Dr Jason Fung - Novel management of diabetes and insulin resistance

in this lecture dr. Jason phone discusses novel management at type 2 diabetes with special focus on dietary interventions so I just wanted to start today with a quote for a Mary Mead and she's a Samaritan scientist who said that never doubt that a small group of thoughtful committed citizens can change the world indeed it's the only thing that ever has right and that's what we're trying to do today I'd like to thank professor Noakes for putting this on because that's what we're trying to do we're trying to reclaim our health and we're trying to learn how to do that so this is a talk about type 2 diabetes and it's about the etiology and reversibility of type 2 diabetes and what we're actually going to do is expose the two big lies of type 2 diabetes so this is type 2 diabetes so what you see here is a fasting glucose or there's actually two things that happen with type 2 diabetes sorts two phases that happen with type 2 diabetes you see this first phase where it goes up very very slowly so this is diagnosis and prior to that you have a very long gentle upslope of your fasting glucose and what that reflects is the increasing insulin resistance that develops and then all of a sudden you get this very sharp uptick and that actually reflects the beta cell dysfunction so the beta cells aren't producing enough insulin and your blood Sugar's all of a sudden go up very high this is what happens and you saw this graph yesterday and you see that as you go from lean to diabetic the insulin resistance slowly increases and this is what happens to the beta cells so the beta cells in a normal lean person as the glucose goes up so this is the the open circle the insulin goes off so as you become more and more diabetic you go from impaired fasting glucose to overt type 2 diabetes what you see is that your insulin starts initially by going up very high in response to this glucose but at some point as the glucose goes up your insulin level actually dips right so as opposed to the resistance which gradually goes up your insulin level actually starts to dip at the end and that's what leads to that very sharp uptick and the question is why so when we talk about type 2 diabetes there's one thing that you always hear it's not actually true which makes it a lie it might be an inadvertent lie but it's the lie nonetheless and that type 2 diabetes is a chronic and progressive disease and that's what they all say but it's not actually true and I can actually prove it to you quite easily so you can look at studies of bariatric surgery so this is where you cut the stomach into the size of a walnut and basically they can't eat and what happens well the diabetes actually goes away so if you look at this study which was published in the New England Journal of Medicine in 2012 what you see is that if you do intensive dietary manage intensive medical management i should say you basically don't nothing really happens but if you do rouen why surgery or if you do a sleeve gastrectomy so these are two different types of bariatric surgery well then the diabetes essentially goes away in conjunction with the weight loss right so I've at about 12 months you see that most people are actually off all their medications so to all intents and purposes cure it and this happens and we've known this for a long time because studies going back even to 1992 have shown that there's two things that are actually quite interesting about bariatric surgery which is one the diabetes this is the glucose you see that it drops very very quickly so within a couple of weeks the diabetes actually disappears so the patient may still be 450 pounds but the diabetes is gone and the other thing is that it's an extremely long-lived treatment right so it goes down and it stays down so again to all intents and purposes cure now I'm not saying that everybody needs bariatric surgery but what I'm saying is that there's something happening here which completely reverses the diabetes so to say that it's chronic and progressive disease is actually not true you can do the same thing with gastric banding so this is the more recent you put a band in the stomach and you squeeze it down so they can't eat and what you see is that again the blood glucose falls down so there is a cure it's not chronic and progressive and you can look at studies of fasting and this is actually my patient Margaret and we started with her taking 120 units of insulin a day plus 2 grams of metformin her hemoglobin a1c was seven percent in four weeks later she was on zero insulin no metformin with an a1c of six point six percent in a year later down some sixty four pounds her hemoglobin a1c is six point two percent so again very very rapid relief of food that diabetes and it's long lived in fact if you go back almost 100 years a fellow by the name of Jocelyn a little-known diabetologist wrote in 1916 that temporary periods of undernutrition are helpful in the treatment of diabetes will probably be acknowledged by all so he thought it was so obvious that under nutrition is going to cure in fact he actually specifically talked about fasting which is crazy right but fasting it was so obvious to him he thought that everybody was going to do this what happened of course was that they discovered insulin and then everything went the way of insulin if you look at food rationing during the world wars so this is not carbohydrate restriction this is everything restriction right so you're talking through nobody having protein nobody adding car bhai nobody had any fat people were starving but if you look at type 2 diabetes what happens of course is that during the war and during the food rationing you had very little type 2 diabetes so again to say that this is chronic and progressive is simply not true in fact you can compare fasting in bariatric surgery and they did a study where they actually fasted these people prior to surgery and this was because they wanted to reduce the surgical mortality