Today, diabetes and prediabetes are a global epidemic. Estimates suggest that one in three people are diabetic or prediabetic. Over the next several decades, experts expect that number to rise to one in two people. Most functional practitioners are familiar with the food and lifestyle interventions that can help reverse Type 2 diabetes, but there are important nuances that go into treatment: how culture and genetics affect the development of the disease, how toxins in the environment foster the condition, and what role pharmaceuticals should play. In this podcast, Dr. Fitzgerald talks to Dr. Mona Morstein, author of Master Your Diabetes, about the key interventions that can help patients prevent, treat, and reverse diabetes.
In this podcast, you’ll hear:
- An explanation of the different types of diabetes
- How Latent Autoimmune Diabetes of the Adult is often misdiagnosed as Type 2 diabetes
- How cultural differences affect the development of diabetes
- What risk factors and genetic predispositions play a role in the development of Type 1 diabetes
- How early infant interventions may have the potential to prevent Type 1 diabetes
- How persistent organic pollutants (POPs) in fat cells play a role in obesity and diabetes
- About the connection between sleep apnea and Type 2 diabetes
- The best lab panels to run for Type 2 diabetes patients and how to interpret reference ranges
- Why testing ferritin in diabetes patients matters
- How insulin resistance affects testosterone levels in men
- Why HbA1c isn’t a great test of blood sugar control (and how to triage a marker of blood sugar control using the GlycoMark test)
- The best lab tests for measuring IgG
- How POPs may play a role in weight loss plateaus
- Why carb restriction is the first step in diabetes management
- How too much dietary saturated fat may contribute to insulin resistance
- The importance of supplementing with fiber when a patient is on a keto-type diet
- How to use supplements to protect against the oxidative damage that accompanies diabetes
- About an Ayurvedic herb that can reduce cravings for sweets and regenerate pancreatic beta cells
Dr. Mona Morstein has focused the bulk of her career on treating all types of diabetes (DM). In late 2017, she published the a superb 500+ page very well-referenced book on the topic, titled Master Your Diabetes: A Comprehensive, Integrative Approach for Both Type 1 and Type 2 Diabetes. Despite written in layman language, clinicians will find it meaty enough to be useful in practice – I especially like the sections on DM complications. In our conversation, we look at the four main types of diabetes, discuss etiology and epidemiology of types 1 and 2. We discuss standard labs, including the limitations of A1C, and the utility of the GlycoMark test. Learn how she does a glucose/insulin tolerance test and specialty lab testing considerations in patient management, managing the microbiome, intestinal permeability, food sensitivities. Diets: Dr. M recommends a very low carbohydrate diet (VLCD), but we had a great sidebar convo on the paradox of VLCD and vegan macrobiotic diets demonstrating equally good outcome – learn why Dr. Morstein suspects that is. Toxins, particularly POPs, but also metals, play a huge role in ushering in diabetes – learn how she’s evaluating and treating. We discuss nutraceutical interventions, medications – what she’s using and why. Of course, no conversation on DM is complete without discussing the influence on lifestyle. An interesting point Mona makes is that the program of treatment must be doable and relatively stress-free. Please give this terrific podcast a thumbs up and share if you like it as much as I think you will, and as always, let me know your thoughts!
- Diabetes expert, author, physician: Mona Morstein, ND, DHANP
- Veteran clinical physician and diabetes expert
- Author of Master Your Diabetes: A Comprehensive, Integrative Approach for Both Type 1 and Type 2 Diabetes
- Founder and executive director of The Low Carb Diabetes Association
- Dr. Morstein’s treatment and prevention plan to better manage all types of diabetes, The Eight Essentials, focuses on a low-carb whole foods diet and also includes exercise, good sleep, stress management, gut health, environmental detoxification, supplementation, and medications.
