← Taking Control Of Your Diabetes® - The Podcast!
Taking Control Of Your Diabetes® - The Podcast!
Top 10 Tips for Living With Type 2 Diabetes – Practical Hacks From Two Endos Who Get It
00:31:13
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- [00:00]
Dr. Steve Edelman
Foreign.
- [00:20]
Dr. Jeremy Pettis
Hello, everyone, and welcome to this edition of the Taking Control of your Diabetes podcast. I am one of your hosts, Dr. Jeremy Pettis, joined by my good friend.
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Dr. Steve Edelman
And colleague, Dr. Steve Edelman.
- [00:31]
Dr. Jeremy Pettis
So Steve and I are both endocrinologists, University of California, San Diego, both living with type 1 diabetes since we were 15 years old. And Steve founded this wonderful organization, Taking Control of youf Diabetes tcoad exactly 30 years ago to the minute today.
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Dr. Steve Edelman
Thank you, Jerry.
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Dr. Jeremy Pettis
Congratulations, Steve. So this is a two part podcast series we just wrapped, recording our first part which was on the top 10 tips for people living with type 1 diabetes. And guess what? Now we're gonna do the top 10 tips for type 2 diabetes. Yeah. So I was in charge of the Type 1 podcast. I came up with my 10 tips Steve had never seen them before. Now Steve is gonna return the favor. He came up with his top 10 tips I've not seen before. So we can go through those and get my commentary as we go.
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Dr. Steve Edelman
Okay, we ready?
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Dr. Jeremy Pettis
Yeah.
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Dr. Steve Edelman
All right, just some opening comments.
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Dr. Jeremy Pettis
Great.
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Dr. Steve Edelman
Type 2 diabetes is extremely common. It's also kind of a complex condition, more than Type 1, and it runs in the family very strongly from generation to generation. The other thing is, you have to realize that there are 40 million Americans living with type 2 diabetes and another 80 million have pre diabetes, meaning that every year a certain number of those go into type two. So you're not alone.
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Dr. Jeremy Pettis
Yeah. And by, you know, just comparison, there's about 3 million type 1 size. So a lot more type 2s. But type 1s are still special.
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Dr. Steve Edelman
Yeah. And here's the thing, it's important for everyone to know, before I get into the 10 tips, that type 2 diabetes is a controllable disease. It's manageable. And I always like this quote from Sir William Osler. The way to live a long and healthy life is to develop a chronic disease and take care of it. So there's no question that when I have patients come in newly diagnosed type 2, they might be overweight, they might have high blood pressure, abnormal cholesterol, and then they get diagnosed, and then they have a good doctor. They might have a multidisciplinary approach. They start working on their diet, start working on the other abnormalities, and that can make them live longer than if they were not diagnosed.
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Dr. Jeremy Pettis
I was gonna say it can be an opportunity to be honest, to get on these medications. People, you see them lose weight, they change their life, literally. And it's actually fun as a provider when those patients come in like you described, starting them on some of These medications, seeing these changes, seeing all these numbers improve, it's really rewarding.
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Dr. Steve Edelman
Yeah, absolutely. We can make such a big impact. Okay. These are not in any particular order, but I feel very strongly, being someone of education and knowledge, is that you should have an understanding of what's going on in your body with type 2. So the first thing I'll say is, it's not like type one. You do have insulin around. You may not have enough.
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Dr. Jeremy Pettis
So tip one is get educated.
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Dr. Steve Edelman
It's knowing about the. Ready for this pathophysiology, the causes of type 2 diabetes.
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Dr. Jeremy Pettis
What is type 2 diabetes? What's affecting my body? What's going on in my body.
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Dr. Steve Edelman
Thank you.
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Dr. Jeremy Pettis
Yeah. Tip one. There it is.
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Dr. Steve Edelman
Okay. Basically, you have insulin. It doesn't work well or you don't have enough. The other important thing to know is that people with type 2 diabetes have a thing called metabolic syndrome, and that's a group of cardiovascular risk factors that can lead to other issues like heart disease, liver disease, kidney disease. Now, these metabolic syndrome includes insulin resistance, high cholesterol, hypertension, obesity, and that's basically the baseline of the metabolic syndrome. Now, it may not be your fault because people with type 2 have central obesity. It runs in the genes, and it's not like the type of fat that people get when they just overeat for years and years. And that's something that's very frustrating for a lot of people with diabetes. They say, I can't lose this weight in my abdominal area. That's part of the metabolic syndrome, as we'll learn as we go through it. Sounds scary. And to start off with all these abnormalities, they're all treatable, but it's important that everyone know that you're not going to be just treating the glucose levels. You'll be treating the lipid levels, the blood pressure, and you'll be fighting weight.
