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Integrative Diabetes Care with Dr. Mona Morstein: Rational Wellness Podcast 253

Dr. Mona Morstein discusses An Integrative Approach to Diabetes at the March 24, 2022 Functional Medicine Discussion Group Meeting with Dr. Ben Weitz.

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Podcast Highlights

8:28  95% of cases of diabetes are Type II and it is related to obesity, among other things. There are about 8 billion people on earth and about 2 million are overweight.  In the US, statistics on obesity are staggering, and even 15% of children are obese.  Over 37 million people in the US have diabetes and another 100 million have prediabetes, so one out of every three Americans have diabetes or prediabetes.  Close to 50% of those over age 65 have diabetes in the US.

11:02  TYPES OF DIABETES:  

1. Type I Diabetes, which is our classic Pediatric Autoimmune disease.  It typically does not start below one and half years and fades out around age 25.  There is an ongoing trial called the TEDDY trial, which stands for the Environmental Determinants of Diabetes in the Young, and they are looking at figuring out what the triggers are, including diet, nutrient deficiencies, vaccinations, infections, stress, etc..

2. Latent Autoimmune Diabetes of the Adult, LADA.  This condition tends to start after age 35 and most are in their 40s and 50s and they are insulin dependent.  Many of them get misdiagnosed with type II diabetes, since many physicians are not knowledgeable about LADA. This type I can be very slow onset where they may not need insulin at first, or they may just need a small amount of insulin, sometimes for decades, or they need full blown insulin from the start.

3. Type II Diabetes. This is the most common form of diabetes and it is insulin resistance driven. Most patients with Type II Diabetes are poorly controlled and many of these will go on to eventually need insulin.  But insulin dependent Type II Diabetes is still Type II.

4.  Mature Onset Diabetes of Youth, MODY.  This is related to genetic mutations where people either are unable to secrete insulin or are unable to receive insulin.  Athena Diagnostics offers testing to measure 1, 2, 3, 4, 5, and 8 of the MODY genes. For this group, sulfonylureas, which are not really good drugs for most of us, work really well for this group.

18:34  Complications of Type II Diabetes:  1. Hypertension, 2. Chronic Kidney Disease, 3. Impaired vision, 4. Neuropathy, 5. Amputation, 6. Pregnancy complications, and 7. NAFLD.  The majority of our cells have an insulin receptor and this allows them to grab glucose and pull it into the cell and turn it to fat and store it or burn it. But there are four cells in the body that don’t have insulin receptors, which are the eyes, the kidneys, the nerves, and the endothelial lining of the blood vessels.  When glucose gets into these cells, there is no insulin to process it, so if your blood sugar level is 300, then the sugar in your eyeballs will be 300. The cells in these tissues therefore become damaged if your diabetes is uncontrolled. If your diabetes is uncontrolled, you have a 4-6 times increased risk of dying from cardiovascular disease. Diabetes is the number one reason people wind up with end stage kidney disease. It’s the number one reason adults go blind. It’s the second most common reason for amputations and there are 356 diabetes amputation every day in the US. Diabetes can lead to non-alcoholic fatty liver disease.

22:05  Laboratory Analysis of Diabetes.  Labs should include CMP, CBC, lipids, Ferritin, which can help to detect anemia and it is an early indication of fatty liver. If there is indication of fatty liver, you do an ultrasound. GGT, which is another liver detox enzyme.  If someone is injecting insulin, then measuring insulin is no longer accurate. C-peptide is a better indication than insulin.  To assess heart disease risk, a standard lipid panel is bogus, so you need an advanced lipid profile and you need to include Lp(a), APoB, Oxidized LDL, Homocysteine, Fibrinogen, HsCRP.  You should check random micro-albuminuria at least once a year, which can show early kidney damage. The diabetic antibodies to diagnose LADA include GD65, insulin antibodies, Islet cell antibodies, Tyrosine phosphatase, and Zinc transporter 8. If it’s type I, then you also want to look at Celiac and thyroid antibodies.  Hemoglobin A1C. There is a .5 variability with this test.  In general, the lower the A1C  the better.  An A1C over 5.5 is already beginning to cause damage in the body such as to the eyes. [Association of A1C and fasting plasma glucose levels with diabetic retinopathy prevalence in the U.S. population: Implications for diabetes diagnostic thresholds]  Over 6 it’s causing kidney damage. [Poor glycemic control in diabetes and the risk of incident chronic kidney disease even in the absence of albuminuria and retinopathy: Atherosclerosis Risk in Communities (ARIC) Study

30:00  A Hemoglobin A1C of 5 translated to an average blood glucose of 100, six is 126, seven is 152, etc. You can have two different patients both with a A1C of 6 but one patient can have good, steady control with only mild ups and downs and another patient could be at 50 for half a day and at 150 for the other half and that patient could also have a A1C of 6.

31:44  There are certain cases where the A1C is inaccurate, including with patients with genetic hemoglobinopathy, like sickle cell anemia, you can’t really use A1C, you’d have to use fructosamine, instead. The only problem with fructosamine is that it doesn’t translate to a glucose number.  If the patient has serious liver or kidney disease, the A1C will be inaccurate and will appear lower. It can be too low if they have serious bleeding or high if they have iron deficiency anemia.

32:36  There are a few studies, including the ACCORD trial where they had patients eat whatever they want and they lowered the A1C below 6.5 by using some very strong medications, including the sulfonylureas, which cause weight gain and water retention, the TZDs, which cause weight gain and water retention, and insulin, which causes weight gain and water retention, and they had more patients dying. They concluded that lowering the A1C below 6.5 is not a good idea because it will cause heart disease and this has led some doctors to recommend not trying to get the A1C below 6.5. But all the ACCORD trial showed is that lowering your A1C below 6.5 without dietary changes and only using very strong medications will increase your risk of heart disease.  If the patient is able to lower the A1C to 5.4 with diet, supplements, and Metformin, they are not going to have a high risk of cardiovascular disease.

34:25  The American Diabetes Association has set the following glucose goals for diabetic patients, but they should be more stringent:

1. A1C below 7

2. Fasting glucose 80-130 mg/dL

3. Post-prandial <180 mg/dL 

Dr. Morstein feels the following goals would be better guidelines:

1. A1C below 6.

2. Fasting glucose <110 mg/dL  Ideal <100 mg/dL

3. Post-prandial <120 mg/dL  Ideal <110 mg/dL 

 

34:50  Diabetic Medications:

1. Insulins:

       A. Basal:

             Long-Acting: Levimir/detemir, Lantus/Toujeo/Glargine/Basaglar, Tresiba/degludec 

             Intermediate-acting: NPH (Neutral Protamine Hagedorn)

      B. Bolus/Corrections:

             Short-acting: regular insulin 

             Rapid-acting: Novolog/aspart, Humalog/lispro, Apidra/Glulisine,

             Very-rapid: Fiasp/aspart

2. Oral Hypoglyemics: 

       A. Biguanides: Metformin HCL, and there is an extended release  

       B. Sulfonylureas, which are problematic drugs because they cause water retention and weight gain and there is a high risk of hypoglycemia:

             Glipizide

             Glyburide, which is the worst one for low blood sugar,

             Glimepiride, which is the best in this group

       C. Mitiglinides, which nobody uses 

       D. Thiazolinediones (TZDs)

             Rosiglirtaxzone (Avandia)

             Pioglitazone (Actos)

       E. Sodium Glucose Transporter 2 Inhibitors–these are not bad drugs, but the sugar can cause bladder infections or jock itch or vaginal infections

             Canagliflozin  (Invokana)

             Dapgliflozin (Farxiga) 

             Empagliflozin (Jardiance) 

             Ertugliflozin  (Steglatro)

       F. Dipeptidyl Peptidase 4 Inhibitors (DDP4 inhibitors)–these seem to be fairly safe, though they are fairly weak.  And at their highest dosage they have a lowering of the A1C of like 0.5, while just taking out grains from their diet will lower A1C by 3.3%.

             Januvia/sitagliptin 

             Tradjenta/linagliptin 

             Onglyza/saxagliptin 

             Nesina/alogliptin

       G. Glucagon Like Peptide-1 Agonist–These are really good drugs that are fairly effective, and they may help patients lose weight, they reduce their appetite, but they are quite expensive.  There may be some nausea as a side effect.

