Decoding Diabetes: Conquering the Silent Epidemic

Understanding Diabetes

Types of Diabetes

Importance of Hemoglobin A1c

Hello, welcome. This week we are dealing with diabetes. This topic is about how to actually conquer diabetes. There are 38.4 million people in the United States with diabetes, and I have a couple people who have emailed me some questions about diabetes as well. So let me start and go over a a couple of things about diabetes. Diabetes is really a major public health issue in the United States. Now, some of you may be listening and think, I don't have diabetes. Well, you'd be surprised. About 20% of the U.S. population has diabetes and they have no idea that they have diabetes. So if you think you don't have diabetes, listen to this, and you want to actually make sure that you actually get yourself checked and that you are for certain that you don't have diabetes. So in 2023, there are about 37 million Americans who had diabetes, and that represents about 11% of the U.S. population. There's basically three types of diabetes: type 1 diabetes, which starts in usually children or teenagers. There are about 1.9 million Americans that had type 1 diabetes, and about 240,000 or so are children and adolescents. Type 2 diabetes is much more common. About 35 million Americans have that, and is often related to your diet and obesity and aging, etc. The third type is gestational diabetes. And that is often diagnosed when a woman is pregnant and they get a glucose tolerance test, which they have to sort of drink some glucose and see how their body actually responds to that testing. Some women who don't do well with that testing have gestational, go on to have gestational diabetes, and later in life they have an increased likelihood of having type 2 diabetes. So when we actually take a look at this, about 14.7% of African Americans have diabetes, and about 12.5% of Hispanic Americans have diabetes, and Native Americans is actually even higher. It can be as high as 20, 20% or so. We spend about$327 billion on healthcare costs related to diabetes. So this is a really, really important disease for us to get a handle on. And if you look at our hospitals, about 10% of our hospitalizations are associated with diabetes. So with diabetes, you're more likely to have cardiovascular disease, you're twice as likely to have heart disease or a stroke. It's also the leading cause of kidney failure. And it also causes a lot of eye complaints and can lead to glaucoma and blindness. So, how would you actually know whether or not you have diabetes? It is something that is normally very silent. So one of the main detectors is that you actually get your hemoglobin A1C checked. So I'm going to repeat that. Hemoglobin A1C is the name of the blood test. Every adult in America should get their hemoglobin A1C checked and should know what it is. If your hemoglobin A1C is less than 5.7 minus 4.6, I know what mine is, then you're considered to be in range. If you are 5.7 to 6.4, then you are in the area what they call prediabetic, or basically it means that you know you're sort of on your way, right? You have an ability at that point in time. Um you have an ability at every time to kind of turn it around, but it it's sort of a warning, it's sort of a warning shot. When you are above 6.4 and particularly significantly above 6.4, then you are in the diabetic range and you are more likely to have complications associated with diabetes. So it is really, really important to get your hemoglobin A1C checked and to actually really know what that actually is. So what are some of the things that are important? And I'll go into some things around lifestyle changes and things that make a difference if you feel like you've been struggling with this or if your doctor has told you that you're pre-diabetic. Alrighty, so we've gone over sort of type 1 and type 2 diabetes as far as when they occur during childhood or adolescence, and as far as why they occur. So, you know, type 1 diabetes, which occurs in children, is really an autoimmune disease. So it is a disease where the immune system really attacks the cells that are actually producing insulin. So in your pancreas, the beta cells are the cells that are producing insulin, and you have an autoimmune disease that attacks those cells. So that is why they actually require usually lifelong insulin therapy and careful monitoring of the glucose. This is different from type 2 diabetes, which is adult onset diabetes, which is more of an insulin resistance. And so the body doesn't use insulin quite effectively. And eventually, what happens because of diet and sedentary lifestyle is a pancreas can't produce enough insulin to maintain the lower glucose levels that you need. All right, we've got Connie on line one. All right, Connie?

