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    #41 - Jake Kushner, M.D.: How to thrive with type 1 diabetes and how everyone can benefit from the valuable insights

    enFebruary 18, 2019

    Podcast Summary

    • The Impact of Diet on Managing DiabetesDr. Bernstein's approach of managing carbohydrates and protein can benefit not only type 1 diabetes patients but also anyone with a functioning pancreas. Understanding diabetes basics can help support kids with the disease.

      Diet can have a significant impact on managing both type 1 and type 2 diabetes. Dr. Richard Bernstein's approach of managing carbohydrates and protein to regulate insulin and glucose levels has shown promising results. It is not just individuals with type 1 diabetes who can benefit from this approach, but anyone with a functioning pancreas. The conversation also highlights the risks associated with controlling blood sugar levels with high amounts of exogenous insulin. This has implications for everyone because the interchangeability of exogenous and endogenous insulin applies to insulin usage in general. Understanding the basics, history, and prevalence of type 1 diabetes can help us support kids with the disease and learn from their experiences.

    • The Impact of Type 1 Diabetes on Children and FamiliesHealthcare professionals play a crucial role in supporting patients and families dealing with the complexities of managing type 1 diabetes.

      Jake Kushner initially had different career expectations and ended up in pediatric endocrinology, where he encountered the profound impact of type 1 diabetes on children and their families. Despite expecting to work on esoteric diseases, Jake found himself interacting with newly diagnosed children and their overwhelmed families. Witnessing the emotional and physical challenges they faced, he realized the complexity and importance of managing this chronic condition. Peter Attia also shared a personal experience with a friend who was eventually diagnosed with type 1 diabetes. Both stories highlight the significant medical and human elements of treating this disease. The key takeaway is the recognition of the multi-faceted nature of type 1 diabetes and the vital role of healthcare professionals in supporting patients and their families.

    • Understanding Type 1 Diabetes in ChildrenTimely diagnosis and treatment of type 1 diabetes in children is crucial to prevent complications and ensure their well-being.

      Type 1 diabetes is a commonly misunderstood and misdiagnosed condition, especially in children. It is characterized by a state of profound catabolism, leading to weight loss, excessive drinking, and frequent urination. Many children with type 1 diabetes present with diabetic ketoacidosis (DKA), which signifies prolonged illness and a lack of proper diagnosis. Without insulin, individuals with type 1 diabetes can quickly deteriorate and face life-threatening situations. The prevalence of type 1 diabetes is significant, affecting approximately 1 in 300 people, with an onset typically around the age of 9. It is crucial to raise awareness about type 1 diabetes to prevent misdiagnoses and ensure timely treatment.

    • Understanding the complex nature of type 1 diabetesType 1 diabetes is a result of an autoimmune response, involving T and B cells, leading to the destruction of insulin-producing beta cells. Its increasing incidence may be influenced by environmental factors or viral exposure.

      Type 1 diabetes is a complex condition with both genetic and environmental contributors. The pathophysiology of the condition involves an autoimmune response, primarily driven by T cells and with some involvement of B cells. This autoimmune response occurs when beta cells in the pancreas, which produce insulin, begin to dump off antigens that provoke the immune system. This leads to the destruction of beta cells and a progressive loss of insulin production. It is important to note that there is no single virus or direct relationship with body weight that can conclusively be attributed to type 1 diabetes. The incidence of type 1 diabetes has doubled since 1960 and continues to increase, possibly due to environmental factors or viral exposure.

    • Importance of Early Diagnosis and Different Diagnosis for Type 1 Diabetes in Infants and AdultsEarly diagnosis of type 1 diabetes in infants is crucial due to rapid progression and atypical symptoms, while accurately diagnosing late-onset type 1 diabetes is important for different treatment approaches.

      Early diagnosis of type 1 diabetes in infants is crucial as the disease can progress rapidly and present with atypical symptoms. Without checking serum glucose levels, life-threatening diabetic ketoacidosis and diabetes may go unnoticed. Unlike adults, infants do not have the physiological reserve to withstand the decline of endogenous insulin production. Additionally, infants may have a more aggressive autoimmune response, resulting in the destruction of 90% of their beta cells within months. For older individuals, type 1 diabetes can smolder slowly for years, making the diagnosis more complicated. This highlights the importance of accurately diagnosing individuals with late-onset type 1 diabetes, as their treatment may differ from those with type 2 diabetes.

    • The Potential of B Cell Targeting in Autoimmune DiseasesWhile targeting B cells in autoimmune diseases may not delay the onset of type 1 diabetes, there is potential in using this approach to treat other autoimmune conditions.

      Autoimmune diseases such as type 1 diabetes and autoimmune thyroid disease often have a common B cell and T cell component. Although the study discussed did not show statistically significant results in delaying the onset of type 1 diabetes with a single dose of rituximab, it highlights the potential of targeting B cells in autoimmune diseases. It is also worth noting that there is overlap between different autoimmune endocrine disorders, and patients with type 1 diabetes may be more susceptible to developing other autoimmune conditions. While there is no definitive way to completely prevent type 1 diabetes, certain factors such as body weight and diet may play a role in increasing the risk. However, it is important to consider that the environmental contribution to type 1 diabetes is smaller compared to type 2 diabetes, making it challenging to determine the exact factors influencing its development.

    • Promoting a healthy BMI to reduce the risk of type 1 diabetes in children.Maintaining a normal BMI in children can be advantageous in preventing type 1 diabetes, but genetic factors and early detection are also important in addressing the disease.

      Maintaining a healthy BMI in children may reduce the risk of developing type 1 diabetes. Peter Attia and Jake Kushner discuss the relationship between body weight and the potential risk for type 1 diabetes. They mention a study using T1D exchange data, which suggests that closer to normal BMI could provide an advantage in preventing type 1 diabetes. It is important for parents to be aware of this possibility and educate themselves and others about the dangers of undiagnosed type 1 diabetes in children. Early detection is crucial in ensuring prompt medical intervention. Additionally, the genetics of type 1 diabetes are complex, with certain alleles increasing the risk. However, the genetic contribution, though significant, is not the sole determining factor.