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Dr. Jeremy Pettis
These things all run together. If you have type 2 diabetes, there's a good chance you are overweight or obese. So you're dealing with high blood pressure, cholesterol. So it's very common. That's kind of where we start. And then, yeah, the good news is these things, I hate to use the word easily, but they're very treatable.
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Dr. Steve Edelman
They are treatable. And once you get these under control, it's much easier to maintain than trying to get to goal. Now, the second one, Jeremy, is a little bit like the one you mentioned in the Type 1 podcast. Understanding the numbers that matter. What are your goals?
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Dr. Jeremy Pettis
Got it. I think that actually was my second tip. Did you cheat. Did you look at mine?
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Dr. Steve Edelman
No, I didn't.
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Dr. Jeremy Pettis
I didn't know your goals. Number two. I like giving labels.
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Dr. Steve Edelman
Okay, the first one is A1C. What should someone with type 2 diabetes shoot for with their A1C?
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Dr. Jeremy Pettis
Generally less than seven. Lucky number seven.
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Dr. Steve Edelman
Yeah. And this is a great opportunity to say that when you look at the lab slip, you know, some guy in the lab puts down the normal range less than 5.7. Do not think you need to be less than 5.7. That probably pertains to all the type 1s out there as well. They should have a separate list that says goals for people with diabetes less than 7. You may not all be less than 7. Some of you may be higher. And I always love when you say going from 10 to 11. Going from 11 to 10 helps 10 to 9 always be etching towards your particular goal.
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Dr. Jeremy Pettis
Yeah, it's not binary, you know, if you're less than seven, you're good. If you're above seven, you're bad. Every little notch lower towards seven matters a lot, actually.
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Dr. Steve Edelman
Okay, what about pre meal blood sugar goals?
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Dr. Jeremy Pettis
You know, I would say probably less than 140.
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Dr. Steve Edelman
That's good. I think that's a good goal.
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Dr. Jeremy Pettis
I mean, that's different than fasting, which I would say even lower. Yeah.
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Dr. Steve Edelman
Okay. And what about two hours after eating? A lot of people like looking at their numbers after eating less than 200. Yeah, I think that's a good goal. You know, I mean, theoretically, you know, less than 180. But I think these are good goals to start from because they're not too stringent. And when we get to the lipid level levels, I'll just go through them quickly. You know, I don't look at total cholesterol. You've heard me say that before because the total cholesterol can be misleading. But I do look at LDL less than 70, and if you have heart disease, less than 55. And you always say if makes most people with diabetes will need some type of LDL lowering drug. We got lots of choices today, too. Were you going to say?
- [07:32]
Dr. Jeremy Pettis
Well, I was going to say, I don't know anybody that's just naturally walking around with an LDL less than 70. It's really hard to do. This is largely genetic. So if you want to get your numbers there. And I always tell people too, I don't care if you ate grass all day long. You can't make that much of a dent in your cholesterol from just dietary interventions. And if you want to get to where you need to be. We're not pushing medications, but you're going to need to take something, some kind of medication to get to that goal.
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Dr. Steve Edelman
Yeah. And you should try not to fight that concept of taking a lot of medications because I've always said type 2 diabetes is a polypharmacy condition. Now, the other thing that people with type 2 diabetes have, when you look at the cholesterol levels, the lipid panel, they have high triglycerides, which is a form of fat. And we try to keep that at least less than 200. But even getting up to 3, 400 is not dangerous. Once you get above 500, you know, you need to really have a serious conversation with your doctor. But also the hdl, that's the good cholesterol. So people, unfortunately they are related to each other. High triglycerides, low hdl. And what you try to do is you improve your glucose control. You may need some cholesterol triglyceride lowering medications. When you lower your triglycerides, the HDL goes up and the HDL we really don't have much control over, but we try to get it 40, 50 range and once again, triglycerides less than 200. And that's something that type 1s don't have to deal with.
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Dr. Jeremy Pettis
Yeah. And I would say of all those, we really, I would say if I had to pick the ldl being the one that we can intervene on the most, maybe the most important, the number for you to keep in mind, you want to keep that less than 70. And this is all still bullet points under tip two.
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Dr. Steve Edelman
Yeah, we're on tip three now.