            Dulaglutide/Trulicity 

            Exenatide/Byetta 

            Exenatide ER/Bydureon 

            Livaglutide/Victoza 

            Lixisenatide/Adlyxin 

            Semiglutide/Ozembic/Rybelsus 

            Albiglutide/Tanzeum

38:30  With respect to Continuous Glucose Monitors, there is the Dexcom and the Freestyle Libre from Abbott and Dr. Morstein finds the Dexcom much more accurate than the Freestyle Libre.

39:50  Diet for Diabetes.  In 2013 or 2014 the American Diabetes Association acknowledged that low carb diets may have value for diabetics. If we look back 100 years ago, there were not that many type II diabetics and the type I diabetics were dying pretty awful deaths until we invented insulin. Then diabetic patients were able to live longer, but they all eventually died of cardiovascular disease, so it was thought that this meant that their fat was too high, so the whole country started preaching eating low fat. Everybody started eating more carbs and things went downhill from there.  Only in the last few years have the ADA turned around and endorsed a lower carb diet for type II diabetics.

41:42  For Prediabetes the PREDIMED study showed that the Mediterranean diet works well.  [Reduction in the Incidence of Type 2 Diabetes With the Mediterranean Diet]  Compared to the low fat diet, the Mediterranean diet reduces diabetes by 52%, which was more beneficial than putting patients on Metformin.  However, the low carb diet performs better than the Mediterranean and leads to most lowering of the A1C.

42:48  There is an outlying diet known as the MA-PI2 Diet, which is the high carb, plant based diet for diabetes.

 

 

 



Dr. Mona Morstein is a Naturopathic Doctor who practices at Arizona Medical Solutions in Tempe, Arizona. Dr. Morstein: has a practice focus on treating patients with autoimmune diseases, hormonal conditions, diabetes, thyroid, and gastrointestinal disorders like SIBO and IBS.  She is the author of the best-selling book, Master Your Diabetes: A Comprehensive, Integrative Approach for Both Type I and Type II Diabetes and she lectures frequently at medical conferences.  Her website is azimsolutions.com.

Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.



 

Podcast Transcript

Dr. Weitz:                           Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. To learn more, check out my drweitz.com. Thanks for joining me and let’s jump into the podcast.

Welcome everyone to the functional medicine discussion group meeting tonight on integrative approach to diabetes care. We’re very happy to be joined by Dr. Mona Morstein. I’m Dr. Ben Weitz and I’d like to make some introductory remarks before making some remarks about our sponsor, and then I’ll introduce our speaker and we’ll get started. So I encourage each of you to participate and ask questions by typing in your questions in the chat box. Then I’ll either call on you or simply ask Dr. Morstein your question when it’s appropriate.

So I hope that you’ll consider attending some of our events in the future. April 28th, we have Dr. Paul Anderson speaking on an integrative approach to cancer. May 26th, Dr. Sarah Thompson will be speaking about a functional approach to maternity. Then the next meeting after that will be June 23rd and that’s yet to be determined. So if you are not aware, we have a closed Facebook page, the Functional Medicine Discussion Group of Santa Monica, that you should join so we can continue the conversation when this evening is over.  I’m recording this event and I will include it in my weekly Rational Wellness Podcast, which you can subscribe to on Apple Podcast, Spotify or YouTube. If you do already list into the Rational Wellness Podcast, I’d very much appreciate it if you could go to Apple Podcast and give me a positive ratings and review.

 

So now I’m very happy to tell you about this evening’s sponsor, which is Integrative Therapeutics. I’d like to take a few minutes to tell you about a few of their products. One of their most popular products is Cortisol Manager, which is an excellent combination of several adaptogenic herbs and phosphatidylserine, which helps to modulate cortisol levels, which can be helpful in modulating blood sugar levels since cortisol surges due to stress can cause blood glucose levels to rise, which I’m sure Dr. Morstein will mention.

Another excellent product in the Integrative line is Berberine, which has quite a bit of research to back up its benefits in helping to control blood sugar and to improve insulin sensitivity. In fact, some studies show that it is equally as effective as Metformin, and can also be used concurrently with Metformin and has been shown to improve Metformin’s efficacy. This Integrative Berberine product is Berberine HCL, which is not an extract of Berberine from Berberine containing herbs, which is in their Berberine complex which is better for use as an antimicrobial for gut health.  In other words, if you’re using Berberine for managing blood sugar or helping with lipids, then you want to use the Berberine HCL. I personally use Integrative’s Berberine product for my patients because of its quality, both for blood sugar management, for control of lipids, and also as a longevity agent since it’s an activator of AMPK. One of the reasons why he Integrative’s Berberine and their other products are such high quality is because the company uses a manufacturing facility that’s a drug GMP facility rather than a dietary supplements GMP, which means that they test every line. They do bio-validity testing, stability testing for up to two years past the manufacturing date, et cetera.

So Dr. Mona Morstein is a naturopathic doctor in Tempe, Arizona who’s a practicing functional medicine doctor at Arizona Integrative Medical Solutions, which has a focus and her practice has a focus on treating patients with autoimmune diseases, hormonal conditions, diabetes, thyroid and gastrointestinal disorders like SIBO and IBS. She’s the author of the bestselling book, Master Your Diabetes: A Comprehensive, Integrative Approach for Both Type 1 and Type 2 Diabetes. I got to tell you, this is one of the most impressive, comprehensive, useful books that you would ever want to have and everybody should have this on your shelf for help with managing patients with diabetes. Dr. Morstein, thank you so much for joining us. You have the floor.

Dr. Morstein:                     Thanks very much, Ben. I really appreciate the intro and I hope everybody can see the lecture, the slides okay. I wrote kind of as a joke an abbreviated diabetes lecture, because it still is like 70 slides. but I try to extract. I’ve taught a lot of diabetes webinars to physicians and it’s usually a kind of a weekend affair, all day Saturday and all day Sunday. So we’ll try to touch upon a lot of things right now today. I also know I’m speaking to physicians, so you’re already coming with a fairly high level of comprehensive knowledge of this condition.

Okay. He just mentioned me. This is me. I will say this, I don’t think we talked talk about this enough in medicine because it’s embarrassing, but I got into diabetes because literally way, way back when, I mean 30 years ago, I missed the I missed a diagnosis of a type 2 patient in kind of an acute crisis of diabetes. So that really shook me to the core. I was a new doc, just starting out in Montana, and it made me doubt if I was a safe, responsible physician.  So the end result was that I just decided to never miss another diabetic patient and I really immersed myself in this condition. So it was nice to take one of the most worst moments of my medical career and turn it into a real growth trajectory that makes me feel very comfortable treating all types of diabetes and kids and adults and so forth to this day. So anyway. Ben already showed the book. You can get it on Amazon. It’s pretty good book. I’m proud of it. Thanks.

Anyway, let’s dive in. There are some statistics just to know about. We’ll talk a little bit about type 1 and of course type 2, but most diabetes is type 2, 95% of diabetes is type 2, and it is related to many things which we’ll talk about, but obesity and being overweight and this abdominal, visceral fat is a big part of it. As we can see the U.S. statistics on obesity are staggering if we’re going to choose any appropriate adjective. Even kids, 15%, that’s so sad.

 Then in the world, right now, we got 8 million people on planet earth, about 2 billion are overweight. It’s not a good thing. With 650 million, about twice the population of the U.S. are obese. So this is not a good thing worldwide, and it’s certainly is feeding into diabetes statistics. So in the U.S. right now, when I did this lecture say when I started 60 years ago, it was only 29 million, so it’s now up to 37 and a little over million people actually have diabetes. Pretty much one out of every 10 people in the mall, or you are going to see has diabetes. Prediabetes is almost another 100 million.

So if we add that up, it is clearly one out of every three Americans have either prediabetes or diabetes at this point in time. With those senior populations, 50% of them have diabetes. You can’t even really wrap your mind around it. So it’s really not a good thing. It’s a huge burden for these people, for the health, for our healthcare system and for the economics of our country as well. In the world, we have right now over 500 million people in the world have diabetes. You can see the deaths and how many pre-diabetics there are. So if you add a pre and diabetes, really 1 billion out of eight people have either prediabetes or diabetes.