    • Risk of Type 1 Diabetes in Relatives and Hemoglobin A1C LevelsHaving a relative with type 1 diabetes increases risk, but there's only a 3% chance your child will develop it. Hemoglobin A1C levels for managing type 1 diabetes have decreased over time.

      Having a direct relative with type 1 diabetes increases your risk by approximately 6 to 10 fold, but it does not guarantee that your child will also have the condition. Even with the increased risk, there is still a 97% chance that your child will not develop type 1 diabetes. However, there are some families where all children have the condition, and even in identical twins, the concordance rate is around 50-60% in the first few years, rising to 80% by adulthood. Fraternal twins also have a higher risk compared to the general population. Over time, it has become evident that the target hemoglobin A1C level for managing type 1 diabetes has decreased to around 5.7-5.9, which is lower than what was previously thought. The conversation highlights the evolution of thinking and understanding in managing the condition.

    • The Hemoglobin A1c (HbA1c) Test: A Key Tool for Measuring Blood Glucose Levels in Type 2 Diabetes.The HbA1c test, with a level greater than 6.5%, is now the primary diagnostic tool for type 2 diabetes, improving diagnosis accuracy and leading to better management and outcomes for patients.

      The hemoglobin A1c (HbA1c) test is used to measure the average blood glucose levels in individuals with type 2 diabetes. This is done by imputing the average blood glucose based on the HbA1c levels. In the past, the diagnosis of diabetes relied on insulin or glucose levels during an oral glucose challenge. However, today, a diagnosis of type 2 diabetes is made solely based on an HbA1c level greater than 6.5%. This criterion was established after the discovery of insulin and the development of the Diabetes Control Complication Trial (DCCT). Prior to the discovery of insulin, individuals with type 1 diabetes had limited options and typically experienced significant complications and a shortened lifespan. Insulin plays a crucial role in regulating the metabolism and determining whether cells are in a state of feast or famine. It helps in storing nutrients in cells during feast times and mobilizing them during famine.

    • The Essential Role of Insulin in Regulating Body ProcessesInsulin is responsible for regulating various important processes in the body, including glucose uptake, protein metabolism, and the levels of circulating androgens. Understanding its interactions with other hormones is vital for overall health.

      Insulin plays a crucial role in regulating various processes in the body. It regulates the levels of free fatty acids and triglycerides in adipose cells, promoting glucose uptake in muscle cells, and influencing protein metabolism. Insulin also affects glycogen levels and can impact lifespan and aging. It has a complex relationship with IGF (Insulin-like Growth Factor) and its binding proteins. High levels of insulin can reduce the levels of circulating androgens and can acutely decrease IGF-1. Insulin and IGF-1 have overlapping functions and can bind to receptors in different combinations, leading to alterations in metabolism. Understanding the intricate workings of insulin and its interactions with other hormones is crucial for maintaining overall health.

    • The Groundbreaking Discovery of Banting and BestBanting and Best's innovative approach to treating diabetes led to the isolation of a substance that lowered blood glucose levels, paving the way for future advancements in diabetes treatment.

      In the early 1900s, Banting and Best made a groundbreaking discovery in the field of medicine. Banting, a surgeon struggling in his practice, stumbled upon an article describing structures in the pancreas that might be related to diabetes. He had the brilliant idea to block the outflow of the pancreas and extract the residual muck to find a potential treatment for type 1 diabetes. With limited resources and time, Banting and Best successfully isolated a substance that lowered blood glucose levels in dogs. They then conducted an experiment on a medical student with type 1 diabetes, further proving its effectiveness in humans. Despite facing rejection, their research eventually won them the Nobel Prize. This groundbreaking discovery paved the way for advancing our understanding and treatment of diabetes.

    • Revolutionizing Diabetes Treatment through Insulin Discovery and Genetic EngineeringThe development of recombinant insulin has significantly improved patient outcomes in diabetes treatment, but the high cost remains a barrier to accessibility, emphasizing the need for market influence and government intervention in reducing prices.

      The discovery of insulin and its subsequent development into recombinant insulin has revolutionized the treatment of diabetes. Prior to recombinant insulin, insulin was derived from animals such as pigs, which led to complications and the need for higher doses. The ability to produce human insulin through genetic engineering has greatly improved patient outcomes. However, the high cost of recombinant insulin remains a challenge, preventing many individuals from accessing necessary treatment. This highlights the need for market influence and government intervention to drive down prices and ensure affordable access to insulin. Additionally, the conversation touches on the importance of clinical trials, specifically the Diabetes Control Complication Trial, in understanding and managing diabetes-related complications.

    • Complications of high glucose levels in diabetesHigh glucose levels in diabetes can lead to various complications such as blindness, kidney disease, and amputations. Achieving tight control of blood glucose levels is challenging but necessary to prevent these complications.

      High glucose levels in individuals with type 1 or type 2 diabetes can lead to various complications. These complications include microvascular issues such as abnormal vessel growth causing blindness, damage to the vascular endothelium, and fragile new vessels that can break and bleed. Additionally, high glucose levels can alter the kidney's functioning, leading to renal failure. Amputations, particularly of toes, are also common due to altered healing caused by diabetic neuropathy and abnormal microvasculature behavior. Preventable amputation, blindness, and kidney disease are all primarily caused by diabetes. The relationship between average blood glucose levels and these complications is monotonically increasing. However, achieving tight control of blood glucose levels can be challenging due to the risk of hypoglycemia and the system's variance and sensitivity to various factors.

    • The Challenge of Managing Blood Glucose Levels in DiabetesCollaboration and continuous monitoring are essential in managing blood glucose levels for patients with diabetes, as it is a complex process that requires more than just following a prescribed insulin to carb ratio.

