Diabetes & Insulin: What Every Patient Should Know

This is going under anesthesia answer with Dr. Brian Schmutzzer. I'm by Headsotter. Zade,

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38 million Americans have diabetes. 96 are pre-diabetic. Yeah, which is a misnomer and we'll

get into that. But there's no I know that the everybody says I'm pre-diabetic. All that means

is you have reversible diabetes, but we're talking about diabetes today on the podcast.

Why do people get it, how it happens, how we fight it, and how it's changed maybe over the last

30 to 40 years? Yeah, and so kind of the classic presentations, like somebody who comes in,

they're drinking glass after glass of water all day long, still thirsty, even maybe having

some urinating in bed at night, tired all the time, going to the bathroom constantly, and then

starting to get some blurry vision. And then they kind of go to the doctor and say, hey,

I just I don't feel right. Even people who aren't necessarily prone to diabetes or family history,

or any of the the predisposing factors, and they find out that their sugar is 300 when it should

be under 100. And so that oftentimes they they figure out they've got diabetes at that point.

So that's a pretty classic presentation. Like you said, 38 million Americans are diabetic,

full-blown diabetic, another 96 million are what are called prediabetic.

Really, they have diabetes. It's just in the early stages. How did we figure out the term for this,

right? Like what exactly is it? And how did we figure out, wow, this is not a good thing.

Yeah, so the story of diabetes is really interesting. So there there were a bunch and so so

diabetes, insulin, non insulin dependent diabetes, like the diabetes we think about older people,

that's actually a relatively new phenomenon. There weren't a lot of people who got that even 50,

60, 100 years ago. Insulin dependent, dependent diabetes used to be uniformly fatal. So it was

often a kid who was probably seven, eight years old and all the sudden they just started not gaining

any weight. They started getting really sleepy. And then they would figure out that they had diabetes.

Now the way that they figured it out, there were a couple ways they figured it out. So the initial,

when it was first identified, one of the initials things that they did was the physician would

actually taste the urine because it would taste like sugar water because they're dumping all that

sugar in the urine. Now the next step they took, and this is a story that I had heard from a guy

who used to do research with, is they would have the boys where, often boys, boys more than girls,

have the boys wear black shoes. And when they went in to go to the bathroom because the way

bathrooms used to be set up, they'd splash some of the urine out of the urinal onto their shoes.

And then when they came back out of the bathroom, by the time it dried, there would be sugar crystals

on their shoes because there's that much sugar jumping into the urine. So that's how they actually

discovered it. Now it's interesting. So let's talk a little bit about what diabetes is specifically.

So diabetes mellitus is what we're talking about. There's another kind of diabetes called

diabetes insipidus for purposes of this podcast. We won't talk about that at all.

So basically all it is is that the body is unable to handle the amount of sugar that's in it,

right? So there's two types and we'll talk a little bit about that here in a minute. But

so basically pathophysiopathophysiologically, when we eat a carbohydrate that breaks down into glucose.

Which is just sugar. It's another name for sugar in the body. Then it goes into bloodstream,

right? From your gut. But that glucose, when it's floating around in your blood, it can't be used

by all your cells. Now muscles are a big one that use glucose. But there's others, right? I mean,

some glucose goes into your liver and gets turned into what's called glycogen, which is a storage

molecule. Some of it gets turned into fat if it's if there's extra sugar in there. But the big thing

is that that that glucose goes in and is used by nerves and muscles. In order to get into

your cells, you have to have a molecule called insulin. Now everybody's heard of insulin because

of diabetes, right? So your body creates insulin on its own. The pancreas does. Yeah, the pancreas

creates insulin releases it in the blood. It releases it into the blood in response to sugar in

your blood. Okay. So normally, let's say you and I were not diabetic, I eat something that has

some sugar in it. The pancreas senses how much sugar that is releases the right right amount of

insulin. That insulin shoves that glucose, that sugar into either the muscle cells, the nerve cells.

And then there's not really any extra leftover. You don't pee it out of the kidneys and it's

and it's all good. It also ideally, you wouldn't need so much sugar that it would turn into fat,

right? You might you might eat enough that it turned into glycogen or that storage molecule,

but you'd have to eat a decent amount of sugar that if you're not able to use it, that would turn

into fat. So insulin is basically the key that unlocks the door of glucose going into cells.

