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Reversing Diabetes with Dr. Brian Mowll: Rational Wellness Podcast 139

Dr. Brian Mowll discusses Preventing and Reversing Diabetes with Dr. Ben Weitz.

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Podcast Highlights

3:08  Type II Diabetes is more a condition or dysfunction than it is a disease, while Type I Diabetes is a classic autoimmune disease, that usually begins in childhood.  Type I diabetics develop auto antibodies against either the insulin producing cells of the pancreas or insulin itself or against some other part of the blood sugar control system leading eventually to pancreatic destruction. They cannot make insulin and need to be on insulin for life. Prior to the discovery of insulin in the 1920s, Type I Diabetics were unable to store energy and they would lose fat and muscle and waste away and eventually die. Insulin is lifesaving for these patients. Insulin is a hormone secreted by the pancreas that allows us to take excess glucose and store it as energy.  What happens in Type II Diabetes is that the cells become resistant to insulin and our glucose levels in our blood go higher than normal.  The fat levels in our blood as triglycerides and cholesterol also become elevated. Type II Diabetes can cause a lot of damage in the body is the leading cause of adult blindness, lower limb amputation, kidney failure, which leads to dialysis, sexual dysfunction in both men and women, peripheral neuropathy leading to numbness, tingling, and pain in the feet and toes and sometimes the hands, autonomic neuropathy leading to gastrointestinal paresis, and dementia and Alzheimer’s Disease.  The term Type 1.5 Diabetes is sometimes used, but there is confusion about this. It is sometimes used to refer to when Type II Diabetics burn their pancreas out and become insulin dependent. Other people use Type 1.5 Diabetes to refer to LADA, which is Latent Autoimmune Diabetes of Adulthood, which is similar to type I but it happens later in life, tends to progress slowly, and may not lead to total pancreatic destruction. Some LADA patients may not need to be on insulin. There’s another condition called MODY, which is a mutation that leads to high blood sugar that is also sometimes referred to as Type 1.5.

9:20  Some of the reasons why Type II Diabetes is so prevalent today include poor diet, processed and refined foods, including sugar, flour, hydrogenated oils, and industrial seed oils, like corn, canola, safflower, cotton seed, and soybean oil.  These all drive metabolic dysfunction. And then there are all the additives, preservatives, and other chemicals in our food supply, as well as sedentary lifestyles.  Also, stress, poor sleep and toxins can block insulin receptors, leading to weight gain and visceral fat stored around our organs, which can lead to diabetes.  Gut dysbiosis and hormone imbalances can also be contributing factors.

12:58  To properly assess patients with prediabetes or diabetes we should monitor both blood sugar and insulin levels.  Dr. Mowll recommends that patients get a glucometer, such as the Precision Neo by Abbott, and start checking their sugar levels regularly.  Besides glucose, we should measure Hemoglobin A1C, which is a measure of damage to hemoglobin in red blood cells by elevated blood sugar. Most people think of it as a measure of blood sugar over the last three months but it is really a measure of glycation damage to proteins from sugar, which essentially carmelizes them.  When we see damage to those cells, we know there is likely damage being done to the lining of the blood vessels and to the kidneys and to the brain and to the other parts of the body. Dr. Mowl said that he likes to picture creme brulee, which is made by putting some sugar on the top and heating it up with a blow torch, forming a hard crust. That’s what happens to our cells in our brain, in our kidneys, on our blood vessels. And that’s what leads to a lot of the complications of diabetes.  Normal Hemoglobin A1C is below 5.6, but ideally it should be below 5. Hemoglobin A1C at 5.7-6.4 is considered prediabetes and at 6.5 it indicates diabetes. We should also monitor insulin levels because if the body is keeping glucose levels down with high insulin levels, that’s not good either.  High insulin is also inflammatory in the blood stream.  In order for the body to degrade a lot of insulin, it uses insulin degrading enzyme and that’s the same enzyme that degrades amyloid plaque in the brain, so high insulin can increase amyloid plaque buildup in the brain, leading to Alzheimer’s Disease.  While the lab range for normal for fasting insulin is large, such as 0 to 21, the functional range is 2.5 to 6.  If it’s above 6, it is elevated.  We can assess insulin resistance with the HOMA-IR score which is computed by multiplying your fasting glucose times your fasting insulin and dividing by 405 and it should be close to 1.  If it is above 2, that indicates insulin resistance.

24:51  The Glycomark Test is another type of calculation that estimates insulin resistance using triglyceride levels along with fasting glucose.

26:03  Insulin resistance is when our cells stop responding properly to the hormone insulin. Under normal circumstances, when we eat glucose and other carbohydrates, it triggers insulin release. But even fat and protein will stimulate some insulin release, though nowhere as much as carbohydrates. Insulin stimulates us to store extra energy in the liver, in our muscles as glycogen, and in fat cells.  What happens in insulin resistance is that if the muscle cells don’t respond to the signals from insulin to store glucose as energy, then glucose will build up in the blood stream, hyperglycemia, which is the hall mark of diabetes.  The vegan community claims that fat in the diet causes insulin resistance, but that is not true. Fat in the blood stream, in the liver, and in the muscles, which results from eating too many carbohydrates, is completely different than fat in the diet.  If somebody were to eat only a thousand calories per day of only fat, they’re not going to build up fat in their organs because they are going to use all of that fat as fuel. Fat in the organs (not fat in the diet) is one of the causes of insulin resistance, along with chronic inflammation. When we eat a lot of carbs, we secrete a lot of insulin and that down regulates the insulin receptors. Also, toxins, such persistent environmental pollutants, can cause insulin resistance.

32:23  Dr. Mowll recommends for most patients with diabetes or prediabetes to follow a low carb, though not necessarily a high fat, diet.  Even the American Diabetes Association, which has tended to promote a lower fat, higher carb diet with a focus on vegetables, whole grains, and fruit for diabetes over the years, says that carbohydrates by a long stretch have the greatest impact on blood glucose levels and blood insulin levels.  For the first time this year, the ADA even recommends that taking a lower carb approach is a viable option for diabetics.  Dr. Mowll recommends that his diabetic patients start with 75 grams of carbs per day, which is about 300 calories from carbohydrates per day, which usually ends up being 10-15% caloric intake.  Dr. Mowll means net carbs, which means that if a food has 15 gms of carbs but if 12 of those grams will come from fiber, then there is only a net 3 grams of carbs.  Fiber doesn’t really have any net effect on blood sugar.  The rest of the diet will consist of protein and healthy fats.

