麻豆传媒

Topic: With multiple studies showing that COVID deaths and complications increase step-by-step with increasing blood sugar levels, a groundbreaking  麻豆传媒 Webinar on Thursday November 12th  from 2 to 3 pm ET will examine national, clinical and community strategies to immediately improve COVID outcomes through comprehensive nutrition information and action.

Journalists and editors are invited to attend this live virtual event and ask questions either on camera or we can relay your questions to the panelists. Register to attend and receive the on-demand recording after the session is concluded. 

Who:

1. - Professor emeritus of Pediatrics, Division of Endocrinology at the University of California, San Francisco (UCSF)
2. - Physician, Founder, Certified in Plant-Based Nutrition and Triple board-certified physician and endocrinology, diabetes, and thyroid specialist at Complete Medicine. 
3. - Founder and Executive Director at Health People 
4. - Brooklyn Borough President
5. Loretta Fleming - Peer educator at Health People
6. Elton Santana - Peer educator at Health People

When: Thursday, November 12, 2PM-3PM EDT

Where: 

This live event will also be recorded and transcribed for use by media and communicators after it is concluded. All registered participants will receive a copy of the transcript, so even if you can't make this event, we recommend you .

Thom: Welcome to this 麻豆传媒 Live expert panel, we’re here with Chris Norwood of Health People – they're an advocacy organization based in New York City for nutrition diabetes and a lot of other topics, so I want to first introduce Chris and ask Chris to tell us a little bit about what we’re going to talk about today and most importantly how your organizations mission to empower people to self-manage their diabetes is even more relevant right now during the Covid pandemic and how that has an impact on both of those crisis going on.

Chris Norwood: Thank you very much Thom – we’re going to look today at how excess blood sugar and nutritional deficits fuel Covid deaths and complications. Let’s start with the chart that will underscore how serious this is. 

Thom: Yeah let me pull that right up.

Chris Norwood: Yeah and while you're pulling it up I’ll describe it. This is  based on more than 10,000 Covid deaths of people with Type II diabetes in England – what it shows clearly is that deaths increase with blood sugar, starting at after 7.5 which is A1C level which is a blood sugar measure and considered really the outside bounds of good control, you can see that deaths go up step by step – 7.6 to 8.9 there were 22 extra deaths per 100 patients. 9 to 9.9 there are 36 and 10 and above there are 61 extra deaths per hundred hospitalized type II patients with Covid.

This really underscores the seriousness and its really, really sad to see something like this which is so avoidable. On the other hand, it shows it so clearly how we can help people protect themselves from the worst Covid outcomes. Think of this – the virus has stopped the whole world and yet with knowing how to bring down their blood sugar and how to eat better people can start to significantly protect themselves from the worst outcomes. Tragically our public health departments and medical establishments are not really letting people understand this. New York city for one had 356% increase of deaths of people with diabetes in the first five months of the epidemic. That’s 356%. The public health department has never said a word about that, never tried to make people understand what is involved and how they can avoid that in the future – New York state had the largest increase in diabetes than any state in the nation and its health department too has never said a word, never tried to help people understand. 

It is a public health crime at this point not to have health departments and the medical establishment having public information and education that people can use. So today we will look at the policy clinical community and individual strategies that people can take to have a much better chance in the Covid epidemic. Thanks, I’ll let the peer educators later talk about community health education.

Thom: Thank you Chris, we have with us Dr. Robert Lustig, he’s an MD and MSL – he’s professor Emeritus of Pediatrics and the division of endocrinology at the University of California, San Francisco. Dr. Lustig you’ve done a tremendous amount of research on nutrition’s impact on health as we look at this pandemic, how do you feel that nutrition should factor into a comprehensive public health mission to reduce the impact of Covid?

Dr. Lustig: Thanks for having me Thom and everyone on the panel. 

We now have two pandemics – not one, we have the pandemic of Covid which ahs gotten all the headlines, and we’ve got the pandemic of chronic metabolic disease which used to get the headlines until Covid. The question is how are these two things related? Are they siloed? Are they separate or are they actually maybe even the same thing? If you take a look at the three demographic groups that are most likely – not to get Covid, but to die – people of color, the obese and diabetes as Chris just informed you. So, what do those three demographic groups share in common? They all share insulin resistance, they all share metabolic syndrome, they all share processed food, ultra-processed food – the question is how in the world could ultra-processed food make you die of an infectious disease? People don’t see the connection – but in fact there are three connections. The first is that the portal that the virus uses to enter your cell, it’s a protein it’s called ACE2 – Angiotensin converting enzyme 2 which happens to be an endocrine receptor, Dr. Thangudu will attest to that. This is something that we know about because it regulates water going back and forth within the cell. The hormone insulin which is high in patients with insulin resistance with metabolic syndrome with type II diabetes, increases the number of portals. So, more chance that you're going to get sick.