So like I said, it becomes energy metabolism storage, but in diabetes, what happens is one of

two things. Type this is this is non-insulin dependent diabetes. Okay. Is the body stops reacting to

insulin? Type one, two, non-insulin dependent, type two, yeah. And we use non-insulin dependent,

insulin dependent now, not type one and two, because what's actually happening, we'll talk about it

later, is type two diabetics are becoming type one diabetics insulin dependent, right? Because over time

you burn out your pancreas so much that you don't even produce insulin anymore. So type two diabetes

are non-insulin dependent diabetes starts with insulin resistance, meaning that the cells are so

used to so much glucose, which means so much insulin that they don't respond to the insulin anymore.

So type two, what are some of the fat, like if I'm walking around like what should I be looking for

if I'm type two? So or if I'm pre-diabetic? So any type of diabetes you're going to have

excessive thirst, you're going to be thirsty all the time, always feeling dry. Okay.

Going to the bathroom a lot because you're drinking a ton of water or whatever fluid. Now the other

part of that is that glucose in your blood actually pushes more of more water into by it's trying

to get it out, so it pushes more water into your kidney, so it makes you pee more also.

Severe fatigue, not like, oh, I'm tired today, but like severe fatigue. I can't even get out of bed,

like I can't walk more than a block, that sort of stuff. Blurry vision often happens. So early on in

the disease, they're not really sure why that blurry vision happens later on, you can actually get

what's called diabetic retinopathy, and then frequent infections. So sugar is a very, very good

molecule for bacteria. So the more sugar you have in your body, the more likely it is you're going

to get it back to your own infection. So those are the symptoms for type, well, but any diabetes.

Yeah. But so again, type one diabetes or insulin dependent diabetes, especially in a kid,

is like a medical emergency. Why do you see, often with diabetic patients, you see

kind of flaky skin or like blood flow, blood flow reduces over time with diabetes.

So it's just the nature. So toes or fingers, that's why they have toes and fingers.

The blood flow is a big thing that reduces. The other thing that reduces with diabetes is

that the nerves themselves don't fire as well. Over time, all that sugar in the blood again

kind of burns out the nerves, just like it does all the other cells. So let's break it down into

like what's considered true insulin dependent diabetes, what we used to call type one diabetes,

and then true type two diabetes or true non-insulin dependent diabetes. So type one diabetes is

an autoimmune disease. We've discovered that in the I think 60s or 70s. So what happens is there's

some sort of molecule, something in there that starts to kill the cells, the beta cells and the

pancreas, that make the insulin. Okay. So over the course of it usually takes till they're about

seven or eight years old, and then they start to notice like they're not gaining weight.

They've got a, so your body uses ketones. You've heard it, you know, eating a ketotic diet,

right? And it's that sort of stuff. So body uses ketones instead of sugar because you can't

use the sugar. And so you start to produce bad breath and there's all kinds of things that come

with that. So eventually there's no insulin coming from the pancreas at all, which means you

can't use any of the sugar in your blood. So usually appears in children. Sometimes if it's not

terrible autoimmune, they can get to like teenagers or you're young adults, but it's almost always

kids. And then a lot of times you don't really notice until those last little few beta cells are

gone and then it's all the sudden they can't use any glucose at all and it's in a medical emergency.

So, and we talked about a little bit about that ketones. The other problem is that if you don't

have that insulin, you end up in what's called diabetic ketoacidosis. I have heard of that. Yeah,

DKA. So that's a medical emergency as well. So what happens is there's no sugar being used at all.

And the ketones go way high and all the breakdown products of the ketones can make you very, very sick.

So the treatment, oh go ahead, go ahead. The treatment for this, you know, pediatric diabetes,

insulin-dependent diabetes, type one diabetes is insulin, injections of insulin, subcutaneous

insulin. So that was kind of the next question I was going to have for you is, do you think producing

insulin is one of the greatest inventions that humans have ever. So I would say it's top five.

So I mean, antisepsis stuff. So meaning cleaning off the skin before you do a procedure.