39:09  Carbohydrate foods that are lower on the glycemic index, slow burning carbs, are better for blood sugar control.

40:37  Intermittent or prolonged fasting can be helpful when implemented into a nutrition program at the appropriate time.  Dr. Mowll said that he does like his clients to eat a meal within an hour and then not eat again till the next meal, say 3-5 hours later and not eat in between. This period of not eating allows your system to reset and your glucose and insulin levels to fall back into line.  He does not find that grazing works well for most clients. When Dr. Mowll starts with a new client he does like them to eat a small meal within an hour of waking up to help with blood sugar regulation.  A 24 hour fast can also be helpful at some point in their program,  but it can be tricky if the client is taking medication or insulin and it is best to heal any thyroid or adrenal problems prior to doing this.

44:30  Dr. Mowll has developed some specific subtypes of Type II Diabetes, which facilitate different treatment strategies. Type O is over insulinized and these are patients that produce too much insulin and they’re insulin resistant and tend to be overweight and have an apple shape.  Type I is the insulin subtype and these patients are under insulinized. They tend to be normal weight or thinner and they don;t produce as much insulin as they’re supposed to when they eat. Type S is the stress type and this stress can come from lack of sleep, from gut dysbiosis, from mental or emotional stress, from chronic pain, from hormonal or other imbalances, or from chronic infections.  Type H is a hormone imbalance that affects blood sugar and that can be sex hormones or thyroid or adrenal hormones.  These categories can help guide the patient care.

48:42  There are various nutritional supplements that can be helpful with patients with prediabetes or diabetes.  Some of the most beneficial supplements are things that we find in our food, like omega 3 oils, vitamin D, chromium, zinc, and magnesium.  It is best to get these from our food, though supplementation can be helpful as well to get the optimal amount.  There are also herbal, botanical based supplements, like cinnamon, berberine, and turmeric or curcumin that can be very helpful.  EPA and DHA, which are omega 3 fats from fish oil, should be at a dosage of one and six grams per day. Eating fish is helpful, though there is risk with fish due to the mercury and other toxins contained.  Dr. Mowl recommends a vitamin D level of between 40 and 70 ng/mL, so typically it means supplementing with 5,000 IU per day and sometimes up to 10,000 IU per day. For people with diabetes, there’s a clear connection between vitamin D and insulin sensitivity and blood sugar regulation.  It is also a good idea to add some vitamin K2 with higher dosages of vitamin D.  Dr. Mowll also finds chromium picolinate or polynicotinate important for glucose regulation, so he recommends a supplement of between 200 and 1000 mcg per day. Dr. Mowll also likes to use vanadium at 20 mg for a short period of time since it can have insulin-like effects on the cells and he has seen it helpful for blood sugar regulation, esp. in patients who don;t make enough insulin.  Magnesium is beneficial. Berberine is an alkaloid compound found in goldenseal and other flowers and it acts in several different ways to improve glucose utilization and insulin sensitivity.  Berberine has many of the same mechanisms of action of metformin and can be used synergistically with metformin and allow a lower dosage.  Too high a dosage of metformin can be stressful on the gastrointestinal system and it can deplete vitamin B-12 and CoQ10, which doesn’t happen with berberine.  Dr. Mowll like green drinks and chlorella, which can be very detoxifying and energizing.

 

 



Dr. Brian Mowll is the founder and medical director of SweetLife Diabetes Health Centers. He is a master licensed diabetes educator and is certified to practice Functional Medicine by the Institute of Functional Medicine. He organizes the highly successful annual Diabetes Summit and consults with clients worldwide as The Diabetes Coach and you can find more information about the Diabetes Summit and his Mastering Blood Sugar course and you can down his free Blood Sugar Manifesto at his website, DrMowll.com.

Dr. Ben Weitz is available for 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, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.



 

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 and to learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast. Hello Rational Wellness podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness podcast, please give us a ratings and review on Apple podcasts or wherever you get your podcasts.

Our topic for today is the prevention and treatment of diabetes. 90 to 95 percent of those with diabetes have type two. Diabetes and prediabetes are epidemic and the prevalence continues to increase in the United States and around the world. 9.4% of adults in the U.S. are diabetic, as many as 15% in some of the states, and this equates to approximately 30 million Americans ,and 87 million people in the U.S. have prediabetes with some estimates quite a bit higher, especially since many people do not know that they have this since at this stage there may not be any symptoms. And rates are especially climbing among children and teens. At least one out of three, and possibly as many as one out of two Americans have diabetes or prediabetes.

And diabetes is a particularly nasty disease.  It significantly increases your risk of heart attack and stroke. Diabetes is the number one cause of chronic kidney disease and kidney failure, and it accounts for 60% of all lower limb amputations. Diabetes frequently results in diabetic retinopathy, which can cause vision loss and blindness. Diabetes also increases the risk of various other eye problems including glaucoma and cataracts. One of the most common complications of diabetes is diabetic neuropathy, whose symptoms include tingling, numbness, and or pain in the extremities, especially in the feet and legs. Diabetes also significantly increases the risk of cognitive decline as well as the risk of falls in older people. And the biggest tragedy is that diabetes is largely preventable.

Dr Brian Mowll is the founder and medical director of SweetLife Diabetes Health Centers. He’s a master licensed diabetes educator and certified to practice functional medicine by the Institute of Functional Medicine. He organizes the highly successful annual diabetes summit and consults with clients worldwide as a diabetes coach. Dr Mowll, thank you so much for joining me today.

Dr. Mowll:           Thank you so much for having me. Excited to be on the podcast.

Dr. Weitz:            Excellent. Can we begin by explaining … Perhaps we can begin the discussion by explaining what type two diabetes is and why is it so prevalent today?

Dr. Mowll:           Yeah, that’s a good question. You just did a good job of laying out some of the statistics and facts and some of the scary things about diabetes. You’re right, it is the leading cause of adult blindness, lower limb amputation, kidney failure, which leads to dialysis, causes sexual dysfunction in men and women, leads to other hormone imbalances. There’s common issues with thyroid disorders and we see other complications like dementia and Alzheimer’s disease and, as you mentioned, both peripheral and autonomic neuropathy, so that leads to gastrointestinal issues from the autonomic neuropathy and we see lower limb, even sometimes in the hand, usually in the feet and toes, numbness, tingling, pain, sometimes very severe pain, resulting from diabetes and the difference between type one and type two, which will help me to kind of talk about what type two is, is really night and day. They’re a totally different disease.