right so you shrink deliver a bid you lose a bit of weight there's less surgical complications but what's really interesting about the fasting is that if you look at the weight loss so this is the fasting this is after surgery the fasting actually did better there was more weight loss and this is the glucose the daily glycaemia it's actually way better then post surgical so of course they went headed to the surgery and everybody got better right and the third one is a low-carb high-fat diet ketogenic diets what happened well again a patient 27 years old she was actually a graduate student in physiology so she got diagnosed she went to her doctor her hemoglobin a1c was ten point four percent she got started on three medications she said forget that I'm going on a ketogenic diet very low carbohydrate diet she lost twenty pounds took herself off of all her medications and what happened ready to her hemoglobin a1c is five point five percent so again for all intents and purposes with the low-carb high-fat her diabetes was cured well that's funny because I thought it was a chronic and progressive disease right so if you look at what cures diabetes you can actually say these things are cure and if I was to say to somebody that well I lost 50 pounds and my dad beauties went away you wouldn't say wow you're lying right diabetes never goes away it's obviously true but what do we do instead we give insulin we give drug than we give low-fat diets right but what happens if you give people insulin do they say oh I took a hundred units a day of insulin and two weeks later I took myself off I'm fine now that never happens right or all I went to a low-fat diet and I'm cured now I'm good no that never happens right so these things lead to a cure and these things do not so you'll never guess of course which way that we treat people right that's our treatment protocols that's our research and our current goal is to normalize the blood sugar right who cares about the diabetes let's normalize the blood sugar so the real problem I have with this all is that it gives people a sense of learned helplessness right so here's the American Diabetes Association and they say well this is a fact type 2 diabetes is a progressive disease you got it get used to it that's the message right don't fight it well actually it's a lie it's not true and the second thing they say is that well sometimes medications may be enough to keep the blood glucose normal and then using insulin to get blood glucose levels to a healthy level is good right not bad the fact that you're using insulin is a good thing and I'm like what the are you talking about right like you cannot be serious if you're taking insulin your diabetes is worse than it's ever been in your whole damn life it cannot be a good thing anybody with this is an ounce of common sense will tell you that but that's what the American Diabetes Association is telling people and you all these are not any better haha so this is what diabetes Australia tells you right so over time type 2 diabetes will need tablets and mo will also need insulin it is important to note that this is just the natural progression of the disease I didn't do that well that's crazy right that's crazy so the truth is actually that if you look at it it's a curable disease but it's a curable dietary disease right so you can't hear a dietary disease with medications it doesn't work for sure it doesn't work the second big lie is that we need to take care of the blood Sugar's right that's what the goal of treatment is to take care of the blood Sugar's right get your Sugar's down take your insulin get your blood Sugar's down that's what we're all taught and this is how we think about it right there so there's so many complications of diabetes the eyes the brain the heart the kidneys you got amputations and so on and they lump both type 1 and type 2 diabetes together and once you get is these high blood sugars which which causes all these things like oxidative stress and advanced location and products and therefore this leads to the complication of diabetes so logically if you think this is true then you get rid of the high blood sugars and you get rid of the complications right that's pretty simple but it's not true and we've known this actually for about six years so if you go back to the cord study which was published in 2008 in the New England Journal of Medicine what you see is that you can take thousands of patients and you can make their blood sugars better so there's the control group which has an a1c up here and you with high doses of medications drop their sugars so that they actually get much better blood sugar control so do they do better no not really they do worse and this caused a big splash when it came out that the hazard ratio of death so these people with the intensive management we're doing worse right they had an increased risk of death by about twenty two percent but it was far from the only trial that showed this in fact there was the Accord the advance the VA DT and the origin trials which had all shown exactly the same thing all of which came out roughly at the same time so treating the blood Sugar's didn't do a damn bit of good right that much we know okay and this was the seven-year follow-up to the Advanced Study which was published here in 2014 in the new england journal of medicine and again if you look at the two groups which are randomized one to type blood sugar control one to not take blood sugar control well what happens well nobody can tell the difference between the two so even seven years out you cannot tell the difference between good blood sugars and bad blood sugars it doesn't make a damn bit of difference right and if you look at other studies so dr. curry from the UK has published a lot from the in the land set and you look at people who start on metformin and they add insulin or they add a second one you can see that a low hemoglobin a1c is actually not good for you right so here you have the insulin group and as you get