Now, the types of diabetes. There is type 1. This is our classic pediatric autoimmune disease. Doesn’t really tend to start below one and a half years. Then even though we call it kind of pediatric, really, the bell curve is going to fade out around age 25, so older than our 18 year old cutoff, but we still consider that’s all that initial pediatric type 1 type condition, right? It’s an autoimmune disease. In my next slide, we’ll talk about that TEDDY trial.

The other type of type 1 is called latent autoimmune diabetes of the adult, LADA. Generally, it’s kind of kicks in from age 35 on, but the vast majority tend to be in their 40s, about 40 to 60 is where we’re going to see that bell curve the most. Now, the big thing with this is that the vast majority of them are misdiagnosed as type 2. I’ve rediagnosed literally dozens and dozens of patients who came to me lean, always been lean, they have type 2, and it’s clearly type 1, right?

So just be aware of that. There are still many physicians that are not knowledge about LADA and are not aware of type 1 happening in adults. This type 1 can be very slow onset where they may not need insulin at first, or they may just need… I have one gal who’s just needed two units of a basal insulin for a decade. She hasn’t progressed. Or these people can come on just as rapidly as a pediatric type 1 and need full blown, full insulin from the get go. So you’ll just have to be able to figure that out with your own patient.

This is the TEDDY trial, stands for The Environmental Determinants of Diabetes in the Young, so TEDDY. So this is a trial that’s still ongoing where they’re following kids and the diets and their vaccines and et cetera, and they’re looking at all of these factors as triggers for what seems to really be an actual trigger that they can clock and start saying, “This is a determined trigger for type 1 diabetes.” So they are looking at a very broad based way of things from nutrient deficiencies to vaccinations and getting sick and psychological stress, all of these things.

So when they are able to quantify it and really put it together and put it out, they put out little bits here and there, but they haven’t yet put the whole thing together. I think that’ll be helpful to all of us to really be aware of what we need to watch in kids early on to help prevent them to not get type 1 diabetes.

Then of course the last type, right? Well, not the last, third of four, is type 2 diabetes, which is the number one diabetes. It’s insulin resistance driven. Gestational diabetes is an insulin resistance type diabetes. These are pretty well known etiological factors, and I’m going to talk about them more in the further slides to come, but all of these things can be factors with developing and also potentially having trouble controlling type 2 diabetes.

Dr. Weitz:                          By the way, doc, if a type 2 diabetic ends up being insulin dependent, has that type 2 now become a type 1 or is it-

Dr. Morstein:                     Yeah, that’s a good question. So, no. So type 1 is relegated to autoimmunity, and both you’re going to be able to pick up for the vast majority. There are always a very, very small percent of antibody negative type 1 patients. That just happens. But the vast majority will have a positive antibody or several positive antibodies. Type 2 diabetes is generally poorly controlled. These people will become insulin dependent type 2 diabetes. So they stay type 2.  There’s a lot of patients who need insulin with type 2 diabetes. For me, unless the patient is literally completely in denial and refuses to change anything about their diet or their lifestyle. There are some patients like that. But for a lot of them, they’re just given misguided information from the physicians they go to. Easily, the vast, vast, vast majority of type 2 diabetic patients never need to be insulin independent.

The last one is a relatively unknown one called MODY, mature-onset diabetes of youth. These are just genetic mutations. These you tend to see, well, grandpa had diabetes and dad had diabetes and Timmy at 16 gets diabetes. But it’s not that bad and they don’t really need insulin. This is mild elevations. Their blood sugars are around 140 or so. These are genetic defects. For example, they make insulin, but there’s a genetic defect in their ability to secrete it, or they can secrete it, but there’s a genetic defect on the receptor that it doesn’t acknowledge the insulin.  So these are generally can be dealt. Most of them have to do with secretion. So sulfonylureas, which are not good drugs that we don’t really like, for this group of people is a good drug, right? If they just take a sulfonylurea, they’ll be fine for pretty much the rest of their life. So there’s one lab, Athena Diagnostics, that does measure all of them, they measure 1, 2, 3, 4, 5, and 8 of the MODY genes, right? If you feel a child needs to be investigated that way.

Just to put it together, a little chart of MODY type 1 and type 2, non-insulin dependent or parents affected and so forth, Acanthosis Nigricans, et cetera, and racial groups, right? Certainly we know with type 2, obviously many Caucasians get it, but Pacific Islanders, Native, right? We’ve been studying the Pima Indians with type 2 diabetes since the ’50s. Definitely Hispanic populations, our African American, very high risk for type 2.

So diabetes, but controlled, nobody has any problems with diabetes when it’s controlled. But when diabetes is not controlled, right? Physiologically, the vast majority of our cells do have an insulin receptor. When this pancreas secretes insulin, it lands on the receptor, sets up this phosphorylation chemical, and then that initiates the glucose transporters, particularly 2, to reach out, grab glucose and pull it into the cell, turn it to fat and store it or burn it as well. But we know insulin is called the fat building hormone. Its idea is to store food for later.  So the problem is there are four cells in the body that don’t have insulin receptors and the glucose is just going to… Osmolarity just walk into those cells. So those cells are your eye cells, kidney cells, neuro cells, and the endothelial lining of the blood vessels, which is why those are the ones that get damaged with uncontrolled diabetes. Because if your blood sugar is 300, your eyeballs are 300. Meanwhile, your fat cells and muscle cells and liver cells, they’re like, “Forget it. I’m not taking you in. I’m going to be resistant.”

So they’re not getting the glucose in, but it is getting in these other cells that by the nature of survival never want to be without glucose so there’s nothing blocking glucose from entering those cells. But this is why the majority of people with diabetes have hypertension. When you have diabetes, considering if you’re just getting regular treatment and you’re not really well controlled, you have a four to six time increased risk of dying from cardiovascular disease, which is not a good thing because everybody dies of cardiovascular disease in America, so you are really at risk.

Chronic kidney disease. Diabetes is the number one reason people wind up with endstage renal disease. It’s the number one reason adults go blind. The first reason people get amputations is trauma. The second reason is diabetes. So pregnancy and fatty liver, most fatty liver, which in America is still called non-alcoholic fatty liver disease, in Europe and probably within a year or two in America, it is going to be called metabolic associated fatty liver disease, because that is a vast majority of fatty liver, right? So diabetes has outstandingly devastating complications.  This is like a daily diagnosis. We have 4,000 people a day diagnosed, 356 amputations a day due to diabetes. About 160 people wind up with endstage renal disease, et cetera. Literally, the amount of money we spend on diabetes in this country is very scary and could really become an economic burden for our country in the future.

Now labs. So this is like one page of labs to consider. Obviously, the basic CMP, CBC with different lipids obviously. I always draw Ferritin. I include Ferritin on every lab, a yearly lab that I do. Ferritin, one, it’s the first way to catch anemia. Before the CBC is affected, you’re going to see low Ferritin. So you can catch people before it gets very serious. But even more so, it’s the number one lab that shows, that indicates a person has fatty liver. When Ferritin is elevated, of course, you’ll do iron panel and look at trans saturation, and as long as it’s not over 50 or so, they don’t have hemochromatosis, and most people don’t have hemochromatosis, about 2% of the population, but when that’s negative, then you can do your ultrasound and see the echogenicity. So… your ultrasound and see the echogenicity. Ferritin is the number one blood lab. When it’s high, that indicates as, and that’s as a liver, acute phase inflammatory marker. The second one is elevated GGT.

Dr. Weitz:                          By the way, Doc, on ferritin, are you using the lab range over 400? What are you using as high?

Dr. Morstein:                     I am. Well, it depends on the lab. Some labs are over 250, some are over… Yes, I am using for high, I am using high. Yes, I am using high. If the lab range was 400 and they were at 380 and you wanted to test for fatty liver, because they have a adiposity as a body type. There’s nothing the matter with that. I’m saying, literally, you’re going to get a great deal of your overweight or obese pre-diabetic or diabetic patients will have elevated ferritin. You’ll do the ultrasound and they’ll have fatty liver.