Thank you, Dr. V. Uh, I'm really glad you're doing this topic because I personally feel like I might be pre-diabetic, but I haven't been tested. I just feel like I've gotten some of those symptoms, you know, like the numbness and you know, tingling and all that kind of thing. Right. But it usually happens like after I've eaten certain foods. So I'm also thinking it might be my diet.

Mm-hmm. Okay. So have you so have you ever gotten your hemoglobin A1C checked? I've never asked for it in that way.

Okay. I don't know. Do they not just automatically do it with your blood test or whatever?

Sometimes they do, sometimes they don't. So Well what what should I be eating? You know what I mean?

Like I like to eat.

Dietary Changes for Diabetes

Right. So, okay, so here's the thing is so one is make sure you get your hemoglobin A1C tested because it may or may not be diabetes, it could be something else. And if your hemoglobin A1C is normal, then you really want to have your physician evaluate why you actually got the numbness and tingling in your legs. It could be something totally unrelated to diabetes, right? Uh-huh. But if you if you if you think your blood sugar uh may be high and you want to actually look at what you should eat, t tell me well, let's start with this. What sort of stuff do you normally eat? Okay.

Well, well, for instance, this morning I had I had cereal, like granola cereal with fruit, which I think is pretty healthy. But, you know, I do love a good cheese egg and bacon. So that's like I might kind of those are my kind of go-to's for breakfast, right? I really love omelets. Okay. For lunch, I might do like a salad or like today is a Friday, or certain Fridays I might do pizza for lunch. I'm just a cheese lover, so you can just think like anything with cheese in it in my diet, I like.

Right.

Uh I love seafood and I love Italian food.

Okay. And so if you go out to eat, you're usually doing Italian, or is there any other type of food that you're I I generally am gonna get seafood, like, you know, give me a crab cake, I'm happy.

Okay, gotcha.

Um but in terms of like vegetables, I love spinach and mushroom. Those are my favorites. And I'm trying to cut down on carbs, but you know, I'd be hungry afterwards.

Monitoring Blood Sugar Levels

Right, right. So, okay, so a couple things. One is that you for every food, so there's a thing called a glycemic index, right? And so what the glycemic index is, is for foods that you eat, it actually measures how much does this actually increase your blood sugar, right? So, so when you actually look at, when you look at your foods, you can compare them by, you know, glycemic index. So there's there's books, there's catalogs, right? Like of comparing one thing to another thing, right? So this ranking system is really, really good for foods that actually contain carbohydrates. So the glycemic index, it goes from zero to 100. And you really want to actually, you wanna try to eat foods that have a glycemic index of like 55 or less, right? Because there there'll be a more, there'll be a slower, kind of gradual sort of uh increase in your blood sugar, right? As an example, with the stuff that you talked about, cereal, right? The glycemic index books, and you can just Google glycemic index, a complete handbook to glycemic index, and you can actually look at your cereals and see which cereals have a lower glycemic index. Okay. Same thing with fruit, right? Certain fruits, grapes, for instance, have a high glycemic index. Apples and bananas have a lower glycemic index, right? So you can kind of compare, so you can pick things that have a lower glycemic index. Pizza, I love pizza myself, honestly. I try to order pizza with a cauliflower crust rather than or a whole wheat crust, because that will also make a difference. If you eat rice, the difference between brown rice and white rice, one has a glycemic index of almost 80 or 90, brown rice has a glycemic index of 50 to 55. So I tell people, get the glycemic index handbook so that you can actually really compare what is going on with your with your foods. The other thing is you can get a continuous glucose monitor that you put on your, you know, you've seen you've seen diabetics with this on their arm and they put their phone up to their arm. Have you seen that?

Not really.

Yeah, so it's a little thing and it kind of goes subcutaneous and you put it on and then and then you just put your phone up. And so as you eat things and you do things during the day, you can see it continuously monitors your glucose. So you can see actually what's actually happening. Is your blood sugar going up or down? And how is it impacted by the things that you're you're eating? There's a lot of things that have hidden sugars in them, and cereal is one of them. Fruits is another. Fruit juices are very high. Rice, white rice, particularly white rice, salad dressings, and smooth and smoothies that are made out of, you know, people think they're eating healthy because they're eating a smoothie.