Second – glucose itself seems to crystalise around the opening of the portal, so the higher the blood glucose the more crystallisation holding the door open so that the virus actually has an easier entre to cells for infectivity, and then thirdly having to do with ultra-processed food is fibrolase food, and fibre in your gut is converted by your intestinal microbiome to short chain fatty acids like butyric and propanoic which are anti-inflammatory and supress the cytokine response, which we now know is the thing that kills you, not the virus. It’s the immune response to the virus that is the actual dangerous thing. So, bottom-line – our food supply is Covidogenic, and in the midst of this debacle, craft can’t keep up with the macaroni and cheese and in fact if you go into the grocery store – what’s missing? The pasta, the candy, basically all the ultra-processed food because no ones going to restaurants, they're all basically cooking ultra-processed food at home, we are actually making this worse, and what we have is we have a CDC and an NIH who have remanded us to three public health measures – social distancing, hand washing and masking – all of which are important and I don’t argue the voracity for any of those three, we have the data for all three of them, but the fourth leg of the stool which they have not even mentioned, is the food and that’s what I hope to be able to convey to the people on this call today. We’re missing the fourth leg of the stool and we’re not doing a damn thing about it.

Thom: Thank you Dr. Lustig – we have with us the Brooklyn Borough President Mr. Eric Adams, welcome Eric – you’ve got a personal story about learning how to manage your own diabetes through this kind of self-management and peer education and also I understand your mothers condition as well, tell us a little bit about that journey and what kind of resources and tools you’ve picked up and adopted to manage your diabetes and make such a great accomplishment?

Mr. Eric Adams: First I think that it is so important the combination of the panellists that you have put together because automatically the role of a doctor is so significant, advising people, but from time to time people believe there's a level of impossibility of dealing with the crisis that they are facing and so your titles are so important and it just sets the standard of what we expect – like no one tells their child when you grow up, make sure you marry a bald President – they say make sure you marry a doctor – but when you have a person who is a public face to tell their personal journey, it personalises that and we’re living in a society where credible messengers and influences can actually change the way we act and perform, and so my journey started almost 4 years ago of when I was experiencing real discomfort in my stomach that I thought it was colon cancer and I went to my internist - in the morning that I woke up to go to see him, I couldn’t see the alarm clock and at first I thought there was sleep in my eyes, but when I kept blinking and rubbing them it was clear that I had lost my sight, and particularly in my left eye and I was losing it also in my right. I was having it for about a month, tingling in my hands and feet – turned out to be nerve damage, they told me it was permanent, it could eventually lead to amputation. High blood pressure, high cholesterol, my body – I put on a few pounds but for the most part I always had a muscular built but I needed to take an internal selfie, I was falling apart inside and diabetes was silently doing its damage without even realising it and probably so many other Americans also sitting back, not realising they are either pre diabetic or diabetic and my doctors – great doctors, my internist has been my internist for many years, they basically gave me the same diagnosis and I visited five of the best doctors in this city and they also told me the same thing. It wasn’t until I decided to do something extremely scientific – I went to google, and googled diabetes and from that I was able to come in contact with some new thinkers who introduced to me – the first time I heard this term called plant based eating and I started that journey after visiting Dr. [inaudible 11:13] in Ohio and three weeks after that my vision came back, three months later my diabetes went in remission, my nerve damage went away, high blood pressure normalised and the cholesterol normalised as well. One week of medicine to really stabilize the advanced stages that I was experiencing, but never had to take medicine again, only took the real medicine and that’s healthy food, plants, fruits, vegetables, beans, legumes and those are the good tasting foods that I consume.

Thom: Thanks for sharing all that with us Eric and in your city especially in Brooklyn but in parts other New York in the tristate area, the pandemic is just continuing and likely to get worse, we had record nearly 1,50,000 new cases nation-wide yesterday. The disproportionate impact that that’s having on racial and ethnic minorities is a major crisis along with these risk factors like chronic disease such as diabetes. How is this impacting your community and what are you seeing as the effect of these kinds of resources that could help people to manage it themselves like you have. What do you think needs to be put into this dual pandemic that we’re experiencing in a way? 

Dr. Eric Adams: I believe Robert really touched on it and I just sent a note over to my staff that I would love to get on an Instagram live or Zoom to talk about this more, because he really touched on something. We missed a golden opportunity in the city of New York – we were feeding several million of residents here and instead of introducing them to this new good tasting food called plant based, we instead continued to feed them fast food, pretzels, chips, chicken McNuggets and all of these foods that really fed their issues with diabetes which in return fed their likelihood that they were going to expire from Covid 19 related reaction. Over 90% of the people who were hospitalised in New York, had comorbidities such as diabetes and over 90% of the people died from hospitalisation also had comorbidities and the second thing is, this was a perfect time of really introducing people to be more preventive in life style medicine and by not doing so we really set people up for failure and I'm really disappointed as we pushed through with our full here and stated, if we’re feeding New Yorkers, we should not be feeding the crisis and we saw a disproportionate number of people who died or were seriously ill because of Covid 19 and those who cycled out of the immediate symptoms, they can’t say – hey, I'm out of the woods, it’s all behind me – because the science is clearly showing us of the long term impacts of covid19 on how its going to impact the lives of people and so we have to get it together and we need to be more proactive and not reactive, particularly in poorer communities, a lack of really healthy food choices is going to have a long term impact on the financial stability of our entire country.