In fact, I oftentimes wish they didn’t have the same name. Type I is a classic disease. It’s an autoimmune condition where usually sometime in childhood, I’ve seen as young as under a year to as old as late teens, they will develop auto antibodies against something in the blood sugar regulation system. It could be the insulin producing cells of the pancreas or enzymes that are involved in insulin production or insulin itself, but some sort of auto antibody against the blood sugar control system often leading to pancreatic destruction. The pancreas, the organ that makes insulin, which controls blood sugar, gets destroyed, and therefore people with type one diabetes need to be on insulin for the rest of their lives. Before insulin was discovered in the 1920s or at least isolated and formulated in the 1920s, there was no cure or even treatment really for type one diabetes.

And what happens there is people waste away. Essentially, they can’t store energy, so they lose all their fat, they start to lose all their muscle mass, they become almost like cachectic like a cancer patient would, and eventually wither away to nothing and their organs start to malfunction. In those cases, insulin is life saving and they need to be on insulin for the rest of their life. Type two diabetes, completely different. Type two diabetes is more of a condition or a dysfunction than it is even a disease. And what happens in type two diabetes is we make plenty of insulin, but our cells become resistant to it. Again, insulin is a hormone made by particular cells called beta cells in the pancreas, which helps us to store energy, in particular glucose. We release insulin when we eat or when our glucose levels in our blood start to get higher than what is considered normal, and we take that sugar and we store it away for later use.  And that’s the role of insulin. When the cells don’t respond to that hormone anymore, though, we can’t store away that extra fuel, so the glucose levels in our blood go up. Also the fat levels in our blood typically go up, so we see high triglycerides, which ultimately leads to high cholesterol. We see high glucose, which leads to all sorts of problems, and damage that we talked about earlier.

Dr. Weitz:            I guess there’s even a diabetes type 1.5, I was talking to another doctor about.

Dr. Mowll:           Yeah, type 1.5 is kind of a slang term, but there are other forms of diabetes. So I try to steer away from that, because there’s not a lot of agreement on what it actually is.

Dr. Weitz:            Oh, okay.

Dr. Mowll:           Some people use type 1.5 to describe people who have type two diabetes and their pancreas burns out, and then they become insulin dependent, which I would call insulin dependent type two diabetes, but other people use it to describe what’s really known as LADA, L-A-D-A, Latent Autoimmune Diabetes of Adulthood, and that is a condition where it’s similar to type one, it’s an autoimmune manifestation that affects the blood sugar regulation system. Again, there’s about four or five different antibodies that can be affected here and different mechanisms within that, but oftentimes leads to destruction of the pancreas. The difference is it happens later in life, so typically past the age of 20, and it’s much more slowly progressing and may not lead to total pancreatic destruction. We have a lot of LADA clients, for example, who don’t need to be on insulin. You can just maintain good blood sugar with a low carb diet and exercise and so forth. But that’s oftentimes described as type 1.5. There’s another thing called MODY, which is a sort of a mutation that leads to high blood sugar. And there’s other things that sometimes people call type 1.5, but I think the big one is this LADA condition, which is an autoimmune diabetes that instead of affecting kids, affects adults and shows up just a little bit differently.

Dr. Weitz:            Okay, cool. And so why is diabetes so prevalent today?

Dr. Mowll:           Well, yeah, that’s a good question. And let’s say type two diabetes, for sure. I think type one diabetes is probably on the rise slightly as well, but not nearly the epidemic that we see in type two diabetes. And again, if we, I like to look at type two diabetes as a spectrum. We look at it almost like a spectrum dysfunction where we can put along that spectrum obesity, we can put along that spectrum metabolic syndrome, which is elevated blood sugar, elevated lipids, high blood pressure, overweight, and there’s other factors that can be looked at as well. Then I would say even dyslipidemia, which is just elevated cholesterol or triglycerides or abnormal lipids. PCOS, which is polycystic ovarian syndrome, is also related to this. Prediabetes and type two diabetes. To me, that’s a spectrum there and it doesn’t necessarily … You don’t necessarily get all of them and it doesn’t necessarily progress that way, but to me these are all a cluster of problems that are related to the same thing.

And ultimately, type two diabetes is the pinnacle of that. It’s sort of the ultimate metabolic disaster, where our lifestyle and our environment come together to create this perfect storm, which leads to metabolic breakdown. If we want to get more specific on that, poor diet, processed, refined foods, including sugar and grain-based foods as well as fats. We see things like hydrogenated fats, which have kind of been phased out, but most of us grew up eating a lot of those. And we still see refined vegetable oils, quote unquote vegetable oils, industrial seed oils, like corn, canola, safflower, cotton seed oil, soybean oil and so forth, these are highly processed, refined fats that can drive metabolic dysfunction. And then all the additives, preservatives, and other stuff that’s jammed into our food, we see more sedentary lifestyles.

People aren’t moving the way that we used to move. We have more sedentary jobs. We don’t get as much physical activity as we used to get in our evolutionary history. We have more stress, we’re getting poor sleep, we have more toxins in our environment, which end up blocking insulin receptors and leading to weight gain and visceral obesity or fat stored around the organs, which can lead to diabetes. We have gut dysbiosis and dysfunction hormone imbalances, and the list goes on and on. All of these things are part of this group of contributing factors and causes that lead to this metabolic sort of perfect storm, which ultimately can put us along that spectrum of gaining weight, becoming insulin resistant, which I mentioned earlier we can talk more about, and then ultimately leading to prediabetes and type two diabetes.

Dr. Weitz:            Okay, cool. Which lab tests do you think are most beneficial for patients to screen for potential diabetes or who already have existing diabetes?

Dr. Mowll:           Well, there’s really two problems in prediabetes and type two diabetes. The first is high blood sugar, but the second one is high insulin levels or hyperinsulinemia. For sure, you should be checking your blood sugar, and I actually recommend that everybody goes out and gets an over the counter blood sugar meter. I recommend one by Abbott called the Precision Neo, N-E-O. It’s relatively inexpensive, you can get it at any drug store. You don’t need a prescription and you can check your blood sugar whenever you want, after meals, first thing in the morning, before you go to bed, and it gives you some realtime feedback. It’s a great tool. I always say it’d be nice if we could measure every test that way, if we could check our thyroid function with a pinprick, if we could check our cardiovascular markers with a pinprick, it’d be, and it was cheap enough, affordable and easy to do, we’d have a lot more awareness when it comes to biomarkers.