But I like smoothies.

Yes. So if you have smooth if you have smoothies and you you're making them with grapes and pineapple, and you know, you you wouldn't eat that many grapes and pineapples as they blended into that smoothie. Right. So I tell people, you know, mm make sure that you get smoothies where they're a little bit more, you know, you have more spinach, maybe some avocado, maybe some cashews, things like that, again, with a lower glycemic index, because that's really, really important. Right? So I think if you get that handbook, one, get your hemoglobin A1C check to make sure that the symptoms you're experiencing are really what you think it is, because it could be something else, and then get the glycemic index uh handbook and you can look up all sorts of foods and you know Where do you where do you get that from? Oh, well you can get this there on Amazon. If you just go to Amazon and and you just Google, you go to Amazon, you put in the search criteria glycemic index handbooks. They're they come up, you know, they're anywhere from ten to twenty dollars. They have some of them laminated posters. But I tell people, try to get the one that is most complete and has like, you know, 4,000 different foods in them. And they'll also have different, if you go out to eat different uh fast foods, they'll have the glycemic index of things that you order at a restaurant. So you can kind of figure out, you know, beforehand, what do I want to order when I actually get to this restaurant?

You know, uh uh the last question on this is I heard you say, like, for instance, with pizza, get like the did you say like the the the wheat crust?

Either the whole wheat crust or the better yet which is the cauliflower crust. Okay.

So my only thing about whether it's pizza or something else where it says whole wheat, a lot of times, how do we know, right? Like that's what it really is, because a lot of times things are marketed a certain way, but then you find out that it's not even because you know, you think you're doing good, right? Like even with the cereals, or it'll say like whole wheat, but then I saw a report that's you know says that it may not be as healthy as you think it is, and it's just marketing.

Yeah, so that's really true. You know, so you know, you're actually making me think of something. I actually have a a cauliflower pizza crust that you can make at home. And what I'll do is give me a couple days, I'm gonna put the I'm gonna put the recipe up on my on my on my website, on my Ask Dr. V website. But there if you there are uh recipes for cauliflower pizza crusts. So you can make your own pizza crust at home, and then you know exactly what has been put in it, right? Because it is really important. I know sometimes, you know, it's a lot to cook, but it really is important that we actually know what's in our foods. And when you do the marketing on food is ridiculous. Like you you have to kind of read the nutrition label, and the nutrition label will give you the the percentage of carbohydrate grams, and it'll also give you the fiber. So you can figure out what are the net carbohydrates. So the net carbohydrates on a food label, or when you take the carbohydrate grams and you minus the fiber, right? And that'll give you what the net carbs are. So if you have 24 grams of carbohydrate, two grams of fiber, then you have 22 grams of carbohydrates. And you can kind of compare it like that looking at the nutritional labels. But it is, you know, it's can it's confusing by design.

Sounds like a lot of work, but I guess I'm working.

Diabetes Medications and Innovations

Yes, exactly. You are working. All right. Thanks for your question. I hope that was helpful. It was. And when is it going to be on your website? I'm gonna try to get it up on my website within the week, and that is going to be the cauliflower pizza crust. I'm I'm actually working on a I'm working on a cookbook too, because I think there's a lot of things that I love to eat that I personally love to eat. And it's like, how do we actually make these things healthier so that we can actually still enjoy what we what we normally eat? I love that. Can you what's your what website again? Our website is askdrv.us, a skdrv dot us. All righty, I wanted to go to a couple of questions that I received by email that people sort of ask me. So one person asked, why is it that diabetes causes so many complications around heart disease, amputations, etc.? So one of the things that happens with diabetes is it causes clogging of your arteries at very, very small vessels. So at your small vessels, it actually causes clogging of your arteries. And it doesn't matter whether or not it's in your brain or in your heart or in your legs or in your arms or where it is. So that is why you get the increased incidence of heart disease. It's the clogging of the vessels. All right, we've got a call on line one. Dwalicia.