- Dr. Mona Morstein website: www.drmonamorstein.com
- Arizona Integrative Medical Solutions: http://azimsolutions.com
- Master Your Diabetes (book): https://www.amazon.com/Master-Your-Diabetes-Comprehensive-Integrative/dp/1603587373
- Organic pollutants and Type 2 diabetes paper https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393257/
- Original ACCORD study: https://www.nejm.org/doi/full/10.1056/NEJMoa0802743
- Ludwig diabetes paper low-carb diet: http://pediatrics.aappublications.org/content/early/2018/05/03/peds.2017-3349
- Feinman and Berstein paper: https://www.ncbi.nlm.nih.gov/pubmed/25287761
- Referenced Diamend product: http://www.priorityonevitamins.com/Diamend-210-Vegetarian-Capsules_p_45.html
Biotics Research Corporation utilizes “The Best of Science and Nature” to create superior nutritional supplements, available exclusively to healthcare professionals.
By providing meticulously formulated nutritional supplements and valuable resources, Integrative Therapeutics promises to enrich your patients and embolden your practice.
Dr. Kara Fitzgerald: Hi, everybody. Welcome to New Frontiers in Functional Medicine where we are interviewing the best minds in functional medicine, and today is no exception. I am excited to be talking to Dr. Mona Morstein. She’s the author of Master Your Diabetes published by Chelsea Green in October of last year. I recommend clinicians if, well, you’re clearly treating diabetes if you’re in clinical practice, that you take a look at her book. It’s a 500-page tome written in plain language, so regular people can actually understand it, but really it’s arguably geared towards the clinician. You’ll find endless, endless pearls, inspiration, treatment, guidelines, botanicals, nutraceuticals, et cetera. It’s a great, great book and she’s got a fabulous bibliography with it.
Before I jump in though, let me just tell you about Dr. Morstein. She is a naturopathic physician. She actually graduated from my alma mater, National College of Natural Medicine out in Portland. She’s now practicing in Arizona. She was actually professor at the Naturopathic College out there for years, and she was an attending physician in their clinic for a long time. Her clinic in Arizona is Arizona Integrative Medical Solutions. It’s in Tempe. She focuses on pre-diabetes and diabetes. I know she does a lot of GI work. Dr. Morstein lectures all over the globe, and she’s the founder and executive director of the Low Carb Diabetes Association. She’s also a member of the Arizona Diabetes Association in addition to actually winning lots of awards in the naturopathic medical community and really being a wonderful ally of our profession.
Dr. Kara Fitzgerald: Welcome to New Frontiers, Dr. Morstein.
Dr. Mona Morstein: Thank you very much, Dr. Fitzgerald.
Dr. Kara Fitzgerald: I remember learning from you years ago. You’ve got a lot to offer us. You’re a natural teacher. One of the pearls I took from you a long time ago, and we’ll talk about it in a little while, was looking at ferritin, changes in ferritin as an early marker of fatty liver disease. We’ll get there. First of all, since we’re focused on diabetes, just talk to me about the types of diabetes that we’re seeing clinically and give me a little bit of the epidemiology behind…
Dr. Mona Morstein: Sure. There’s three kind of more main types and one off-main type. The main type of diabetes, of course, is Type 2 diabetes, which is associated … The disease is insulin resistance where a body’s cells stop listening to insulin and the signals it produces and doesn’t take glucose out of the bloodstream, and so people develop diabetes. This is associated with people who are, in general, overweight or obese.
Another type is Type 1 diabetes, which is an autoimmune disease where a person’s immune system attacks their own pancreatic beta cells, which are the cells that produce and secrete insulin so that these cells are no longer able to do it to the physiological need of the body, and these people will need at some point to be injecting insulin as a result.
Type 1 we usually see in our pediatric population which goes from about one and a half to 25 although in medicine pediatrics ends at 18. Type 1 can get into the mid-20s. Then later from the mid-30s and above, we can get another kind of type 1 called latent autoimmune diabetes of the adult which comes on generally, not all the time, but slower, a slower autoimmune disease of diabetes, but still can wind up patients requiring insulin at older age.