So anyway, we have that with glucose, so let’s check it. Secondly, there is a test called hemoglobin A1C, which is sort of the … Becoming the standard, not quite the standard yet, but becoming the standard in type two diabetes management. It’s not a perfect test, but it’s a really good test, and essentially we describe it as sort of an average of your glucose over the past three to four months. What it really measures is damage to red blood cells, hemoglobin, done by elevated blood sugar. There’s a certain of these A1C receptors on hemoglobin and red blood cells that can be glycated, and when it gets glycated, it means there’s sugar molecules bound to them. And when it gets above a certain percentage, we know that the sugars are running too high, actually causing damage to those cells.

And the problem is when we see damage to those cells, we can extrapolate that and say, “Well, good chance there’s damage being done to the lining of the blood vessels and to the kidneys and to the brain and to the other parts of the body,” which are at risk when it comes to high blood sugar. Hemoglobin A1C is a much more stable marker. Normal, if anybody wants to go get one, is 5.6 or less, 5.6% or less. We like to see it around five. Most of our clients will end up with an A1C between 4.8 and 5.5 percent. Diabetes is diagnosed at 6.5 or greater, and prediabetes is 5.7 to 6.4, so that’s the hemoglobin A1C. As far as …

Dr. Weitz:            I’ve heard you describe the glycation, which not everybody is familiar with, as caramelizing the proteins.

Dr. Mowll:           Yeah, so glycation is what the hemoglobin A1C test measures on the red blood cell, but other cells can get glycated like brain tissue, like the lining of our blood vessels and you’re exactly right. What happens is that high, that sugar, that elevated glucose circulating around the bloodstream acts as an oxidant and your audience has probably heard of oxidative stress, which is like rust on a bumper or the browning of an apple when you take a bite out of and leave it on the counter, that oxidation glycation is similar, but instead of oxygen, it’s glucose doing the damage. It binds to certain protein molecules along, in those cells. And yeah, caramelizes it like we like to picture creme brulee, they put some sugar on the top and heat it up with that little blow torch and it forms that hard crust. That’s what happens to our cells in our brain, in our kidneys, on our blood vessels. And that’s what leads to a lot of the complications of diabetes.

Dr. Weitz:            That’s pretty scary.

Dr. Mowll:           Yeah, pretty nasty.

Dr. Weitz:            Do you recommend a glucose tolerance test where you challenge them with sugar and then measure the glucose again?

Dr. Mowll:           It’s an interesting test and I think it can be really helpful. If people have diabetes already, I don’t recommend doing it typically because, essentially you’re … It’s like somebody who you know has celiac disease saying, “Well, let’s have you go eat a whole loaf of bread and a bowl of pasta and just kind of see what happens.” It’s kind of mean, right? So I don’t typically recommend it for people who have diabetes, but if you are in the prediabetic range or your blood sugar, let’s say you go in and have a fasting blood sugar test, and normal by the way is around 76 to 92. Mid-80s is kind of perfect, so let’s say you come back and the test is 99 or 103 or something like that, then you may want to consider going and having a glucose tolerance test done. What you do there is take about a, it’s usually a 75 gram load of glucose, which is like a sugar syrup that you drink, they check your blood sugar before and then they’ll check it at intervals after that. Usually it’s 60, 90, 120 minutes.

You can also check insulin. So I mentioned a few minutes ago the other thing that happens with type two diabetes and prediabetes is elevated insulin levels. You can also check insulin as part of a glucose tolerance test. It’s called an insulin response test. And you would, again want to check fasting and then you can see what happens to your insulin levels. Sometimes the glucose levels look okay, so fasting glucose is okay, maybe it goes up a little bit too high after that glucose syrup. The threshold to diagnose diabetes at that point is 200, so that’s really high. If you do the glucose syrup and your blood sugar goes up to 180, they say you’re prediabetic, not type two diabetic, but that’s still very, very high. Maybe it goes up higher than it should and then comes right back down. You may not know you have a significant problem, but if you check the insulin, sometimes what you’ll see is maybe fasting, it’s normal, but when you take that glucose load, it shoots up super high. The insulin post glucose challenge should not really ever go above 30, and sometimes we’ll see it go up over a hundred …

Dr. Weitz:            Wow.

Dr. Mowll:           After a glucose challenge, and so what’s happening there is the body’s keeping the blood sugar down, but it’s doing it by releasing like a surge of industrial strength insulin in order to keep the blood sugar down, and that’s not okay, because that insulin causes us to store fat, particularly around the organs and in the liver, it causes us to, it’s inflammatory, so it circulates in our bloodstream inflaming the blood vessels. High insulin levels needs be degraded and it’s degraded by an enzyme in the brain that also degrades amyloid plaque. When we’re degrading all that insulin, we don’t have that enzyme to degrade amyloid plaque, so we get plaque build up in the brain, which is one of the main links to Alzheimer’s disease. High insulin, even without high blood sugar can be a huge problem. And so that’s why, if you’re going to do that test, I would also test insulin at the same time.

Dr. Weitz:            And when we look at fasting insulin, what is the optimal level? Because the range is actually pretty big for the normal, quote unquote.

Dr. Mowll:           Yeah. The way I explain it, a lot of people don’t realize, but that test is not a functional test. Most doctors will not order an insulin test to evaluate metabolic health or diabetes or prediabetes. They’re essentially ordering it when they order it, because they suspect an insulinoma. And insulinoma is basically a tumor on the pancreas that causes the excess release of insulin. That reference range is really tied to insulinoma, not to functionally healthy insulin release. We have to apply a functional range to that. And we do this in other things too, like thyroid. Sometimes there’s a functional range. We do the same thing with triglycerides. When people, when doctors evaluate triglycerides, they’re oftentimes evaluating for cardiovascular risk, not metabolic health. We have a functional range with triglycerides as well. But the functional range for insulin fasting is 2.5 to 6. That’s the range that we use.  And so when it gets above 6, that’s elevated. There’s a calculation you can do called HOMA-IR H-O-M-A-I-R. It stands for Homeostatic Model of Assessment of Insulin Resistance, and you multiply your fasting glucose times your fasting insulin and divide it by 405, and what happens there is it gives you a number, it should be close to one. Once it gets up over two, it’s starting to get elevated and what you’ll see is if you have a fasting glucose of 85 and a fasting insulin of 5, that puts you pretty much right at 1. Once that starts to grow, either the glucose or the insulin, your HOMA-IR score goes up and that’s what many researchers use to assess insulin resistance in research studies.

