← Diabetes Core Update
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- [00:03]
A
Welcome to this special two part series of Diabetes Core Update where we will discuss weight bias and stigma. This is important because weight bias and stigma permeate the experience of living with obesity. It leads to measurable adverse outcomes and when it is present in healthcare interactions, it affects all subsequent care that the patient receives. There's also importantly something we can do about it. I'm your host, Dr. Neal Skolnick, professor of Family and Community Medicine at the Sidney Kimmel Medical College of Thomas Jefferson University. This special series of Diabetes Core Update is sponsored by Lilly. Joining us for today's episode are two individuals who will inform us and share thoughts with us from two very different perspectives. First, let me introduce Dr. Shawn Worden. Dr. Worden is a clinician and obesity researcher and he is a clinical trialist. He has a doctorate in pharmacy and medicine from the University of Toronto. He is medical director of the Wharton Medical Clinic, which is a community based weight management and diabetes clinic. He's an adjunct professor at McMaster University and York University. And if you've been reading the literature over the last few years like I have, you've been seeing his name a lot. He is an author on many of the pivotal obesity trials that you've seen come out, including the Step one trial of Once Weekly Semaglutide published in the New England Journal, the Surmount 1 trial of tirzepatide, also in the New England Journal. He's co lead Author of the 2020 Canadian Clinical Practice Guideline on obesity in Adults. He's author of the Surmount Ford Trial, the Step five trial, and I could go on and on, but I'm out of breath. You get the idea. Sean, welcome to ada's podcast.
- [01:53]
B
Thank you very much, Neil. This is great to be here. I love the ADA community. This is important to talk about obesity when we're talking about diabete and these comorbidities, but even more important to talk about bias and stigma and to be here with Patti. So this is going to be great.
- [02:10]
A
And Patti Neath, let me now introduce you. Patti, you are a lawyer. Former counsel for regulations and legislation at the US Department of Labor. Patti is past chair of the Obesity Action Coalition, an 80,000 member nonprofit organization dedicated to representing people affected by obesity. She has been an invited speaker who's spoken at numerous large speaking engagements, including the Partnership for a Healthy America Summit, events at the Republican and Democratic National Conventions, the Obesity Society, the Obesity Medicine Association Congressional briefings. She's on the National Academy of Sciences Roundtable on Obesity Solutions. She is a member of The World Obesity Federation Policy and Prevention Committee, and a commissioner on the Lansing Commission on Obesity. Patti, welcome to our podcast.
- [03:08]
C
Thanks so much, Neal. I'm so excited to be here, and I've gotten the chance to work with Sean on a couple different projects, and I'm so excited to be here with him, too.
- [03:20]
A
I'm looking forward to the discussion. And Patti, can you start us off by sharing with us how you decided to start working and advocating in the obesity space?
- [03:32]
C
Sure. I'm happy to start with a little bit of history about myself. I've had obesity since childhood. It's not a choice. I didn't choose to be one of the biggest kids in the room. And like so many people, my obesity just got worse as I got older and grew into adulthood, and I developed severe obesity. But throughout all that time, because I was living in a larger body, I was subject to all sorts of bullying and discrimination. And it really got to the point I got so used to it that I started believing all the negative things people said about me. I had what's called internalized weight bias. I took all those negative feelings and turned them all those negative thoughts, things, not necessarily feelings of other people, but turn them in on myself. The best way I can describe it is to say I became my own worst bully. And it wasn't until I was in my 50s that I found an obesity medicine specialist who understood exactly what was happening. And I started working with a couple very gifted psychologists and working on stigma reduction to start not saying such incredibly negative things to myself that I had been saying so for sayings for so long that I stopped hearing. I had to relearn how to hear those thoughts again. So I had been doing that work and working with an obesity medicine specialist for about a year. And at the time, my obesity medicine specialist is Dr. Scott Kahan here in the Washington, D.C. area. And at the time, he was the clinical director of the Stop Obesity alliance, which is based at George Washington University, also here in Washington. And he asked me if I would come to a roundtable. It was a group of physicians and other medical professionals working on a tool for primary care providers on how they can help treat obesity as the disease that it is. So there was a lot of angst in the room. I'm like, well, you know what? Prior to this, I never talked about my weight, never talked about my weight because it was such a source of shame and guilt for me. But I thought, you know, I can do this. I can. I can talk about my own experiences and that, yes, we're worthy of respect and compassion and adequate treatment for whatever diseases we have. So that's how I got started. And a couple weeks later, I was testifying before the FDA about the need for more medical treatments. It was in the context of a medical device, but I didn't speak to the device. I just spoke to the need for more treatments.