The last one is one called mature onset diabetes of youth. This is just a genetic disease where people, for example, might make insulin but there’s a kink in their pancreas in secreting it or there’s a kink in their receptors in receiving the insulin. These people have a very mild, mild form of diabetes that usually can be pretty easily treated.
Dr. Kara Fitzgerald: Okay. And the epidemiology?
Dr. Mona Morstein: Diabetes is a worldwide epidemic. In the United States, we have about 30 million people with diabetes, and we have about 90 million people with prediabetes. If you add that up, it’s 120 million people. If we have 360 million people in the country, pretty much one out of every three people in America right now are either pre-diabetic or diabetic, which goes along with the fact that around 70% of people in America are either overweight or obese.
Type 2 diabetes is around 90 to 95% of people with diabetes. Type 1, the autoimmune disease, is around 5 to 10%. Worldwide there’s 300 million people with diabetes and a huge overweight obesity crisis going on worldwide as well. The CDC, Centers for Disease Control, say, “If everything continues as it’s going now, by 2040 or so, one out of every two people will have diabetes.” It’s definitely a huge crisis all around the world.
Dr. Kara Fitzgerald: Yeah. I wrote an editorial for alternative therapies some years back where if you look at some of the tighter reference ranges like the San Antonio heart study, looked at glucose and insulin and HOMA-IR in quintile division and found a very normal blood sugar greater than 87, that we wouldn’t even bat an eye at, was associated with increased heart disease and an insulin above five was trending. We see it in our normal population all the time, so these trends like starting to march on the metabolic continuum even before frank prediabetes or true diabetes. It seems like unless we’re actively swimming against the current, we’re going to fall on that path.
Dr. Mona Morstein: Yeah. I mean I think people can sometimes make extremist statements of where our blood sugar should be all the time. But, yes, there is a huge problem from multifactorial reasons why being overweight and being obese is happening and in insulin resistance, all the factors involved in causing that, it’s not just one thing. I mean, there are people, if I may be so blunt, that weigh 300 pounds and are not insulin resistant. Then we look at Asians. If they gain 10 pounds, they could be insulin resistant. We have different effects culturally. We have different effects genetically. We have different effects with capacity to detox environmental chemicals. It’s a quirky thing. But, as a general rule, it’s a big, big, big, big problem for a growing number of Americans.
Dr. Kara Fitzgerald: Talk about risk factors. Now, the bulk of our podcast I think most usefully will be focused on Type 2 diabetes and we’ll get into labs and we’ll get into your PE and your interventions and causes. But just flipping through your book and reading about the TEDDY study for instance and Type 1 diabetes. Talk to me about risk factors. It’s pretty interesting. They’re looking at diet. They’re looking at immunization. They’re looking at toxin-exposures…
Dr. Mona Morstein: Yeah.
Dr. Kara Fitzgerald: Tell me what they found with regard to Type 1.
Dr. Mona Morstein: Well, you know what? The study is not yet out, so they’re still in the accumulating and analyzing data. But the TEDDY study is an ongoing, very innovative study and this is for Type 1. They’re trying to figure out what are really the main factors for why a person comes down, so to say, with Type 1 diabetes. Now of course with Type 1, you do need a gene. If you don’t have the gene for Type 1…
Dr. Kara Fitzgerald: Which are? Which are? Go ahead with…
Dr. Mona Morstein: The HLA-DQ 2s and 8s.
Dr. Kara Fitzgerald: Got you.
Dr. Mona Morstein: If you don’t have these genes, it’s not going to happen. But many people have these genes. The idea is what turns them on. Yes, we’re looking at things.
Now, know Finland historically had the highest per capita Type 1 patients in the world, and the Finns have done studies that if they give infants vitamin D3, if they give infants omega-3 fish oils, there is a significant decrease in those infants developing Type A versus in control groups that didn’t receive either of those nutrients.