Thom: Thank you Eric, Chris we’ve heard Eric talk about a lot of the things that your organisation Health People has set out to do, tell us a little bit about the role of peer education in cases like Eric’s and giving them the tools and the support to manage their own diabetes and what you're doing with that.

Chris Norwood: Well thank you, I'm not sure Eric has a peer but it’s so important – people feel – how shall I say – they’ve been sick for so long, they feel its impossible, there’s nothing they can do. Someone from their community comes and starts showing them and telling them what they can do, someone has lost a 100 pounds themselves, someone who has reversed their own diabetes, then it becomes believable as the Borough president said credible messengers. We through special federal funding – which ended just as this crisis started, we trained a group of peer educators from the Bronx, nobody had ever done this before, most of them had diabetes themselves, so their family members did, they put 2000 people on Medicaid in a diabetes healthcare course, a succession course that is a record for a community group but I believe this should be done not only all over the city, but all over the country and its really sad to say that both the Trump administration and the Cuomo administration defunded this just as the Covid epidemic was making it clear how crucial controlling diabetes and other chronic disease was to controlling the Covid epidemic, and again with nutrition, with plant based eating, again someone coming to you from your community – its not always easy to find the right things in the South Bronx or East New York, but people get together in groups, they brainstorm together, they say this store has that, you can get this there, it’s just so important.

Thom: Thank you Chris, Dr. Lustig for people who have any of these kind of chronic conditions as the pandemic maybe is hitting their region, they might say – I've got this condition, I’m overweight – whatever else it might be, I can’t really do anything about that and I'm focused maybe on protecting myself on the pandemic and they're not making the connection between those two things. In what you're advocating with adopting a diet that results in lower insulin or insulin sensitivity, how quickly if someone were to switch to that, could they start experiencing the health benefits that could in fact help them deal with Covid if they had the misfortune of contracting it? 

Dr. Lustig: I'm glad you asked. So a lot of people say, the die is cast, I've been eating fast food for the last 50 years, I'm just as much a fast food addict as the guy in the white house, what am I going to do – by the way I think that’s one of the reasons why the CDC and the NIH haven’t mentioned food, is the fast food addict in the White House, they don’t want to piss him off more – 

Fact matters – we studied this, not with Covid but with insulin resistance, we took 40 street children from our obesity clinic at the University of California, San Francisco – all Latino and African American -low socio-economic status, all high sugar consumers, all fast-food junkies, all with metabolic syndrome. What we did was we studied them on their home diet and then for the next nine days we catered their meals. No added sugar. No added sugar. We took their percent calories of sugar from 28% of calories down to 10% calories. 

So we took the pastries out, we put the bagels in, we took the chicken teriyaki out we put the turkey hot dogs in, we took the sweet yogurt out we put the baked potato chips in, so we didn’t give them good food, we took the sugar out and we put starch in. now I'm not going to tell you starch is good, but compared to sugar it’s a walk in the park. And then 9 days later we studied them again. Every aspect of their metabolic health improved in 9 days fast. Their fasting insulin went down, their glucose went down, their blood pressure went down – the amount of fat in their liver went down and most importantly their pancrease started making insulin properly and their insulin sensitivity improved by 25% in 9 days flat.

We’ve done the same thing in adults and it took two weeks. So, people who say – oh I can’t do anything about it, or the dye is already cast or I've been eating this way for the last 50 years, what’s going to change? You can change your metabolic health status in nine days if you got your insulin down, if you basically ate a real food diet – now I'm not necessarily a plant-based diet advocate per se, I think you can do it with animal products also, what you can’t do it with is ultra-processed food. If you think Cheetos is food – all is lost. It’s just that simple. But, if you eat real food which is what we advocate, you can change your metabolic status in nine days thus number 1] preventing diabetes, reversing your risk for heart disease, getting rid of fatty liver disease and most importantly now, reducing your risk for dying from Covid. so, this is not a fait accompli - you can do this, anyone can do this but you have to know what you're doing and you have to know why.

Thom: Eric we’ve heard Dr. Lustig explain this very clearly that it doesn’t take all that long for it to start having positive effects, based on your own experience and what we’re looking at with what’s impacting New York with Covid and the diabetes concerns – what would you like for the public to know about – be a cheerleader for us, how can they gain some confidence and some momentum that they can do this and that it will have an impact in just barely a week according to Dr. Lustig.

Dr. Eric Adams: Well as I stated, we’re talking about – it was three weeks before my vision returned as well and what the doctor is saying I think is crucial to know that there is no age limit to this, the body wants to heal, we just have to get out of this way three times a day, breakfast lunch and dinner – my mother at 80 years old, 15 years diabetic, 17 years on insulin, she decided to go whole food plant based and in two months mom was taken off her insulin and nine of her medications were cut in half and she was cycling off – I think we have to recapture out health system. Right now what we’re doing is not sustainable. You can’t have 30 million Americans diabetic, 84 million are pre diabetic, spending 80 cents on a dollar on chronic disease and believe that we could continue to have a pipeline of young people who are actually getting these diseases earlier and earlier. And our systems are in a real conflict with each other, until we – number 1] become honest about this conversation and everything from our medical schools, our institutions, where we feed people in correctional facilities, in schools, ACS, in child protected custodies, every place we feed people government should not feed the crisis. We should really be moving out this country to a health place and I'm excited because young people are now engaged, they're looking at their menus in school and they're saying they want to have this great relationship of improving not only their mothers at home, but mother earth – our eating habits, they're actually destroying our planet in the process and so there's a new energy, you have a great deal of doctors – like the program we have at Bellevue hospital, first of this kind in New York with lifestyle medicine. I think people are moving to a place of wellness and they are taking control of their eating habits and how they are looking for better food in their communities. So I'm excited about the future, I think we need to have the right leadership at the federal, state and city level that will move our country to a more healthier place.