higher and higher a1c yeah you do worse but you also do worse with the lower and lower a1c so it's actually not that good for you here you have gluco toxicity and my guess is that here you have insulin toxicity right it's not good for you right so you as a physician you think that this patient with a hemoglobin of a1c of six percent is doing fantastic but they're not going to do any better than if there anyone see was ten and a half right they're doing terribly because the problem with type 2 diabetes is that we're not treating it right so whenever you have a disease you need to treat it the root cause of it you can't just treat the symptom if you treat the symptom it doesn't do anything so we know that type 2 diabetes is a disease of insulin resistance but what do we treat we treat high blood sugars right that's not the disease what are we doing about the insulin resistance it's almost like you have an infection if you have a gangrenous foot or flesh-eating disease you need to treat it with antibiotics this infection is going to cause a fever but you don't say oh let me give you some Tylenol let me give you some acetaminophen right and then no I'm going to give you high dose acetaminophen well that leg is falling off right you need antibiotics because you're actually treating the cause here but yet for type 2 diabetes which affects so many millions of people we don't treat it at all we just treat the symptom of the high blood sugar what are we doing about the insulin resistance nothing so what happens the diabetes gets worse that's exactly what's happening to all of your patients so what happens over 10 years 15 years is that you start with metformin then you take a few more medications then you take insulin then more insulin then more insulin right guess what if you're ending up with a hundred units of insulin a day your diabetes is not better your diabetes is worse why because you never actually treated the disease right because the disease is all about insulin resistance and you're treating blood sugars so again in The Lancet in 2012 they did a study where they look that screening for diabetes and shopping malls and so on and they screened like 10,000 people and it turns out that when you screen people you don't actually see any benefit and they're like wow that's pretty amazing well if your treatment is all wrong and you're not actually treating a disease it doesn't make any sense to screen for it because you can't treat it anyway right and that's the real reason why the screening is completely useless because these are just giving more insulin so if you're going to start talking about how are we going to cure these patients and why are we going to cure these patients how it's happening you need to start by looking at the treatments you know already work right so why is it that these these treatments work why is it well bariatrics is the easiest to study because it's the best best studied and there's a defined point where you can measure it well what happens well some people think it's due to the GI effects so it's because of the hormones in the stomach and when you cut the stomach they don't produce these hormones ghrelin and so on there's something called the foregut hypothesis if food hits the foregut and there's a hind get hypothesis turns out it doesn't matter because it doesn't matter whether you do a roux on why whether you do sleeve gastrectomy or you do a restrictive so there's two types of bariatric surgery there's restrictive and there's mal absorptive right so restrictive means you actually restrict whether people can eat like a lap band for instance mal absorptive means that you rewire their intestine so nothing gets in and that's the rule on why but it doesn't matter what you do you can cut outs thumb maker you cannot put out stomach it does well either way so clearly this is not the case maybe it's because you lose all that fat it's due to the weight loss right this is the whole thing that weight loss causes diabetes and yesterday we talked about the fact that obesity doesn't actually cause diabetes they're both diseases of hyperlinks insulin emia but there is an idea that well if you just cut out that fat well then you've lost a lot of weight and the diabetes should get better but it's not true right so there was a study published in 2004 in the New England Journal medicine where they did liposuction because with this exact idea that you can remove fat cells right so you vacuum it out so here's this big thick peel of a fat and what they did was they did liposuction and you vacuumed it all out you can't touch this big fatty liver of course because that's on the inside but all the subcutaneous fat you take out well according to this thought well if it's all due to weight and that'll be good but it turns out that when you take out all the subcutaneous fat it doesn't do anything for your diabetes right so if you look at insulin resistance if you look at blood glucose there's actually no difference before or after so it's not due to the weight it's due to something else the only thing that you can say causes the cure in bariatric surgery is this acute profound caloric reduction right because you're not eating right so dr. Taylor in the UK at Newcastle did this study called the counterpoint study and what he did was he put people on these extremely low calorie diets and what was great was that the blood sugar came right down so from 9.6 it went to 5.9 in only seven days right these were extremely low low 500 calories a day sort of diet and what you can see is that the liver fat goes down preferentially so you can see that there's a thirty percent decrease in liver fat there wasn't a thirty percent decrease in the body weight but in the liver fat it does go down and you can see that this is from yesterday that if you take out the liver you can shrink it very fast because most of it comes down within the first two weeks that liver fat comes out preferentially far before the subcutaneous fat does and if you look at the paddock