That's probably number one. Okay. Number two is probably antibiotics. That's probably saved

more lives than anything else. But I would put insulin in there in top three probably. Now diabetes,

especially true insulin-dependent type one, pediatric diabetes is fairly rare. It's not, I'm sorry,

rare is probably not the right term, uncommon, but not rare, I guess it's uncommon, certainly not

a common disorder. So you probably haven't saved as many lives with insulin as you, or with insulin as

you have with some of these other things. How are we mass producing it? Yeah, so that's funny too. So

we talked about this in the last podcast, which is why we're even talking about diabetes this time.

And if you want to go listen to the last podcast, you can do that. So Eli Lilly is a company who created

Indianapolis company that I've known for a long time. They actually supported my undergrad,

or my undergrad training. So they actually were taking the pancreases of pigs, grinding them up

and separating out the insulin from it. That's what they were doing from. I think it was maybe

the 1930s when they discovered in 1920s, which is expensive. Yeah, super expensive. You have live

animals like, yeah, of course, yeah, and lots of research and development at that point, lots of

trials. Now what they do is they use a type of bacteria. They convert the genetic code of that

bacteria that every time it reproduces it releases insulin, and then they pull the insulin out of

the bath of the bacteria, clean it out, spin it down, and then they have insulin. And they can even

make it make different types of insulin. So they're short-acting, medium-acting, and long-acting

insulin. They can force that bug, that bacteria, to reproduce a bunch of either short, medium,

or long-acting insulin. And then they just bottle it up and ship it out for you to inject yourself.

So I've seen this over the last probably 30 years with my dad, right? Because he's diabetic,

diabetic, type one diabetes. He had it from... Well, no, I'm sorry, type two, right? He had it from

eight. Yeah. So probably when he was, I'm going to say 45 years old and on. Maybe 40,

in the history. Yes. Okay. So that's probably where it came from. So hard disease and diabetes.

Yep. Yep. So that's my dad's side. Great genes looking forward to it. But he would take shots

at first. So the only way to get it would be shots every day when he became insulin diabetic.

Insulin dependent. Correct. Then in his older years, now you have the drip. So it'll sense.

Yep. So it's connected to him all the time. So it senses, hey, now's the time.

An insulin pump. Right. Yeah. Insulin pump that he kind of hooks up here. Yeah, those are

cool. So they actually met... They have a CGM or continuous glucose monitor and they measure

his blood glucose consistently 24 hours a day, 365 days a year. And then that insulin pump is

programmed to respond to whatever that number is. So if that number goes to 250, it gives a certain

amount of insulin. If it goes down to 75, it doesn't give any insulin because that's too low. So

type two diabetes, which is probably what he started with, makes up 90 to 95% of all diabetic

cases and is an insulin resistance to start with. So this is your classic person who's overweight,

eats a bunch of processed food, sugars, all that sort of stuff. And basically what happens is they're

they're making their pancreas pump out so much insulin that over time the body becomes resistant

to that insulin. Now what we've now done is we've actually taken type two diabetics who continue

because they say, oh, I've got medication for this now. I'll take med form and I'll take and we'll

talk about the GLP ones later, but I'll take a GLP one. I'll take genuvial, take whatever these

medications. I'll take all these things and then I can just eat like normal. Sure. So now the body

is not only you know, using those medications to force that insulin into the cells, but now it's

also producing more and more insulin because you're still eating all that sugar, right? And so eventually

if you have type two diabetes long enough or non-insulin-dependent diabetes long enough,

you burn out those pancreas cells just like you would have done from the autoimmune disease.

And now you have insulin-dependent diabetics because they burned out their beta cells and their

pancreas. The other thing I wanted to say too is, you know, my, there's blood sugar. Yes,

EGMs. Yeah. Continuous ghost monitors. So like my mom, yeah. She doesn't, I don't believe she's

dependent on insulin, but you know, she has a monitor. Yeah. So like it's a little patch. Yeah.

Boom. Can check it with the phone. Yep. And you can see what the, but I think it's interesting,

though, how far we've come with insulin and the types of treatments you can get with insulin.

My sister actually is in the medical field, but she's a scientist. She's, you know,

she's, yeah, you told me that in the lab. And she actually worked on an inhalable insulin.