TEDDY is looking at what about nutrient deficiencies? But they’re also looking at what about the mother’s health during her pregnancy? What about the vaccinations? What about environmental exposures? What about getting sick, the child getting sick? What about the ingestion of foods that have some association with Type 1 development?
Dr. Kara Fitzgerald: Well, what have they found? Can you give me some meat? I mean-
Dr. Mona Morstein: No, I can’t.
Dr. Kara Fitzgerald: You can’t?
Dr. Mona Morstein: I mean the study is not yet reported. Now, the problem is I see a lot of Type 1 kids, and in reality, there’s so many of these you cannot pinpoint it. Many of these kids, they were raised … The parents fed them organic food and didn’t vaccinate them and it’s a healthy, functional family, and they didn’t put new carpeting down with all these toxins and the kid was healthy and, bam, gets Type 1. In reality, that’s the main presentation. There are some kids who got sick beforehand, and there’s an idea with Type 1 that … The interesting thing with Type 1, I think, is that there are kids who develop the antibodies but haven’t yet developed the disease. When they analyze these kids that already had positive antibodies, showing the disease is in process, but it hasn’t clinically manifested based on…
Dr. Kara Fitzgerald: What antibodies?
Dr. Mona Morstein: With an autoimmune disease, the white blood cells are say attacking these pancreatic beta cells, and they’re producing antibodies against these cells. These kids had insulin antibodies. They had islet cell antibodies. They had an antibody GAD65, but they didn’t have diabetes. We see that the immune system is already attacking their pancreas, but it’s holding its own yet.
We can see this some other times in patients who have, for example, Hashimoto’s. We see elevated antibodies. But they don’t need the hormone yet, right?
Dr. Kara Fitzgerald: Mm-hmm (affirmative).
Dr. Mona Morstein: They found that these kids almost invariably have leaky gut, intestinal permeability. There’s an idea that viruses from the gut like Coxsackie B virus through the leaky gut gets through, and then it goes through the pancreas and initiates an autoimmune response.
Naturopathically, you think, well, if we could get hold of these kids and right when the antibodies are elevated and maybe heal the leaky gut and support their immune system with nutrients, ashwagandha, with D, with fish oils, maybe we could prevent the onset of them. It’s just that obviously we’re not, as a rule, just randomly testing diabetes antibodies in all pediatric patients walking in our door.
Dr. Kara Fitzgerald: Yeah, that’s right.
Dr. Mona Morstein: We know the gut seems to be involved, and it will be great when we get the studies to really find out. But from my experience, 25 years, I cannot say with any, any assertion that any of the factors that they’re looking at have played out with any regularity in my Type 1 patients.
Dr. Kara Fitzgerald: Clearly, it’s going to be multifactorial and there’s individuals…
Dr. Mona Morstein: Yeah, or it may just be karma. It may just be that’s what God said you’re going to deal with in this life.
Dr. Kara Fitzgerald: That’s pretty interesting. What about some of the early studies looking at different caseins triggering …
Dr. Mona Morstein: Yeah, well, that’s what I said, the food sensitivity. Obviously gluten, there is a triad of celiac disease, Type 1 and Hashimoto’s. That’s a very well-known triad of autoimmunity, and so gluten is associated … If someone has celiac disease and they are not aware of it … Man, I have had some Type 1s, when they were diagnosed in the hospital, were tested for celiac and it was positive.
My idea with celiac, and I mentioned it in the book, is that … I mean, this is a test. We should be testing all kids as soon as they start eating grains, as soon as they start eating wheat just to try to catch any celiac right from the get-go, any celiac patient so that we can help prevent, I believe, other autoimmune conditions like Type 1 developing. Gluten, for sure, dairy has been associated. But if we look at dairy … I mean for all the people in the world who eat dairy, there’s a lot more than those than there are Type 1 diabetic patients. We can’t say that everybody who eats cow’s milk or sheep or goat or whatever winds up getting diabetes because there’s caseins so there has to be some individual response to it that we can’t make a general population observation.