fat for instance it will go down thirty percent even while your own weight only goes down about ten percent so the body weight goes down but the liver fat comes down more and this is the reduction in liver triglycerides so the fat in the liver basically so you see this as normal this is before the weight loss you know lots of fatty liver here and it goes right down and what happens to the insulin resistance this is from yesterday again that this is a normal person this is their insulin sensitivity before you lose all that liver fat you have a lot of insulin resistance when you lose all that liver fat all of it comes back right so what you see again the same thing that you saw before dr. Taylor saw that there's a significant improvement in the insulin sensitivity so for those who aren't here yesterday we talked about why fatty liver causes insulin resistance and this is what we talked about well if you have to think about what insulin actually does right so insulin you eat food the insulin goes up and what they do is you store sugar as sly kajen then you store fat which is de novo lipogenesis so you produce triglycerides you store it in the fat and when you don't eat or when you're fasting that will come out you'll decrease your insulin that sugar and that fat will come out so in the normal situation you have this where the liver cells are easy that under insulin the food goes in when they're fasting low insulin it comes out but what happens of course under conditions of high persistent instant when your insulin is up all the time what happens is that you get a huge fatty liver so what happens is that insulin is is having a hard time because you're trying to shove all this fat into this huge fatty liver and it's really hard because just like blowing into that overinflated balloon for the same amount of blowing in you're going to move less air that's insulin resistance right so for the same amount of insulin is getting really hard to keep shoving it in and when your insulin if you don't take your insulin shots for instance all this sugar kind of comes flowing out so you take more and more and more insulin to keep all this sugar kind of bottled up inside and this is what leads to the vicious cycle right so you get the insulin resistance you get the high insulin levels you get the fatty liver fatty liver leads to more resistance more resistance leads to high insulin and that's what's happening but what happens to the excess carbs in that liver well there's only three possible ways it can go you can burn it off but when you're eating when your insulin is high you're not going to burned off there's no reason to write you're in a storage mode so the second thing is that you can store it in the liver and that's what you do right you get this big fatty liver and the third thing you do is you can export it out so your liver takes that excess fat and kind of send it somewhere else and one of the places it sends it to is the pancreas so what happens is that you get fatty pancreas when you start pulling out all that liver fat within the counterpoint study what happens is that you get a slower decrease so the liver fact comes down very quickly but the pancreatic fat slowly comes down and what happens to the beta cells you can see that their function is now restored so those beta cells weren't dead they were just dysfunctional they were being blocked by fatty pancreas and that's the key because there's two things that happen in type 2 diabetes there's both the resistance and the beta cell dysfunction and you can restore both with in this case acute caloric restriction you can see this first phase insulin response which is again another test of pancreatic function you can see that it's much slower but it does go up over time so now you're actually reversing the two defects that happen in type 2 diabetes so this is a twin cycles I patha sis that he published but to put make it a little bit easier this is really what we're talking about right so you've got excessive carbs that go in especially the refined ones which leads to very high insulin right so again insulin is the key here it leads to fatty liver which leads to Pat against and resistance which leads to more insulin this is a vicious cycle it just keeps getting worse and worse over time but there's actually two cycles that are happening here you've got one this is the fatty liver which is called hepatic steatosis and you've got in fat against Lee resistance so that's one cycle but second cycle is that you're sending this fatty fat out to the pancreas so this fat and the pancreas leads to beta cell dysfunction which leads to high blood sugars which leads to more insulin production now it's being blocked because you got beta cell production you're basically going to Mac though your your pancreas to pump out as much insulin as it possibly can so that's why if you're calling the first slide you've got very very high insulin levels so that's the twin cycles and both of these are vicious cycles if you don't treat it it's going to get worse so you have to actually break both of these cycles and there's one key player in these which is insulin the excess of carbs which leads to the insulin see the whole problem we have with type 2 diabetes is that we're treating the wrong thing here right we're treating the blood glucose the blood sugar the problem to put it simply in type 2 diabetes is that you have too much sugar ok but it's not just in the blood it's everywhere in the body so now what we do is we take the sugar out of the blood and we shove it somewhere else in the body right so if you imagine that you have a sugar bowl right if your body is like a bowl of sugar when you eat the sure comes in and that bowl is full so it will just spill out into the into the blood but instead of getting rid of it what you do is you take insulin and you shove it back into the body and the body sends it somewhere else because it says what am I going to do with it it turns it into fat it sends it to the eyes it sends it