      Managing blood glucose levels in patients with diabetes is incredibly difficult. Physicians often have the expectation that patients will simply follow a prescribed insulin to carb ratio, but it's not that simple. Patients can't always achieve perfect blood glucose levels, and labeling them as noncompliant is unfair. It's comparable to trying to fly a plane solely relying on instruments instead of looking at the horizon. Patients and physicians can easily become frustrated with the constant fluctuations in glucose levels, leading to high and low cycles. The DCCT trial aimed to normalize blood glucose levels, but it was challenging because there were no established best practices at the time. Through conference calls and shared best practices, they were able to reduce A1c levels from 9% to 7% over a decade. It highlights the importance of collaboration and continuous monitoring in diabetes management.

    • Study on Reducing Diabetes ComplicationsInterventions can reduce complications in type 1 diabetes, but conducting large-scale trials is costly. Careful consideration of resources and managing side effects, such as weight gain, is necessary for effective intervention.

      The significant findings from the diabetic retinopathy and diabetic nephropathy trial led to a groundbreaking paper in the New England Journal of Medicine. This paper proved that reducing complications in type 1 diabetes is possible through intervention. However, the resources and costs required for such studies are immense. The trial had a budget of over $100,000,000 and included only 1400 patients over 7 years. The expenses were primarily allocated to coordinating centers, care provision, and patient follow-up. Despite the positive outcomes, there were drawbacks as well, such as an increase in hypoglycemic events and weight gain due to higher insulin dosages. Additionally, the trial highlighted the issue of weight gain in type 1 diabetes, which has been linked to poor cardiovascular outcomes. Overall, the trial set a precedent for modern type 1 diabetes care, showcasing the importance of intervention in reducing complications.

    • The long-term benefits of tight blood glucose control for individuals with diabetesStriving for near-normal blood glucose levels can greatly reduce the risk of cardiovascular disease in individuals with diabetes, even if control later becomes less tight. However, managing blood glucose volatility is crucial in the present.

      Maintaining tighter control over blood glucose levels can have long-term benefits for individuals with diabetes. The discussion highlights how individuals who had tighter control for seven years, even if they later had less tight control, still retained some benefit from those initial years. This suggests that striving for near-normal blood glucose levels can significantly reduce the risk of cardiovascular disease, bringing it closer to that of a non-diabetic individual. However, achieving and maintaining tight control can be challenging, as demonstrated by the high variability in glucose levels experienced by those with poor control. While potential cures and advanced therapies are being explored, it is important to focus on managing the volatility of blood glucose levels in the present to support individuals living with diabetes.

    • The Impact of Blood Glucose Levels on Diabetes Complications and Cognitive Impairment in ChildrenEven short exposures to high blood glucose levels can have long-lasting effects on gene expression and cell behavior, especially in children with type 1 diabetes, emphasizing the importance of managing glucose variability and educating about carbohydrate intake.

      There is a growing understanding that diabetes complications are not as simple as previously thought. Research suggests that even short exposures to high levels of blood glucose can lead to permanent and profound changes in gene expression and cell behavior. This means that intermittent exposure to very high blood glucose, whether due to volatility or absolute level, can have long-lasting effects on the body. This finding is particularly concerning for children with type 1 diabetes, as they may be at risk of cognitive impairment if their glucose variability is not properly managed. It also raises questions about the impact of unhealthy foods on blood glucose levels, highlighting the need for better education and awareness about carbohydrate intake, especially for children.

    • Managing Type 1 Diabetes: The Constant Battle of Blood Sugar LevelsLiving with type 1 diabetes requires vigilance in managing carbohydrate intake to maintain stable blood sugar levels, posing a significant burden for individuals and their support systems.

      Living with type 1 diabetes requires constant vigilance and careful management of blood sugar levels. People with this condition must be mindful of their carbohydrate intake to avoid dramatic spikes and dips in blood glucose. Even seemingly insignificant choices, like picking croutons out of a salad, can have a significant impact on blood sugar levels. This can be a challenging and frustrating reality for those with type 1 diabetes, as it involves constant monitoring, finger sticks, and potentially painful testing. It's a responsibility that both adults and children must bear, which can be a heavy burden on both the individual and their loved ones.

    • The cognitive load and mental health challenges of living with type 1 diabetesUnderstanding the burden faced by individuals with type 1 diabetes is crucial in providing necessary support and tools to alleviate guilt, shame, and self-blame.

      Living with type 1 diabetes can create a significant cognitive load, leading to high levels of stress and mental health challenges. Parents and individuals with type 1 diabetes constantly worry about blood sugar levels, insulin dosing, and potential hypoglycemic episodes. This cognitive load can be overwhelming and affects one's ability to enjoy life fully. Studies have shown that approximately 45-50% of individuals with type 1 diabetes experience depression or anxiety, which can be debilitating. It is crucial for healthcare providers and society to recognize the immense burden faced by those with type 1 diabetes and provide the necessary tools, support, and understanding to alleviate guilt, shame, and self-blame. Blaming and shaming individuals for high hemoglobin a1c levels only reinforces the negative cycle and hampers progress in managing the condition effectively.

    • Transforming Lives with Continuous Glucose MonitoringContinuous glucose monitoring devices offer hope to individuals with type 1 diabetes, helping them better manage their glucose levels and experience significant positive changes in their overall well-being.

      Diabetes distress and anxiety can become so ingrained in a person's life that they accept it as the norm. They may feel antagonistic towards the medical establishment for not fully understanding their condition and their loved ones may struggle to understand the complexities of managing diabetes. However, there is hope in the form of continuous glucose monitoring devices. These devices can help individuals with type 1 diabetes better manage their glucose levels and improve their overall well-being. When people have successfully used these devices, they have experienced significant positive changes in their ability to think, feel, and navigate the world around them. The discovery and adoption of these devices have the power to transform lives for the better.

    • Failure of First Generation CGM's and the Role of Exercise in Improving Diabetes ControlExercise, especially intense exercise like marathon running, can greatly enhance diabetes management by activating AMP kinase, an enzyme that promotes glucose uptake in skeletal muscles, highlighting the potential for alternative approaches to insulin-dependent pathways.