Hi, doctor. My name is Dwalicia Lee. Thank you for taking my call. Appreciate that. So I'm listening to your information that you provided to the previous caller. And I actually went and pulled up my blood work that I just got done. And I was trying to look at the numbers that you indicated because it did say that I was pre-diabetic. So I'm trying to make some changes where I need to make them. But what did you indicate we should be looking at?

So as far as the the range for your hemoglobin A1C or as far as w your diet, or as t tell me what your so so first of all, did you did you know before today that you were pre-diabetic?

I think they told me this maybe last year or something. And then so I asked about my numbers previously or now whether or not they changed. And I think, you know, they could my doctor didn't break it down thoroughly for me. Right. So I said I was gonna try to go to a nutritionist to see if I can get more information.

Yes. Yes, okay. So so so you think you've been pre-diabetic for about a year? Yeah, uh maybe for yeah, I'm a year or two. Okay. And do you have do you know from last year to this year whether or not your number went down or up or where you're at?

So I'm looking at my what I'm looking at my reports right now. Which number, where should I be looking? Like this report is should I be like I'm looking at the lip pit panel? I'm looking at should I look at the glucose?

Yeah. Yeah, so so so when you actually okay, good question. So when you actually look at just your glucose, that's just one-time spot glucose. That's really not, I mean, it's helpful, but it's not very helpful. Your hemoglobin A1C, they don't spell out hemoglobin on the lab test. So usually it'll say HG A1C, right? So and and it sometimes they'll spell it out, but it's your hemoglobin A1C. And what that does is that does a look back. So that looks back over three months, right? So you so you can't, for instance, you can't eat healthy for three or four days, go get that blood test and think you've changed something, right? Right. Right? It tells you what you've been doing for the last three three to four months. That is why that is a better test. So do you see your HG or hemoglobin A1C on your lab tests? Okay. Uh I see the hem yeah, I see, okay. You say M H C? No, A1C. It's hemoglobin A1C. It'll say H G or it'll say H E M G. I see the hemoglobin uh test, but I don't see absolutely where Right. So so it's confusing because when your doctor tests your blood count and you get a complete blood count that has your hemoglobin on it. That's different.

Here it is. Here it is, hemoglobin A1C. Okay, okay, you got right here.

Here it is right here. Okay. All righty. Okay. All right. See, this is why this is so important, right? Yeah. Yeah. I want people to get woke around their health care. I want people okay, so all right, so you have that number now. Do you want to share with us what it is? You don't have to, it's your personal information.

Yeah, well, okay, I'm online and I'm telling you anyway, but so the previous one was 6.0523. Okay. And then it just say the current one is 6.0.