Oh, that's cool. For years. That's cool. And I'm not sure if she's working on that still,

but she works for a medical company, pharmaceutical company that does some diabetes research. And

they were working on an inhalable insulin. That'd be great. That'd be great. It would be, wouldn't it?

Yeah. But I think it'll go ahead and go ahead. They haven't inhalable a bit effort now too.

Oh, do they really? Yeah, it's called Neffi for, for allergic reactions. So cold, my younger

son has a, has a peanut allergy. And so we've had this, the injectable. So you don't need the,

yeah, you just sniff it up the nose. So I think it's, I think it's really interesting how far

we've come with the medication itself, with insulin itself, like that we're talking about

inhalable insulin now, where you can just carry it around. And that I would, and the whole reason

we brought this up is the fact that pharmaceutical companies charge outrageous prices for drugs, right?

So that I would understand that's a new formulation, a new way to do things. These insulin

types of insulin that companies like Eli Lilly are producing cost them almost nothing now.

I mean, and they charge you, you talked to some of these people, yeah, how much is 500, 600,

$600 a month for their insulin. And so the whole reason we got into this is there was an

episode of the pit where, where a guy couldn't afford his insulin, right? There's no reason.

It's just price gouging, right? At this point, there's no reason that insulin should cost

$450, $600 a month. Now, if you get the new, new and improved, squirt up your nose one,

then I see it, right? That's a new, that's a new drug. It's more convenient. But the, the injecting,

the medication, and you know what they've done. Some of these companies have done, which is just

absolutely ridiculous. They've patented the delivery device. So you inject it, right? So it's not

just pulling up a little insulin out of it, right? They've patented the delivery device,

which is not a drug that goes off patent in seven or ten or ten years. And that makes it more

expensive. Correct. And they can continue to charge that price because they patented the injection

device. It's a device that now you can't go back and say, well, it's seven years or ten years.

So that leads me to my next point and probably to our next segment here with this is GLP ones.

So you're looking at the cost of GLP ones, right? 200, 500, 1000, whatever it's going to be.

Those are medications. But have they patented that device? So like, well, but who cares?

I mean, who cares? But does that raise the cost of it? It will, if they, if they go the route of

patent and the device uses that, yeah, right thing that you like turn to get. Yeah, yeah, yeah.

So, so what's going to happen when it goes off label is that the, would it started to already?

No, but it hadn't been around long enough to go off label yet. So what is the, there's compound

compound. So that's different, right? So that's generic, right? Well, no, that's going off label.

So compounding is taking the compounding pharmacies, they'll actually take that semi-glutide.

Let's say that's the most common. That's, you know, it was epic. They take that raw semi-glutide

and compound it with whatever they need to put in it for you to be able to inject. And then

it's a separate medication. That's why it's cheaper. Correct. Correct. Now, being generic means that

every pharmaceutical company out there can now make it, now you have to produce it in a different

way, but it can end up being essentially the same thing. Sure. At that point, that's off patent

generic and things are less expensive that way. So that, I can't remember when that happens,

we could probably look it up. It's a few years. When there's target labels and correct

winter labels. It's right. Exactly. That's the same thing. So it's a, it's a couple of years away,

maybe three or four years away before that they're off label use for diabetes. Now, the weight

loss portion of them, or I'm sorry, generic use for diabetes. The weight loss portion of them

is going to be years and years. Really? Just patenting them now. So every time you patent a drug,

you patent it for a specific use. So if you patent it for a new use like weight loss,

then you start that whole 7, 10, 12 year patent over again. So when that patent is over, 7, 12 years.

But he can make it then it's fine. Yep. How effective are the GLP ones at

and why at the reduction of or the blood glucose? Or are you talking about weight or both? No,

no, no, no, diabetes. So the way a GLP one works, it's a hormone that's released by the gut. So

glucose gone like peptide one is the name of it, right? And these aren't actually glucose gone

like peptide one. There they are mimics of that. So they actually just go to that GLP receptor.