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Dr. Jeremy Pettis
Oh, okay. So tip two is know your numbers, your A1C, your blood glucose and your cholesterol and your blood pressure. We want to keep less than 130 over 80. And the same kind of comments that these are generally oral medications, you know, easy to treat. So make sure you know that. You know, we say ABCs, ABCs, A1C, blood pressure, cholesterol, know those at every visit. Tip three.
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Dr. Steve Edelman
Wow. Tip three, we don't have to spend too much time on, but find a knowledgeable care team. Now, in the olden days, people went to a real diabetes clinic. There was the primary care doctor, the endocrinologist was nearby. You had the dietician, the exercise physiologist, and a diabetes educator and perhaps even a touchy feely person like Dr. Polonski dealing with the emotional and behavioral issues of living with diabetes. And we don't have those anymore. But you can figure out what specialists you need the most and then go after the best person find, talk to friends, talk to the local diabetes organization. I actually talk to some of the representatives that sell diabetes drugs and device and say, hey, because they call on all the doctors in town.
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Dr. Jeremy Pettis
So when should somebody with type 2 to see an endocrinologist?
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Dr. Steve Edelman
Yeah, that's a great question, but I'm supposed to be leading this. I'm kidding, I'm kidding. That's a great question. If you have newly diagnosed type 2, your A1C is at goal, your weight's at goal, and you're on one of the basic medications like metformin, you may not need to see an endocrinologist more than, I'd say, once a year because there's so many advances going on in type 2. All the GLP1s, which we're gonna get to on one of the tips, they have so many other advantages, you know, primary care doctors, God bless them, but they can't keep up with all the advances in diabetes. Okay, what were you gonna say?
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Dr. Jeremy Pettis
No, I just got, you know, usually, to be honest, like we talk about, there's a shortage of endocrinologists and not Everybody with type 2 can get in to see somebody. So honestly, Steve, the type people with type 2 that we see in our clinic tend to be people that have had it for a longer time on insulin or maybe a more complicated regime. Certainly, then I wish I could see everyi really wish I could see every newly diagnosed type 2, because I think that's actually the most important time to intervene and get people to take this seriously, take their medications, get their blood sugars under control and keep them there, rather than we'll start one medication, wait for you to get out of control, then try to intervene. I think being more aggressive early is really important.
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Dr. Steve Edelman
Yeah, we call that treat to target for all you listeners. All right, tip number four. This relates to diet. You don't have to eat cardboard. You can eat the foods you like. And there's a couple basic rules. You eat the foods you like in moderation. Portion control is probably the most important thing you could do because you know you don't want to. You get type two when you're a little bit older and you're set in your ways of what you like to eat. And I like to tell people two to three well balanced meals a day, avoiding concentrated carbohydrates and fats most of the time. So it comes down to just eating the foods you like, but not restricting yourself so much that you hate Having.
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Dr. Jeremy Pettis
Diabetes and meeting a good dietitian. I would say along those lines because there's little substitutions that you can make. Everybody likes to snack, but what's a good low calorie, low carb snack? The one thing that you really have to pay attention to is what you're drinking. I'm not talking about alcohol, although alcohol is important. But if you're throwing down a lot of juice and soda, that's a lot of empty calories. Maybe switching over to diet soda or Gatorade zero. These kinds of things, these little substitutions, you really don't have to suffer because you can find usually something that you like and you can cut out a lot of calories and a lot of carbs that way.
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Dr. Steve Edelman
Well, you covered the area I was about to cover exactly that. It's not just diet.
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Dr. Jeremy Pettis
That's a new tip. Is it still part of the same tip?
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Dr. Steve Edelman
Yes. Well, it's the same thing. It's food, eating, drinking.
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Dr. Jeremy Pettis
So this tip is food?
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Dr. Steve Edelman
Yes. Okay, I said diet.
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Dr. Jeremy Pettis
Okay.
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Dr. Steve Edelman
All right, you're right, Jeremy. We have the choices now of non caloric beverages are tremendous. And you know, I love the mio, the flavor drops. There's Bai. You mentioned Gatorade zero. I like Powerade zero Now I do too.
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Dr. Jeremy Pettis
I like it better. I like Gatorade straight up Gatorade better than Powerade, but I like Powerade zero better than Gatorade. Zero.
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Dr. Steve Edelman
Yeah. And for people that say to me, they say, oh, I drink regular Coke because I don't like the taste of diet. You know, that drives me nuts. And I always try to convert people with diet. Root beer, that's one that tastes exactly like diet.
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Dr. Jeremy Pettis
Pepper is really good too.