Gestational Diabetes Awareness

Community Engagement and Support

Managing Insulin Dependence

Key Takeaways on Diabetes

Okay, so you're in Okay, alrighty. So you were uh six last this year and you were a six last year. Okay. So right. So the pr so in order to to so that is in the pre-diabetic range. So to get below the prediabetic range, you're trying to get below five point seven or so, right? Ideally, if you could even get below five, you'd be in a really good range, right? So so what you so is your question about how to do that? Yeah. Okay, all right. So so one is if your insurance provides for or you can get a nutritionist, that is a very good start, right? And I tell people to sit down and write out what you what you eat. Because in our mind, we think we eat healthier than we actually eat, right? Sometimes just take a picture of your plate, right? This is what I had today, this is what I had for dinner, and just take a picture of your plate before you start eating, right? And so you want to sit down with a nutritionist. I would also recommend that you get the glycemic index uh book that I was talking to the other caller about, right? So you can look at where can you switch out things because usually it's it's really it's it's it's not major changes. It it can really be minor changes that that really make a difference. I I had someone that I was uh working with and he said, you know, he really liked beer, and beer is you know has a lot of glucose carbohydrates in it. So I said, well, then get rid of the potato. And the french fries and the bread, right? And so he did that and he kept his beer. So, you know, there might be one thing that you really like and you want to keep that, right? So don't try to, yeah, don't try to be, you know, draconian about it. You know what I mean? So, you know, if there's one thing, I really like this. Like I really like rice as an example for myself. Okay, I'm a big rice eater. So what I did was I switched out brown rice and I couldn't even tell the difference. Right. So, all right. And then when you do that, then you're gonna do that for three months. And then, you know, right around Christmas time or right around Thanksgiving time, get your hemoglobin A1C checked again to see whether or not it actually really worked. And then call me back and let me know. That I will too. Okay, I wanna I appreciate that information. All righty, thank you. I have a question that was emailed in to me. Peggy from Capitol Hill uh wanted to know what are the signs that your blood sugar is too high or too low. Very good question. So when your blood sugar is too high, you'll often have symptoms like you may urinate more frequently. You might think that you have a urinary tract infection. In fact, a lot of times when people come to the emergency department to see us, they think that they have a urinary tract infection, and then we check their blood sugar and we realize that their blood sugar is very high. Also, you might have nausea and vomiting and abdominal pain. Some people get very thirsty. Their mouth gets dry, they get very thirsty. They also have extreme hunger pains and get extremely hungry, so they'll eat and be full and then suddenly get very, very hungry. Also, some folks actually get fatigued and have sort of a lack of energy. I also had one patient who had blurred vision, and he came in because he felt like he needed uh better glasses. And each time I gave him a pair of glasses, he needed a better pair of glasses. So his vi vision was constantly getting worse. So those are some of the signs and symptoms of high blood sugar. Now, low blood sugar is very different. Low blood sugar, which sometimes happens if people get too much insulin or too much medication for diabetes. In that situation, people get sweaty, they get shaky, they can have a seizure, they can have, they can go into a coma. If someone is awake and able to uh drink for us in the emergency department, we will often give them orange juice, and that is one of the things that brings up blood sugar very fast. So if you are a diabetic, orange juice is not necessarily the best thing. So, but that is what we do for folks that have a very uh low blood sugar if they're able to actually drink for us. All righty, thank you for the question. I have another question from Katisha, and she said, We've all heard that we should limit our sugar intake, but what are other ways to prevent diabetes, especially if it's hereditary? So let me actually talk about the concept of diabetes being hereditary. So, you know, certainly there is some evidence that diabetes type 1, the autoimmune type that shows up in children or adolescents, that that is or can be hereditary. Now, often when people talk about diabetes, they're often talking about type 2 diabetes, which starts as an adult. That is not necessarily as hereditary. A lot of times we call things hereditary, but we have to realize that we eat with our family, and often we all eat the same thing. Uh we have very, very similar your eating habits kind of come from your family. So sometimes people will say, Well, this runs in my family, or I think it's hereditary. And really what's going on is that everybody's really kind of just eating the same. But the way to actually prevent it, in addition to the glycemic index that we talked about in the handbook, is to also get the continuous glucose monitoring. And you want to really uh make sure you're doing this in conjunction with your physician. It often requires a prescription. It is a subcutaneous little thing that you slap on the back of your