- [06:45]
A
Patti, I thank you so much for sharing that story because as much as all of us as clinicians take care of people who have obesity, we don't often hear as honest a representation of the difficulties that people have throughout their life. And your description of realizing that you were worthy. Of course, that's right. And we often, we don't realize the struggle that people have gone through and if we're not careful that we are at risk of continuing to perpetuate. And we'll come back to some lessons that we might be able to learn about how to be careful in our interactions when we talk to people. I want to shift now, Sean, to you. I first saw you speak a few years ago when you presented one of the pivotal obesity trials at the American Diabetes association scientific sessions. It was a great presentation. It was critically important data. And then you and I spoke last year on an ADA podcast about the semaglutide in knee osteoarthritis trial from the New England Journal. I had always known you as an accomplished obesity researcher and frankly was blown away when I heard you and Patty discuss obesity bias and stigma last June at the science sessions. Can I ask you, where does that just incredible sensitivity come from?
- [08:15]
B
That's a thank you, Neil, for asking that. And it really, it comes from the fact that that's why I went into obesity medicine in the first place. So the academia and the science and the physiology and the biological aspects, that to me comes relatively easy. It's straightforward. We do it because we're in medicine and we can. So we should do it because that's what we're good at. So go ahead and do it. So in a sense, I don't always feel that if somebody's applying their biological capacity to medicine, that that's enough. That's what you should do. Step outside and let's see what else you got. What do you got? And what I saw was Dr. Arya Sharma presenting. I was a third year internal medicine resident and he was presenting on obesity medicine. I presented on hypertension and the challenges that black Americans, black people with this disease, is it a real disease or is it a social problem? Was it a racism problem? Was it a stress problem? And so when he spoke to the fact that obesity was biological and scientific and it was social and it was bias, which equals prejudice and it was stigmatizing, which equals stereotype and it was discriminating, which equals racism. It spoke to everything that I dealt with as a person on a regular basis. It was my field. There was no debate from that one talk that this was the area that I was going to go into. It had biology, it had science, and also had all the aspects of a person living with obesity feeling hurt, shamed, discriminated, internalized bias. And that's the way that my people feel on, on a regular basis. I didn't have to do something that connected with the experience that, that me as a, as a, as black black people have, but it sure helped me to have that passion for this field and that's why I, that's why I do it and that's why I love it.
- [10:17]
A
Thanks so much for sharing that background. And it's so important because we, we all come from different places and to understand that context and your passion, Sean, comes through very, very clearly and strongly. Patti, let me turn to you now. On the first, first of this two part series, we talked with Rebecca Pearl about how weight bias and stigma is common. And in fact Rebecca made the point that we all have bias even when we think we don't. She said something like, it's part of being human and therefore we need to be aware of that bias if we're going to combat it. Patti, can I ask a fair bit about your experience with obesity and particularly your experience you shared, your early experiences and how it affected you, but your experience with obesity in a healthcare setting and both when things are done right, what that means and sometimes when they're not.
- [11:15]
C
I'd like to start with an analogy that might help your listeners put this into perspective and help them identify some of their own biases. The analogy is this. Let's say you're into home renovations and you want to knock out the wall between your living room and your kitchen. So you have an open space plan. So, and it's not a support wall, the whole roof isn't going to come down. So you pull out your sledgehammer and you start hacking away at the wall and you realize there's brick behind the plaster and you're knocking some of the plaster off and it's starting to, you know, you're making some progress. And then you do that with your sledgehammer every day for a year and the wall is still there because the sledgehammer can't get through the brick on its own. You're exhausted. You've been trying this for a year and it hasn't worked. In that situation, would you say to the person with the sledgehammer or to yourself even, would you say, you're a failure? You just don't really want this wall to come down, do you? You don't have enough willpower to knock this wall down, do you? We'd never say that in that situation, would we? We'd say, I think I need a different tool.
- [12:42]
A
Brilliant.