Dr. Weitz:                          By the way, Doc, I don’t know if you’ve noticed, but recently, some of the lab ranges have gone up. I had a patient last week with ALT of 65 and I said, “Oh, your liver enzymes are up.” Then it said normal. It was an asterisk underneath. This was a UCLA lab. New reference range, it’s now up to 70 is normal.

Dr. Morstein:                     I don’t think anybody who’s a real… I Just did a webinar series with a hepatologist and things on liver conditions. They’re not going to agree with that.

Dr. Weitz:                          Well, this is the normal range is the average American as a result of two years of pandemic drinking.

Dr. Morstein:                     Yeah, of course. Totally. Absolutely. I once called Sonora Quest because they’re postprandial insulin range was from 29 to 89. Now, when you look at studies where they are measuring postprandial insulin, pretty much the cutoff was around 30 where they said that it should be not higher than 30. I called Sonora Quest to research, how did they get their range? Do you know? Sonora Quest said, “Oh, well we just took 50 of our healthy employees, measured their postprandial insulin and got the range.”  That’s literally how they set up the lab value. That’s measuring millions of people. The lab ranges, we do have a right to be a little question them at times. I agree with that. The other ones that you can see are fairly standard. Remember that as soon as someone injects insulin, you cannot measure insulin. You have to measure the C-peptide. Anyway, C-peptide is a better reader than insulin, I think, anyway.

You can’t measure insulin once if they’re a type one diabetes because, they’re going to probably have insulin antibodies. Or once you inject insulin, you’ll make insulin antibodies. We want to switch to C-peptide. The cardiac risk panels, because we know cholesterol is pretty bogus to judge cardiovascular disease risk. The other panels are, these are better. Random micro-albuminuria, you’ll want to check at least once a year, if it is elevated, showing early kidney damage, you can repeat it every three months. Those are the diabetic antibodies.  The classic one for LADA is GAD65, but I would just do the whole diabetic antibody panel. Because sometimes it’s not, GAD and it is a different antibody and you don’t want to miss it. Then of course, celiac, and Hashimoto’s, at least once a year with your type one diabetic patients, you’ll want to check Hashimoto’s if they’re literally gluten free, you can’t really measure for celiac. If for some reason they’re just going to eat gluten, then you’ll want to check that every year as well.

Dr. Weitz:                          What about the new kid on the block, uric acid?

Dr. Morstein:                     Oh, yes, uric. Well, so uric acid going back, yes, uric acid obviously, elevated uric acid, not just gout, but it is an indicator of also risk of kidney disease, even heart disease and patients with diabetes. I don’t do uric acid that much because I already know their risk. What’s their A1C, what’s their et cetera? I don’t do a lot of uric acid. I will do them, I’ll do the micro albuminuria. I’ll do other things. Yes, it is an indicated lab. If you just want to throw that in, for sure. Thanks Ben.

Now, just to say, this is the conventional A1C lab reference ranges, pre-diabetes and then diabetes 6.5% and higher. The problem is, is with A1C, one, it always has a 0.5 variability. If you get a six, it could be from 5.5 to 6.5. There’s always this little variability. Now, we do know the lower the A1C, these old studies are still referred to this day. The DCCT and the UKPDS done in the 90s, type one and type two, showing that literally lowering A1Cs from nine to seven, based on basic and then aggressive control, made huge differences in the occurrence of complications.  We still need A1Cs to be as low as we can. Unfortunately, even though they don’t count person being pre-diabetic until it’s at 5.7, studies will show that an A1C over 5.5 is already beginning to cause damage in the body, such as to the eyes. Or over six, it’s causing kidney damage. In the pre-diabetic range, people are already having damage. This is a problem, because people, “Oh, it’s five, seven, whatever. That’s not that bad.” Well, okay, it’s not that bad, but it is causing damage. We do want to get people under controlling and get them protected.

Dr. Weitz:                            I think there’s a misunderstanding of what hemoglobin A1C is. I think a lot of people don’t really think about it too much and they just say, “Oh, this is three months of average blood sugar.” Really, this means that proteins in your body are being damaged by sugar.

Dr. Morstein:                     Well, yeah, I mean the A1C is a protein on the red blood cell. What we’re measuring is what percentage is covered with glucose. An A1C of five is 5% of those proteins are covered with sugar and 6% is 6% of it. It doesn’t seem like much, but of course we can translate this to blood sugar numbers and they go striking each number decimal higher is about 26. Five is 100, six is 126, seven 152 and up. There’s a fairly exponential rise per percentage of this glucose bound to the A1C protein on the red blood cell. I do have this slide just showing, there’s different ways.  You can get an A1C of six. You can have steady, good control, or you can be up down, up and down all day with an average of six. If you are at 50 half the day and at 150 half the day, you could get an A1C of six. We have to be aware that you always want to monitor blood sugar, not just take an A1C, because we don’t know what the blood sugar is doing to get that A1C. Then here’s a very, very busy slide, just saying when the A1C can be inaccurate. There are different races have different A1Cs.

Of course, the genetic hemoglobinopathies, if you do have a patient with a genetic hemoglobinopathy, like a sickle cell, you can’t really use A1C, you’d have to use fructosamine, instead. The only problem with fructosamine is that it doesn’t translate to a glucose number. It’s just low, normal, or high, but we can’t translate it into glucose like we can in A1C. Then different, depending on how, if they have serious liver, then the A1C can lose efficacy as well. Liver, kidney, iron anemia, et cetera. Last, the problem with the A1C also was these studies.  These studies, particularly the Accord. The accord was a study where they had people eat whatever they want. Because why would we ever deal with the diet in measuring medicines? They had people eat whatever they wanted, their goal was to get them less than 6.5% of an A1C. As a result, they had to use a lot of strong medicines, which was sulfonylureas, which caused weight gain and the water retention. TCDs, which cause weight gain and water retention, and insulin, which causes weight gain and water retention. They had a high amount of people dying.  As a result of this study, I can’t tell you the amount of patients who come to me and say, “Oh, my doc doesn’t like that. My A1C is at 5.8 and literally wants me to eat more carbs to get it higher, so I don’t have cardiovascular disease because of the accord study.” The accord study, that’s all we, and then the advance, these studies use the worst drugs that we have. This accord study is what took the TCDs off the market.

Now, they’re back on, but very rarely used. Probably all of you have also heard patients say, “Oh, my endo doesn’t want me to get less than 6.5, because I’ll get heart disease.” This is ridiculous. It’s solely based on the accord. If I get a person on a diet and supplements and maybe Metformin down to 5.4, trust me, they are not going to have a high-risk of cardiovascular disease. Just to be aware. The ADA has these glucose goals. I think we all want it a lot more stringent.

Because we can get it with the way we’re doing it versus the way the ADA tends to do it. Getting everything down back to as much normal as possible is the goal. These are the diabetic medications, there are insulins, they’re basically split to basal, which is covering the fasting glucose, which is either long-acting or intermediate. NPH is the worst insulin we have. Certainly, by far, has the highest rate of hypoglycemia. Very hard to deal with. Some people need it twice a day. Some people need it three times a day. It can last for eight hours.  It can last for 15. It’s a difficult insulin, but it is super-cheap. That’s why we’re seeing a little resurgence of it now in patients who can’t afford insulin as it’s priced now. Although I order a lot of insulin from Canada, it’s much cheaper there. Or people I have patients just drive down twice a year to Mexico and get their pens from nothing, just walking into the pharmacy. Then there’s the bolus, which is meal or correction. We have short-acting, regulars by far are the best for meals, but isn’t used very much nowadays for a couple of reasons.  The rapid-acting, and then the very rapid-acting, which acts within five minutes. These are our insulins. We have the oral hypoglycemic. There’s nothing the matter with Metformin. You’ve got Metformin, and then you’ve got the ER, because some people who can’t handle Metformin in the gut, the ER, they will be able to handle the extended relief. The sulfonylureas are problematic drugs, they do cause water retention and weight gain. They have the high-risk of hypoglycemia.

Glyburide is the worst one for low blood sugar, so we’d want to stick with Glimepiride. The mitiglinides, nobody uses. Why would we use this? I could take a sulfonylurea maybe once a day for 24 hours. Why would I want to take a tiny sulfonylurea with every meal? Nobody uses them. The TCDs, I just saw a patient on one for the first time in nearly a decade. The sodium glucose transporter to inhibitors, not bad drugs, except the sugar can cause bladder infections or jock itch or vaginal infections, but most people don’t have this recurrently.