Thom: Thank you so much Brooklyn Borough President Eric Adams, I know you have a hard out in a couple of minutes, we’re going to move on to talk to another of the doctors doing this kind of research and some of the peer educators, but we really appreciate you taking the time to be with us and share your perspective and story on all this. Thank you very much.

Dr. Thangudu, tell us a little bit about what the science that you’ve done says about the benefits of a diet specific plant centred lifestyle that we’ve been discussing about reducing chronic disease – what are your studies showing about all that?

Dr. Thangudu: Yeah so I have been on a plant based journey which started with me about two years ago and saw such profound impact on my life and my family’s life that I started digging into the science and as many of you know, in the past couple of years there has just been a huge outpouring of science supporting a plant centred diet and like Dr. Lustig said before, it doesn’t have to be plant perfect, it doesn’t have to be plants only, but does have to incorporate plants. So I have been delving into that science but big journals have been publishing on this, JAMA has had multiple articles on it in the past year, Cell had one on ultra-processed food I think in 2019, and so the science is there supporting plant centred diets. Even the ADA and ACE diabetes guidelines have plant based diet in them, a diet that is focused on high quality food, fruits, veggies, whole grains, legumes – and so as I started learning about plant based diet I had some very brave patients – I started my own practice around that time that is focused on lifestyle optimisation, left the traditional system because I just felt the same things that we’ve talked about here, we are living in a healthcare system that is not focused on health optimisation, it focused on a fee for service model that is sort of a churn and burn through the day, get patients in and out and I just saw that here in San Antonio we have a very large diabetes practice, one of the largest in world, yet patients are still getting worse and our diabetes epidemic is burgeoning. So I decided to step away and start my own practice where we really focus on lifestyle optimisation and starting with a plant-based diet but also additionally using motivational interviewing, goal setting, exercise, sleep, stress management, all of these things that all of us know are very important but are ignored in the traditional setting of misaligned reimbursement and also perhaps physician, lack of education and a lack of time. And so what I have seen in my patients, I have been studying a cohort of patients that I serve that is retired San Antonio police officers and fire fighters, utilising endocrinology expertise, so of course we use medications but with a real focus on deprescription and optimising lifestyle with a focus on plant centred diet. None of my patients are completely plants based - probably maybe a handful of them are, but we have reduced A1C significantly and also improved patient engagement and empowerment and these are folks who have been struggling with diabetes in a different care setting for decades. Most of my patients have had diabetes for more than 10 years, often more than 20 years and I have been able to pull these patients off – I had a patient last month who was taking a 100 units of insulin a day, or more – and within two weeks she was off of insulin completely, by changing her diet. And so the anecdotal stories that I have are just profound in both type I and type II diabetes, even in patients who are “last stage” diabetes. There are some patients who are not going to be able to get off all of their medications, may be many patients that cant get off of all of their medications, but everybody is on their place in their journey and there is a lot that we can do to help engage and empower them to reduce their dependant on medications and more than that improve their chronic disease risk, because as we know, diabetes increases risk of most things, most chronic diseases like kidney disease, eye disease, cardio vascular disease, stroke, but here in this acute time – corona virus is staring us right in the face and as an endocrinologist I suspected this early in the crisis and I actually did a webinar on diabetes and immunity and early in the pandemic started counselling my patients, I have a small patient panel because of the high touch practice that I have, but I told my patients – look you guys are going to be highest risk, this is a time – its going to be hard but it’s a time to buckle down. Check your blood sugars frequently, make sure you're doing all the things you're already doing, don’t fall off the wagon and I'm happy to say that some of my patients who have had Covid, have come through, knock on wood – none of my patients have had to be hospitalised, but I tell them – if this had been you a year ago when your A1C was – we would be talking about a lot of different things than we’re talking about now, but there have been multiple studies that have shown even at 0.8% A1C reduction, significantly decreased patients risk of severe Covid requiring mechanical ventilation and ecmo and also death, just a small A1C reduction, so it doesn’t have to be – if patients are able to transform their lives and their worlds upside down overnight – fantastic – blood sugar can come down from 400 to 100 literally overnight, I've seen it happen on continuous blood glucose monitoring, but even if patients can not completely flip their lifestyle upside down, its about progress and everybody can make progress whether that’s one plants based meal a day or three, and so I think that you're absolutely right – everyone has said here, we need to have a public health outreach because this is important stuff and powerful stuff that people need to know, because here in San Antonio we have a large Hispanic population and people are told – oh my grandma, my grandpa, my mom, dad, aunts, cousins, sisters, brothers- all have diabetes, I'm just going to get it anyway, and when we really know -type II diabetes is a lifestyle disease, its 80% lifestyle, 20% genetics, or something close to that, so we really need to empower people that diet runs in families too, so if we can change that, that is something that is in our power to change and your lifestyle is in your hands and even if you have gotten sick with one of these diseases, you still have the power to improve or potentially even reverse it.