arm. And that actually allows you to really monitor your glucose minute to minute. And so, and it gives you an awareness of actually what what what things are making a difference. I know there's a lot of talk when we talk about diabetes, there's a lot of talk about diet, but I I want to make sure that people don't forget about exercising. And exercising doesn't have to be going to the gym, you don't have to run a marathon or anything. Just do 20 minutes of walking a day. You know, take the steps at work rather than taking the elevator. Just do little things. Little things really, really do really make a difference. And so I think that's very important. One person sent me in an email question, Dr. V, thanks for doing this topic. I recently was diagnosed with diabetes. I want to understand a little bit more about the medications and how they actually work. And are there any new medications that are on the horizon? Okay, so this is a this is a really good question. So, so some of the things that people use in addition to the continuous glucose monitoring, you'll find that some people are on an actual insulin pump, right? So an insulin pump is something that also delivers insulin continuously. It is actually inserted so subcutaneously into your body and it monitors in conjunction with the continuous glucose monitoring. So it is able to see what your glucose is and then deliver what you actually need in real time. The other thing that that people use or medications that are used are some of the GLP1 uh medications that are new. So this is also something that's new: the Manjaro, the Ozempic, the Wagovi. And these medications enhance insulin secretion and it inhibits the release of a thing called glucagon. And glucagon uh increases your glucose level. And it kind of promotes you in feeling like you're full, right? And so, and it's it's being used right now for folks that have an elevated hemoglobin A1C being used to sort of help with glucose control. So, some of the things that are on the horizon, there's uh a thing called an artificial pancreas that is being tested. And this really combined, again, it's used with the continuous glucose monitoring, and it is basically it uses algorithms to automatically adjust insulin delivery based upon what your actual glucose level is. So you may hear of people talking in the future about an artificial pancreas. There's also a thing called SGLT2 inhibitors. These drugs lower your blood glucose by preventing glucose resorption in the kidneys. And what this does is this actually leads to more glucose being excreted in your urine so that it is not sort of running around in your blood system. This is also something that is currently being tested and it's kind of like a new therapy. We're also seeing immunotherapy, which is research to actually target the autoimmune response that occurs in type 1 diabetes and helps improve the beta cell function, the cells that actually secrete, that secrete insulin in both type 1 and type 2. Lastly, there is gene editing, and this is similar to the research that is being done with the CRISPR technology that has actually led to a lot of really amazing results with sickle cell patients. So, gene editing is also being explored to correct genetic defects so that the stem cells that actually produce the beta cells in your pancreas will actually produce better beta cells and you'll actually get more insulin production. So these are all sort of things that are on the horizon. I tell people, you know, if you've been diagnosed with diabetes, you want to, you know, just start off with some of the traditional medications and work with your primary care provider to actually start with some of the regular medications that are out there that are sort of first line therapy. Alrighty, I've got a question from Margaret in Silver Spring. And she actually said that she just had uh she's currently pregnant and she had a glucose tolerance test and she failed it and she did not do well on it. And she wants to know what she should do and what are the implications for her child. All right, so a couple of things. Not everyone who fails a glucose tolerance test goes on to develop diabetes, but it certainly is a significant indicator and risk factor. One thing is that your OBGYN should be having a conversation with you about gestational diabetes. The impact of the child on gestational diabetes is that patients that are pregnant with gestational diabetes will have a larger baby. They will have, they will have a baby of a larger weight. You can also get certain complications related to gestational diabetes. So if you have failed your glucose tolerance test, and this is a test that you take when you're pregnant, they asked you to actually, you know, drink, drink some glucose, literally, and then what they do is they actually check how did how did you do with your blood sugar after that. So typically what happens is after pregnancy, usually the problems with the diabetes will resolve. But what we have found is that later in life, 50% of the people who had gestational diabetes will go on to have type 2 diabetes. So it is really, really important that you actually, if you were diagnosed with gestational diabetes, that you actually call in and that you actually speak with your doctor and monitor your hemoglobin A1C. Because as I said, 50% of these folks will will go on to develop adult onset diabetes. So if you failed that test, make sure to monitor your blood sugars and your hemoglobin A1C as you as you go on in life. So thanks for that question. Alrighty. Does your business