You can get a euglycemic DKA in type twos, which sucks. You have to be like, people be aware of that. Then you have the DPP4 inhibitors, which don’t seem to be a problem very much. It’s just that at the highest dose, they have a lowering of the A1C of like 0.4, 0.5. Frankly, just taking out their grains will lower them 3.3%. They’re fairly useless drugs. They don’t do very much. Then we have the Glucagon-like Peptide-1 agonist, these are good. These are great. Patients like them. Most of them can handle them, even with the nausea. Once a week shot, they can lose a little weight.

Their appetite is better. Their blood sugar is better. These are well, good drugs. They’re just spendy, and so people have to hope their insurances will cover them. Otherwise, people are using for insulin, vials and syringes or pens or pumps, and then the CGMs. Dexcom is pretty good. FreeStyle Libre for the type twos, is pretty inaccurate. People get it, but it is not the best CGM.

Dr. Weitz:                          Dexcom is more accurate than-

Dr. Morstein:                     Yeah, Dexcom is 100% more… I was trying to go backwards. There we go. Dexcom is 100% more accurate than a FreeStyle Libre, absolutely.

Dr. Weitz:                          I know Dexcom usually recommends wearing it on the abdomen. I’ve seen some people put it on in the back of their arm. Is that acceptable? Do you know?

Dr. Morstein:                     Yes. That is acceptable. Also, back here in the back, is also acceptable. it’s just subcu. For example, this is probably the most common area people wear their Omnipod pump, which is in the back here. People love wearing their Omnipod here, and it’s the exact same technology and depth. With the Omnipod here, you can have your Dexcom here.

With diets, so in 2013, ’14, the ADA did acknowledge that low-carb diets have value in working with diabetic patients.  Now, if we go back, what happened with the ADA is that, diabetic patients say that needed, type one diabetics 100 years ago before Banting and Best were inventing insulin in Toronto. We didn’t have many type twos and the type ones would die pretty awful deaths where they just ate themselves. We invented insulin and diabetic patients were able to live longer until they all died of cardiovascular disease. They’re doing autopsies on all these patients with diabetes and they had cholesterol in their arteries. If you go back to the 70s, that meant their fat was too high.  That was 1978 was when the country said, “Wow, we should all eat low-fat.” Everybody started eating all these carbs and things went downhill from there. The ADA said, “Yeah, we’re seeing all this fat in these autopsies, so we should have a huge amount of carbs in our patients with diabetes and not much fat.” This has been going on for decades until recently, just in the last years, they’re turning around, which is something for them to do. They started acknowledging low-carb diets is, a physician could do this in an acceptable way.  

For prediabetes, this PREDIMED diet is very well known where they did Mediterranean diet versus low-fat and even Metformin. The Mediterranean diet, which is really just a super-healthy, non-processed food, omnivore type diet. Here’s the study and, the Mediterranean diet with olive oil or nuts and no calorie restriction reduced diabetes incidents by 52%, which was higher than putting people on Metformin. In other words, just eating a healthy Whole Foods omnivore diet with good oils can prevent diabetes.  This is what pretty much everybody was eating until they invented fast foods and candy bars. This has been a diet for humanity for centuries, and it works to not get diabetes.

Now, this is an outlier, I think we need to discuss, which is the MAPI2 diet. This is the high-carb plant-based diet. There is a company there. Actually, I wrote a book, Master Your Diabetes, but the mastering diabetes folks are doing this diet. They’re doing this high-carb, plant-based diet.  There is actually good studies on this diet. They did a six-month study of this diet. Now, this was all men. This was all type-two diabetic men who had pretty high A1Cs, and this was the typical diet that they ate. Now, the mastering diabetes people aren’t doing macrobiotics. This diet was what we classify as macrobiotic. You can see just all kind of foods that we wouldn’t think people with diabetes should eat. The results were outstanding in every area. The A1C from 12 to 5.7, pretty amazing.  Things like HDL went up, LDL went down. C-peptide actually raised a little bit. This is their lipids, the onset. After months, from acceptable, there was only 31%. After the six months, almost 94% of the patients had acceptable triglycerides and pretty good stuff. They had weight loss, they lost hip circumference.  Their BMIs went down, their muscle mass gained. This is everything we want to see, eating this diet. Now, these guys were fed this diet. This is a hard diet for people to put together, but in the study, they were delivered their meals. They just got everything fed to them. Now, this is kind of, I copied and pasted. This is from the Mastering Diabetes Group, and you can see what they want you to eat a lot of, which is, grains and legumes, veggies and fruits.  Then what they want you to eat just a little bit of, which is, things like pastas, avocados, because they’re worried about too much fat, especially saturated fat. Nuts, which is too much fat. Then there are other things that they don’t want you to have at all, which is meat and poultry. Part of this is the idea that animal protein, I think interpreting this, I went to a lecture from Dr. Joe Pizzorno, who’s a naturopathic physician. Brilliant. He did one of the best lectures I’ve ever seen, which was on cellular acidity, right? Now, in reality, our blood doesn’t really change alkaline or acid because tiny changes are so devastatingly bad, but the cell, we’re looking at intracellular, there can be acidic changes. And animal protein and salt are two of the main, main, main foods that cause the acidosis and that is causing insulin resistance. So in this diet, removing all the animal products is really pulling out that whole thing. The problem is you can’t eat half this diet and half of the other and have it all merge. This diet will work 100% its way or low carb will work 100% its way, which is what we’re going to talk about right now. Right?

So low carb, for diabetes, we’re usually looking at 40 or less carbs a day. Okay? The studies on low carb, there are a lot of studies on low carb, but this one that I want to show you, if you look at the authors on this study, first of all, Richard Bernstein, Richard Feinman, huge low carb, there are some really well known low carb researchers, Westman, Eric Westman, big keto guy. And so they did this study showing being a dietary carbohydrate restriction, first approach in diabetic manage, and this is what happens when you are doing a low carb diet, pretty much everything we want to have happen for people with diabetes. So this was with type two diabetics.

Then managing type one diabetes with very low carb diet, this was published in pediatrics. This wasn’t a study so much as it was a survey. And they surveyed a group on Facebook called type one grit, which is a very, very passionately low carb group for type one diabetes. Notice Bernstein and Westman are in [inaudible 00:48:45] these same people. Dr. Richard Bernstein, by the way, was my mentor. He wrote the book, Dr. Bernstein’s Diabetes Solution. He was the one who brought low carb diet to diabetes. He also was the one who taught us how to use insulin better. For example, using insulin to cover carbs, to cover protein and to figure it out in a completely different way than conventional care. And that works a lot better. David Dikeman, he’s a big low carb guy.  So they did this survey of parents of type one. And here’s the exceptional glycemic control of type one diabetes without adverse effects was reported by these people and their kids on a low carb diet with type one, with the reported mean of A1C at 5.6, which is pretty outstanding. So low carb diet is what most of us work with and what most of us want to do. But if one of my patients really wanted to do mastering diabetes, 100%, I don’t mind. The studies are good. They’ve been replicated. But you’ve got to choose one extreme or the other. So it’s total carbs minus fiber. It’s not the amount of sugars on the label. It’s total carbs minus fiber, right? That’s what a label should be. And these are the low carb nos, pretty much, right? The big groupings of foods that we’re taking out of the low carb diet, right? Which you probably know about.

And then Bernstein set up the idea of six grams of carbs at breakfast, 12 at lunch and supper because of the Dawn phenomena at breakfast raising our blood sugar innately. And so having less carbs at breakfast, and then as we’re up and moving around lunch and supper, we can have a little more then. And fat is a free for all. And protein is also weighted a little bit as well. We don’t want to overdo protein. We do need people getting in calories though and having energy and so forth. So we do a little. The protein is one gram per kilogram versus 0.8 for adults in general. And then we allow fat to make up many calories too.

I mean, obviously you all know how beneficial exercise is to people with diabetes with metabolic syndrome, prediabetes, people who are overweight and et cetera. It does pretty much everything we need it to do to help reverse that in patients. And then we can put it obviously aerobic. Resistance does burn 19 times the glucose that aerobic does. Now, I’m not talking if you’re going to decide to do a 10 mile hike with 3000 foot elevation, then the aerobic is going to work pretty well. But if you’re a half hour on a treadmill versus a half hour of lifting weights, you’re going to burn more glucose with the weights, right?