Dr. Kara Fitzgerald: Well, let me just ask you and then we’ll move over to Type 2 because we’re going to talk about that a lot. I mean, you’re going to clearly be flagged in your practice if mom presents with Hashimoto or dad has some sort of an autoimmune thyroid disease going on or they already have been diagnosed with celiac and they’ve got young kids. You’re going to be flagged to consider that I’m sure. Do you ever test for the HLA genotypes?
Dr. Mona Morstein: I have not. No. I haven’t. I have every now and then if a parent has Type 1. I’ve tested kids for just the antibodies.
Dr. Kara Fitzgerald: The antibodies.
Dr. Mona Morstein: Right? Because I guess I’m more interested in that than if they just have the risk for it. Right?
Dr. Kara Fitzgerald: Sure.
Dr. Mona Morstein: I’m more interested in doing that with kids.
Dr. Kara Fitzgerald: The key antibodies you’re going to look at are the anti-insulin antibodies and the GAD?
Dr. Mona Morstein: Yeah, GAD65 is an enzyme in the beta cell and the islet cell antibodies. There’s a few others but those are the main ones. There’s the zinc 8 one, but there’s a little panel of diabetes antibodies. In a lot of patients, the adult patients with Type 1, the signifying antibody is the GAD65. That’s the one. If you have a skinny Type 2 diabetic and they were never overweight and they were eating right and exercising and they “came down” with Type 2, you should have a high suspicion that they actually have Type 1. Testing for GAD65 will give you potentially a new diagnosis. I’ve had to re-diagnosed dozens and dozens of misdiagnosed Type 2 diabetic patients who really had LADA.
Dr. Kara Fitzgerald: Okay. All right. Good. That’s really useful for us. Let’s move on to … Give me the risk factors to Type 2 diabetes. We’re primarily talking to a clinical audience so they’re going to have the general idea. But let’s run through them and then we’re going to talk about your workup and your treatment and all of that.
Dr. Mona Morstein: Well, Type 2 is more … We’ve got those kind of figured out. Obviously, having abdominal adiposity. The insulin resistance certainly comes from that beer belly. The abdominal fat produces inflammatory cytokines that cause cellular insulin resistance. Obviously, we would associate people maybe overeating. But not only overeating, but overeating foods that produce say nutritional deficiencies, that they’re not getting in D or omega-3s. They’re not getting in zinc and magnesium and fiber and things that can help the cells not become insulin resistant. Also not getting fiber can injure the microbiome. We do know that if the microbiome is producing inflammatory cytokines, those can transverse through into the body like tumor necrosis factor alpha and cause cellular insulin resistance. For eating a bad diet, it may also not be getting us nutrients, but it could be harming our gut microbiome, which then systemically can initiate insulin resistance.
We certainly have, for example, environmental toxicity. Environmental toxicity is totally associated … The persistent organic pollutants can also be called obesogens, can certainly be called diabetogens, and we have very good studies that in people that have more chemicals in their fat cells, they have more insulin resistance and more risk of diabetes.
You can also say … Gosh, sleep apnea is super associated with developing poor appetite control, craving for carbohydrates and gaining weight. In fact, the NHANES, our National Health and Nutrition group, found that if a person gets less than five hours of sleep at night, their risk of becoming obese increases 235%.
Dr. Kara Fitzgerald: Wow, wow.
Dr. Mona Morstein: Not like 10%. We’ve got to look at … Of course, lack of exercise, obviously, since that is one way to develop muscles which burn most glucose and of course burn calories. We’ve got a lot. You can also say hormonal if they’re producing too much cortisol, if they’re not working with good stress management and not only producing more cortisol, but of course many people handle stress by overeating. There’s lot of interrelated aspects of etiological factors with our Type 2 diabetic patients.
Dr. Kara Fitzgerald: Talk to me about, in addition to the abdominal adiposity, some of the obvious presenting signs of someone on the diabetic continuum. What are the other physical exam findings you’re looking at?