 



 

Dr. Weitz:                            I’ve really been enjoying this discussion, but now, I’d like to pause to tell you about the sponsor for this episode of the Rational Wellness Podcast. This episode is sponsored by Pure Encapsulations, which is one of the few lines of professional nutritional supplements that I use in my office. Pure Encapsulations manufactures a complete line of hypoallergenic research-based dietary supplements. Pure products are meticulously formulated using pure scientifically-tested and validated ingredients. They are free from magnesium stearate, gluten, GMOs, hydrogenated fats, artificial colors, sweeteners and preservatives.

Among other things, one of the great things about Pure Encapsulations is not just the quality products but the fact that they often provide a range of different dosages and sizes, which makes it easy to find the right product for the right patient, especially since we do a lot of testing and we figure out exactly what the patients need. For example, with DHEA, they offer five, 10 and 25-milligram dosages in both 60 and 180 capsules per bottle size, which is extremely convenient.

                                                Now, back to our discussion.

 



 

Dr. Weitz:            Are you familiar with the GlycoMark Test and is that a useful test?

Dr. Mowll:           I like it too. That one uses triglycerides and glucose, so if you don’t have a fasting insulin test, you can do that one. I can’t remember the exact formula or the reference ranges, but it’s similar. I think there’s a multiplication then you do like a, you have to use the log function I think on the, on your, on your scientific calculator, which most smartphones have, but it’s pretty cool and it’s, yeah, it’s good. I like it. And basically, it’s a similar theory. The difference is instead of looking at insulin, you’re looking at triglycerides, which is kind of a surrogate for insulin resistance. What we find is the more insulin resistance, the higher the triglycerides go. Most of our clients, after they do some care with us, their triglycerides are down between like 40 and 70, and if they have triglycerides in that range and a glucose under a hundred, they’re going to have a good GlycoMark. Once that triglyceride level starts getting up around a hundred or higher, that GlycoMark’s going to get elevated.

Dr. Weitz:            You just mentioned insulin resistance several times. Can you explain what insulin resistance is.

Dr. Mowll:           Yeah, so I mentioned it earlier, but I didn’t really dive into it too much. We make this hormone insulin, which actually is an energy preserver really. When we eat food, if we eat extra calories that we can’t necessarily burn or utilize at this time, we store them. And insulin is the hormone that’s largely responsible for that storage. What happens is in the presence of when we eat food, glucose in particular triggers the biggest insulin release, but fat will at some level, protein will at some level. When we eat those foods, we release this hormone insulin, it kind of opens up storage. Storage in the liver, storage in the muscle, storage in the fat cells, for extra energy, and we take whatever we can’t burn or use at the time, we sock it away for later use, so to speak.

And what happens in insulin resistance is for one reason or another, and we can get into some of those reasons, our cells don’t respond properly to that hormone. We describe it as like insulin is a key that opens the door that would allow the glucose to get into the cell, if we’re talking about glucose, and if that key doesn’t open the lock, like somebody stuck some gum in there or it’s an old lock and it’s just jammed, then the glucose can’t get into the cell through that door. It has to go look for another door, and fortunately there are many doors on the cells, but the more and more insulin resistance there is, the less doors open and the less we’re able to get glucose into the cell. Eventually it starts to build up outside the room, in this case, and that’s high blood sugar, hyperglycemia, and a hallmark of diabetes.

There are many causes for that insulin resistance. And one of the things I like to caution people is you’ll hear a lot, this is the cause, that is the cause. From the vegan community, we often hear, “Oh, it’s too much fat in the diet. That’s what causes insulin resistance.” Well, that is just absolutely not true. What they’re doing there is conflating this idea of elevated fat and fat in the liver contributing to insulin resistance, which is very much true with fat in the diet. And they’re two totally different things. Fat in the bloodstream and fat in the liver and fat in the muscles is completely different than fat in the diet. Somebody who eats, let’s say somebody were to eat a thousand calories a day of only fat, they’re not going to build fat in their organs, they’re not going to have extra fat floating around in their bloodstream, because they’re going to use all that fat to fuel their body.

It’s not fat in the diet, it’s fat stored in the organs and fat stored in the muscles and fat floating around the bloodstream, which can be one of the causes of insulin resistance. We also have to look at chronic systemic inflammation. That is in fact I think the main driver of insulin resistance. There’s too much insulin. My friend, Dr. Jason Fung uses this as his main cause, which again, I think that I have a little bit of a problem looking at it as the cause, but it is a cause, when you overconsume carbohydrates or just overconsume food in general, we release these surges of insulin and the way he described it as like an alcoholic becomes desensitized to alcohol, somebody who smokes becomes desensitized to nicotine, drug addicts become desensitized to whatever drug they’re doing. We become desensitized to insulin, and that does happen.

There are studies showing we downregulate insulin receptors when our insulin levels are high, so that’s a cause. We have to also look at toxins. Certain toxins, environmental pollutants, POPs and other chemicals that are found in plastics, in our food supply, in our water supply, in our air, will actually interfere with insulin signaling at the cell level. There’s a lot of different things that can cause insulin resistance, but the bottom line is that lock gets gummed up, the key doesn’t open the lock, the glucose can’t get in to be burned for fuel and it builds up in the bloodstream.

Dr. Weitz:            Interesting. Yeah, I’d like to touch on the toxin thing, but I just wanted to mention, I just opened up an email from Tom O’Bryan and he’s speaking at a diabetes summit and I thought, oh, it must be Dr. Mowll’s diabetes summit and it’s called the Mastering Diabetes Summit. I started looking at it and there were a number of talks about how the ketogenic diet is the worst thing in the world, and I thought, I don’t think that’s his summit.