Thom: Dr. Arti Thangudu, M.D, she’s a physician and the founder of Complete Medicine, right – and also, she’s certified in plant-based nutrition and she’s also a triple board-certified physician and works as an endocrinology, diabetes and thyroid specialist there in San Antonio, thank you so much for sharing your thoughts Dr. Thangudu, we’ll come back to you for more shortly. 

I want to introduce next a couple of peer educators that we have joining us, we have Loretta Fleming, hi welcome Loretta, thank you so much for joining us, and we also have Elton Santana, Elton thank you for joining us too. I want to ask Chris briefly, Chris can you kind of sum up for us what Elton and Loretta do as peer educators and I want to ask them to share a little bit about their experience working in that role.

Chris Norwood: Yes, I will. What they do is really quite amazing, we started this maybe four years ago, we just went out in the community and looked for people who didn’t know but wanted to be diabetes peer leaders and people came forth, they didn’t know what it was about, but they knew something had to happen and this is the total power of trying to put communities in charge of their own house. Since then they do usually a six-session course, but we have a seventh session also because this is the Bronx and our amputation rate is so high unfortunately, so we often do a seventh session on footcare for people with diabetes.

They take it everywhere. They take it to churches, to public housing, schools, we did this course in homeless shelters and we had an 87% graduation rate in homeless shelters and according to evaluation by the New York city health department, the participants reduced their emergency room visits by 45% in six months, so what they do is take people the information they don’t have, it is so terrible not to give people this information, especially the people who need it most, and then they give them real encouragement and support to start thinking about how they're going to use this information. As Dr. Thangudu said, people can just take one step, two steps, they’ve had the experience someone comes to the first class, they're going their bottle of soda and they say – you're not taking this away from me, and we say – we won’t! You’ll take it away yourself if you want to – so I think they're much better at explaining what they do and what they see and I think its important to remember here, most people in the United States, their nutrition – I shouldn’t say nutrition – their malnutrition education from television since the day they were born. So, something that seems very basic, they haven’t really been informed before.

Thom: Loretta can you tell us a little bit about your personal experience in getting your A1C under the danger level using this same kind of nutrition lessons and support plans that you yourself are taking to the community as a peer educator.

Loretta Fleming: Yes, there was a time when I was 378 pounds, my A1C were like in the 12’s or the 13’s and by me taking the diabetes self-management program, the diabetes prevention program, I went from 378 down to 240 and my A1C went down to 5.7 – so, this program does work. As Chris said – we have been all over, we have went to adult day centres, I have done many a classes in adult day centres and we go and we teach people education. There's a lot of things that people didn’t know about diabetes and they just thought that diabetes was a death sentence and we taught them that its not a death sentence, but it’s a changing of what you eat. We’re not telling you not to eat it, but we’re telling you to change your habits and take baby steps. I used to be a person that used to love pasta and bread, I got to a point where by taking these classes now I'm not a pasta eater anymore and the bread – I eat ultra-thin breads now. I used to go through a three litre of soda – Pepsi every day. I haven’t touched a Pepsi in about 5-6 years now. So, this program does work, it does work and I've had so many people who have taken the class, they come back to me and they tell me – I've lost 15 pounds, I've lost 20 pounds, I stopped drinking soda now, I drink more water, just little changes that they have made through taking these classes, have helped them to maintain their weight and maintain their A1C and their diabetes. 

Thom: Elton can you tell us a little bit how your experience as a peer educator has not only helped you impart this knowledge to people in your community but its helped you to practice what you preach yourself.

Elton Santana: Absolutely, I've been a diabetes self-management peer leader now for a couple of years. And the first few months, I am doing workshops with senior citizens, mostly senior citizens. Actually, my A1C has gone down to the point where my doctor took me off of my diabetes medication. And so, as Loretta mentioned, this system definitely works. I am living proof of it because my A1C has been down at 6.5 rather. And it's been that way now ever since I was taken off the medication. So, through teaching people, reaching out to them, it's very important, especially now with the pandemic. What we are doing now is we are actually calling people on the phone since I have to work from home now, through a computer system which is called Unite Us, and we teach these people what the blood sugar levels are and what to look for, what is too high, what is acceptable, what is too low. We also teach them about the plate method, which is this chart here, which teaches me and how to teach, how to explain the plate method and portions; how to read labels, how to look out for the sodium and the sugar and the products that they buy. We teach them how to deal with emotions because from what I found calling these people, they are very afraid. They are afraid to go to the doctor, and we try to encourage them and tell them, “It’s okay. Now, doctors are making sure that if you go to the hospital, that you are going to be safe, that they have measures.” And we teach about lower extremity amputation prevention and we teach them how to take care of their feet. And by practicing what I preach, I have been able to sustain my A1C at 6.5 and in fact, when I speak, when I follow up with these clients, they tell me as well that they have improved. They are very appreciative and very receptive to this and as Loretta said, this program does work.