Dr. Mona Morstein: Well, they may have wounds that don’t heal well. They may also be getting a little fungal, athlete’s foot or even … I just had a diabetic patient develop ringworm. There’s a little more fungal growth since fungus loves sugars. But in general, these people can walk around kind of like hypertension. Maybe they feel tired. Maybe they feel fatigued. They’re moody but you can’t really … If it’s very bad, they may be urinating a little more. The problem is it can be a little bit silent for people. I have had so many Type 2 patients. I ask, “Well, how were you diagnosed?” “Oh, I hadn’t had a yearly for six years, so I went to the doc and just thought I would get that.” Bam, you’re a diabetic patient. There aren’t a lot of overt signs unless it is really spinning very badly out of control.
Dr. Kara Fitzgerald: What’s the standard lab panel you’re looking at with your Type 2s? Then I want to talk about some of the specialty tests that you use and some of the nutrient markers you’re looking at.
Dr. Mona Morstein: I think with Type 2 obviously your basic yearly panel. We do want to check obviously lipids, the kidneys, the livers, your basic CMP, CBC. I always include a ferritin because ferritin is by far the number one marker, if it’s elevated, that indicates fatty liver. Before GGT and before liver enzymes are elevated, in general, by far the most reliable one is an elevated ferritin. Now, you can rule out hemochromatosis, but only 2% of the population has hemochromatosis and those numbers for ferritin are 700, a thousand. Ferritin can be elevated but less so. Fatty liver is now the number one chronic liver disease in the country, so it’s a lot more popular or common, I should say, than hemochromatosis.
I would like to do vitamin D. Of course we’re always doing glucose. We’re doing hemoglobin A1C. It’s good for the Type 2s to get a C-peptide so we just know where is their pancreas production of insulin. If a person injects insulin or has an insulin antibody, insulin is no longer really a good marker. The other thing with insulin is that it doesn’t really have a range. It just says it’s six or eight. But we have a range with C-peptide generally from 1.1 to 4.4. There’s a lot of Type 2s that will show up at five or six showing pretty clear insulin resistance. But we’re also looking to see if it’s getting low, if they’ve been Type 2 and uncontrolled for a long time and it may indicate that they actually do need to start on insulin. C-peptide is a good test. I think it’s also good to get an hsCRP. Obviously we know the number one reason uncontrolled people with diabetes die is cardiovascular disease. Checking inflammation, checking fibrinogen.
We may want to do one of those specialty … Instead of just cholesterol and triglycerides, do the specialty panels with lipoprotein A and apolipoprotein B and just get a little more risk factors for cardiovascular disease. We may want to check homocysteine as well for another cardiac risk. I probably said vitamin D. We could check the thyroid. Insulin resistance does decrease thyroid in men. Testosterone, free and total testosterone can be decreased from their insulin resistance, and even worse, if they were put on a statin drug. Very bad combination to maintain good testosterone levels in men.
The GlycoMark is a specialty test that helps us interpret … You get an A1C and it’s six. The problem with an A1C of six, which on average means your blood sugar has been around 126 say, that could mean that’s because you wake up at 80 or you make it about a hundred and it goes to 140 during the day, so you have a pretty narrow range of blood sugars that have an average of 126, or it could be you go down to 50 and up to 240 and it still gets an average of 126. The A1C isn’t necessarily accurate for control. It just gives you an average three months number.
The GlycoMark is an interesting test that really helps understand if the blood sugars are elevated, particularly after meals. Are you having acute excursions after meals? That can be a good help in understanding the A1C, as well as a diet dietary and a glucose graph, but also giving patients motivation to maybe tighten up the diet just a little bit to get that GlycoMark number in range. I guess off the top of my head, those are a few things that we’ll be drawing.
Dr. Kara Fitzgerald: You know what? I haven’t gotten the GlycoMark. I mean, is this something I can get through a standard lab?