- [12:44]
C
That's what's been lacking to a large extent in obesity care. We've been told for years the typical move more, eat less and weight will drop off you like magic. That. That. That's some sort of silver bullet. Well, it's not. We've all tried that and I think the statistics and Sean could probably knows this. Something like 5% of people keep off weight by that method. But we've really needed different tools. And it's frustrating that the medical community, they need to acknowledge that OKC isn't a matter of willpower. I can't tell you how many times I've had a medical professional wag their finger at me and say, it's all my fault, basically. And you start to believe that's what I believed. I thought it was my fault and that I was a failure. Despite all the other successes in my life, I thought I was a failure.
- [13:44]
A
Yeah. And I think that's so important, the way you just said that, Patti, despite the other successes in your life, that old thought of someone doesn't have enough willpower. They don't work hard enough. My gosh, what you've accomplished as a lawyer, clearly you have willpower, you have intelligence, you have the ability to accomplish amazing things. There's something here going on that doesn't. There's a disconnect. That old theory just doesn't hold water. Sean, your thoughts about what Patti was just describing.
- [14:18]
B
Yeah, I really love the analogy. That's a beautiful analogy because see this. This brick wall that we. We have identified what that brick wall is, and we didn't quite know what it was previously. So the science and the biology helped us to identify. Even if we didn't end up coming up with a sledgehammer that can end up going through it, the fact that you identified that's a genetic b. Neuroscience process within the brain, the hypothalamus in the mesolimbic system allowed us to develop sledgehammers that can make it through this. This genetic component that is called counter Regulatory hormones that pushes the weight back up. If we didn't identify that, we'd be back into the zone of just blaming. That's why that. That lecture by Arya Sharma, who is a nephrologist and a scientist, helped me to understand that, that the discrimination, the bias and as the stereotypes were driven at times by a lack of understanding of physiology and science. And we saw that in hiv, we saw that in diabetes, we saw that in cancer, we saw it in all kinds of things. So we in obesity medicine 10 years ago, five years ago, were in the same zone that people were in in the 1920s and 1880s with cancer, where it was your problem and it was a humor and you were bad and evil come out of that, and we're much happier.
- [15:46]
A
Can you. So what an important point. And can you go over for our listeners the short version of that underlying pathophysiology that we now understand that makes it so difficult for people to sustain weight loss? Yeah.
- [16:02]
B
So this is an interesting topic. The reason why I'm saying this is because this is a good thing to understand it, but it sometimes feels really bad when we explain it. And sometimes doctors and scientists, as they're explaining it, don't sometimes understand the emotion that's behind somebody who gets the explanation. Here's fatalism here is that this is fatal. Are you telling me that I can't do anything about this? That this is scientific, as scientific as. And as fatalistic as the color of my eyes and whether my hair is going to be curly or straight? Is that what you're saying to me?
- [16:39]
A
Me?
- [16:40]
B
And. And sometimes the science is it. It's unfortunately, that challenging. It's that it. There's that much of it there. But that science allowed us to understand how to treat this condition in the first place. So with that backdrop of understanding that we're explaining science, that helps us to get to a better place, helps everybody to understand why this science is actually here. And it's for people living with obesity, not for someone who needs five pounds off. If you're listening to this podcast and eat five pounds off, go to the gym, go to the gym, eat better. If you're living with obesity, food noise in your head, and there's significant elevated weakness comorbidities, then this is a conversation about science that would benefit you. So we figured out that this was in the brain. And the brain is a difficult place to actually understand, which is why psychiatrists and neuroscientists are still having difficulties trying to figure out what is going on up in the Brain. Two main areas, three main areas of the brain that are involved in this. The hypothalamus, which is an automatic regulatory area. If too many genes are in there that regulate your weight, that say the weight should go up, your weight will be higher. The, the mesolimbic, which is a hedonistic part of the brain that needs to do two things really well. Eat and reproduce. Eat and reproduce. So that's opioids are the main neurochemicals there, and the cannabinoid system and dopamine, intense systems that drive those two things. E and reproducing. If you've got a genetics that are a little too much on that side, it'll go a little bit higher. You just need a little bit of genes to push it up. And then the executive lobe, which connects with the mesolimbic system and says stop eating, stop overdoing certain things. And sometimes the pathway isn't perfectly smooth. Where the executive lobe can tell the mesolimbic system, stop. The food noise, stop. Except all of these things. So when we smooth out all those areas, the hypothalamus, the mesolimbic, and the pathway from the executive lobe, or doing cognitive behavioral therapy, making the executive lobe stronger, we have treatment options. But without understanding that even just one pound down or going on a diet, you haven't even lost a pound yet. You just went on a diet. It's hour six, it's day one of you having less calories than you did the day before. Those counter regulatory hormones start pushing up to get the weight back up and you've got to use your executive lobe to try to squash it. And executive lobe doesn't have a pathway that's, that's as nice as someone who's, who is thinner and you're at a disadvantage because of your genetics. So that's what the physiology is. And when we understand that, we can start to get to this other part of bias, stigma and discrimination that really hampers the entire field.