Thom: Thank you, Elton. Dr. Lustig, in the goal of reducing or eliminating ultra-processed food from the diet and creating a lower insulin diet or getting the body to a state of insulin sensitivity, can you explain a little bit about how that works and what are some of the pathways toward achieving that sort of the underpinning of what a lot of this peer education is based on?

Robert Lustig: I am going to give you one hour's worth of biochemistry in about 30 seconds. Everybody thinks.

Thom: The timer is on.

Robert Lustig: Yes, okay. Everyone thinks it's about obesity, it's not. There are three fat depots in the body – three. One is called subcutaneous or for the lack of a better word, big butt fat. Cosmetically undesirable, but metabolically inert. Doesn't matter but that's what you measure when you stand on the scale. Second one is visceral obesity or big belly fat. Now that one's important and that one causes metabolic derangement, and that one it turns out is most responsive to stress. Not diet, but stress. So, the more stressed you are, the bigger your belly. And we know that because people who have endogenous depression, who are actually losing weight, still end up with increased visceral fat and metabolic disturbance on that basis because the visceral fat sends messages to the liver directly through what we call the portal system. The third fat depot is the most important for this discussion, and it's the liver fat. And the liver fat only has to be a total of 300 grams, that is, less than a pound in order to wreak metabolic havoc on the rest of the body. So anything that drives the liver fat, you don't see it on the scale, but that's what's causing the biggest change in your metabolic status. And that's what's fomenting all of the chronic metabolic diseases that we know about today – type two diabetes, hypertension, lipid problems, cardiovascular disease, cancer, dementia, fatty liver disease, Polycystic Ovarian disease, you name it. Those are the diseases that basically are due to liver fat. And what we've learned is that that liver fat is not coming from the fat in your diet, that liver fat is coming from carbohydrate and very specifically, sugar. Well, sugar is the marker for ultra-processed food because 74% of the items in the American grocery store have been spiked with added sugar for their purposes, not for yours because they know when they add it, you buy more. So what we find ourselves in is a vicious cycle of consumption and metabolic disease and continued consumption. And they are making out like bandits, and we are getting sick. Not only are we getting sick, we are getting fat and stupid at the same time. And the fact, the matter is if you stop the liver fat production, if you get rid of the sugar, if you get rid of the refined carbohydrate as well because that's also driving insulin up. You can turn this around; you can reduce your liver fat as we did in these kids in nine days And you can basically reverse this entire process. You can get rid of your diabetes.

Thom: Thank you, Dr. Lustig. Dr. Thangudu, I wonder if you can make the connection to some of what Dr. Lustig described and to research on the impact it has on the immune system. So diabetes, hyperglycaemia other metabolic dysregulation or, Dr. Lustig you used another term for, you said, I forget what you said. You didn't say dysregulated, you said it was distorted or something. I forget what the word was you said. In any case, Dr. Thangudu, what's the impact on the immune system when your body is in that state?

Arti Thangudu: Yes, so first I just want to add to what Dr. Lustig said. So I have a lot of patients who come in, who are perfectly comfortable eating a low carb, ultra-processed bar for breakfast, but they are terrified of bananas. So we have this entire healthcare community and community in general that is just so misinformed about what is truly healthy, that we truly have our work cut out for us because there are so much marketing – the health food section of the grocery store essentially is oftentimes selling glorified ultra-processed junk food. And so we've got to change the narrative to go back to the produce, go back to the – I talk to my patients about what a processed food means like with an apple, I can figure out okay, the farmer grew it, picked it, cleaned it, just delivered it, I picked it up, ate it. Okay, Apple Jacks, how did that get from the farm to my plate? I don't know, either. So that's all ultra-processed. And so we really have to encourage people to understand what an ultra-processed food even means because I think they are so much a part of our community now that people just don't know what's healthy and what's unhealthy anymore. And I loved that you talked about the liver because insulin resistance of the liver is a huge part of what is causing diabetes, hepatic gluconeogenesis or the liver constantly producing sugar and not listening to insulin signalling, is a huge part of insulin resistance that we need to cut down with things like diet, exercise, avoiding these ultra-processed foods, stress management, sleep, all these lifestyle things that are important. Specifically with immunity and diabetes, I like to think of it in three parts. One is inflammation, two is immune cell function, and three is vasculopathy. So basically, diabetes is a state of inflammation. So when you have an infection and you have diabetes, you've got a double whammy of inflammation that is more likely to get into a vicious cycle and go out of control. Also, diabetes affects immune function. So there are certain cells in the body like neutrophils, macrophages, a complement cascade, all of these cells are involved in healing, fixing an illness, but in diabetes their function is impaired – diabetes, specifically with hyperglycaemia. Now, diabetes, even though we don't feel it, it wreaks havoc on our blood vessels. So the third part of how diabetes impairs immunity is through vascular dysfunction. So, for vascular flow, the vascular walls get thickened; impaired blood flow, impairs your body's ability to get immune cells to the areas of the body that need healing and also impair getting oxygen to those places too. And so you need those things to heal. So with this triple whammy of inflammation, immune dysfunction and vasculopathy, diabetes is just a feeding ground for infections. The problem with diabetes and infections is when you are infected, blood sugars go higher. And so it gets into this vicious cycle of infection and high sugar, worsening the infection. So we really need to target it before it gets to that point. And now with COVID, a mainstay of treatment is steroids. So, people with diabetes on steroids, or even sometimes the general public who doesn't have diabetes, steroids increase blood sugar too. So while steroids do improve COVID outcomes, if you have issues with your blood sugar and then you are getting high dose steroids with COVID, now you are in a situation where we really need to manage that blood sugar aggressively. Otherwise, we may be counter active to the use of the medication what it's being used for.