Dr. Weitz:                          Hey, Doc. Can I just ask you question about the diet, just to go back for a second?

Dr. Morstein:                     Oh, yeah. I’m sorry. I didn’t need to. If I’m-

Dr. Weitz:                          No, that’s okay. Yeah. So the low carb program you’re outlining, less than 40 grams. That’s very, very low carbs. Can you get a reasonable benefit with, say 50 to 100 grams? A lower carb program reduces the high glycemic carbs, takes out the refined carbs, but say the person has maybe a slice of gluten-free toast in the morning with their eggs and they have a yam with their dinner, and maybe they have some beans with their salad at lunch.

Dr. Morstein:                     I mean, they’re going to see elevations in their blood sugar. It just depends on how much, right? But generally, no, if you’re following low carb, those are not on the diet for low carb. Now, why not have a piece of base culture bread. Or if you go to a dietdoctor.com, dietdoctor.com has amazing recipes. They have these rolls, which are six ingredients. You mix them together. You bake them. You get these super tasty rolls that are two grams of carbs per roll. So the idea is there’s low carb bread, there’s low carb tortillas. You can make your own low carb rolls. Birch Benders has low carb pancakes. You can get Shirataki noodles.

So the idea is when you’re working with patients this way, here’s the deal, for every 20 seconds you spend taking some food or food group out of a patient’s diet, you want to spend about five minutes adding in the alternatives, because otherwise their psychology starts getting narrower and narrower and narrower. And it’s not like they have to live. They could have base culture. A slice of base culture bread is four grams of carbs and four grams of fiber, which is going to even further reduce the carbs that they eat. So if they have a sandwich at lunch with base culture bread, that’s eight grams of carbs, eight grams of fiber-

Dr. Weitz:                          What kind of bread are you saying? It’s not something I’ve heard of.

Dr. Morstein:                     Oh, it’s called base culture. B-A-S-E culture bread.

Dr. Weitz:                          Okay.

Dr. Morstein:                     So I’m saying that there are breads that people can eat, that will work for them without it being Dave’s Killer bread, which you can’t have. No, you can’t have this, you can’t have Ezekiel bread, but try this bread or try this granola. I have a reference sheet that once I go through, I have a eight or 10-page diabetes handout for the diet. So we go over everything. Then I have a reference sheet with recipe books, 300 15-minute low carb recipes. Oh, you want maple syrup? Well, guess what? Nature’s Hollow has it, Birch Benders has it, Lakanto has no carb maple syrup made with monk fruit, right? So if you give people some of these alternatives, so the diet isn’t this whole change, they can still have some things they really like, but it’s low carb and it’s going to do what we want to have done, that’s how this is a successful protocol for them, right? That’s how they buy in. And that’s how they have success with it.

Dr. Weitz:                            So in your opinion, you want to have success with the type two diabetic, it’s got to be super low carb or you’re not going to be successful.

Dr. Morstein:                     Yeah. That’s how I work with patients. Yes, yes.

Dr. Weitz:                            Okay.

Dr. Morstein:                     Now, otherwise, the rest of the exercise, I’m sure you had plenty… The only thing with exercise is that if they’re insulin-dependent, I have a whole lecture on doing exercise with insulin-dependent diabetics, because depending on the intensity, the length, so forth, you are going to have to figure out how to deal with their insulin before, during, and after. So you can get pretty good at it. You just need a little data to make these decisions, but that’s the most difficult patient to work with initially, are the insulin-dependent who are starting to really dive into exercise.

Dr. Weitz:                            So Dr. Watson [inaudible 00:57:44], you showed some slides about the Mediterranean diet as being helpful in preventing diabetes. But now you saying no way.

Dr. Morstein:                     No, no, no, no. That’s if you don’t have diabetes.

Dr. Weitz:                            Oh, okay. That’s preventing it from happening.

Dr. Morstein:                     That is preventing it. Now, if you have it, that you’ve stepped over that line and now we got to yank you back a little more tighter. So yeah. Now, I just have some things with blood sugar and exercise. It doesn’t matter where the blood sugar is when they start in terms of how well they’ll be able to exercise. The golden is I don’t agree with this 65 to 180. I tell patients to mostly be around maybe 80 to 170, if they start exercising around there, they’re going to have better effect. And the same with where their insulin levels are, if they’re on insulin and how it’ll affect their performance. So I’m working right now with a 16-year-old teen, who’s a cross country skier and has desires to get into the Olympics and so forth. So we’ve been getting really good at figuring out his food and his insulin before and after his races. So you just need a little data a couple times and you can figure this out if you have some aptitude with insulin and work with patients who are also athletes.

Dr. Weitz:                            Do you recommend a insulin pump?

Dr. Morstein:                     I’ll let patients decide what they want to do. Some patients for sure, do not want something embedded in them, 24/7. They just don’t. Other patients love it, because they don’t have to inject themselves five times a day. And you can have good control or bad control with any system, right? And you can also have success with any system. Now, pumps do give us a better control of basal insulin because we can direct the basal all throughout the day, exactly how that patient needs it versus I just inject in the morning and I just inject in the evening and there you go, it’s set. So pumps are the best for basal. They’re not good for meals. You can’t use the pump to decide what meal your insulin you’re going to do because they’re just doing the typical conventional figuring out of glucose, which is not a good way to do it.

So you’re going to have to still figure out your insulin for the meal and then tell the pump what to inject. But it is good for basals. It’s just that you can’t demand a patient get a pump and not every patient wants them. So you’re going to have to work with the basals else-wise, right?

In terms of stress. So this was an interesting study. It was stress management. Everybody was a type two. They had treated, which was one and a half hour groups for eight weeks. And in the people that got stress training management, look at their drop in their A1C. I mean, this is ridiculous. That’s better than any medicine, any oral hypoglycemic, or even better than a GLP-1. The stress management is dropping better than any of those medications versus the control, which had really no statistically significant drop. And the thing with stress is that stress can worsen diabetes, but diabetes can worsen stress. So we have to be aware of the psychology of having diabetes. “What am I going to eat? I have to check my blood sugars. I thought I ate right and yet now I’m at 170, this sucks, blah, blah, blah. I’ve been exercising more. My A1C is still 6.6.” I mean, it’s an intense condition and it’s 24/7.

So we want to be there always for patients. We always want to be finding everything positive that we can, giving them support, acknowledging when they get burnt out and helping them work through it, right? But the arrow is both ways. With the microbiome, again, its own lecture, but we have seen that with type one diabetes, they have found elevated Zonulin and Occludin in patients who have positive type one antibodies, but have not yet had the clinical disease show up. Right? So, that’s interesting. So we also know that short chain fatty acid, right, so fiber fermented by the Firmicutes bacteria family turns to short chain fatty acid, which is really, it’s the food of the colon cells. But it does a lot of things systemically. One is help produce GLP-1 from the intestines, which will help us monitor our blood sugars better.

So are people eating enough fiber? In fact, even with a low carb diet, we do need to make sure they’re getting enough fiber in. They may need a fiber supplement because low carb diets have been shown to decrease the amount of the Firmicutes family, which are the fiber eaters and short chain fatty acid producers. So we do need to make sure that they’re getting good fiber in on the low carb diets.

Dr. Weitz:                            Yeah. There’s a company that’s now producing [inaudible 01:04:09] and they have it in a product that’s been shown in a study to help manage glucose.

Dr. Morstein:                     Yeah. All right. That’s good. Yeah.

Dr. Weitz:                            That’s one of the [inaudible 01:04:19] producers.

Dr. Morstein:                     I will admit I’m very wary of any one probiotic really working systemically if everything else isn’t coming together. You know what I’m saying?

Dr. Weitz:                            Sure.