      The first generation of CGM's (continuous glucose monitors) for people with type 1 diabetes was a failure due to the lack of effective solutions in managing the condition. Simply badgering patients to check their blood glucose levels and take insulin before meals was not realistic or effective. However, exercise, particularly intense exercise like marathon running, has shown to significantly improve diabetes control. This is because exercise activates AMP kinase, an enzyme that drives insulin independent glucose uptake in skeletal muscle. The difference in glucose disposal between insulin dependent and AMPK driven pathways can be dramatic. Further research is needed to understand the exact mechanisms behind this and to determine if insulin sensitivity is more influenced by insulin or AMPK.

    • Exercise and Insulin: A Powerful Combination for Type 1 Diabetes ManagementDistance or aerobic exercise can significantly reduce insulin requirements in individuals with type 1 diabetes, providing a powerful tool for managing blood glucose levels and reducing insulin therapy's volatility.

      Exercise, specifically distance or aerobic exercise, can significantly reduce the amount of insulin needed by individuals with type 1 diabetes. Marathon runners and distance athletes who engage in high-intensity, long-duration exercise have shown a remarkable ability to lower their insulin requirements. This suggests that exercise can be a powerful tool in managing blood glucose levels and reducing the volatility associated with insulin therapy. While the specific mechanisms behind this phenomenon are not well-studied, the idea of using exercise to reduce overall insulin exposure is an exciting prospect for individuals with type 1 diabetes. Additionally, the conversation highlights the importance of finding the right balance between exercise intensity and duration to maximize the benefits for blood glucose control.

    • Managing diabetes with a low-carb, high-protein diet and insulin controlDr. Bernstein emphasizes the importance of controlling carbohydrate consumption to manage blood glucose levels effectively and minimize insulin-related errors in both type 1 and type 2 diabetes.

      Dr. Bernstein's core idea of carbohydrates causing blood glucose excursions is supported by the rule of small numbers: consuming more carbs requires more insulin and increases the chance of mistakes, while fewer carbs lead to less insulin and fewer errors. Dr. Bernstein's book, "The Diabetes Solution," offers practical tips for managing both type 1 and type 2 diabetes, including complications. He suggests avoiding carbs, covering protein and fat with medium and long-acting insulin, and following a low carb, high-protein diet. However, it is important to note that the impact of protein on insulin response is somewhat debatable, as it is delayed over hours and influenced by factors such as exercise. Dr. Bernstein advocates for covering protein with regular human insulin, which aligns better with the kinetics of protein absorption and glucose response compared to rapid onset insulins.

    • The problematic approach of relying on insulin pumps and a high-carbohydrate diet in managing type 1 diabetes.A low-carbohydrate diet has been proven beneficial in managing type 1 diabetes, resulting in improved health outcomes and fewer hypoglycemic events. Joining support groups can provide valuable resources and guidance for adopting a low-carb lifestyle.

      There is a problematic approach in managing type 1 diabetes that involves relying heavily on insulin pumps and consuming a high-carbohydrate diet. This approach leads to erratic blood sugar levels, increased burden of illness, and various negative emotional and physical consequences. It is suggested that the insulin pump and insulin companies promote this approach to sell more insulin and pumps, creating a profit-driven incentive. However, a low-carbohydrate diet has been found to be beneficial in managing type 1 diabetes, resulting in better health outcomes and fewer hypoglycemic events. Although it may require giving up some pleasure in eating, the long-term benefits outweigh this sacrifice. Joining support groups like Type 1 Grit can provide valuable resources and guidance for those interested in adopting a low-carb lifestyle.

    • Transforming Patient Care through Personalized ApproachTaking the time to truly listen and support patients can have transformative outcomes, even for those considered hopeless. Building rapport and utilizing tools like continuous glucose monitoring (CGM) are crucial for effective management of type 1 diabetes.

      Changing the way doctors practice medicine can have a transformative impact on patients. Jake Kushner realized that the tight schedules in endocrinology made it impossible to provide comprehensive care to patients with type 1 diabetes. To address this issue, he decided to see patients only at the end of the day, spending as much time as needed with each individual. Despite being less efficient, this approach allowed him to truly listen, understand, and support his patients, leading to transformative outcomes. He discovered that even patients who were deemed hopeless and on a path to poor health could be helped with the right level of care, compassion, and understanding. By establishing rapport and taking the time to ask open-ended questions, patients felt more comfortable sharing and acknowledging their difficulties. This approach is especially crucial for teenagers with type 1 diabetes, who require patience, love, and suspension of disbelief to effectively manage their condition. In terms of tools for managing type 1 diabetes, continuous glucose monitoring (CGM) is essential, although unfortunately, not all insurance companies cover it.

    • Access to affordable healthcare and support for families of children with type 1 diabetes is a challenge, but the low carb community offers resources and information to help manage the condition effectively.Low carb advocates provide valuable resources to help families manage type 1 diabetes, but caution is needed when considering a ketogenic diet due to potential risks. Research is ongoing to improve treatment options.

      Access to affordable healthcare for families with children diagnosed with type 1 diabetes is a significant challenge. The expenses associated with managing the condition, such as insulin costs and continuous glucose monitoring, can place a tremendous financial burden on these families. However, there is a growing community of low carb advocates who are working to support individuals with type 1 diabetes. Resources such as books, Facebook groups, podcasts, and YouTube videos are available to provide information and tips on low carb diets and managing the condition effectively. It is crucial for individuals with type 1 diabetes to be cautious when considering a ketogenic diet due to the potential risks of diabetic ketoacidosis and other complications. Research and clinical trials are being conducted to address these concerns and improve treatment options.

    • Risks of SGLT 2 Inhibitors and Nutritional Ketosis in Type 1 DiabetesPatients with type 1 diabetes using SGLT 2 inhibitors or following a nutritional ketosis diet should be aware of the risks of delayed recognition of insulin deficiency and closely monitor their glucose levels.

      Patients with type 1 diabetes who take SGLT 2 inhibitors may not recognize the signs of life-threatening insulin deficiency due to the effects of these medications. The SGLT 2 inhibitors can lower glucose levels by dragging glucose out into urine, which makes it difficult to monitor blood glucose levels for insulin deficiency. This can lead to a delay in seeking medical care and receiving appropriate treatment. This phenomenon of delayed recognition and cognitive dissonance can also occur in rare cases in people with type 1 diabetes who follow a nutritional ketosis diet. It is important for healthcare providers and patients to be aware of these potential risks and to closely monitor glucose levels when using SGLT 2 inhibitors or practicing nutritional ketosis.