They're called GLP one receptor agonist. So they look like it to the body and cause that receptor

to fire just like there was that that in the body. So what do they do? So they stimulate insulin

release number one. Great, right? More insulin. So you're not going to burn out the pancreas

necessarily. They suppress glucose gone, which is the hormone that kicks it the other way to release

to release, I'm sorry, to, yeah, to release sugar into the blood. Okay. They slow stomach emptying,

which is why they work for weight loss. Correct. Makes you feel more full. So you eat less.

In theory, you eat less. That means there's more sugar in your body. So was that just

happy side effect? So the GLP one was just the side effect, like the weight loss was just the side

effect. And now it's becoming the reason. Well, there's people who still take GLP ones for diabetes.

So because if you're pre diabetic, do you get written up a prescription for it?

So I don't know what the insurance companies, I don't know what glucose number

insurance companies are really strict with the GLP ones. Yes. Yes. Very strict. Yes. Yes.

And so because of that slowing, slowing some being stomach emptying, it slows down or it reduces

appetite. It also reduces appetite in the brain. And they don't know exactly how that all works,

but it reduces appetite in the brain as well. Now there's several versions of these now. There's

the semi-glutide, which is just the basic GLP one. Then there's the tersepotide, which is like

three, does three things. Now there's even a new one called remaglutide or something like that.

It does like four different mechanisms. So they're building on that basic molecule of semi-glutide

and some people say semaglutide. So whatever you want to correct me, it's fine. But so they're

building on that basic molecule and getting more and more and more and more ways to make these work.

There's actually a lot of evidence that not only does the GLP ones treat diabetes,

they also cause weight loss, but they also reduce your risk of cardiac disease, they increase

fertility. There's like all these things that they do now. And they're finding all these side

effects, which are good side effects. Not every side effect is bad. They're finding all these

side effects within the treatment of diabetes. When you are an anesthesiologist,

when you are prepping for surgery or performing surgery, performing anesthesia on somebody,

what is the protocol with diabetics? So that depends. So diabetics by default, if you're a

diabetic for more than one year, you have gastric paresis. Now it's not necessarily clinically

significant, but that means you're more likely to throw up during surgery. So we treat almost

every diabetic who's been diabetic for more than a year as a full stomach, meaning that you're

likely to vomit and aspirate. So more times than not, you're going to do a general anesthetic with

an endotracheal tube to protect the airway in a diabetic than you are in a non-diabetic.

We want patients off of the GLP ones for a week, at least, for elective surgery. We still treat

them as a full stomach. And then we want patients off of the SGLT2s for three to four days, depending

on which one it is, which is another type. It's kind of a cousin of the GLP ones. Works on a

different mechanism. So those are a couple of things. We do ask patients to continue to

check their blood sugars. And then the majority of the other medications, you just stop the day

of surgery, right? So we don't want people taking metform in the day of surgery because it was

like the cacidosis. We don't want people taking some of these other daily, like you wouldn't take

an oral semi-glutide or even the daily injectable semi-glutide the day of surgery. But people who do

insulin, inject insulin, we want them to continue to take it up all the way to the night before.

And then usually what we tell them is the long-acting doses that they would take the night before,

we say just cut that in half because you're not going to have anything in your stomach in the

morning. But yeah, diabetes is definitely an issue. Over time, it can cause, like we said,

all those issues with the vascular system. It can cause the joints to get stiff, including

the TMJ, the joint here in your jaw. So sometimes, diabetics who've been diabetic for a while have

a hard time opening their mouth. Why is that just this receptor? No sugar deposits in all your joints.

You have that much sugar in your body. It deposits in your joints and over time, it kind of scars

it down. So all the joints get tight. Okay. So there's a lot of side effects of diabetes.

And so about 75% of those, if you treat it well, if you have good blood glucose control,

you don't actually progress any of that stuff. But there are still things like the kidney damage

tends to progress, even if you control your blood sugar as well. A lot of the joint stuff

continues to progress. Trying to think what else? Some of the vascular stuff and not all of it.

