue than refined white bread because at least there's pulverized fiber in there. But when you pulverize and take something from whole, when I mean whole, I mean a grain that's intact, like you could see steel cut oatmeal, you could see freque, you could see quinoa, you can see a farro, you could see all of these different ancient grains where the pieces are intact and actually don't even absorb all of the calories from whole intact plant foods, whether whole kidney, whole beans, whole kidney beans, any bean, lentils, peas, intact whole grains, whole fruits, whole vegetables, even whole nuts and seeds. We've actually seen studies where you only absorb about 75% of the calories from whole almonds versus almond butter, for instance, where you absorb almost all the calories. Not all, but let's say I think 98% versus 75%. Now, nuts and seeds are still calorie concentrated even with a 25% discount, but they're not. They're not. That's a significant drop. It goes from very high to just high calorie density and nuts off for some chew. And there is something to be said about having a little fat in for the satiety, the satisfaction part, not necessarily the fullness part, but to be happy with what you're eating. Um, I think in general, high fat approaches are overrated. If you look at blue zones, the longest living people in the world tend to eat a higher unrefined or minimally processed carbohydrate versus fat, with, with only slight exception, let's say Ikaria, Greece, where they like carbs and the fats might come close, but it's fine. It really depends on the quality of what you're eating, not, you know, what ratio fat or carbs or even, you know, protein, as long as you have enough to maintain muscle throughout life. Now, when you're talking about refined carbs and then saturated fat, not polyunsaturated fat. Polyunsaturated fat can increase body fat in excess. Any fat can, because very calorie dense, but less likely to build up in the abdominal fat area, what we call the visceral area. And therefore I would say saturated fat excess is more likely to increase the risk of diabetes than a polyunsaturated fat or even a monounsaturated fat represented by, for instance, many. There are some nuts and oils that have polyunsaturated fat. Walnuts, for instance. And then of course, you have flaxseeds, you have a grapeseed oil, a very underrated oils, neutral flavor, but high smoke point. And the cholesterol lowering properties of polyunsaturated fat if you don't overdo it. Okay, if you overdo it. But if you overdo saturated fat, you're more risk than if you overdo polyunsaturated fat. And then of course, monounsaturated fat, which is typically reflected by avocados and almonds and then olive oil. And of course they're going to cause less of an issue with cholesterol. They're neutral fats, monounsaturated fats that don't tend to raise cholesterol. They don't tend to help lower it either. But polyunsaturated fats do. They, polyunsaturated fats tend to increase the expression of LDL cholesterol receptors on the liver. So the liver is grabbing cholesterol out of the bloodstream and using it to make bile. And then you poop out your cholesterol. Because I knew in this webinar like, okay, Dr. Fai is going to tell me, how does our body get rid of cholesterol? Do we, do we pee it out? Do we sweat it out? Do we breathe it out? No, you poop it out in the form of bile. And if you want that to really be risk sucking fat out of your chol, your sucking cholesterol out of your bloodstream and getting rid of it in poop. You want to keep your saturated fat low, okay, Keep your fiber high too. You can actually increase the fraction of cholesterol that is in the gut excreted, whether it's from food by never being absorbed in the first place, or it's bile, which is a digestive juice that the liver makes and stores in the gallbladder. And every time you eat it goes, squeezes, gallbladder squeezes and excretes bile into the bile duct, which then mixes with food. Bile is two thirds cholesterol. And your body, at the end of the 25ft of small bowel, just before the large bowel, in an area called the ileum, tries to recirculate, tries to absorb some of the cholesterol of the bile, the cholesterol with it back into the bloodstream, you know, so if you eat enough, good, healthy source of fiber, particularly Soluble fiber. But don't worry, just you'll get plenty of soluble fiber if you're just eating a nice, healthy, minimally processed plant. Predominant doesn't have to be plant pure eating pattern. So your fiber is really up there, you know, preferably at least 2, if not 3 grams for every 100 calories, if you want to know. But if you wanted to shoot for general number 40 grams a day of intact fiber, not, not fiber that's been processed and added to foods. And there you go. So with optimal, obviously with above optimal belly fat and too little muscle or movement, let's stand up again as that's mentioned. Ah, yes, easy to do. I'm