    • The Impact of Diet and Hyperinsulinemia on Cardiovascular Health in Type 1 DiabetesThe Standard American diet, particularly high-carbohydrate consumption, increases the risk of cardiovascular diseases in people with type 1 diabetes. Understanding the role of insulin in macrovascular disease highlights the need for further research in promoting cardiovascular health.

      The Standard American diet may be contributing to cardiovascular disease in both diabetic and non-diabetic populations. The discussion highlights the impact of hyperinsulinemia on weight gain and cardiovascular outcomes in type 1 diabetes. It is observed that individuals with type 1 diabetes consuming high-carbohydrate diets are at risk for cardiovascular illnesses. This suggests that the harmful effects of the Standard American diet extend beyond just diabetes. The conversation also touches upon the role of insulin in macrovascular disease compared to glucose in microvascular disease. The uncertainties surrounding the exact mechanisms and links between insulin and cardiovascular disease reveal the need for further research and understanding. Overall, the conversation underscores the importance of dietary factors in promoting overall cardiovascular health.

    • Understanding Insulin Levels and Their Impact on HealthMonitoring insulin levels and striving to lower them can have significant health benefits. Understanding the area under the curve of insulin production provides insights into metabolic function and potential interventions, such as autophagy. Self-quantification and staying connected to one's physiology are valuable in managing insulin levels for optimal health.

      Monitoring insulin levels and finding ways to reduce circulating insulin may have significant benefits for overall health. The discussion highlights the importance of understanding the area under the curve (AUC) of insulin production, which can provide valuable insights into metabolic function and potential interventions like autophagy. While individuals with type 1 diabetes have the advantage of directly knowing their AUC through insulin injections, others must rely on indirect indicators like average glucose levels to estimate it. The conversation emphasizes the value of self-quantification and staying connected to one's physiology. Overall, monitoring and managing insulin levels can play a crucial role in optimizing health and well-being.

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    • The impact of consistent exercise, stress, alcohol, and other lifestyle factors on HRV [1:11:15];
    • Optimizing zone 2 training with Morpheus [1:18:15];
    • Using heart rate recovery (HRR) as an indicator of athletic conditioning and the balance between aerobic and anaerobic systems [1:22:45];
    • The importance of tracking HRV trends over time rather than focusing on data from a given day [1:29:00];
    • Effect of GLP-1 agonists on heart rate and HRV [1:34:45];
    • Where HRV belongs in the hierarchy of health metrics [1:42:00];
    • Parting thoughts [1:46:30]; and
    • More.

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    The Peter Attia Drive
    enJune 10, 2024

    #304 – NEW: Introducing quarterly podcast summaries - Peter shares his biggest takeaways on muscle protein synthesis, VO2 max, toe strength, gut health, and more

    #304 – NEW: Introducing quarterly podcast summaries - Peter shares his biggest takeaways on muscle protein synthesis, VO2 max, toe strength, gut health, and more

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    In this quarterly podcast summary (QPS) episode, Peter introduces a new format aimed at summarizing his biggest takeaways from the last three months of guest interviews on the podcast. Peter shares key insights from each episode, covering diverse topics such as protein and muscle building with Luc van Loon, toe strength with Courtney Conley, VO2 max with Olav Aleksander Bu, liquid biopsies for cancer with Alex Aravanis, gut health and probiotics with Colleen Cutcliffe, and road safety with Mark Rosekind. Additionally, Peter shares any personal behavioral adjustments or modifications to his patient care practices that have arisen from these engaging discussions.

    If you’re not a subscriber and are listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or our website at the episode #304 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.

    We discuss:

    • How Peter keeps track of his takeaways from each podcast episode [5:15];
    • Luc van Loon episode: fat utilization, muscle protein synthesis, dietary protein, aging and inactivity, and more [8:45];
    • Behavioral changes that have come about from the conversation with Luc van Loon [23:45];
    • Courtney Conley episode: importance of toe strength and the impact of dedicated foot training [26:45];
    • Olav Aleksander Bu episode: the importance of VO2 max for lifespan, and the practicalities of measuring and improving VO2 max [36:45];
    • Behavioral changes that have come about from the conversation with Olav [56:00];
    • Alex Aravanis episode: liquid biopsies for cancer detection [1:01:30];
    • Colleen Cutcliffe episode: the importance of gut bacteria balance, and the potential therapeutic uses of probiotics, particularly Akkermansia [1:16:45];
    • Mark Rosekind: the significant issue of road fatalities and injuries, their causes, and practical safety measures to reduce risks [1:27:00]; and
    • More.

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    The Peter Attia Drive
    enJune 03, 2024

    #303 - A breakthrough in Alzheimer’s disease: the promising potential of klotho for brain health, cognitive decline, and as a therapeutic tool for Alzheimer's disease | Dena Dubal, M.D., Ph.D.

    #303 - A breakthrough in Alzheimer’s disease: the promising potential of klotho for brain health, cognitive decline, and as a therapeutic tool for Alzheimer's disease | Dena Dubal, M.D., Ph.D.

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    Dena Dubal is a physician-scientist and professor of neurology at UCSF whose work focuses on mechanisms of longevity and brain resilience. In this episode, Dena delves into the intricacies of the longevity factor klotho: its formation and distribution in the body, the factors such as stress and exercise that impact its levels, and its profound impact on cognitive function and overall brain health. Dena shares insights from exciting research in animal models showing the potential of klotho in treating neurodegenerative diseases as well as its broader implications for organ health and disease prevention. She concludes with an optimistic outlook for future research in humans and the potential of klotho for the prevention and treatment of Alzheimer’s disease.

    Disclosure: Peter is an investor in Jocasta Neuroscience, a company working to develop klotho as a therapy for people with Alzheimer’s disease.