to the kidneys it sends it to the legs it sends it to the heart but you're not getting rid of it so your bowl of sugar is still full the next time you eat sugar comes in it spills out you take more insulin you shove it back in and what happens is that you've got sugar everywhere in your body right so what happens well everything just starts to rot your eyes you get blindness you get heart attacks you get strokes you get amputations you get kidney disease everything starts to go and all the while your doctor saying look how good your blood Sugar's your a1c is six percent good for you the only person that feels better in all of this is your doctor right because while your feet are falling off and you're going on dialysis he's going look at what a good job I did with you right and this is why they say it's a chronic progressive disease it's a lie that they have to tell themselves because it's obvious that it's a curable disease right but if it's a curable disease why are all those patients getting worse the only conclusion is that there he that doctor is a bad doctor but he can't face that psychologically you cannot face the fact that you're treating people wrong so what you say instead is look it's a bad disease there's a chronic progressive disease and I'm doing the best that i can write because psychologically that's a lot easier to face so they've lied to themselves and it's not just the doctors it's thin the Diabetes Association's everybody they actually believe this right otherwise they wouldn't put it on there not malicious they're just deluded right it's different so the whole problem is all wrong you're not treating it correctly because all you're doing is like it's if you have garbage in your kitchen and instead of throwing it out you put it under the rock right and then you say wow look how clean my kitchen is right and then when when when the rug gets full you say I need a bigger rug right let me get a bigger rod right and then you say wow look how clean my kitchen is meanwhile your whole house it's just starting to smell and you just don't know why the key to the treatment of diabetes of course is to burn down all that sugar right and the only way you're going to get rid of the sugar is either burn it off or not take it in right because this is the key right here is the insulin and major part of that is the refined carbohydrates it's not the only place it's not the only piece of the puzzle but it's a very big piece of the puzzle right so you have these people who go on low carb diets ketogenic diets and they do fine because they're reducing their insulin right because if the insulin which leads to the insulin resistance which is your major problem so the solution is to lower insulin right this is what the bottom line is is that it's the insulin which causes your type 2 diabetes that's the bottom line right but we don't lower insulin we give insulin with the mistaken assumption that we're doing patients good so if we're starting to go towards a cure for type 2 diabetes you gotta understand what's causing it right so this is the thing high insulin levels excessive carbohydrates that's what's going to cause your fatty liver and that's what's going to lead to this whole twin cycles I just win cycles that is the pathophysiology between type 2 diabetes so once you understand that it's really easy to look and say well how are we going to cure it well that's pretty obvious then decrease your insulin and decrease your carbohydrates but of course that's not what we do of course we don't tell people to take less insulin we give them more insulin we don't tell people to take less carbohydrates except here in this auditorium we tell them to take more carbohydrates right fifty percent carbohydrates sixty-five percent carbohydrates watch that dietary fat right you can't take too much fat but the fat was not the problem the problem was the carbohydrates so this is the thing when you start to decrease your carbohydrates and sometimes you have to decrease it a lot what's going to happen is you're preferentially going to release the fat from the liver you're going to decrease your insulin resistance you're going to take out the fat from the pancreas and that's going to reverse your beta cell dysfunction and therefore your diabetes is going to get better now instead of getting worse and worse and worse you're now going to be able to drive those twin cycles in reverse because you're going to get better as you take out more of the fatty liver you're going to get lower insulin resistance which means your insulin is going to go down right so we're actually heading in the wrong direction we're moving in the wrong direction we're heading where the cycles are getting worse instead of getting better and then you wonder why nobody's getting better then because you don't know why everybody's getting worse you call it a chronic disease so this is the thing this current treatment paradigm is completely idiotic right it's essentially like giving alcohol to an alcoholic right so if you have a disease where the problem is too much alcohol if you take it away they might get the shakes and then you give them alcohol and you might say wow look how good you're doing with all that alcohol right I'm gonna put you on a high dose insulin infusion high dose vodka in fusion right but it's not going to make your alcoholism worse so make your symptoms better but it makes your disease worse right so if you think about what we're doing for insulin we're making the symptoms better your blood sugar is great so your doctor feels great he's doing a good job that you're falling apart that's the problem right you simply can't treat a hyperinsulinemic state with more insulin that's crazy we know that type 2 diabetes you have very high insulin levels so our knee-jerk reaction of course is to give more insulin and wonder why people are getting worse it's pretty obvious why it's getting worse you're hyperinsulinemic why are you giving insulin are you a right that's the question you