flexing my quads, flexing my glutes already slowly sitting back down, actually sparking up the metabolism a bit. It doesn't take a lot. Just read the American Diabetes association physical activity guidelines. Then once we have a above optimal belly fat and too little muscle or too little movement, you end up getting insulin resistance and then the burnout of the pancreas. I didn't mention amino acids, protein, particularly animal protein, which is where you find these branched chain amino acids and particularly Valine in excess. Because remember, your body can't store protein, so having too much doesn't help. And having too little is also an issue too. You don't want to lose muscle mass. Losing muscle mass over time is a risk of diabetes, cardiovascular disease, dementia and cancer in and of itself. So protein is a very. What have you done for me lately? Tissue. And it is a just on time delivery nutrient, if you will. So I want you to, you know, consider that. Okay, so we have excess dietary fat, right? That is what becomes body fat. But excess refined carbohydrate particularly can make storing the fat that we eat more permissive. It's more carbs are permissive to making the fat that we eat become stored fat. So they really work together. In fact, sometimes I'll say if you're going to have a really high carb meal, maybe see if you can, you know, cut back on the fat content. Or if you're going to have a very high fat meal, maybe see if you can cut back on the carb content. Unless it's a non negotiable 5% fun zone moment, which is, you know, we're not worried about you 365 days out of the year, maybe 345 days, just ask you not to take all 20 days off, if you will, in a row because it averages out. It's how we live our life. Average over Time not. There's no single food choice at any single point in time that's in and of itself a mistake. It's, that's just a extremist baloney. No pun intended. We've already talked about excess animal based protein sources and then really at the end of the day, just excess calories in general are the issue. Okay. And we are living in a calorie overload society. All right, so we've discussed these risk factors. Let's review them. Sedentary throughout the day again, I'll do my stand and squat, flex and sit down. Eating crap that's calorie, rich, refined and highly processed foods too often. I mean, I enjoy a little crap too. I don't want to have anybody tell me you can't ever eat a brownie again. Or what. That doctor who was helping Paul Stanley of Kiss manages cholesterol. I said you can't eat ice cream again. Paul said, you're talking to the wrong person. I can hear about how often and how much, but you're not going to tell the guy that wrote Rock and Roll All Night and Party Every day to never have ice cream again. It's actually a very cool two minute video on YouTube. He's Paul Stanley on growing old. If you want to watch it. It's great. Two minutes. Very, very. It's a, it's lay, layman discussion, but it's very valid. It reflects all the five keys of the Flex 5. Consider a honorary Flex 5 black belts, as a matter of fact. Family history. But the family history is largely due to learned behaviors. Again, genetics loads the gun, but lifestyle pulls the trigger. We have. If someone has higher genetic risk, I mean, I have genetic risk. It's terrible. My father was on insulin by the time he was in his early 40s. He had diabetes by the time he's in his late 30s. I do not, and I am obviously way, way older than that. As I mentioned earlier, I'm approaching 56 this year and therefore technically closer to 60 than 50 now. Overweight, we've discussed high blood pressure predicts diabetes. Not always associated with insulin resistance because you can get other blood pressure from other causes, like really excess amounts of salt. There's so much stealth sodium and. But when you have insulin resistance, your body becomes even more sensitive to salt and sodium. So. And then smoking, of course, and then poor sleep, obstructive sleep apnea. That's untreated. A lot of inputs to high blood pressure, high triglycerides. We've already talked about that. That's a Predictor, usually high triglycerides go up before blood sugar. We just mentioned sleep apnea, which can increase insulin resistance if you don't treat it. And by the way, weight loss for many, not all, is a great way to improve obstructive sleep apnea. And then, you know, we've already discussed what crap is, so you probably know this by now, that insulin resistance with normal sugar but high insulin is there for years prior to type 2 diabetes. What do you ask your doctor to do on your physical? Ask not just for a fasting glucose. Ask for fasting insulin if you get them both at the same time. And be well hydrated. By the way, don't go there starving and dehydrated. I mean, well, you need to be fasting, but don't go there dehydrated, please. It makes your blood sugar look higher than it really is. Remember that