Thom: Thank you, Dr. Thangudu. To Loretta, I'd like to ask, we've heard just what some of the sciences backing up the reasons why this is so important. Loretta, what have you seen as some of the challenges that your clients have experienced and what kind of strategies have you recommended to help them overcome some of those hurdles? Your audio is not live. Loretta, go ahead and unmute. Go ahead.

Loretta Fleming: One of the somewhat problems that a lot of my clients had, is getting off of the breads as I said earlier. I was a bread eater. I loved my hero sandwiches, I was a pasta eater, I was a spaghetti eater, I was a rice eater. And it was very difficult at first for me to wean myself off of it, but I explained to them, “If you want to eat rice, maybe try brown rice instead of the white race. If you want to continue to eat bread, instead of eating the big slices of bread, try the ultra-thin bread.” The ultra-thin bread only has 40 calories per slice. So if you are eating two slices, that's only 80 calories. Try to cut down on the amount of carbohydrates, your breads, your pastas. And like I said, if you want to eat rice, try brown rice. A lot of people don't like brown rice; they said it doesn't taste right. I said, “Well, if you want the brown rice, maybe use a low sodium booty and cubes in your rice to season it up, to give it that flavour. Maybe that will help you.

Thom: And Loretta, what about exercise and how somebody who maybe hasn't made exercise a part of their lifestyle – to get the body moving more, they say that sitting is harmful for us. What do you recommend and what do you talk about with your clients about getting some more movement day to day?

Loretta Fleming: Well, I have had four surgeries on my lower back, my lumbar spine. So there was a time where it was very, very difficult for me to exercise. But what I explained to them is that when you are doing household chores, that's a form of exercise. If you are making up your bed, if you are sweeping, if you are mopping, that's a form of exercise. If you are moving, if you are dancing around your house, that's a form of exercise. So, as long as your body is getting in some type of movement every day, whether it be dancing or cleaning or washing clothes or whatever, that is a form of exercise. So I let them know it doesn't have to be running and jumping, somewhat. It could be just moving around in your house, doing household chores, cleaning. That is a form of exercise.

Thom: Thank you, Loretta. Elton, as Loretta is describing some of these things that are small steps building toward a better lifestyle, how do you create an action plan and share that with your clients to help them to recognize these achievements and take the right steps in that direction?

Elton Santana: Well, first of all, I listened to them because often times they actually explain things about their lives and how they go about eating and exercising, doing chores and so forth. Walking – I let them know that walking is very important. Now the action plan would be something that that person can achieve in one week. So weekly, they can make an action plan and they can customize it to their lifestyle. Maybe they can walk 30 more minutes than they usually do, or they can eat a little bit less of the white rice. They can eat a little bit more of the vegetables that are good for them. So, an action plan is something that is achievable to that person and that is customized to that person. And that's what we teach them.

Thom: Thank you, Elton. Dr. Thangudu. How important are sleep and exercise? And I know it's a loaded question because the answer is very. Tell us why they are important?