So is the GLP1, do you think that is going to be, I don't want to say on the same level

of insulin, but like it's already the mainstay of non-insulin-dependent diabetics. GLP ones

are already like probably second line. Most people will try the metformins and that sort of stuff,

first line, and then everybody else pretty much gets put on a GLP1. Because there's so many benefits

of it, right? So you're diabetic. You're already now at higher risk for cardiac disease. You're

already now at higher risk for retinal damage. You're already now at higher risk for sudden death

and all that sort of stuff. So the GLP1s reduce all that independent of their effect on the blood

glucose. So I would just say, we've talked about this on the podcast before how probably within

the last hundred years, right? We've lived longer, right? Yeah, yeah, it's interesting. So if you

believe the biblical telling of the world, right, people would live till they were 900 something

years old, and then the blood came and God said, nobody will live more than 120 years. And then

people were living in that 120-year range until they got to the point where there were a lot of

things like disease and that sort of stuff. And so typically what happened for all of basically

modern history up until about a hundred years ago, people would die from either accidents

or infections. And so the first thing that happened before we solved the accident problem

was that the infection problem became better once we had antibiotics, right? So that increased

life expectancy. And then you probably also have some degree of sewage and just overall cleanliness

of society that happened next. And so that increased life expectancy. And then the other thing that

would have increased life expectancy is just like we talked about is just diagnosis and treatment

and all that sort of stuff of disease. So yeah, so I, you know, you look at this curve and it was,

you know, life expectancy was very long and then it dipped and then it got super low like during

the middle ages. And then it's been steadily increasing with a little blip down during COVID and

then back up now. So insulin is a big part of that. Insulin is a big part of that. So I thought we'd

also do so diabetes like there's a lot of discussions about what myths and continue. I'm going to

fix your camera. Of course, what myths and what's what's true and what's not. And so the

I'll go through just a few quick myths. So myth number one, eating sugar alone causes diabetes.

So that is an untrue statement. Okay. Overall, there's a lot of things that can cause diabetes,

right? So I might eat so much sugar, you know, I've got whatever, you know, I'm eating

600 grams of sugar a day, right? That's probably extreme. And genetically, I may not get diabetes,

but you might eat 100 grams of sugar a day and still get diabetes. So it's a complex metabolic

disease influenced by genetics, weight, diet and lifestyle. Okay. Myth number two, thin people

can't get diabetes. And that's what I used to think before I went to medical school. It's like,

you look around and you're like, oh, you know, I mean, I know that I know the young people who

get totally insulin, right? I get, you know, you know, the young people who get insulin,

dependent diabetes are thin, but you're like, yeah, everybody else is overweight. Not true. Type

two diabetes can occur in people with normal weight. And it's probably related to diet. Maybe they

don't gain the weight. Maybe they don't get the fat on their visceral fat or the fat on their

organs or at least not visibly, but there are a lot of ways. There are a lot of people who are

normal weight or even underweight who are diabetic. Myth number three, once you have diabetes,

nothing can be done. So that's a myth in the sense of, well, I'm just going to give up because I

have diabetes. It's not a myth in the sense of once you do cause that damage, the likelihood of

reversing that damage is infinitesimally small. So now if you're an insulin dependent diabetic type

one, you have diabetes forever and you have to take insulin forever, period, right? That there's no,

there's no other way around it. Your body does not produce insulin. You have to give it exogenous

or outside insulin. The type two or non-insulin dependent, you can get to the point by diet and exercise

where it's controlled, but I would not say that you are ever cured of your diabetes. Okay.

So one other myth, let's the last one here, medications fix the problem. This is what I was just

talking about, right? Medications treat the problem. They don't fix the problem. And the way that

the way that I sort of look at this now, and I'm not comparing these two diseases in any way,

shape, or form morally or biochemically, but treating diabetes and treating HIV at this point

are essentially the same thing, right? You have the disease. It's in your body, you know, with HIV,

it's a virus with diabetes. It's a breakdown of those beta cells that create the insulin.

You have the disease. As soon as you get it, you have it forever. If you do the right things,

you take the right medications, you treat it the right way, you eat diet, exercise, all that sort

of stuff, you basically are in remission, right? So there's people who take these new medications

for HIV that, you know, basically prevent any replication of the virus itself. So basically,

you have zero virus in your blood. You're still HIV positive. If you're great with the diabetes,

you have no extra sugar in your blood. You're basically in remission, but you still have diabetes.

Okay. So all right. All right. What a podcast here. Yeah. I really like this one. I mean,

it hits home for for my family too, because I mean, it's just both sides of the family. Yeah.