if you're dehydrated, blood sugar is expressed in milligrams of sugar per deciliter of blood, right? So let's say 95 milligrams per deciliter. The deciliter part of it is how well hydrated we are. If you're really dry, that denominator is going to drop. But the blood amount of blood sugar in your body is the same, so it can make you look more, make your blood sugar look higher than it normally would be. So remember that you do not have any reason to not drink water prior to a fasting result. A fasting blood test. There is fasting for God, no water. And there's fasting for people who think they're God. Many of my colleagues, you can have water unless it's some type of radiological test or other reason to not drink water. Please do drink water. As a matter of fact, I would like you to drink enough water that you will have to pee again by the time you get to the lab. All right? That will give us a truly accurate fasting blood sugar, fasting glucose, and then get a fasting insulin with it. And if that fasting insulin, even with a normal Sugar Less than 100 milligrams per deciliter is less than. I'm sorry, five or higher, right? Five micro international units per liter or higher. That's the standard used in the United States. Five or higher in the US Lab or the equivalent, you can look it up online, do conversions in a international lab. You know, in, in Europe, for instance, Then you have some degree of suboptimal insulin sensitivity. I mean, I would say that to me. I would like to see People less than five, at least at most five or less for fasting insulin with a normal blood sugar. At that point, I would say, you know what, we certainly have very low risk for having insulin resistance. It's mostly reflecting insulin resistance in the liver. When you're looking at fasting insulin, fasting sugar, that's true. But if you're relatively physically active enough, getting at least, for instance, 8,000, if not 10,000 steps per day, you're also exercising at least a couple times a week, and you've got those numbers fasting insulin less than 5 with a fasting glucose less than 100. I'm pretty comfortable that you're not one of the people at high risk in the United States for insulin resistance driven metabolic syndrome, prediabetes, type 2 diabetes. Okay, then what happens is you get a calorie overloaded over time, the next step happens and you, you start to get metabolic syndrome. And that's where not only the fasting insulin is high, but you meet three of these criteria. You measure your abdominal circumference about an inch above your belly button with your arms preferably resting to the side. You could do it yourself with just one arm resting to the side. Kind of wrap it around, but better. If you have a doc or a nurse or your spouse or life partner, a friend, whatever, do a really, truly arresting relaxed abdominal circumference. You're not supposed to suck your gut in, you're not supposed to push it out either. It's just supposed to be relaxed. And if that level is over 37 inches in men, and if you're Asian in terms of Pakistani or Indian or China, from China or Japan originally, ethnic ethnicity wise, even 35 inches would be a threshold. Or in centimeters. 37 inches is 94 centimeters for men or 30, about 32 inches, technically 31 1/2 inches for women. So it's or 80 centimeters. In other words, it's not hard to meet the abdominal circumference criteria. Then you have to have two of the following four. You have to have a resting blood pressure on average, right? That's 130 or higher in the top. That's enough. You don't have to have the bottom one, you don't have to have the bottom one high as well. Either one of these two is enough. But it's got to be not just one blood sugar blood pressure check, but I would say at least checking it repeatedly, you know, five, six times, truly resting both feet flat on the floor, back against back, rest, resting, quiet environment with appropriate sized cuff at Heart level, that is a resting blood pressure. And if you check at least five times, and it could be five days in a row or it could be five weeks in a row. And those numbers, particularly if they could be done in the morning first thing, because this is when blood pressure tends to be higher. If your blood pressure is good within an hour of awakening, I'm pretty happy. Uh, then you have a metabolic syndrome. Now, if you're already on blood pressure therapy, you just presume you meet these criteria because if you stop taking the blood pressure meds, almost for sure your doctors started them because blood pressure numbers were higher than these fasting triglycerides. Number two would be, some would say, Doc, you know, 150 is old. American Heart association now says 100. But these are International Diabetes Federation numbers. So I could make the case and agree that 100 milligram per deciliter for fasting triglycerides is the threshold where I would be concerned about metabolic syndrome. But if we want