- [19:30]
A
That's so helpful, Sean, because I think it really is important for us as clinicians to understand that even if we don't remember the details, to understand the concepts of counter regulatory hormones and metabolic adaptation, all making things very difficult both to lose and sustain weight loss. Because then when you understand something, you communicate differently. And I'll tell you, when I have shared that sort of information with patients, it has not been unusual that that becomes a let me pass you a tissue moment as they begin to tear up because they realize, and I've had people say so you mean it's not my fault? No, it's not. And there's such a burden that is lifted then when we can explain that to patients. Patti, let me turn back to you. What are some of the things that you feel that we as clinicians can do in order to avoid weight bias and stigma and handle things better?
- [20:31]
C
There are so many small things that can be done, say, in the clinic that help providing adequately sized gowns. You know, some physicians who still blame their patients don't do that. They think that they're going to shame people into losing weight. Shame and blame doesn't ever help. It just hurts. Just makes you feel bad. And some just don't think about it. I. In fact, I would think that's the majority of people. If you haven't lived in a larger body, you may not think about whether you have exam room chairs that people can fit into or train your staff not to make comments about people's weight or weigh your patients in private, because weight is a sensitive topic, as we all know. Lord knows, it's as sensitive as anything else that causes trauma, frankly, because that's what patients have experienced is trauma, both from society and from the medical community. You know, I've been in places where I went for a mammogram the one year they didn't have gowns large enough, and so they had me put on two that barely fit, one from the front, one from the back. Then they had me wait in a room with people who were just there waiting for other patients. Wasn't even just patients. Here I am, barely covered and sitting among strangers who are, you know, especially when they're not other patients who may be undergoing the. Going through the same thing. You know, things like that. I didn't go back for 15 years after that first mammogram. It was such a horrible experience, and it's so simple. That's a simple thing to correct. But there are many other things that are deeper than that that's just touching the surface. Adequate facilities, identifying your own biases. I would urge every medical professional to take the Harvard Implicit Bias Association Test. There is one for. Wait. It's really revealing, I think. Leave your judgments at the exam room door. You know, so many people make assumptions about me. I asked a medical. A group of medical students I was talking to to say what they think about what they're assuming about my health just from looking at me. Well, one of the big things was they assumed I had diabetes. I don't have diabetes. But until you're. Until you ask your Patient. Until you find out and be curious about your patient, you don't know. I had a friend, another patient, whose doctor said, you need to exercise more and he was exercising three hours a day, five days a week. I'm not sure what else he was supposed to do with that, but the doctor wasn't curious enough to even ask him. So many assumptions being made just based on our physical appearance. You got to be curious about your patients. All medical professions professionals need to be trained in obesity medicine. That is crucial and we're having trouble getting that accomplished. It's not happening. So many people are written prescriptions for medications with no support. And you know, these medications can be life saving, but they're serious medication. You need to have support on your side. That's a big problem in our community right now for patients and using shared decision making in obesity. It's empowering. And I never had that. I always had the finger wag until I started working with an obesity medicine specialist.
- [24:31]
A
Patty, you make so many critically important points. John, I'm interested in your thoughts and the question that I had presented Patti with and was what can we do as clinicians to avoid weight bias and stigma? Patti, you had many good thoughts. Sean, I'm interested in your thoughts here as well.