Arti Thangudu: Yes. So, I want to piggyback on to what Elton said, and the action plans are hugely important. And we call them SMART goals in lifestyle medicine. But basically giving patients a specific, measurable plan instead of telling them to take over the world overnight helps them do the work to get to the goal. So if a patient comes in and says I want to lose 20 pounds, I say, “Whoa, well, that's not a goal. That's a wish because we don't have a plan.” So, a goal without a plan is simply a wish. I try to engage patients to say the work is what's important. If you do the work, you will get the goal. But if you focus on the goal instead of the work, you will not achieve that goal. You'll just be thinking about it. And so I think that's really important. You said sleep and exercise, right. So, sleep is very important. One, if you are getting poor sleep or you have an untreated sleep disorder like obstructive sleep apnea, which a lot of our overweight and obese patients, even normal BMI patients, I had sleep apnea after I delivered my son and I was normal BMI. So if you are not getting good, restful sleep at night, your risk of metabolic disease goes up. If your sleep is not good, you also are at higher risk of making poor choices –poor choices with regard to diet, exercise, food, relationships, your ability to manage stress goes down significantly. So, if a patient is getting very poor sleep, and they have a goal that is related to diet and exercise, I tell them “Look, I like your diet goal. I like your exercise goal. But let's set you up for success by fixing the sleep first,” because if we don't fix the sleep, it is highly unlikely that we are going to be able to fix anything else. And there are patients that I have treated for a slew of disorders, whether it be diabetes or depression or PMDD or something like that, that we get them sleeping better and wallah, their problems are fixed. It's very, very, very important. I've learned this in my own personal life. I learned it from my children. Actually I have a four and two-year-old – I watched how bad they did when they didn't sleep well and how great they did when they do sleep well. And I thought wow, that must be happening to adults; we just have a better filter. So I think getting great sleep is very, very important. And then exercise too is very, very important. One, for mood – I had a psychiatrist once telling me exercise is the most underutilized antidepressant, which I think is very true. Exercise releases endorphins. I know I am a better doctor, mom and wife when I exercise. And mood plays a big part in all chronic diseases. But also with insulin resistance specifically, we have seen that patients with diabetes improve their blood sugars immediately after they exercise. In fact, there was a study that showed one 45-minute bout of exercise on the elliptical, improved insulin sensitivity and insulin resistant in adults – one bout immediately. So, of course, that insulin resistance comes back if you never exercise again, but it's very impressive how quickly exercise works on insulin resistance. And I have patients too who wear continuous blood glucose monitoring systems and they say, “Wow, doctor. The days I exercise, my blood sugars are way better.” I've seen type one diabetic patients who actually have to lower their insulin doses when they exercise. So, exercise has a profound impact on insulin sensitivity.

Thom: Thank you, Dr. Thangudu. Dr. Lustig, let's take it now to the mental health question. Metabolic health, sleep and exercise, all sound like they have very important impact. What's the science behind that and what do you think is a good takeaway for how we can support mental health so that we can be prepared to deal with all of these things, so we make sure we have good metabolic health?

Robert Lustig: So we have two other pandemics. We have a pandemic of addiction and we have a pandemic of depression – addiction and depression. And they are also metabolic diseases. People think that these are somehow unrelated, these are different. They are not. There are three things in food that matter – three. One is tryptophane. Tryptophane is the rarest amino acid. It is also the precursor of serotonin, and serotonin is the anti-depressant neurotransmitter. That's why we give SSRIs to patients with depression is to try to up their serotonin. Well, you cannot be serotonin if you don't have enough tryptophane to make the serotonin out of. Well, because tryptophane is the rarest amino acid, it's actually hard to come by and processed food is very, very low in it – number one. Number two, omega-3 fatty acids. So, omega-3 fatty acids are found in salmon, flax in marine life, marine oils in general. But that doesn't make a very good ultra-processed food because that has a fishy flavour. It is very specifically divorced from processed food in general. But omega-3 fatty acids are essential in terms of improving neuro-transmission in the CNS, and omega-3s alone have been shown to cure depression. But we are not eating them. Number three, too much sugar. And sugar, because of its effects on insulin resistance, ultra-mitochondrial function in the brain, leading to both addiction and depression by activating the reward system, fomenting addiction and also through the phenomenon of insulin resistance actually leading to dementia as well. So, these are the three primary factors in food that make a difference in terms of mental health. They also happen to make a big difference in terms of metabolic health because in fact, metabolic health and mental health are the same thing. So, fixing it with real food fixes those three, fixes the insulin resistance, fixes the liver fat, basically fixes you. The way I try to tell people, the way I try to explain it to people, it’s very simple – if a food has a label on it, it's a warning label because real food doesn't have a label, real food doesn't need a label. Are there any labels on radishes? Are there any labels on broccoli? Or is there any label on a plum or a peach? Is there any label on meat? No. The reason is because those are real foods. Any food that's been processed, however, requires a label. So, everybody should look at any food with a label askance, and if we actually shopped around the edges of the grocery store and ate the label-us food, we would be doing much better.

Thom: Thank you, Dr. Lustig. Chris, I am going to ask you to bring it home and tie it all together – food, sleep and exercise are all medicine. And we need to be prepared better with all these kinds of lifestyle habits so that we can deal with chronic and acute disease better. What do you think is the important take-home for all of this and what resources from local and our national government needs to be thrown into educating people about all these things?

Chris Norwood: I just want to thank 麻豆传媒 in the panel before I bring it all together. I like that this is been recorded. I think everyone can refer to today's webinar to really understand both how simple this is and complex at the same time. And again, we have to insist that our health departments and medical establishment – I know I go many places where people wish they had a mute button, but we just have to insist. We can't watch this anymore. And beyond that, to me, it's always, it's always giving the community the resources, training educators from the community and having them go out where they know how to reach people and the people, they reach will believe them.

Thom: Well said, Chris. Thank you so much. With that, we'll go ahead and draw things to a close. Anybody on the call from the media, you are welcome to use quotes or video from today. We are going to share with you the recording and the transcript if you are on the list of people who registered. If you didn't register, email us at [email protected] and we'll get you that information. With that, I'll say thank you to Chris Norwood and health people, Dr. Robert Lustig, Dr. Arti Thangudu; peer educators Elton Santana and Loretta Fleming; and we also had Brooklyn Borough President, Eric Adams. Thank you all very, very much. Stay safe, stay healthy and good luck.

Robert Lustig: Thank you.

All: Thank you.