Dr. Mowll:           Not mine. No, no, no, no. Those are, they’re friends of mine who run that, but they’re heavy duty vegan advocates. Basically they teach plant-based, ultra low fat diet, keep fat grams under 30 a day, which is basically no fat, and eat a lot of fruit. I found that that doesn’t work very well. I’ve had a lot of clients who have tried that and failed spectacularly with it, so it does help some people. There are certain genotypes, phenotypes, whatever, that seem to respond well to a low fat diet. But the large majority of our clients, and I don’t teach a high fat diet by the way either, but the large majority of our clients seem to do really well with a low carbohydrate approach and avoiding processed, refined foods, moderating protein, moderating fat, and getting plenty of exercise, and then supporting the body systems to make sure the body’s functioning optimally.

Dr. Weitz:            When you talk about a low carb, what is the best diet for most people with diabetes?

Dr. Mowll:           Again, I found that a low carb approach makes sense. Carbohydrate foods, in particular, starch and sugar, drive the production of insulin, which is known as a fat storing hormone. I mean, even the ADA and the American Association of Diabetes Educators say throughout their information and they’re very, very conservative, that carbohydrates by a long stretch have, or by a long shot, have the greatest impact on blood glucose levels and blood insulin levels.

Dr. Weitz:            But traditionally, the ADA has tended over the years to promote a whole grain type of lower fat approach until recently.

Dr. Mowll:           Yeah, I’m not saying that they’re pushing low carb, but they do say that carbohydrates have the greatest impact on blood sugar. There’s a little bit of a disconnect there. They have, you’re right. In recent years, they have started to warm up to low carb. This year, in fact, they’re even saying it’s recommended as a viable path, but they tend to go with this idea that diabetics deserve to eat what everybody else eats. That’s sort of their general mission or general approach to nutrition when it comes to people with diabetes. And so they look at it as there’s medications, so there’s no reason for you to suffer and not get to eat cheesecake just because you have diabetes. As ridiculous as it sounds, that’s their general approach. But getting back to the main question, I’ve found, doing this for over 15 years, that …

Dr. Weitz:            By the way, what do we mean by low carbs?

Dr. Mowll:           Right. Carbohydrate foods are foods that are higher in starch and sugar. All foods have carbohydrates, fat, and protein, so there is no one … Even a white potato is not purely carbohydrate. There’s a tiny bit of protein in there and a little bit of fat. They all have all three, but like a white potato is mostly starch. Starch is long chains of glucose. If you’ve ever seen a lap pool and those lane dividers, they have those little buoys that are all chained together, that’s kind of like if you imagine those as glucose molecules, that’s what a starch molecule looks like.  And that’s what’s in a potato, that’s what’s in pasta, that’s what’s in breads and things like that.  When we eat those foods, we have an enzyme called salivary amylase in our mouth that immediately starts to break those apart into sugar molecules, into glucose molecules.  Sugar, on the other hand is a simple molecule and there are different types of sugars, but table sugar, like white sugar, that people sometimes put in their tea and coffee or honey, for example, is basically a combination of fructose and glucose.  Glucose is what we measure in the blood when we measure blood sugar. Fructose is an altogether different molecule that does not raise blood sugar, but gets shuttled to the liver and ultimately, typically stored as fat in the liver. When we eat table sugar, we’re eating about half fructose, which goes to the liver and gets converted to fat, and about half glucose, which gets absorbed into our bloodstream and either gets used in the cells for fuel or gets stored. And again, the hormone that’s in control of that is insulin. Anyway, what’s a good amount of carbohydrate?

Dr. Weitz:            Yeah, like for example…

Dr. Mowll:           You measure carbohydrate in grams, right?

Dr. Weitz:            Yeah, I saw one recent paper where they were recommending a low carb diet that had 45% carbohydrates.

Dr. Mowll:           Right, exactly. So, a 2000 calorie diet, 45% is what like I don’t know, 800 calories, that’s 200 grams of carbs. That’s a lot of carbs. And the average American consumes about two to 300 grams of carbohydrate a day, and sometimes more, sometimes up to four or 500, so the average American is eating a lot of carbohydrate. And so you can see why we get these problems, because it creates these surges of insulin, leads to insulin resistance, fat storage, and all sorts of other things. We usually start at about 75 grams of carbohydrate, which is about 300 calories from carbohydrates a day. That ends up being around 10 to 15 percent of caloric intake and oftentimes will go lower. It’s really, we talk about eating to the meter. We have our clients check their blood sugar. We’ll dial in their macronutrients, starting with about 75 grams of carbs. We put together a protein recommendation and then fill the rest in with healthy fats and, then we do it in a way that’s healthy, non-refined, non-processed as much as possible, and make it accessible and doable for people.

But 75 grams is probably a good starting point. One last thing I’ll mention on carbs is there’s some confusion around net carbs, diabetic carbs, and so forth. We do recognize net carbs. Net carbs is, they’re still listing fiber as a carbohydrate on the labels, I believe. And so if there’s a, let’s say there’s 15 grams of carbs in something like an avocado, but 12 of those grams come from fiber, fiber doesn’t really have any net effect on blood sugar. Maybe a little bit, but not much, we generally subtract those out. An avocado, if it’s got 15 grams of total carbs, but 12 come from fiber, we would call that three net carbs. And that’s how we would count that food.

Dr. Weitz:            Do you find it helpful to look at glycemic index or glycemic load of carbs?

Dr. Mowll:           A little bit. I mean, if you’re eating a lot of carbohydrates, yes. If you’re maybe in the prediabetic range or you’re sort of like pre prediabetes and just, it’s on your mind a little bit or you’re like a marathon runner or an athlete that where you’re eating a fair amount of carbohydrates for fuel. I do think it’s best to eat slow carbs, so carbs that break down more slowly don’t raise your blood sugars quickly. Those would be things like …

Dr. Weitz:            Legumes…

Dr. Mowll:           Or like, yeah. Legume … Beans and legumes, certain grains, if you want to eat grains, like barley, for example, is lower on the glycemic index than something like rice would be, although I generally recommend steering away from grains. There are certain fruits like berries which are considered low-glycemic. Even apples are lower glycemic if you stick with a smaller apple or a half of an apple. You can probably get away with that. Grapefruit and some citrus lemons and limes are low-glycemic. They don’t have a ton of sugar in them. And there’s other foods like that, so you can pull up a glycemic index chart. I generally recommend sticking with the low-glycemic category, not the moderate or high glycemic categories.