to be picky and just stick with the International Diabetes Federation, which may update their guidelines and drop it to 100, just like the American Heart association has for fasting triglycerides, great, I'll leave it up to you. I wouldn't, for instance, say that at 121, I'm super happy. I'd like to see double digit fasting triglycerides. But technically speaking, International Diabetes federation criteria is 150. Or if you're international, it's 1.7 millimoles per liter or you're on some type of triglyceride therapy, typically called a fibrate. Phenofibrate is the most common type, but you could also be on a prescription form of purified omega 3 fatty acids, which are also FDA approved certain types for triglyceride lowering, although there are some over the counter forms that are also good purified well enough that they would have that pharmaceutical effect. Three is the so called low good cholesterol. It's kind of a misnomer. I don't want to discuss the, the biochemistry of lipid particles right now, but let's just make it pretty simple. If your HDL is below 40, and it's really the quality of HDL that matters more than the quantity. But anyway, if it's below or equal to 40 if you're a man, otherwise 1 millimole per liter. If you're in Europe, and I think Canada will be using the millimole per liter, or if you're a Woman, if your HDL is less than 50 milligram per deciliter or 1.2 millimole per liter or you're on an HDL raising therapy and those therapies are, you know, we would consider a certain statins to be HDL raising, not, not Lipitor, otherwise known as Atorvastatin. But you make the case, especially if it's pretty close that, you know, HDL is just above the threshold that Rosuvastatin or otherwise known as Crestor is an HDL raising drug. Other drugs that definitely raise HDL are a prescription niacin. I just don't recommend it anymore because we're, we've learned as far as I'm concerned, that the way that niacin raises hdl, remember I told you it's quality over quantity. The way that niacin raises HDL may be a dysfunctional form of hdl. And in fact, if you have a very high hdl, I would not be too particularly presumed presumptive that it's healthy, especially if there's family history, because very high HDL can mean that it's a, what we call constipated hdl. HDL is a protein or high density lipoprotein HDL that basically moves cholesterol in the, in the, in the economy of LDL of lipid particles towards removal from the body is part of something called reverse cholesterol transport. It's a bit of an oversimplification, but it's, that's true. And if HDL's ability to pick up cholesterol is good, but its ability to get rid of it, or efflux as we call it, is not good, you just end up with a bunch of, you know, constipated HDL high levels. But it's not reflecting that it's doing a great job and removing a ton of cholesterol. It's that there's a bottleneck in the system. Fasting sugar, last but not least, obviously this is where metabolic syndrome overlaps with prediabetes or full blown type 2 diabetes, I presume, but we're talking about stages here. So if you're fasting sugar, and I did not put the milligram per deciliter there, I apologize, is a 100 milligram per deciliter or higher. That would be the criteria for prediabetes if it's repeated at least one more time, truly fast, I mean truly well hydrated fasting glucose. And in the millimol units is 55, I'm sorry, 5.55 millimoles per liter. Now many Might argue that. Hey, we've got a better test. It's not just a snapshot. A1C is a blood test that checks the average of blood sugar over at least six weeks and maybe three months. Doc, why, why, why use fasting sugar? A1C you can get non fasting and I'm all with all of that, that's fine. I would do both. But sure, yeah, but I'm to get an insulin sensitivity. I need a fasting glucose anyway with my fasting insulin. But sure, why not check an A1C and I'll tell you why. Because fasting glucose typically does not go up first. Elevated elevated blood sugar usually goes up after meals before fasting does on the order of something like four out of five times. So I want both because if fasting sugar is normal and we have a scenario where the insulin may be high and say all I have is just insulin resistance, no prediabetes. But then we check an A1C and you'll you see it's 5.9 for obviously above 5.5 the threshold old you don't have just insulin resistance or even insulin resistance with metabolic syndrome. Presuming you have the criteria prior not just the sugar here, but three out of the five that we're talking about, you actually have pre diabetes. Okay. And if it's 6.5 or higher, as we see here, an A1C of 6.5 is going to be actual full blown type 2 diabetes. So let's talk about prediabetes though on the way I think we mentioned well hydrated fasting glucose of that 5.5, 5 or 100 if you're in the US an A1C from 5.5 to 6.4. You might hear some say it's 5.7. That's true. The American Diabetes