Dr. Morstein:                     Now, the lipopolysaccharides, so these are associated with type two diabetes, insulin resistance and fatty liver. So having a healthy gut on many levels, fiber that makes short chain fatty acids, it’s not leaky. It isn’t overproducing the lipopolysaccharides. These are all gut oriented ways. We know that gut tumor necrosis factor alpha can get into this systemic system and go to our muscle cells and produce insulin resistance. So the gut is pretty, really important. Having a very healthy gut is… Here’s another study with endotoxins and diabetes. So type ones who had the macro-albuminuria had higher LPS. They had higher LPS in patients with diabetes and hypertension.

So it’s amazing how these gut problems can cause havoc so systemically. And then with environmental detoxification, even the World Health Organization wrote that lead and arsenic causes insulin resistance and an increased risk of diabetes. Mercury as well. Now the PCBs, the PCBs are very well studied for gaining weight and becoming diabetic. The phthalates, which I may have spelled wrong. I don’t know. It’s hard to spell the word phthalates. And then they study the Canadian Aboriginals with their high risk of diabetes, a much higher body mass of environmental chemicals. There is this organization, diabetesandenvironment.org, it’s a nonprofit created by a researcher woman whose son developed type one diabetes. And she collects all the research on environmental impacts on type one and type two diabetes. And she has a free newsletter that you can get, I think it’s every week or at least every month.  Sarah, somebody, I forget her last name. But I think one of the most important studies was this bottom one that I made red. So they had two groups of obese patients that were equaled out in age and smoking and drinking, all of that was the same. And then they had, one group had diabetes and one group didn’t though they had the same obesity. And what they found that was different in this group with diabetes was this significantly higher levels of persistent organic pollutants in their fat through fat biopsies. So you’ve got overweight people. Who’s going to turn into a diabetic? Likely the one that has more environmental chemicals in them, such as POPs, PCBs, et cetera.

So it’s pretty frightening given how much people use these at home and it’s on our food. And if you walk into a store, I mean, they’ve been spraying toxins for bugs and stuff. We can’t get around it. You see this fantastically horrific statistic that newborns have almost 300 chemicals now in their cord blood. It’s crazy. So we do want to detox patients, getting their house clean, no fragrances at all. Have all their supplies and body stuff being clean, using natural weed killers or pulling them. Here in Arizona, there’s an exterminating company that’s all organic. I used to use them now [inaudible 01:08:47]. Yeah, I had a big ants problem. The ants suck in Phoenix. But they would come and they’d spray peppermint oil, literally. Not in the house, they never sprayed in the house, but outside they would go and- They never sprayed in the house, but outside they would go and they would spray peppermint oil. But honestly now diatomaceous earth works fantastically. We got to retrain people to not have all these chemicals around in their own homes and then to detox.

Now sweating, there’s loads of studies with sweating. I have them, I didn’t put them on the slide, but sweating releases chemicals, heavy metals, even micro toxins like okra toxin has been found in sweat.  When I went to medical school, when we did dead lab, just working on cadavers, it was in an old RV that didn’t have any ventilation. It was disgusting. Of course all the formaldehyde. And so what we would do is, of course we wore onesies of plastic and whatever, but nonetheless, as soon as dead lab was over, we’d run to our gym, which had a sauna. So I’m in the sauna, maybe 20/25 minutes after class and I could taste the formaldehyde coming out of my skin. I could literally taste it, in the sweat. It’s crazy.  So people don’t sweat in America because it looks, oh my god, I have an arm thing. So we want to teach patients always sweat, wear enough clothing so that when you exercise, you sweat, get a sauna, sweat in it, go out and sweat, just sweat, it’s so detoxifying.

And then there’s many other things with detoxification that I’m already probably boring you in overtime, but I don’t have time to do it, but you guys already probably know how to detox mold or chemicals, heavy metals. All of these can be a problem for diabetes. But number one, if someone’s finances are limited, you definitely want to do chemical testing. That’s number one for sure.

Last, this is my last section, is supplementation. Supplements do everything from better mood to antioxidants. Now, diabetes causes damage through oxidative pathways. That’s what it’s doing. There’s the hexosamine pathway, there’s a browning pathway. There’s many pathways of pro oxidative damage going on in the body, that’s causing diabetic damage. You always have to put people with diabetes on antioxidants, aside from other ones, I will always put people on a multivitamin. I always put people on a fish oil, but the next thing is antioxidant protection so their blood sugars will not cause damage in that regard. And not only that, but you can reverse neuropathy, you can reverse kidney damage.

 I have an obese guy who went off the wagon over the last couple of months, on his diet. He had positive random microalbuminuria. And so I have him on some antioxidants and I have him on this great tincture, it’s from Heron Herbs, it’s called Two Treasures. It’s a such a great kidney protection formula. And so he’s on it. And so even though his A1C went up, his kidneys remarkably got better because of the antioxidants and the herbs, which was amazing and surprising, but beautiful to see. His kidneys really got a lot better. So our antioxidants and our supportive products really can make a difference in these patients.

Dr. Weitz:                            What would be your full program for a patient with kidney disease as far as supplements?

Dr. Morstein:                     Well, let’s go through some of them, and I’ll give you a [crosstalk 01:13:20]… I have a supplement summary [crosstalk 01:13:23]…

Dr. Weitz:                            Okay, good.

Dr. Morstein:                     Now for Type 1 prevention, fish oils reduce risk and so does vitamin D3. There’s no reason an infant can’t be on 1000 IUs a day. And if his breastfeeding mom can take fish oil, which mom should, because fish oils are really good at preventing postpartum depression, for her to take it during pregnancy and afterwards, or I would just do that through the breast milk for a breastfeeding newborn.

But as they get older putting them on fish oils and vitamin D, this is just a good thing. Especially if there’s, God forbid, any autoimmunity in their family. Now, if they develop a honeymoon, there are studies that showed these niacinamide alone or with vitamin E actually can help prolong the honeymoon. Now you might also want to throw in a pancreatic glanular, you might also want to throw in a Gymnema Sylvestre, an herb that has been shown to help revive the pancreas and even increase the C-peptide and it is not niacin, it’s niacinamide. But you can see it doesn’t prevent people from getting diabetes but if the kids enter a honeymoon period, this can help extend it. And honeymoon periods, they can go for years. I have worked with kids who had seven year honeymoon periods. It can also just last for weeks, so we don’t ever really know. But we want to try to extend that as long as we can, if the child initiates it to begin with. We never really see it in our Type 1 adults.

Now supplements. So if you’re adding supplements you’re not going to have to adjust the insulin, it’s not that extreme, so don’t worry about that, okay?

Benfotiamine, if that’s how you pronounce it, is a fat soluble fireman. Now this kind of twists us, because we usually think fat soluble is a little harder to absorb than water soluble, but not benfotiamine, it’s much more absorbable. And you can see the biochemistry where it’s becoming the cymene pyrophosphate, it increases transketolase activity and that blocks glucose damage. It prevents that browning glucosylation of sugar landing on protein, and so that’s what it’s blocking and this is amazing and it’s very good. The therapeutic dose is around 450 milligrams. And there’s studies in protecting neuropathy, retinopathy nephropathy. Well, that’s what we’re looking for, right? So it’s totally safe.

 I have a product, this is totally proprietary formula, but I made a product called Diamend and it has benfotiamine in it at therapeutic dose, but even if you’re just doing it by itself, it’s a really good product, mixing it with alpha-lipoic acid or just giving alpha-lipoic acid and particularly R alpha-lipoic acid, because the S alpha-lipoic acid is not active in the body, but the R is. So, this is also shown to normalize AG formation, advanced glycosylated end products, hexosamine is an oxidative pathway. So it’s really helping people.

Dr. Weitz:                            What dosage of lipoic or R lipoic acid…

Dr. Morstein:                        You’d want to do at least three to 600 milligrams a day of R. Now, if you’re doing just alpha-lipoic acid, which is half R and half S, then you’d want to be around 1200 so you get that 600 of the R and you could throw out in your body the 600 of the S.