Dr. Weitz:            Okay. What about intermittent fasting or fasting? And I know that for years we were preaching everybody needs to eat within an hour of waking up and then you should have a small meal or snack every three hours throughout the day, and now it’s really popular, especially in functional medicine, anti aging and wellness circles to do some version of intermittent fasting, and frequently this involves skipping breakfast.

Dr. Mowll:           Yeah, I just saw today that Dr. Oz is recommending everybody skips breakfast in 2020 now, so you know it’s hit the mainstream at this point. But yeah, intermittent fasting can be an effective strategy, and there’s many different ways to do intermittent fasting. It doesn’t just have to be skipping breakfast, but it can be a very effective strategy. When I start a new client, we actually have them eat something within an hour of waking up. I’m not a big fan of grazing, unless you’re like a vegan and you’re eating just a ton of leaves and plants and that’s the majority of your diet, like a gorilla. A gorilla will eat actually a high protein diet, but they get most of their protein from leaves, but they’re just eating like pounds and pounds, like 50 pounds of spinach a day, you know?

If that’s what you’re doing, then great, but other than that, I recommend eating all your food within an hour and then having like eating blocks. You might eat from 8:00 to 9:00 AM and then from noon to 1:00 and then 7:00 to 8:00 or 6:00 to 7:00 or something like that. And then don’t eat in between. That’ll allow your system to reset itself, your insulin levels can fall, your glucose can get back in line, your body can function normally for a little while and then you can eat again. There is a time and a place for intermittent fasting and I do recommend it a lot once we get deeper into a treatment plan with our clients, and it can be very helpful to allow insulin levels to come down. It probably is not really going to have significant longterm benefits.  Like I haven’t seen a lot with stimulating autophagy and cell repair and things like that on a, tacking on four hours to nighttime fast, but it can help with hormone fluctuations and can help to resensitize our cells to insulin when you’re kind of early in the process. I think a longer term fast can be even more beneficial, and after you fast for about 24 hours …

Dr. Weitz:            Like 24 hours or 48 hours or …

Dr. Mowll:           Yeah, 24 hours, you’re going to kind of burn through all your glycogen stores, so you’re going to deplete all your stored sugar, and so that’s when you really start to tap into your fat stores. The body starts to release more growth hormone after 24 hours, which helps to maintain lean body mass and starts to upregulate fat burning. You really start to gain some additional benefits past the 24 hour mark. Of course, a lot of our clients are on medications, they’re injecting insulin, so having them do a long fast can be really difficult in the beginning, so we don’t typically do that right out of the gate, but at some point along the way we do. And for someone who’s a little bit healthier, someone who has maybe the early signs of prediabetes or something, doing some extended fasting can be really helpful. The only time I don’t recommend doing that is so there’s a known thyroid issue that’s not being managed well or adrenal fatigue or adrenal dysregulation, those people fast, like long fast, can put a lot of stress on the body and so I think it’s best to heal those areas before we do long fasting.

Dr. Weitz:            I understand you have come up with some specific subtypes of type two diabetes as a way to change, modify your treatment strategies.

Dr. Mowll:           Yeah, so I know we’re a little short on time, so I’ll run through it pretty quickly, but there are four subtypes essentially of type two diabetes, and the first is a type O, which is over insulinized, and those are the people that we’ve mainly talked about today. They produce too much insulin, they’re insulin resistant, we can test insulin levels, it’s high, they tend to be overweight, maybe not obese, but at least overweight or have some visceral adiposity, like that apple shape. That’s the most common of the subtypes, but there are three others. The second one is I, which is the insulin subtype and it’s under insulinized. These are folks who have type two diabetes, it’s not type one, it’s not LADA, there’s no autoimmune issue here, but they’re under producing insulin, and there’s a variety of reasons for why that can happen.

They tend to be either normal weight or thinner, on the thinner side, and we check their insulin and it’s actually low and we do an insulin response test like we talked about earlier, and they don’t release insulin as much as they’re supposed to when they eat. Those folks either need to be on a little bit of insulin or oftentimes we can help to sort of revive the pancreas to make more insulin again, and there’s different strategies that we use for that. There’s two other subtypes which are almost completely ignored. The third one is a type S which is a stress type. A lot of people don’t realize the connection between stress and high blood sugar, but it is a very potent connection, and that stress can come from lack of sleep, it can come from gut dysbiosis, it can come from mental, emotional stress, it can come from a loss of a loved one or divorce or separation or move or some other type of major life stress, major life event. It can come from chronic pain. It can come from a hormone or a number of other imbalances in the body, like chronic infection in the blood. These types of stressors will cause our adrenal glands to make extra cortisol and adrenaline, which raises our blood sugar. And that can ultimately lead to adrenal dysfunction, but in the meantime, we get a prediabetes and oftentimes type II diabetes.

And so we have clients where their insulin is normal, their blood sugar is high, but it doesn’t look like a normal diabetes case. What we find out there, they’ve dealt with a tremendous amount of stress or they’ve just got this chronic pain that’s just always nagging them, driving stress into their system, and once that’s handled, oftentimes their blood sugar will come back down into the normal range. The last type is type H, which is a hormone imbalance, and that can be sex hormones like testosterone or estrogen, progesterone, or more commonly, it’s related to thyroid and adrenal hormones. Not to be confused with type S, this is where the adrenal dysfunction is the primary thing. It’s not that there’s chronic stress or there’s something that we can pinpoint there that we can handle, it’s actually the hormone imbalance itself. Hypothyroidism is oftentimes at the root of this, but we see adrenal dysfunction as well, and other things. There are a few other things that can show up like mitochondrial dysfunction and toxins as we mentioned, but those are the main four subtypes that we classify. And when we sort of look at a new client, we’ll sort of think about those four as we create a care plan for them.

Dr. Weitz:            I can see how those could be really useful. We are a little bit short on time. I’d like to make the last question about which nutritional supplements can be beneficial as part of an adjunct to your care for patients with diabetes or prediabetes.

Dr. Mowll:           Yeah, great question. And I break supplements into two categories. So we look at nutrient based supplements and botanical, herb based supplements. The nutrient based supplements are things that we would normally find in our food, things like omega-3 oils, vitamin D, chromium, zinc and so forth. And then magnesium. And then there are herbal or botanical based supplements, which are things like cinnamon, berberine, turmeric, curcumin and others. For me, the nutrient based supplements are kind of a cornerstone. We want to eat a good diet, we want to use food as medicine, and then sometimes we can supplement to sort of fill in the gaps. Most people I think need and can benefit from some omega-3 support. We just don’t get those healthy omega-3 in our diet as much as we should. And there’s risk with fish today, even though I recommend eating fish.