association does say that the range for prediabetes for A1C is 5.7 to 6.4. But I kind of err on the side of caution with the American association of Clinical Endocrinologists which puts the threshold of A1C starting for prediabetes at 5.5. You could have a two hour oral glucose tolerance test. I think it's rather tortuous certainly. Or glucose tolerance testing in pregnancy is very important, should not be skipped. But it's a very time and labor intensive test. To do a two hour oral glucose tolerance you have to go in fasting they're going to make you drink 75 grams of very sugary population. It's rather disgusting. I don't want to discourage it. I mean, if your doctor says do it, please do it, and then they'll check your blood sugar at 30 minutes, 60 minutes, 90 minutes, 2 hours, and if at 2 hours that blood sugar is still high in the range of 140 to 199, you've got yourself a really, really robust diagnosis of prediabetes. That's the gold standard is oral glucose tolerance testing. But with A1C it's just far more practical, easier to do a wide population wide oral glucose tolerance testing. Too expensive, too time intensive, and frankly a bit of a challenging experience to expect to do quite a bit. Do remember that if you have low iron anemia, low iron anemia, or even just low iron, where you have restless leg syndrome and you don't have low enough iron to be anemic, but your ferritin, for instance, is low. Ferritin is a blood test for iron that can be low before you get low hemoglobin, before you become frankly anemic, but it can be low enough that you have some fatigue, some restless leg syndrome. And if you have a ferritin level less than 50, you also, though not as much as full blown iron deficiency anemia, free anemia if you want to call it, since we're talking about free, meaning a ferritin level of less than 50 despite a normal hemoglobin. I could make your A1C look higher than it really would be under normal iron status scenarios. And, and many, many, many are going to be. Most African Americans actually have a reference range, should be, I think, personalized to the African American community. I, I look at the data, I'm going to keep looking at it. But ask your doctor about how to interpret your A1C if you're African American if it's only slightly elevated. Okay, not saying don't do a 1C or that's total BS if you're African American, but I'm saying there is data that for many African Americans the A1C will look higher at any similar level of blood sugar versus for instance, someone who's Caucasian or Asian. Okay, all right, now we're at the diabetes point. We've already talked about these numbers. If you have a fasting sugar of 126 or higher milligram per deciliter, that's well hydrated, or it's a millimoles per liter 7 or higher, or your A1C is 6.5 or higher, or you have an odd 2 hour oral glucose tolerance test, it's not just 140 to 199, but at 2 hours is 200 or higher or in millimoles 11.1 or higher, then we're talking about type 2 diabetes or could be another form of diabetes. Okay, I must say, I don't, I didn't say type 2. Here, let me re, let me re state that these criteria apply to any type of diabetes mellitus, okay? Whether it is maturity onset diabetes of the young, aka Modi M O D Y whether it's Lada, latent autoimmune diabetes of adults, Lada, full blown type 1 diabetes, which is more aggressive, not just the smoldering type of autoimmune diabetes that LADA is. Or it's the most common of all, obviously type 2 diabetes. Okay? Now if you have a non fasting sugar, not one after a glucose tolerance test, but you just walk in the office kind of feeling funky. Excessive thirst, hungry despite eating, urination, excessive urination or unintentional weight loss for sure. Because remember, insulin helps protein get into the body. It's not good to lose weight due to low insulin and burnout of your pancreas. Ability to make insulin if you have a non fasting sugar under those symptomatic conditions of 200 or higher that can also be adequate to diagnose type 2 or any type of diabetes. Okay, so now let's get into some of the basics regarding the Flex 5 lifestyle and we'll talk about a way to learn the methodology in more detail. But again, it's like becoming a mixed martial artist of health and well being by learning the skills and knowledge in the five key areas of healthy longevity and I would argue happiness. As you see underlined in the bottom right of the screen, learning skills and knowledge in mind matters. For instance, learning about how slips are an opportunity, not a crisis. In fact, we can say slip stand for stop, look, investigate, plan. Learning about the hunger scale and understanding where early hunger is starting to come in so that you're not waiting so long that you end up overcompensating with so much hunger later in the day. Because didn't well, you didn't plan well and didn't bring your food with you. Again, food environment to why am I really hungry? The