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Dr. Steve Edelman
Is that right?
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Dr. Jeremy Pettis
Yeah. Coke Zero.
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Dr. Steve Edelman
I've never had the regular Dr. Pepper, so I wouldn't know. So anyway, the bottom line is don't you know you're going to learn to improve your eating habits slowly and it comes down to common sense. Don't fall for all the magic diet pills out there that you see on television or online. It just comes down to eating well balanced meals two to three times a day, limiting the portion size. Okay. Five exercise. And I know you know this quote, if you don't find time for exercise, you're going to have to find time for disease. God bless. Larry Verity, exercise physiologist that spoke at many of our original TCOIDs and with type 2, we're just assuming folks are maybe a little bit older, have problems with weight, which gives you problems with their joints. You have to start slow, like walk for 10 minutes even and just slowly increase the amount, the distance. You don't have to join Jeremy's fancy gym with all these people in spandex.
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Dr. Jeremy Pettis
I go to the ymca. Steve goes to LA Fitness. So you got the fancy jam. I don't, but obviously I agree with this Steve, but I wouldn't even call it exercise because sometimes that can be off putting to people. They immediately imagine playing basketball and kayaking and these things that they've never done before. So it's moving your body. I know you'll get into the goals, but things like walking, stretching, all these things can make huge improvements. Even if you don't change your weight, you can change your distribution of fat, muscle, your insulin sensitivity, all these things. So sorry, I kind of cut you off there.
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Dr. Steve Edelman
No, you didn't, you didn't. I'm adding on to that. Just walking in a pool, a lot of resistance. And I know you do that naked, don't you?
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Dr. Jeremy Pettis
Yeah, all the time, twice a day.
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Dr. Steve Edelman
What about dancing around your living room naked? Yep, there you go. And you know, even gardening. I know that you're growing certain things that are allowed to be grown in California back there. So any type of activity, oh my God, that's double whammy. You know, the bottom line, you're right, Jeremy. I use the word exercise, it's old school, but you want to move your body, you want to get your heart rate up a little bit. The one thing I want to.
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Dr. Jeremy Pettis
Well, let me just say the Official recommendation is 30 minutes a day, at least five days a week. And that when you put it in that terms, it's obtainable and it's not going to the gym and putting on spandex. It's something sustainable. Keep your heart rate up a little bit. Could be walking around the block, it could be in these other activities you enjoy, but that it becomes doable. But maybe you start with one day a week and you work your way.
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Dr. Steve Edelman
Up there just walking to your mailbox. The one thing I want to say is that we don't want to motivate you so much that you haven't exercised in five years and tomorrow you do something extensive. Sometimes there's a lot of underlying heart conditions that you don't know unless you stress yourself. So if you're one of those couch potatoes and now you're really going to get out there and move your body around, it's probably a good idea to just mention that to your doctor and they may even get a stress test on you, some test of your heart and That's a win win. If you have a problem, they'll address it. If you don't, then they give you the green light to exercise. Okay, this one I know you're gonna love.
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Dr. Jeremy Pettis
Yep. I hope it has a really long title.
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Dr. Steve Edelman
The most important type 2 diabetes medications. We have GLP1 receptor agonist and SGLT2 inhibitors. Which one you wanna cover first?
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Dr. Jeremy Pettis
Are these different tips?
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Dr. Steve Edelman
Yeah, they're tips.
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Dr. Jeremy Pettis
Okay. All right. It's unclear what tip we're on.
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Dr. Steve Edelman
Let's start with number six.
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Dr. Jeremy Pettis
Okay. GLP1s. These are drugs like Ozempic, Manjaro, trulicity, et cetera. Super important once weekly injections, game changer medications, not just for diabetes, but I would say health, you know, just changed the world in terms of what these drugs can do. And the positives that keep coming out about these drugs.
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Dr. Steve Edelman
Yeah, well, you know what? They first came out, it was to glucose control, and then they lost a tremendous amount of weight. Then came all the other, quote, unquote indications, meaning other conditions that they have been proven to treat. And we'll talk about obstructive sleep apnea, kidney function, fatty liver. Did I miss any?