    We discuss:

    • Dena’s fascination with aging and how she came to study klotho [3:30];
    • Biological properties of klotho: production, regulation, decline with age, and factors influencing its levels [11:45];
    • Potential benefits of klotho on brain health [22:00];
    • The relationship between soluble klotho protein, platelet factors, and cognitive enhancement [33:45];
    • The role of platelet factor 4 (PF4) and it’s interaction with GluN2B in mediating cognitive enhancement [46:45];
    • Benefits of klotho observed in a mouse model of Parkinson’s disease [55:45];
    • Benefits of klotho observed in a mouse model of Alzheimer’s disease [1:03:00];
    • Promising results of klotho in primate models, and the importance of finding an appropriate therapeutic dose before moving to human trials [1:08:00];
    • Speculating why a single klotho injection has such long-lasting effects [1:25:30];
    • Potential cognitive benefits of klotho in humans, the impact of the KL-VS genetic variant on klotho levels, and the need for human trials to confirm these effects [1:27:45];
    • The interaction between the KL-VS genetic variant and APOE4 and how it impacts risk of Alzheimer’s disease [1:34:45];
    • The significance of klotho levels: studies linking lower levels to increased mortality and the broader implications for organ health and disease prevention [1:47:15];
    • Measuring klotho levels and determining an individual’s KL-VS status [1:52:15];
    • The promising potential of klotho for Alzheimer’s disease treatment, and the importance of philanthropy for funding research [1:58:00]; and
    • More.

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    The Peter Attia Drive
    enMay 27, 2024

    #302 - Confronting a metabolic epidemic: understanding liver health and how to prevent, diagnose, and manage liver disease | Julia Wattacheril, M.D., M.P.H.

    #302 - Confronting a metabolic epidemic: understanding liver health and how to prevent, diagnose, and manage liver disease | Julia Wattacheril, M.D., M.P.H.

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    Julia Wattacheril is a physician scientist and director of the Metabolic Dysfunction Associated Steatotic Liver Disease (MASLD) program at Columbia University Irving Medical Center. In this episode, Julia delves deep into the complex world of liver health, beginning with a foundational overview of liver physiology. She provides an in-depth look at how alcohol impacts liver function, breaking down the metabolism of ethanol and its detrimental effects. Julia then shifts the focus to understanding liver function tests and optimal enzyme levels, providing a detailed explanation of AST and ALT and elucidating why fluctuations in these levels may or may not be concerning. She provides a primer on the four major stages of liver disease, discussing risk and emphasizing the importance of early diagnosis. Julia highlights the role of liver disease in increasing the risk of cancer and cardiovascular disease and covers in detail the various strategies for diagnosing, treating, and preventing the progression of liver disease.

    We discuss:

    • Julia’s training, the importance of liver health, and the challenges and innovations of hepatology [3:15];
    • The complex and crucial functionality of the liver, its four most essential functions, and more [8:45];
    • Liver injuries: historical and evolving understanding of causal factors, and the progression to liver diseases and cancer [13:15];
    • How the liver metabolizes nutrients and what happens in the presence of excess calories or alcohol [24:45];
    • Methods of diagnosing liver disease and how insights guide treatment and management strategies [33:30];
    • The poisonous nature of ethanol to the liver [40:30];
    • Varied responses to alcohol, damaging effects of alcohol beyond the liver, and the process of advising patients on their alcohol consumption [47:15];
    • Understanding liver enzymes AST and ALT—interpreting levels, lifestyle factors that affect them, and diagnostic approaches [58:30];
    • Interpreting liver function tests for fatty liver disease, and the challenges of diagnosing liver pathologies, particularly in children versus adults [1:13:15];
    • Comprehensive liver health assessments via imaging and various diagnostic tools to prevent overlooking potential liver pathologies [1:18:45];
    • Potential impact of recreational drugs, statins, and other medications on liver function test results [1:26:45];
    • Shifting nomenclature from NAFLD to MASLD to reflect accuracy in the underlying pathophysiology and understanding of liver diseases [1:30:30];
    • Pathophysiology of MASLD, the need for proactive screening, and the significance of liver fat percentage as an indicator of metabolic health [1:36:30];
    • The importance of screening for rare conditions alongside common metabolic diseases associated with fatty liver accumulation [1:42:45];
    • Practical strategies for managing MAFLD [1:45:30];
    • The impact of fructose consumption on liver health and the challenges of disentangling its effects from other factors like obesity and insulin resistance [1:52:45];
    • The potential of GLP-1 agonists for the treatment of MASLD [1:57:45];
    • How the four stages of liver disease have evolved [2:00:30];
    • Increased cancer and heart disease risk associated with early-stage MAFLD [2:05:15];
    • Emerging drugs and therapies for addressing fat accumulation and fibrosis related to MAFLD [2:12:15];
    • Peter’s major takeaways [2:18:45]; and
    • More.

    Connect With Peter on TwitterInstagramFacebook and YouTube

    The Peter Attia Drive
    enMay 20, 2024

    #301 - AMA #59: Inflammation: its impact on aging and disease risk, and how to identify, prevent, and reduce it

    #301 - AMA #59: Inflammation: its impact on aging and disease risk, and how to identify, prevent, and reduce it

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    In this “Ask Me Anything” (AMA) episode, Peter delves into the often misunderstood concept of inflammation. He first defines inflammation and differentiates between acute inflammation and chronic inflammation, the latter of which is linked to aging and a plethora of age-related diseases. Peter breaks down the intricate relationship between chronic inflammation, obesity, and metabolic health, and highlights the signs that might suggest someone may be suffering from chronic inflammation. From there, the conversation centers on actionable advice and practical steps one can take to manage and minimize chronic inflammation. He explores how diet plays a crucial role, including the potential benefits of elimination diets, and he examines the impact of lifestyle factors such as exercise, sleep, and stress management. Additionally, he discusses the relevance of food inflammatory tests and concludes by examining the potential benefits and drawbacks of drugs and supplements in managing inflammation.

    If you’re not a subscriber and are listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #59 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.