stall technique S T A H L It's actually like halt but with the S added for the reasons being if it's s sugary, salty, savory, just super delicious, you know, I mean to the point where it's almost a drug that could be a reason you're eating not hungry. T, you know, could Be a tired. Of course, fatigue definitely increases appetite for me. A could be angry or anxious sta and then h is hungry. If you're hungry, by all means, eat. You know, I, I don't recommend trying to starve yourself through intermittent fasting. Eat when hungry. Truly hungry. The stall technique will help you stop when comfortably full. That's the way of the blue zone is the best simple way to achieve health. And all of the benefits from fasting is by avoiding overeating. You typically will eat a little more frequently throughout the day if you follow this approach. People in the national weight control Registry that maintain the best weight reduction, for instance, eat about five times a day. Breakfast, snack, a lunch snack, dinner, a snack. Or you could put the two snacks anywhere in between. Whether it's breakfast, lunch, breakfast snack, dinner and then a healthy light snack before bed. Whatever the case may be. There's many other skill sets. Sleep and stress management. We're talking more about trauma these days, these skills and then getting help in the area of psychology, especially if it's. We're talking about significant issues of trauma or depression or anxiety. Very, very important and in fact the positive mindset that comes with mind matters, which is, you know, positive psychology. Look, we live on this third rock spinning around a small sun on the periphery of a violent empty universe. I'm not convinced that we've met alien life yet anyway. Certainly it's not robust and a plethora of it out there. We're very fortunate, we're very fortunate to be having this experience called life. It's unbelievable actually. And then finding your why. Why? I mean, not I want to get off drugs, I want to avoid knee replacement. Those are all nice. But I'm going to ask you to unpeel the onion. Those are many whys. I mean really why, why? You know, is it that you want to keep robust sexual health until you're 90? Is it because of your desire as an older parent like me to make sure you're there and as healthy as possible and not give your children the the legacy of a high risk lifestyle that could leave them having to take care of you for 10 years or, or more, maybe a little less. But you know, the average American lives their last 10 years in sickness or to walk the Great Wall of China and be able to travel the world when you're retired or whatever the case may be. Could be that you're like Paul Stanley and I need to stay in physically good shape because I'm a rock star that is accountable to my fans. See how the Accountability gets mixed in here. All of these keys have skills and knowledge that work together in unison. I separate them for you. Just like I could say there's five members of a band, you know, it's the Eagles, let's say. But Hotel California is one beautiful song. But there are separate members. Okay, that being said, nutrition, we can't go into it in detail here. I would encourage you to consider taking the Flex 5 lifestyle masterclass. The nutrition module is fantastic. I'll mention the web address here, but also mentioned again in the towards the end where we also have just the nutrition module available. Okay. The Flex 5 Lifestyle Masterclass is a serious one year video library access. We ask you to finish it within three to four months, preferably no more than six. Picking the lessons that you think are most pertinent to you. If you think they're more in the psychology. And you want to watch the stress and sleep lessons first before you go through anything in module one, which is fine with me because module one is all about medical stuff. There's a nice overview of the Flex 5 and Module 1, but we talk about medications and labs. You can skip those things. Just go right to what you think is really important, the sleep lesson. I like this environments idea, how I can set up my environment for success so that the healthy choice is the easy choice of the default choice. But then eventually just watch all of them within six months for sure. Maybe three, four months eventually. Because whatever your pain point is, I'm telling you, you cannot go into the world and expect to maintain health without being a true mixed martial artist of health and longevity. If you just try to do with just nutrition or just exercise, or just just diet and exercise, you're going to be like a kickboxer in the UFC octagon as Conor McGregor, whatever you think of him as going off the rails these days, but when he came out of the UFC as a great striker to fight the best boxer, Floyd Mayweather in a boxing ring, he did say in a at a press conference to Floyd that you need these boxing rules to keep me from killing you. Because boxing