So good omega-3 supplementation I think is important. Somewhere between one and six grams of combined DHA and EPA per day. And you can check the label, the bottles. If the bottle doesn’t tell you how much EPA and DHA there is in the fish oil, then don’t use it. Make sure it tells you how much is in there and then add those two up. EPA plus DHA, DHA, excuse me, and those should add up to a thousand or more per day. And there are certain ways of tweaking that depending on what we’re trying to accomplish. I also recommend vitamin D for most of our clients. You can check, obviously vitamin D, 25 hydroxy on a blood test, it should be around 40 to 70, maybe a little higher is okay, and if it’s not at least up in that range, then supplement with some vitamin D3. Typically we’re doing 5,000, I use per day, sometimes up to 10, and sometimes as little as 2, but somewhere in that range, I think is really helpful. For people with diabetes, there’s a clear connection between vitamin D and insulin sensitivity and blood sugar regulation.

Dr. Weitz:            Use vitamin K with the vitamin D?

Dr. Mowll:           Yeah, especially if we get up into the higher doses, I think it’s important to do some K2 in particular. You can get vitamin K1 through a lot of foods, but vitamin K2 is hard to find. If we’re up over 5,000 units of D, we’ll definitely add in some vitamin K2 as well.  I like chromium. Chromium is important for glucose regulation and glucose tolerance.  Most people don’t get enough chromium in their diet, so you can supplement anywhere between 200 micrograms up to a thousand micrograms, if you’re trying to really make an impact on your blood sugar of chromium per day, I think that can be helpful.

Dr. Weitz:            And in which form?

Dr. Mowll:           Yeah, either picolinate or polynicotinate. Both of those have good research behind them and seem to be effective.

Dr. Weitz:            And do you like vanadium as well?

Dr. Mowll:           Vanadium is a little trickier. It’s a metal salt and it can be toxic at certain levels, so I use that one short term. I’ll use maybe 20 milligrams of vanadium short term. I think it’s milligrams, milligrams or micrograms. I can’t remember, but we’ll use that one more short term. I’ve seen supplements with 50, 100, I think it’s milligrams of vanadium and that …

Dr. Weitz:            Yeah, I think it’s milligrams.

Dr. Mowll:           Yeah. That, I think there’s some caution there. So I’d be a little bit careful with pushing the vanadium up too high, but vanadium sort of has insulin like effects on the cells, and there are some studies that show vanadium supplementation can sort of act as insulin and help to reduce blood sugar. I’ll use vanadium more in people who don’t make enough insulin and it can be helpful in some cases. Magnesium, really important for many, many reasons. Good blood sugar health is one of them. And then on the herb front, berberine can be really effective. Berberine is a alkaloid compound found in golden seal and other flowers. It acts in several different ways to improve glucose utilization and insulin sensitivity. And it’s one of the most effective compounds we have. Cinnamon can be good as well, especially if you’re eating carbohydrate and you want to lessen the impact of carbohydrate on your blood sugar system, taking some cinnamon at meal time can be really helpful.

Dr. Weitz:            Berberine is kind of a natural form of metformin and can also be used synergistically with metformin, correct?

Dr. Mowll:           Has many of the same mechanisms of action as metformin, yeah, absolutely. Metformin does not derive from berberine. It’s a different chemical structure altogether, but they do have similar mechanisms of action.

Dr. Weitz:            Yeah. And they can actually be used concurrently, right?

Dr. Mowll:           It can, yeah. You have to be a little bit careful. Usually what we’ll do is sort of balance, like if somebody is maxed out on metformin, we’re not going to max them out on berberine also, but oftentimes we’ll do like a little transition where we’ll work with their doctor to back down on metformin and increase the berberine and that can help them, it can be less of a stress on the kidneys and less stress on the gastrointestinal system. Metformin is really hard on the GI track, it depletes vitamin B-12, it interferes with vitamin B-12 absorption and interferes with the production of coenzyme Q10, so I don’t like to see people maxed out on metformin for too long if we can help it, even though it’s a pretty safe drug. If we can help to replace some of that with berberine or something else, it can be helpful.

Dr. Weitz:            Great. Any other herbs?

Dr. Mowll:           Well, I like green drinks and I like chlorella. Chlorella is a, basically an algae that’s pretty high in iron. It has some protein. By weight, it’s high in protein, and it’s very detoxifying. It’s very energizing, it’s got a lot of chlorophyll. I like to do some chlorella and I love to do green drinks, which is like basically powdered vegetable and fruit extracts. Usually they’re very low carbohydrate, very low calorie and can give you a nice burst of energy. And I actually like to use those as sort of a multi, because they … It’s kind of plant medicine. It’s got all sorts of vitamins, minerals, nutrients, phytochemicals that we don’t even, necessarily haven’t even identified yet and certainly haven’t put into pills. I like to use food as medicine whenever possible and a green drink is a great way to do that.

Dr. Weitz:            That’s great. Awesome. I think we’ll wrap there. Can you tell our listeners how to get ahold of you and find out about your programs?

Dr. Mowll:           Yeah, so probably the best way, I have my own podcast called Mastering Blood Sugar. I’d love to have you on there doc, maybe sometime here in the future, but Mastering Blood Sugar, you can check out Apple, we’ll be starting … Or iTunes, we’ll be starting our next season here relatively soon, and for other information, just go to drmowll.com, that’s D-R-M-O-W-L-L.com. I have a resource on my website called the blood sugar manifesto, which is free to download and it’s basically got all my best advice in there, some information about supplements, diet, exercise, stress management, sleep management, all those things are included. If you want to get some good free information, go to drmowll.com and download that blood sugar manifesto.

Dr. Weitz:            This has been a great podcast doc. I got a lot of good information. I have a ton of additional question, so if you’re up to it, maybe we could do a part two at some point in the future.

Dr. Mowll:           Yeah, I would love to do that. Maybe a little bit of a deeper dive. It’d be great.

Dr. Weitz:            That’d be awesome. Thank you so much.

Dr. Mowll:           Okay, doc, thanks for having me on.

 

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