    We discuss:

    • Defining inflammation (and the cultural impact of Napoleon Dynamite) [1:45];
    • Acute vs chronic inflammation [8:00];
    • The connection between chronic inflammation, aging, and age-related diseases [11:00];
    • The impact of inflammation on metabolic health [18:30];
    • Understanding and diagnosing chronic inflammation: blood tests and other approaches, and challenges with measurement [20:00];
    • Factors that contribute to low-level chronic inflammation [28:00];
    • Minimizing inflammation through diet [29:45];
    • The important role of fiber for gut health and inflammation [33:45];
    • A closer look at the impact of trans fats and saturated fats on overall health [34:45];
    • Why Peter prefers dietary fiber from food sources over supplements [38:30];
    • Debunking “superfoods”: emphasizing proven methods over marketing claims for reducing inflammation [39:00];
    • Is there any value in over-the-counter food inflammatory tests? [42:30];
    • Food elimination diets: how they work, symptoms and markers to watch, challenges and limitations [45:15];
    • Identifying dietary triggers for gut-related symptoms through low-FODMAP diets like the “carnivore diet” [51:15];
    • Dairy: the complex role of dairy on inflammation and individual responses [55:00];
    • Wheat: the complexities and conflicting evidence around wheat's inflammatory effects [57:45];
    • How exercise influences inflammation [1:02:00];
    • How sleep quality and duration impacts inflammation [1:07:00];
    • The potential impact of chronic psychological stressors on inflammation [1:13:00];
    • The impact of oral health on inflammation and overall well-being [1:15:00];
    • The role of medications in managing chronic inflammation [1:18:15];
    • Supplements: evaluating the efficacy of various anti-inflammatory supplements [1:22:15];
    • Parting thoughts and takeaways [1:27:00]; and
    • More.

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    The Peter Attia Drive
    enMay 13, 2024

    #300 - Special episode: Peter on exercise, fasting, nutrition, stem cells, geroprotective drugs, and more — promising interventions or just noise?

    #300 - Special episode: Peter on exercise, fasting, nutrition, stem cells, geroprotective drugs, and more — promising interventions or just noise?

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    In this special edition celebrating 300 episodes of The Drive, Peter discusses a variety of popular topics and health interventions and classifies them based on their level of evidence and relevance using the following categories: proven, promising, fuzzy, noise, and nonsense. Peter first delves into the topic of geroprotective molecules, covering rapamycin, metformin, NAD and its precursors, and resveratrol. Next, he explores the significance of metrics like VO2 max and muscle mass, as well as emerging concepts like blood flow restriction and stem cells. The conversation extends to nutrition, addressing questions surrounding long-term fasting, sugar consumption, sugar substitutes, and the contentious role of red meat in cancer. Peter not only provides his current stance on each topic—most of which have been covered in great detail in the previous 300 episodes—but also reflects on how his opinion may have evolved over the years.

    We discuss:

    • Defining the categories of “proven, promising, fuzzy, noise, and nonsense” [3:15];
    • Rapamycin [9:30];
    • Metformin [17:00];
    • NAD and its precursors [24:30];
    • Resveratrol [32:45];
    • The importance of VO2 max, muscle mass, and muscular strength for lifespan [38:15];
    • Blood flow restriction (BFR) training [44:00];
    • Using stem cells to treat osteoarthritis or injury [51:30];
    • Fasting as a tool for longevity (and why Peter stopped his fasting protocol) [55:45];
    • The energy balance theory [1:06:30];
    • The idea that sugar is poison [1:12:00];
    • The idea that sugar substitutes are dangerous [1:22:15];
    • The debate on red meat and cancer [1:28:45]; and
    • More.

    Connect With Peter on TwitterInstagramFacebook and YouTube

    Special episode with Dax Shepard: F1 and the 30th anniversary of Ayrton Senna’s death

    Special episode with Dax Shepard: F1 and the 30th anniversary of Ayrton Senna’s death

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    This is a special episode of The Drive with Peter’s friend and fellow car enthusiast Dax Shepard. In this podcast, which commemorates the 30th anniversary of the death of Brazilian Formula One legend Ayrton Senna, Dax sits down with Peter to better understand what made Senna so special and why Peter remains an enormous fan. This conversation focuses on Senna’s life, the circumstances of his death, and his lasting impact and legacy on the sport of F1.

    We discuss:

    • Peter’s interest in motorsports began as a child [2:30];
    • The drama and dangers of F1 [6:00];
    • What made Senna special [13:00];
    • What Senna meant to Brazilians [24:00];
    • The cause of the fatal crash [28:15];
    • Why Peter is obsessed with Senna [40:30];
    • Being the best versus having the best record [43:30];
    • Senna’s unique driving style and incredible intuition about automotive engineering [46:30];
    • Back to the day of the dreadful race [53:00];
    • What Peter believes caused the crash [1:02:45];
    • Views on dying young, in the prime of life [1:13:00];
    • Senna lives on in his foundation and in safety changes adopted by F1 [1:21:00];
    • Statistics aren’t enough for fandom, and why people like who they do [1:24:15];
    • The biggest difference between F1 today and F1 in the 80s [1:28:30];
    • Senna’s driving superpower [1:30:30];
    • The fastest drivers currently in F1 [1:38:30];
    • Current F1 obsessions [1:45:00];
    • How hard it is to do what the top F1 drivers do [1:50:15];
    • Dax’s love of motorcycles and his AMG E63 station wagon [1:52:15];
    • Awesome Senna mementos from Etsy [2:01:15];
    • What makes specialists interesting, and Max’s devotion to F1 [2:10:15];
    • What Senna might have done if he had not died that day [2:14:00];
    • Michael Schumacher and Max Verstappen are also top F1 drivers [2:17:30];
    • Interlagos in Sao Paulo Brazil is always an incredible experience [2:18:45]; and
    • More.

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    #299 ‒ Optimizing muscle protein synthesis: the crucial impact of protein quality and quantity, and the key role of resistance training | Luc van Loon, Ph.D.

    #299 ‒ Optimizing muscle protein synthesis: the crucial impact of protein quality and quantity, and the key role of resistance training | Luc van Loon, Ph.D.