is a limited sports that I don't say it's not real. It's very real boxing fan when it comes to real street fighting, mixed martial artistry, your jiu jitsu, your boxing, your kickboxing, your wrestling, your Muay Thai, all of these things have to come together. And the same with the Flex 5. It's like learning a new language. It's like getting a degree. It's like learning to become a black belt. In this case of the Flex 5 lifestyle, physical activity, not just exercise. That's great, but you know, I'm gonna now talk about activity, gonna get up, but non exercise activity time. You see that neat there and eat so much to be gained in non exercise activity time. You wouldn't believe how much is getting up more frequently, taking little walks and accumulating 8 to 10,000 steps distributed throughout the day. To be honest with you, if you're older, have joint issues, even 6,000 steps and if you don't, hey, you have an issue, maybe you've, maybe you've lost a limb from diabetes or from an accident or from being one of our amazing military veterans. Find another activity, wheelchair activity, swimming, whatever the case may be, find what works for you, what you like. Anything you do will be phenomenal. It's the consistency of physical activity, not the intensity. Do I think that, you know, sealing the deal with some structured exercise, you know, for 150 minutes a week or so, or maybe a little more brisk exercise, you could whittle it down to 75 minutes a week. Sure. But if you just do an exercise and sitting all day, that's not going to be too great. Sorry, said sitting again. I'm going to stand up again. Right. Flexing the quads, Flex the glutes, stretching the arms. Okay. Environments, food skills and understanding how to set up your home, work, travel, local car while you're on errands, while you travel to another city. Social skills, how to learn to say and no thank you. For many people are very anxious about saying no thank you. It's an insult in some cultures and so forth, but there are ways to set up boundaries so that you are still respected. Even if the, the offerer may be a, you know, a crap food pusher, there's kind of a, a codependent and wants you to jump into the, to the, to the, the crap dependency circle with them to reduce their level of guilt. There's ways to discuss this that don't put you in that situation. Leave them respecting you. If not liking the fact that you're saying no, no thank you, but not angry. So they're learning assertiveness without pushing the threshold past to aggressiveness or you know, kind of being passive and getting walked over and, and stepped on and just say okay, whatever you say, I'll just, you know, that's, if you want to, that's fine. That's a 5% fun zone. But there's skills and social environments, very important. Learning about physical environments, that's your, your four Season, state, air quality outside. And there's a bunch of issues that when you start to think about it, you can develop skills to help improve your health by understanding skills and knowledge in physical environments. And last but not least, accountability. Whether you do it in a, you know, simple sense just I'm going to start tracking my food or I'm going to start tracking my blood pressure or weight. I'm okay with that. And once weekly, first thing in the morning after peeing and pooping weight with, you know, no clothes on or the same clothes on. I just don't want you to worship at the altar of the scale or code to a program or obviously do the Flex 5 masterclass where we have not just the masterclass video library but you get to be part of the private community, the Flex 5 private Facebook community where I answer questions every week and you get this real camaraderie with the students and alumni of the Flex 5 masterclass. Or you hire and you spend some really significant dough good for you on a one on one coach, whether it's a psychologist, a dietitian or both and a trainer. All of that, that's accountability. But you want it to be a compassionate accountability. Accountability you like, you appreciate that's helping serve your. Why you know, with all due respect to the show, because I've met Jillian Michaels and I've actually helped with one of the shows at Thanksgiving reunion in the past. The idea of, you know, being yelled at and vomiting on the treadmill is not my idea of accountability. Alrighty. So here are some examples of the Flex 5. These are black belts. Ricardo has been maintaining now for almost eight years. Full blown metabolic syndrome, almost type 2 diabetes, multiple hypertension drugs. Now he takes an option only half of 1, 1 pill for blood pressure rather than 4 different medications. Insulin levels, better than me, which kind of, you know, it's kind of irritating because I, my genetics are that bad. That being said, I'm very proud of Ricardo. He's extremely smart, educator at a university, mba, attorney. So these are very smart people. Lynn, excellent. She