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Dr. Jeremy Pettis
No, it's just that usually, like when a drug comes out to the market, you know, when it gets goes, you know, from a couple thousand people in a clinical trial to a million people using it, it's common for something negative to come out. Oh, gosh, we didn't know that this drug adversely affected the liver. This is the opposite with GLP1s. We started with, hey, it lowers blood sugars a little bit. That's great. And now, gosh, it helps reduce heart disease, kidney disease. You said obstructive, all these things. So people say, are these drugs safe? You know, they've been around since 2005. We've had them for over 20 years now. And the positive benefits keep adding up. So I have a number of type 1 friends and patients that would kill to be on these medications. So that's what I'm saying. It's a real opportunity here. If you have type 2 diabetes, these are indicated and can be, you know, change your life, help you live longer. I mean, that's wild.
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Dr. Steve Edelman
Yeah. And the listeners and viewers should know that the American Diabetes association gives doctors directions of which drug to use first, which drugs to use second. And they clearly say, you know, lifestyle plus metformin first, but they quickly go to the next level. Especially if you have any degree of heart disease or kidney disease. They say, right to a GLP1 receptor agonist. Or an SGLT2 inhibitor, which we'll cover next.
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Dr. Jeremy Pettis
Yeah, I mean, I would say if I had it my way, if you have type 2 diabetes, every single person should be on a GLP1 plus one of these SGLT2 inhibitors, which we'll talk about next. They're fantastic medications with a lot of benefits. And I think, again, I'm a big believer in being kind of aggressive early. So that's my two cents.
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Dr. Steve Edelman
That sounds like a Burger King commercial. If I had it my way. You know what? We're not too far from that. As soon as these drugs become a little less expensive, more competition out there. I see that happening, and I think you should be treating pre diabetes earlier too. Now, the SGLT2 class, that's Farziga and Jardian, and a drug called Mpifa and Invokana, these drugs were the same thing. They came out, they were supposed to just lower glucose, and they quickly learned that they also reduce. One of the main reasons why people with type 2 and type 1 diabetes pass away is from congestive heart failure, a form of heart disease. And they are super effective. Then they did a study looking at kidney disease, and so they have been shown clearly to reduce the progression of chronic kidney disease due to diabetes. So both these classes.
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Dr. Jeremy Pettis
And let me just add that these drugs for azigaardians, once a day pills, these GLP ones, once a week injection. So if you get on a drug, you know, you take a small pill. Honestly, they're small. Once a day and a once a week injection, you can control, I would argue, up to 80% of people with diabetes. Right there.
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Dr. Steve Edelman
Yeah. And I think the earlier you start them, the better. And I think for everyone listening, if you're not on one of these two drugs, you should really think about why you're not on them. And if you don't really know the reason, you should have a discussion with your healthcare professional.
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Dr. Jeremy Pettis
Absolutely.
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Dr. Steve Edelman
Okay.
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Dr. Jeremy Pettis
So, Steve, such good points, and I gotta say, you know this. I gotta run because I got a kiddo I gotta pick up. But I'm confident that you can take our listeners through the remainder of your list. And I'm gonna listen, and if I have any comments, I'll talk about it on the next podcast.
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Dr. Steve Edelman
Okay?
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Dr. Jeremy Pettis
So best of luck, viewers. Please don't tune off just because I'm leaving. I know it's really, really tempting, but Steve's gonna take it from here.
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Dr. Steve Edelman
All right. Drive carefully. All right, we're gonna go to tip number seven. And this is all about continuous glucose monitoring. I like to call it the crystal ball of blood sugars. And it's your own personal laboratory in the palm of your hand. Now, I know what some of you are thinking. What if I'm not on insulin, will I be eligible for it? Well, no, he won't be eligible for it, but they do have them over the counter. Now Dexcom has the Stella Libre has the Rio. And I'm not saying buy two a month for the rest of your life. It's such a great way to see your blood sugars every five minutes in relation to what you eat, how much you eat, the type of exercise, the intensity of the exercise. And a lot of times people have an eye opening experience and they say, oh my gosh, I never realized. I bumped up to 275 after eating meals. Or they may be on a pill called a sulfonylurea that may cause you to get too low and you don't even realize that you're getting low at night. So I would say everybody should have access to a cgm. And if you're not eligible, I would do anything you can to go out and buy one over the counter and just experiment and see how you do. And you can. It'll change the way you take care of your diabetes and lifestyle management. Now, if you're on insulin, it's invaluable. In fact, all you have to be on is one shot a day to be eligible to be approved for a cgm. Even if you're on basal insulin, even if you're just taking