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    Luc van Loon is an internationally renowned expert in skeletal muscle metabolism. In this episode, Luc starts with an exploration of the roles of insulin and triglycerides in endurance exercise, highlighting their impact on skeletal muscle metabolism, and he offers profound insights into the significance of protein in this context. He elucidates how different protein types and forms influence muscle protein synthesis rates, exploring the nuances of protein absorption, digestibility, amino acid quality, and their implications for performance and recovery. Delving deeper, he differentiates between animal and plant protein sources, unraveling the distinctive properties of various protein types, from the differences between whey and casein to the emerging trends in collagen protein supplementation. Moreover, Luc dissects the intricate connections among physical activity, lean muscle mass, muscle protein synthesis induced by resistance training, and dietary protein.

    We discuss:

    • Luc’s background and insights about fuel selection during exercise [3:30];
    • Fuel utilization during endurance exercise [9:30];
    • Fat metabolism, intramuscular lipids, and the nutritional dynamics of endurance sports [17:15];
    • The optimal window for replenishing intramuscular fat stores and glycogen post-exercise [25:15];
    • Luc’s interest in protein metabolism and exploration of amino acids' dual role as building blocks and signaling molecules in driving muscle protein synthesis [32:15];
    • How protein metabolism differs between sedentary individuals and those engaged in predominantly strength training or endurance training [38:45];
    • The basics of how proteins are digested and absorbed, and how muscle protein synthesis is measured [50:30];
    • How factors like food texture, cooking methods, and protein composition impact muscle protein synthesis, and the importance of protein distribution throughout the day [59:45];
    • Differences in whey and casein proteins, and the ability of ingested protein to stimulate muscle protein synthesis [1:03:30];
    • Dietary protein distribution and quantity for the maximization of muscle protein synthesis [1:09:00];
    • Muscle loss with age and inactivity and the importance of resistance exercise to maintain type II muscle fibers [1:17:15];
    • Differences between whey and casein proteins, and the importance of both quantity and quality of protein sources [1:28:30];
    • Optimizing muscle protein synthesis: exercise, timing of protein intake, protein quality, and more [1:37:00];
    • How to preserve muscle while trying to lose weight [1:46:00];
    • Anabolic resistance and overcoming it with physical activity [1:55:45];
    • Importance of protein intake and physical activity in hospitalized patients [2:06:30];
    • Reviewing the efficacy of collagen supplements [2:13:30];
    • Plant-based diets: how to ensure a balance of amino acids, and other considerations [2:20:30];
    • Future research: understanding protein metabolism in the brain [2:23:45]; and
    • More.

    Connect With Peter on TwitterInstagramFacebook and YouTube

    Related Episodes

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    210 - What is the right dose of HRT for you? Hormones and premature ovarian insufficiency

    How do you work out what the right dose of HRT is for you and balance the benefits with any potential risks?

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    Corinna shares her experience of premature ovarian insufficiency (POI) – menopause before the age of 40 – and of the challenges she faced in getting a prescription for a higher dose of estrogen to help both her symptoms and future health.

    Dr Louise and Corinna discuss why hormone needs and absorption can vary from woman to woman, particularly for those with POI.

    Corinna’s three tips for those who may suspect they have POI: 

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    2. If you are diagnosed with POI make sure you seek out a specialist in the condition to get the best care.

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    #86 Omnipod 5 Update: Our experience thus far after 2 months

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    MORE INFO AND RESOURCES FROM THE EPISODE

    Juicebox Podcast 3 part series on Omnipod 5 click HERE

    For Stacey Simms' (from Diabetes Connections) episode on the Omnipod 5 click HERE

    ALL ABOUT DIY LOOP

    Loop Docs Website
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    Follow the show on Instagram @sugarmamaspodcast
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    *Buy me a Coffee is a no strings attached way to support the show! Every donation given, whether it is a one time gift or a monthly membership, goes to making this podcast come to life each and every week.

    Support the show

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    #16 Part 1: The 411 on the 504 Plan for Type 1 Diabetics

    #16 Part 1: The 411 on the 504 Plan for Type 1 Diabetics

    In this episode I have the pleasure of chatting with Janelle Haas, volunteer 504 plan advocate who frequently fields 504 questions from JDRF and families needing help establishing a 504 plan.  What is a 504 plan?? Great question! It can be so confusing and overwhelming, especially when dealing with the already overwhelming Type 1 Diabetes diagnosis. Basically, a 504 plan is a legally binding document that all T1D students in grades KG to 12 need to ensure they are safe and treated fairly while at school.  Janelle and I talk all about what it entails and things you need to consider when drafting your child's. (scroll down for the email I wrote to my school)

    Model 504 Plan from ADA: https://www.diabetes.org/resources/know-your-rights/safe-at-school-state-laws/written-care-plans/section-504-plan

    Janelle's email (be kind, y'all... she's a brave lady): janellehaas@msn.com

    Section 504 of the Rehabilitation Act of 1973:
    https://www.diabetes.org/resources/know-your-rights/section-504-rehabilitation-act-1973

    The email I wrote to my school (it was too long to include here so I will link to the website so you can read it there):
    https://sugarmamaspodcast.com/episode-16-the-411-on-the-504-plan-for-type-1-diabetics/
     



    Support the show

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    Ep. 15: Managing Holidays with T1D

    Ep. 15: Managing Holidays with T1D

    With the holidays approaching, managing T1D can feel daunting and impossible. What do you do when the table's full of all this food you don't normally eat? Or when your drunk aunt keeps pestering you about how badly she thinks you're taking care of your blood sugars? What do you do when you just want to strangle everyone gathered around the turkey? Listen to this episode for some tips on how to handle this fun but stressful season.

    Join the Half-Dead Pancreas Club! 

    What to do next...

    1. Leave a review on Apple Podcasts
    2. Join the Half-Dead Pancreas Club
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    Affordable Insulin: A Breakthrough on the Horizon

    Affordable Insulin: A Breakthrough on the Horizon

    Resources

     

    Listen to more episodes of The Huddle at adces.org/perspectives/the-huddle-podcast.

    Learn more about ADCES and the many benefits of membership at adces.org/join.