was a pharmacy tech. She had significant rheumatoid arthritis which was something she was kind of self conscious with. But after engaging, now maintaining I think four as you met her. And let me just think for a second here. So I mean I think I've known lynn for over 10 years. So she's now maintaining for over 10 years. Rheumatoid arthritis, inflammation, dramatically better mobility, way better. She's not retired but she's doing great. Brad, fantastic. He had a major fall it kind of was a wake up sign. Significant obstructive sleep apnea. Also, you know, just doing phenomenally well learning these skills step by step. And then most of them not as much Brad, but the other two, Lynn and Ricardo really went for a kickstart. They used meal replacements which are fine. I just don't believe in, you know, shakes forever. But clearly a high quality shake like ZPro25, which I don't have anything to do with, you can find it on Amazon. They're not going to pay me to tell you this. Or you know, your own smoothie you make with your own protein with some flax seeds and some unsweetened soy milk. You know, so you can be more plant based with pro pea protein, whatever or even slim fast high protein I think is better than the regular slim fast, any one of those. They're really all evidence based. We've seen multiple randomized control trials for short term weight loss. But if you don't learn the Flex 5 lifestyle skills in addition to the kickstart that meal replacements can provide, you know, there's a high likelihood you'll just rebound. Okay. Oh my wonderful Rick. I just love him to death. He's had hypercholesterolemia, never saw cholesterol below 200 in his adult life. That's he was 18 until he did Flex 5. He's had a tragic loss of a family member due to the hypercholesterolemia that this beloved person did not follow. So there is something to be said about when you're getting healthier. I'm going to be always straight up with you. You have to be prepared that you'll live longer and see things that other people who sign out early won't. You may even consider to start to progressively, for instance, make younger and younger friends, those that have just as much ability as you have due to the mobility and benefits and the payoff from the Flex 5 lifestyle. And last but not least here, Romaine. Wow, what amazing story here. I mean she is still maintaining over 25% weight reduction for full remission of type 2 diabetes. A mobility improvement for. I can't remember, it's double digit number of years. This is not bariatric surgery, by the way. None of these clients or past patients have had bariatric surgery. The fact is that I've done hundreds of pre bariatric surgery evaluations and post operative surveillance. I have no issue against bariatric surgery. I think it's just like meal replacements. It's a tool. It's just, it's not an engine, it's a turbocharger. So it's not like bariatric surgery instead of lifestyle change. You'll get the kind of results that you'll get if you do it that way. It's bariatric surgery as a kickstart or lifestyle change. But none of the people that you're seeing here have had bariatric surgery. So thank you. And let me give you again the, oh, I don't think I did in the first place. The website for the Masterclass information page and then the nutrition module. If that's what you're focused on first, that's fine. To check out the information page and sign up if you wish for the Flex 5 Lifestyle Masterclass, it is DPM. And just imagine that stands for Diabetes Prevention Masterclass DPM or Disease Prevention Masterclass dpm.drtom refi that's just D R T O M R I f a I again d r t o m r I f a I so again dpm.drtommer fai.com if you want to look at just taking the nutrition course because maybe the funds are not there for you, you can use Flexible Spending Healthcare Savings Account, by the way, for the $349 cost of the Flex 5 lifestyle masterclass. But the nutrition module, which is very in depth, I think it's six hours, is only $99. And that's the same website address with the word nutrition ad at the end. So dpm.drtommerfai d r t o m r-I f a I.com nutrition dpm.drtomMerfai.com nutrition I hope you got something out of this. Please, by all means, click like click share this video and make comments. We'd love to hear what you're thinking. And please be well. You know you have power beyond what you know when you learn the Flex 5 lifestyle skills. Even if you just follow me on Facebook at my public page, you'll easily find facebook.com Dr. Facebook.com D R T O M m D or use the Facebook search engine. Just search D R T o M Refi, MD. By the time you get to Dr. Tom Refy, I'll probably already be the number one option. Follow me there. That's not really a structured social media page for the Flex 5 masterclass, but you know, you could accumulate information over time. But the best way is to do the Masterclass or at least in the nutrition module. Be well. Thank you so much.