have to ask that was very non-pc by the way so now if we go back to what we're talking about here these are the things that lead to a cure and these are the things that lead to worsening diabetes well what do all these things have in common they all increase insulin you're going in the wrong direction then these things all decrease insulin so therefore your diabetes is going to get better right and that's what we can do we have all these millions and millions and millions of people and we're just going this way and we teach it in the universities and we teach it to our dieticians and we teach it to our diabetes education centers that hey you need to eat low-fat hey you need to take your drugs right but all the while they're getting worse it's a disease of too much insulin so the truth number two is that the cure for type 2 diabetes is not to lower your blood sugars that's just irrelevant the cure is to lower the insulin because that is the actual problem so this is the hormonal obesity theory so there's a lot to it we didn't go through it all yesterday but the key player in this entire thing is the insulin right that's what you got to focus on and there's a lot of things that contribute to increase insulin there's this whole insulin resistance the main this I think is the main problem but there's also protective factors right fat dietary fat is going to help reduce your insulin for instance vinegar right sauerkraut lactic acid vinegar acetic acid all very traditional sort of remedies for high blood sugars and guess what they actually worked but not very well fiber which is what we talked about the there's proteins and ink returns and cortisol dwarf wheat which is what the doctor Davis talks about a lot and maybe bad as contributing but there's a lot of contributing factors but once you know what you're trying to do which is lower insulin then you can you can target any of these right the major one is still going to be the refined grains right but this insulin resistance this fructose I mean there is no way anybody should be taking in sugar right and that's the main message that almost everybody agrees on except those calorie people right they're like yeah you can take sugar it's only a hundred calories right you cannot because it leads to insulin resistance and it's actually worse than that because not only had does the insulin resistance lead to the entire metabolic syndrome the hypertension not so much there there is a link there but it's actually not as tight as everything else but you got to realize that this increased insulin level leads to obesity leads to the high triglycerides which is very typical of diabetics it gives you diabetes it gives you fatty liver and gives you all of the metabolic syndrome right these are all diseases of hyperinsulinemia so the obesity didn't cause the diabetes the obesity didn't cause a fatty liver they're all caused by insulin and the problem of course that you have is that as you develop the metabolic syndrome it leads to all these diseases of civilization so your heart attacks or strokes your periodontitis everything all your complications your retinopathy your amputations your peripheral vascular disease everything that we deal with all comes down to hyperinsulinemia right and but now that you know you can actually treat it and the good news is that it doesn't require any drugs it doesn't require any surgery the thing is that you can cure this and think about it for a second right if you don't have diabetes you cannot get diabetic nephropathy if you don't have diabetes you're not going to get diabetic I disease if you don't have diabetes you're not going to get diabetic nerve damage it's impossible because you don't have the diabetes right and it can all be done with no drugs no surgery and virtually no cost right there are miracle drugs out there for hepatitis C and HIV and stuff but they're very expensive so you can't cure those people without those expensive drugs that's not what we're talking about here this is a treatment that's available to you and me and to everybody in the world because they can do it the only thing it requires is the knowledge and the courage to challenge the conventional thought because we're just going in the wrong direction right and I know what you're thinking it's time to get started but what i do what do i do well really the place to start is right here right this is what we're trying to do here we're trying to change the world because it can be done you've seen it in our patients we've seen it but we have to get the knowledge out to people that yes this is a disease that can be cured right and if you're sitting there and you're thinking okay yep but what do I actually do right I don't know enough about it well there's programs that can be helped for instance if you go to my website the intensive dietary management com you can get your patients to join our long distance program right the world is only a mouse click away and will provide the dietary counseling and as physicians you monitor the sugars you monitor the blood work and so on that's a program that's available we have patients from New Zealand we have patients in the UK as long as you have an internet connection we can help people right that's the most powerful thing it's time to get started right because we're so far behind or 30 40 50 years behind the ball here and we have people who are dying of their diabetes right dying of their heart failure and so on but we don't have the knowledge and we don't have the courage to change the world there's a world of type 2 diabetes out there right in that world that world which is full of heart failure and full of heart attacks and strokes and blindness and dialysis amputations obesity that whole world that whole world changes today because we can do this this is something that's available for everybody thank you

Channel: Karen Thomson

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Id: jRJlfhrYbmM

Length: 42min 54sec (2574 seconds)

Published: Fri May 24 2019