believe in the empowerment of the community? Do you want to be part of advancing their understanding of health and overall well-being? Ready to reach more people while growing your brand in visibility? If you'd like to advertise, 30-second and one-minute spots available, email our team at info ataskdrv.us. That's info at askdrv.us, and find out how you can advertise today. We'd love to see how we can work together and reach and empower more people. Alrighty. Jared from Harrisburg, this is an email question. He said, Life as a diabetic is really hard. I currently need insulin three times a day. Is there any way, any way for me to be weaned off of this? Jared, this is actually a really good question. So a lot of people get on insulin and sort of really believe that it is for life, but it doesn't really have to be, but it does require a lot of a lot of work. So one is if your goal is to get off insulin, you really want to do this in conjunction with your physician. Because whatever you're gonna begin to do, you want to make sure that that that you're getting hit his or her medical advice about the things that you're doing. So in general, if you want to actually get weaned off of insulin, you would first need to actually sit down, have a conversation with your physician and get a nutritionist. You also want to make sure that you are checking your blood sugar. Continuous glucose monitoring would be the best, but your physician can tell you how frequently you actually need to check your blood sugar if you're gonna do this. When you actually go to try to get weaned over time, and it does take time because you're adjusting your lifestyle significantly. So in when you actually do this, your physician may want to see you in his office more regularly. They may want to monitor your glucose and your hemoglobin A1C more frequently, but it is possible. One of the things that I think is important is you really want to look at not only your diet and your exercise, but anything else that a nutritionist actually thinks would actually make a difference for you. Some people actually use what we call intermittent fasting, where they take all three meals during an eight-hour period of day. So maybe it's 10 a.m. to 6 p.m. and they eat breakfast, lunch, and dinner between 10 a.m. and 6 p.m. So that it kind of gives their pancreas a rest for the for the remainder of the 24 hours. So those sorts of techniques actually can make a difference, but again, you want to actually make sure that you're designing this specifically for you and your profile. It makes a difference how much insulin you're on, there's different types of insulin, there's regular short, short-acting insulin, there is long-acting insulin. People take insulin one time a day, two times a day, three times a day. So you've got to really design a program that is specifically for you. I think that between the intermittent fasting, changing and lowering the glycemic index of the foods that you eat, plus exercising, there are a fair number of people that can actually get off insulin. And what is important is once you get off insulin, you've really got to be careful about the triggers. I'm just thinking about a couple of patients that I actually worked with. I had one patient. He actually went to the ICU because his blood sugar was over 800. So normally your blood sugar should be about 100, 120. He was on insulin three times a day. We were able to actually work with him and actually get him off insulin. And he did have to convert over to the pills. So there are diabetic pills like a metformin, glucophage, to lower your blood sugar. So he was on the oral hypoglycemics, did very, very well on the oral hypoglycemics, I would say for about a year or so. And then what happened was Thanksgiving and Christmas came. And that was really a trigger for him. And between the sweets, the fruit juices, the alcohol, the desserts, he ended up back on insulin. But he it but it kind of led him to really understand that this is something that you really, really have to keep going. Because it was a little bit harder to get him off insulin the second time. We were able to work with him and get him off insulin the second time, but it definitely was a little bit harder. So again, you you really want to, if you if you have a physician that is not interested in having this conversation with you or doesn't think it's possible, you really might want to or doesn't want to refer you to a nutritionist. You really might want to actually go to another physician. The ones, the the people that um really need to be on insulin for life are the type 1 diabetics, which is the autoimmune disease, where it has attacked their pancreas and they are not able to produce insulin because of the autoimmune disease. So those are the ones that are really not able to get off insulin and and really have to stay on insulin for their entire life. All righty, we are uh wrapping up here. So I just want to kind of go over a little bit about what we discussed today and what you can expect next week. This has been a great show. I want to reiterate the importance of everybody knowing what their hemoglobin A1C is. It is really, really important that everyone know what their hemoglobin A1C is and trend that over time. If you've been told you're a prediabetic, you want to make sure to actually, you know, get yourself into a nutritionist and work with your doctor to really get your hemoglobin A1C preferably under 5, but at least under 5.5. Email me any questions. It's info at askdrv.us. Look forward to talking to you next week.