Heart disease and diabetes on one side, heart disease on the other side. And so you're like always

looking for those. You're always looking for it. And I'm at the age, right? I'm at the age where

I've got to look at it. You know, I've got to look at what we eat, how we eat it, how are we?

You know, what are we feeding our children, right? You know, are they at risk? That's sort of

thing. It's so it is multi-generational. So I think what we do have to focus on is diabetes,

prevention, and treatment without medications. And so that's diet and exercise. Like diet and

exercise are medicine. And again, no matter what you think of our current HHS secretary,

diet and exercise are key. So that includes what? You reduce processed foods and sugar, right?

It's not easy on our modern society, but eating real whole foods with low sugar content is important.

And then staying away from refined carbohydrates, right? So it's one thing if you got a carbohydrate

like a sweet potato. Yeah, exactly. Yeah, complex carbs, that sort of stuff. As opposed to drinking

a coke that's got high-frope toaster corn syrup, that is a highly processed refined carbohydrate.

Diet and exercise, but primarily exercise improves insulin sensitivity. So the more you work

your muscles, the more insulin receptors they have on those muscles, the more that you're going to

get that sugar blood glucose to move into the muscles. When muscles contract, they pull glucose out

of the bloodstream. Okay, so again, same thing. You're building that muscle while you're working out,

you're driving a ton of sugar into your muscles because it takes a lot of energy that sugar is

energy to make those muscles work. And so one of the biggest things, and I actually just talked about

this the other day, and I can't remember with who is walking is like the key, right? So if you look at,

if you look at all the studies that are coming out now, if you put 12 to 15,000 steps per day,

your likelihood of any metabolic disease is infinitesimally small. So you do that every day,

seven days a week, yep. So walking is just as good as anything else, right? Probably better than

running because it doesn't hurt your knee. Yeah, right. But but there is a definite correlation in

number of steps and decreased disease. Okay, resistance training is big, right? And that's big for

a number of reasons. And I won't mention the guy's name who talks about this a lot because he was

in a certain set of files that made him not look very good. But I know who exactly we were talking,

yes. So he talks about, right? So resistance training is important for this to stay healthy,

but it's also important because the more bone density and muscle strength you have, the older

you get, the more ability you have to actually do the things you need to do, do your grocery,

you know, buy your own groceries, do your own grocery shopping, go the lawn, walk up the stairs,

right? So you got to have all this functional ability. And then finally, just daily movement,

right? And if you can't get that 15,000 steps, just even getting up and like walking around the house,

sometimes when I'm at work or on the phone or whatever, I'll just start doing like half raises,

just as something to do to move around because I don't sit still well, but aside from that, yeah.

So those three things, walking resistance training and any kind of daily movement, big for overall

health. Awesome. Yeah. Well, if you want more information too, again, there's tons of publications

out there. Who do you trust? Who do you go to? Yeah, I mean, so the easiest thing to do if you want

just like comprehensive information about diabetes is go to what's called the Cochrane review.

Okay. It's at England, I think. And they take all the studies about one particular topic. If you

just Google or chat GBT Cochrane review diabetes, you'll be able to find all the studies. They take

them, put them all together and then do what's called meta analyses where they say like we've looked

at 20,000 studies and here are the best ways to treat diabetes or prevent diabetes or whatever it

is. So that's a big way to do it. Actually, to be honest, medscape is actually a pretty decent,

like if you're not a clinician, you're just somebody, you know, lay person in the public who wants

to read about diabetes. Medscape is the name of the website. They do a pretty good job. And then

if you want to delve deeper into it and you have access through like university pub med,

it comes from the like national science foundation or something like that. And so you can get all

the articles real like the primary articles and read through them there. But I would say, you know,

to our audience, probably medscape and Cochrane review are the two places to go. Awesome. Well,

this has been another edition of Going Under anesthesia answered with Dr. Brian Schmutzler. If you

want to see any of the podcasts that we've done over the last four seasons, go back and check it

out on Spotify, Apple music, Apple podcasts and YouTube as well. It is all there and it is very

comprehensive. We touch on basically every subject over the last four seasons and more to come.

Thank you so much, sir. Awesome. We'll see you in the next one.

Track you by the butterfly network.