- [24:52]
B
Amazing. Thank you so much for asking this. So here's what we can do. We can, we can, we can work on stigma and discrimination. You can't really work on bias. So this is so important and so much of an understanding. So in the Canadian obesity guidelines, so as the lead author of that guidelines in 2020, we shifted the world. The world had a shift when this guideline came out and why. We had a epidemiology chapter, a science chapter, pharmacotherapy, nutrition, exercise, da, da, da, da. None of those really mattered. They were nice chapters, they were good, but they were the same as any other guideline. The one thing that we did different, we made sure that the bias and stigma chapter was the first chapter and that before you read anything else, even the epidemiology, don't go past this chapter if, don't read anything else if you can't get this and understand this. So what did that mean? It meant that what we did, instead of having the physician always thinking about, I want to know what the patient disease is and what this causes and what this inflammatory condition caused, we're always forced, the focus or the camera angle is always on the patient and their organs and their disease state. We turned the camera lens towards the doctor and told them they were the problem, not that the patient was the problem, but that they were the problem. Felt very uncomfortable. It wasn't nice to have the lens back at me, at myself, to say that, you've been doing it wrong. What do you mean I'm doing it right? I'm a good doctor. Nope, you've been doing things wrong for a long time because you didn't know. So we're not coming at you hard. We're just letting you know that this is what's been happening. And if you're open enough to understand that, you can have a better practice. You're biased, and you know that you're biased. And why are you biased? Because you've seen the Little Mermaid at least once, and Ariel is this big and Ursula's this big, and you've seen lots of other things that you're exposed to all the time that have formed your opinion. We have a Tim Hortons here. That's just. Any Tim Hortons is a donut place. So if I see somebody who sees 300 pounds going into a Tim Hortons, this is Sean Wharton. I'm thinking to myself, because I'm biased and I've got biased things that float through my head, do you really need to go into Tim Hortons for a donut? Is that what is happening right now? Wait a minute, Sean, you're biased, which means that that person may have been 350 pounds and they're 300 now, and maybe they're going in for one donut instead of 10. Why can't they have a donut? Are you really that Is that you don't understand that that person may have way more willpower than you've ever had in your entire body and your entire brain ever, because you've never had to deal with this. But that was my biased thought, my recognition of it, my ensuring that I don't stereotype and stigmatize and have stigmatizing equipment and I don't discriminate. And so that's the same as prejudice. Stereotype and racism. Start to get rid of the stereotypes so you don't inform your prejudice or make it worse and don't have racism. So you can have prejudice and not be racist and not do racist stuff. You can have bias and not do discriminatory stuff. But the only way to do that is to recognize your prejudice or recognize your actual bias. So that's what the Canadian obesity guidelines. That's why they're famous and not because of the other chapters. And that was super important to us. I love the science, but I love the Change that we were able to actually get from the community and from doctors. So the. The very first article that came out after we published the Canadian obesity guidelines is a doctor that wrote in and said, I'm really upset by these guidelines. They told me that I'm a bad doctor. And they. And the patients are the problem. They're the ones that overeat. They're the ones that should put the fork down. They're the ones that should have billboards that say, this is what you eat instead. Like, they're not bright enough or capable enough. They need a big billboard. This is a doctor writing an article that got published, got published about this. So let's see. Are we biased? Were the doctors doing the wrong thing? Do we need a grand apology to our patient population? Yes, we do.
- [29:08]
A
That's an unbelievable story. And what. What I just was struck by, Sean, when you were talking about this, is your humility that you say that you have biased, too. And I think you use the phrase that we need to be open to understand. And that's so important because none of us know it all. And we need to, as clinicians, be open to understanding, be open to our patients. We're almost out of time. I have one last question before we bring things to a close, and I'll ask Patti. Let me ask you to go first, then Sean. And because of time constraints, to be somewhat brief, but. But a critical juncture occurs when we open the conversation about weight with patients. Any suggestions how to open that conversation, Patti and then Sean?
- [30:04]
C
Yeah, I have a couple suggestions. One is to whatever the patient is they're seeing you for, treat that first, look past the weight. I've had physicians that have started with the weight and never gotten to the problem I actually had, even when it was totally unrelated to weight. That's a problem. So, you know, again, leave judgment at the door and be curious about what's going on with your patient. That's the first thing. The second is if you are in a position to be able to talk about weight at that point, if you have a little time or whatever, ask permission. I've never said no to that conversation. And I have had a couple physicians who were very honest about what. Who have asked me that, and I've said yes. And they're very honest. They were very honest about. We don't. I'm not exactly sure how to help you. And they suggested things that have worked for other patients. One of them, for instance, I had a cardiologist that suggested I check out the Duke program. I went to University of North Carolina. So I wasn't going to Duke, but I took his meaning. But it was a constructive conversation is what it was. And to always think about the fact that your patient has been injured. 99.99% of your patients have experienced bias and stigma in medical practices. And that's a mountain you have to understand is there and need to overcome.