one shot of fast acting a day with dinner, you are eligible. And it'll help you not only adjust your insulin, but titrate the insulin. And because of the alerts and alarms, it'll warn you when you get too high or before you get too high. And it'll also warn you before you get dangerously low. So you'll get a number, you'll get a trend arrow will tell you which direction your blood sugar is going. And I can't tell you how that has changed so many of my patients. Diabetes control and I think overall satisfaction with living with diabetes. In fact, they've done tons of studies looking at people with type 2 on CGM and they all seem to do much better. And lastly, we talk about these hybrid closed loop systems where the pump communicates with the CGM and automatically gives insulin to keep your blood sugars in a tight range. Well, well, they're used in type 2 now to a very great extent. So they're the backbone of these systems as well. Okay, tip Number eight. This is more of a Jeremy touchy feely. Get the support and find your people. What does that mean? I started off by saying that type 2 diabetes is very common. There's almost 40 million people in the United States compared to 3 million with type 1. And I think it's so nice to have a diabuddy or be in a group of other type 2s. Don't let any type ones in there. They'll mess it up. Because you guys are a special breed. You have a certain type of diabetes, you can do certain things that type ones don't do, like take some of these medications. And it's a lifestyle. It's differences in lifestyle as well because of the relationship to weight and, and all the different cardiovascular abnormalities. So, you know, find a local group in your area, find a group online. And we actually have a TCOID group for people with type 2 diabetes. And at least you can start there. And if you're, if you're living isolated, no one with type two, it's tough. And I know there's a lot of social stigma out there with type 2 diabetes as well, because everyone thinks you just ate yourself into getting diabetes. Okay, let's talk about the diabetes warranty program. This is basically like the diabetes warranty program on your car. You get your car serviced and evaluated on a monthly basis, or I should say on a regular schedule basis, not monthly. You'll go broke and supposedly your car will run better and last longer. It's the same with our bodies. So what are the categories? Let's just go through them. Eyes. Get a yearly dilated eye exam from an ophthalmologist who is familiar with diabetic eye disease. That's it right there. And the reason why you have to do that, because there's no symptoms of diabetic eye disease in the early stages. Any condition that doesn't have symptoms, you have to screen on a regular basis. If eye disease cause pain, you, you know, you wouldn't need a screening program. As soon as your eye hurt, you'd go to the eye doctor. What about kidneys? That's the second one. Get a yearly test of your kidneys. We talk about the estimated glomerular filtration rate, blah, blah, blah, EGFR and the urine microalbumin to creatinine ratio. Those are the two most important. We got lots of videos on our website about that. And these are the tests that you want to get done early because when they start to become abnormal, that's when you want to jump on it and get the appropriate therapy. Once again, there's no symptoms of early diabetic kidney disease. What's the third? Third is nerves. Well, you get problems with your peripheral nerves. You get numbness, tingling. And your doctor can do a simple test on you when you go to the visit called the 10 gram monofilament test. And they can pick up diabetic neuropathy much earlier, before you develop symptoms. So that's a test that you should get from your healthcare professional once a year. Okay, next is heart disease. That is such an important area for a diabetes warranty program. We've already covered some of the ABCs of protecting your heart. A1C and aspirin two A's, B is blood pressure, C is cholesterol. D is drugs like GLP1s and SGLT2s. And what is E? So it's A, B, C, D, E. Now, E is evaluations of your heart. Everyone should be getting A, at baseline, a stress test. Then you can get an exercise stress test where you get on a treadmill and they measure your heart rate. Then you can do an echo stress test where they look at the wall motion of your heart before and after getting on the treadmill. And then they have other things like the cardiac CT and the cardiac echo. So it's important to talk to your doctor and say, hey, do I need any evaluation of my heart? And I can tell you that these tests are under ordered and people with type 2 are prone to getting heart problems and it's so great to pick them up earlier. Okay, the last one. Ask questions about diabetes and learn all that you can about type 2 diabetes. Knowledge is power. And I think our website at tcoid we have a type 2 video vault. But even on our homepage we have a lot of the most recent videos that we have done. We've done them on the diabetes warranty program, on fatty liver, on the cardiorenal syndrome, all these conditions that go along with having the metabolic syndrome. And remember, if you have type 2 diabetes, you have the metabolic syndrome. But once again, all the different aspects of the metabolic syndrome can be totally controlled. So I'm going to finish with three statements that I used to say from the beginning of our first TCOID conference in 1995, bringing back great memories. You have the main responsibility for taking control of your diabetes. It's not your wife's, it's not your husbands, not your sons, not your doctors. You have the main responsibility. So you have to be your own best advocate, know what you need and go out and get it. And the last one is be smart and be persistent. So with that, take control of your diabetes. You owe it to yourself and your family, Sam.