Other supplements, vitamin C preventing the aldose reductase pathways in your eyes. So when you have a blood sugar of 200 and your eyeballs get 200, that’s too much stuff in your eyeballs, so it starts off shooting off a lot of antioxidants to keep the osmolarity from I guess, your eyes from blowing up. So, meanwhile then, that’s turning to sorbitol and the antioxidants are thrown out and we get fructose, and then we get cataracts, we get retinopathy and so forth.  Now, vitamin C and bioflavonoids inhibit that initial pathway. The problem is we have to watch vitamin C with people with diabetes no more than 1500 a day, because it looks like glucose, and it can raise glucose levels on some glucose meters. We know that when we give IV glucose, usually people need to have a snack, because that can kick out their insulin and lower it when we are giving vitamin C. So, a little C and bioflavonoids are fine. The alpha-lipoic acid, NAC, N-acetyl cysteine does a lot of stuff for people with diabetes. Of course, we always think of it producing glutathione and liver and lung protection, but it does decrease insulin resistance, and of course, a very good antioxidant in general. So [nic-taurine 01:19:43], good for the eyes, especially with retinopathy, it’s the number one amino acid in the heart. Of course, it does help make a bile salt in the gallbladder, but that doesn’t tend to be necessarily a big thing with diabetics. The fatty liver could make a gallstone however.

The acetyl-l-carnitine at 1500 to 3000 milligrams. Even Diabetes Care Journal, which is from the ADA journal has good studies showing how it reduces peripheral neuropathy. A very good safe one.

Magnesium tends to be the number one nutrient deficiency in patients with diabetes. So maybe checking their red blood cell magnesium as well.

The Gymnema Sylvestre, which is called Gurmar in India, sugar destroyer, decreases cravings, helps increase pancreatic functioning. Here’s a really great thing for your patients who have very little willpower, particularly around the holidays, is that if you have Gymnema Sylvestre in a tincture, I used to do this when I was at the medical school and saw students, we would eat a little organic raisin, so sweet, then put a couple of dropper fulls of Gymnema tincture in your mouth for about a minute and then swallow, and you can’t taste anything sweet for up to one and a half hours. So you put raisins in and they’re these disgusting things you can’t taste, you have to spit them out.  So for patients who cannot control their cookies at the holiday parties, put some Gymnema in their mouth and swallow it and they can’t taste it, they’ll have to spit it out. You can’t eat it, it’s really intense. Very helpful.

And then of course, curcumin just awesome, tumor necrosis factor alpha, as I said, is an insulin resistant factor. It’s an antioxidant, it’s an anti-inflammatory, we know it reduces Alzheimer’s in diabetic patients. Ben already did all the talk about berberine. I do have the method of action [crosstalk 01:21:58].

Dr. Weitz:                            By the way, do you have a favorite form of curcumin?

Dr. Morstein:                     Oh, curcumin for sure. I think the best is Designs for Health Curcum-evail; that stuff kicks butt, I think, so that’s the one I use, it’s Curcum-evail by Designs for Health. And then here’s the berberine method of action, it’s just like he said, the AMPK, everything it does. Green tea, blueberry. If I had to choose between Gymnema and bitter melon, I will always choose Gymnema myself. Of course, we have the old cinnamon studies, like the one, the two and the six grams a day, how it helps, it doesn’t hurt anybody to do cinnamon. They have done a lot of studies on it.

Dr. Weitz:                            Doc, what dose of Gymnema Sylvestre?

Dr. Morstein:                     Oh, with Gymnema, anywhere from three, in my product there’s a thousand, but anywhere from 400 to 2000 is a good safe dose, and you should see some effect. So, if you have patients who have proliferative diabetic retinopathy and you’re going to lower the blood sugar, you could cause them to have a bleed. And you cause them to have a bleed because when the blood sugar goes down, the insulin goes down, but then insulin like growth factor comes out and that causes angiogenesis. And that causes a bleed.  So I did cause a bleed in a patient with PDR early on, and that was horrifying because they needed laser, it was a fiasco. You feel terrible. But then I decided to not have that happen anymore with patients who had PDR. I know it looks like a lot. They only need to be on this for a month or two with the initial lowering of the blood sugar.

But, in two other patients with PDR, they never had any problems with their eyes. It was very stable. Now I put everybody on a multiple vitamin and fish oil. I will use my diabetic product, which means it contains alpha-lipoic acid, it contains bilberry and NAC and benfotiamine, so that product contains that stuff. So I would add in taurine and a little selenium, and you’re going to protect these eyes so they don’t bleed with the sudden drop of the blood sugar in their eyes.  But before you do a low carb diet, patients are like, I haven’t been to the eye doctor for a couple of years; you’re like, okay, you go and when you’re done, come back, because I’m not going to put you on a protocol until I know what’s going on with your eyes.

So this is basically a multiple vitamin, mineral, fish oils, comprehensive diabetic product, or breaking it down individually, probably some vitamin D3. I use vitamin D3 complete, from allergy research, that comes with vitamin A, because you need vitamin A, because the vitamin D receptor is bound to an RXR receptor, a retinoid X receptor. So if they don’t have enough vitamin A, their vitamin D receptor won’t work and the whole process doesn’t work. So you have to throw in a little vitamin A, K and so forth. So, that’s my lecture. I’m sorry if it went too long.

Dr. Weitz:                            No, no, it was awesome. Can you mention that herb that helps with kidneys?

Dr. Morstein:                     Yeah. I can write it. Should I write it in the chat?

Dr. Weitz:                            That’d be great.

Dr. Morstein:                     So it’s from Heron. So it’s Heron Herbs, which is owned by Eric Yarnell, who is a master herbalist. And his specialty is men’s health and kidney health. And so he made this product called Two Treasures and it’s a tincture. And so that’s what I use, I use that with patients who are on lithium, people who have kidney damage for whatever reason, it’s a really [crosstalk 01:26:45].

Dr. Weitz:                            Yeah. If you have a patient with chronic kidney disease, what would be your full program, what else would you put them on?

Dr. Morstein:                     Well it depends. If it’s a IGA nephropathy, I’ll do food sensitivity, testing of IGA, not IGG, but IGA. I use Alletess and they have an IGA option. They have IGG. So I would do that tidy up the diet. Fish oils are great for the kidneys, Ginko and salvia miltiorrhiza is great. This Two Treasures is great because it has a lot of the other herbs, the [Peristeria 01:27:28], the rhubarb, all of the other herbs that, we have science, I have a whole lecture, I think I might talk about it in my book, but I have a lecture on treating, more specifically, complications in patients with diabetes. And I go over the science and the herbs and so forth with them, but you’d want to do cordyceps. There’s a naturopathic physician, Jenna Peterson who had kidney disease and that’s her whole practice, is treating kidney disease. She wrote a [inaudible 01:28:03] article and said for sure cordyceps with kidneys as well.

Dr. Weitz:                            [inaudible 01:28:10] data on astragalus?

Dr. Morstein:                     Well, she specifically said cordyceps.

Dr. Weitz:                          Okay.

Dr. Morstein:                     But, when is astragalus going to hurt anything.

Dr. Weitz:                          And of course, we have modified citrus packed in.

Dr. Morstein:                     Yeah. I don’t use that for the kidney very much, mostly I use to prevent cancer metastases, but I haven’t used it… Oh, thanks. Thank you. So, I actually haven’t known to use that for the kidneys.

Dr. Weitz:                          Yeah. Apparently it prevents fibrosis, chronic kidney disease, there is some data on it.

Dr. Morstein:                     Luckily so does the alpha-lipoic acid and the benfotiamine.

Dr. Weitz:                          Okay.

Dr. Morstein:                     So for sure.

Dr. Weitz:                          Excellent. Okay. Well, that was awesome doc.

Dr. Morstein:                     Thank you. Thank you. Thank you everyone, I appreciate that. Thank you.

Dr. Weitz:                          Absolutely. And thank you everybody. See you next month. Thank you, Mona.

Dr. Morstein:                     Okay. Take care, Ben.

Dr. Weitz:                          Okay, bye.



Dr. Weitz:                            Thank you for making it all the way through this episode of the Rational Wellness podcast. And if you enjoyed this podcast, please go to Apple podcast and give us a five star ratings and review. That way more people will be able to find this Rational Wellness podcast when they’re searching for health podcasts.  And I wanted to let everybody know that I do now have a few openings for new nutritional consultations for patients at my Santa Monica, Weitz Sports Chiropractic and Nutrition Clinic. So if you’re interested, please call my office 310 395 3111 and sign up for one of the few remaining slots for a comprehensive nutritional consultation with Dr. Ben Weitz.  Thank you and see you next week.

 

 

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