- [31:45]
A
That's so helpful. Sean, your thoughts about opening the conversation and thank you.
- [31:51]
B
And again, I'll go back to that. The Canadian obesity guidelines where we did the five A's, and in the five A's, the big A was the ask apart. And as Patti has pointed out, the reason why we ask is because we're doing the grand apology. The grand apology was I'm apologizing for the way that I treated people living with obesity in the past. I'm apologizing for the physician you saw half an hour ago or just yesterday that still does not understand weight management. And so what I'm going to say to you is the way that we treated obesity in the past. You can use this exact sentence, people, if you want to write it down. The way that we treated obesity in the past was not effective and we didn't recognize a number of things. Would you be open to a conversation about weight management management now? Or you could even say the word weight. The way we managed weight in the past was not effective. We know more. Would you be open to a conversation about weight now? Then once you get past that, there's three next sentences and you need to do it with this tone and with this cadence. Your weight is in a range that qualifies you for weight loss surgery. Is this something you're interested in looking at? Not. Weight loss surgery is excellent and this is the way it goes. And that's what I used to do. And the person didn't hear that weight loss surgery works really well and it may be an option for you. What they heard was, Dr. Wharton thinks that I'm so big that I need weight loss surgery. He is being mean to me. And that's what would be typed out in the Google reviews. Then I changed the sentence to two. The cadence and the tone of fact. Your weight is in a range that qualifies you for weight management surgery or weight loss surgery. Is this something you're interested in looking at? Then wait for an answer yes or no, and be good with that answer. If it's a no, they may come back to you at a later stage where they want it, or they may just mean no. And that's fine. Your weight is in a range. It qualifies you for medication that have an impact on weight. Is this something you're interested in looking at? Wait for a yes or a no and believe it and feel it and understand it and be good with both of those answers because now you're a doctor that they'll come back to. And the final one was cognitive behavioral therapy. Many people dealing with elevated weight can benefit from cognitive behavioral therapy. Is this something you would like to potentially look at? So those three sentences and the initial ask are how you get through as a clinician not showing your bias? Remember, you're biased. You're a biased person talking to somebody and you're using a non discriminatory language to be able to show that you apologize for your bias and everybody else's and you're with them and you're going to be kind to them and you're going to be compassionate.
- [34:39]
A
Sean, thank you so much. And thank you for the detail that you just went into, even the language that you use so that we have some guidance when we need it to how to approach permission based care. We're about out of time. Patti, do you have any final thoughts for our listeners?
- [35:03]
C
My final thought is give your patients hope. You know, for so long, people with obesity haven't had hope of treatment, but there's every reason to hope now. And partnering with your patients, supporting them and giving them hope is very important and a good way to build trust and to have your patient come back to you even when they're not doing well.
- [35:32]
A
So important. Shawn, any final thoughts you'd like to share with our listeners?
- [35:38]
B
The final thing is understanding this field of bias, stigma and compassion is also about understanding the word love. We as doctors don't use that word love very often. And when we talk about it, we're not talking about loving your patient. You're talking about letting your patient know that they are loved, that they are cared for. They're cared for because we took the time to go through all the science and figure it out. They're cared for and they're loved by the community because we're working on our bias and stigma and we're getting there. And so reminding them that they're worth our time and that they're loved by people in their lives, by their community, by sometimes their workplaces and showing that compassion and reminding them that they're worth every effort that they're putting towards it and we're putting towards it is important.
- [36:29]
A
You just took my breath away. Dr. Sean Wharton, thank you so much for joining us.
- [36:35]
B
Thank you very much, Neil. This has been terrific. This thank you for having me here.
- [36:40]
A
And Patty Nees, thank you so much for joining us.
- [36:43]
C
It's been a pleasure. And the more we can talk about bias, stigma and the effect on the medical community, the better.
- [36:53]
A
And most of all, of course, thanks to our listeners. Thank you for joining us on what has been really a enlightening and moving discussion of obesity, bias and stigma, where we've all learned a lot, learned about leading with curiosity and compassion, the importance of kindness, the importance of love, leaving judgment at the door. This special series of Diabetes Core Update is sponsored by Lilly. We want to thank you for listening. The American diabetes association. I'm Dr. Neal Skolnick. Till next time, stay safe and keep learning.