Dr. Mona Morstein: Oh, absolutely. You bet you.
Dr. Kara Fitzgerald: Is it a first morning fasting? When do you go
Dr. Mona Morstein: No, it’s just … Well, I mean, it doesn’t need to be fasting but you’re going to usually do it with your
Dr. Kara Fitzgerald: With the others.
Dr. Mona Morstein: … Regular labs that need to be fasting.
Dr. Kara Fitzgerald: What is it exactly looking at?
Dr. Mona Morstein: There’s this chemical called 1,5-AG which is in our body at a certain level all the time. The kidney resorbs it so that it has this range of say it’s like 9 or 10 to 26 or so. When your blood sugar goes high, the kidneys open up to release the glucose generally if it gets over 200 and unfortunately the 1,5-AG is sucked out with the glucose, so when we measure it in the serum, you have a low level. The lower the level of the GlycoMark, the higher the excursion of the glucose was, right?
Dr. Kara Fitzgerald: Okay.
Dr. Mona Morstein: It’s a little opposite of what we’re thinking, but we actually want higher levels of GlycoMark showing that we never really had any acute elevations of the A1C.
Dr. Kara Fitzgerald: You’re still using the A1C but with the caveats you just talked about and then you’re kind of, tightening
Dr. Mona Morstein: Yeah, especially…
Dr. Kara Fitzgerald: … it up with the GlycoMark.
Dr. Mona Morstein: Yes. Yes. Pardon me for interrupting. But if the A1C comes back at 10, your glucose is always high. You’re going to have a low GlycoMark in that regard but more of … Where is it? If it’s at 6.5, is it the nighttime or is it after meals? It helps us pinpoint a little more acute elevations when the number isn’t that bad. It’s not ideal but we’re trying to figure out where are those rises coming.
Dr. Kara Fitzgerald: Are you doing glucose, insulin tolerance tests?
Dr. Mona Morstein: I do those … I’m going to do those in pre-diabetic patients. I think it’s a really bad thing to do it in people who have diabetes. If you do a test like that, I mean, obviously the blood sugars are just going to shoot up and we already know they have diabetes. In pre-diabetic patients, often I may do a fasting glucose and insulin.
I actually have them eat a meal from a fast food place because I’m always interested in seeing what does food have to do with this instead of just the glucose drink? Because we don’t eat glucose. We eat food. I make them eat a certain meal at a fast food place and then retest their glucose and the insulin about an hour and a half later. That can give us a very good idea of just how insulin resistant, mild, moderate, severe that person is.
Dr. Kara Fitzgerald: Yeah. Okay. Good. You’re giving them two lab slips, fasting, blood sugar, fasting, insulin. Then you say, “Go to McDonald’s and have a Big Mac and some fries?” Then go back…
Dr. Mona Morstein: No. No. No. I do send them to McDonald’s but they get a pancake order, but only eat one pancake. They have one syrup and they have one hash brown and water. That’s a hundred grams of refined carbohydrates with a crap load of saturated fat. If that doesn’t cause them to be insulin resistant, then they will not become insulin resistant. I figured that out with the nutrition online of McDonald’s, so it’s in that 75 to hundred gram carbs.
Dr. Kara Fitzgerald: Wow. Okay. All right. Yeah, that’s useful. Okay. Good. Specialty testing. I mean, you mentioned stool testing in the book. Talk about that and are you looking for intestinal permeability, like with the zonulin or lactulose, mannitol? What are some of the specialty tests you’re thinking about in this population?
Dr. Mona Morstein: In the Type 2 populations, first, food sensitivity I do if there’s another condition associated, say if they have diabetes and psoriasis or asthma. Although obesity can just cause the asthma since it’s so pro-inflammatory. We realize that a diabetic diet is pretty restricted. To just do a food sensitivity test and take out even more foods, we have to be careful. People have to eat. If there’s a reason specifically, they get migraines, they have asthma, they have psoriasis, they have GERD, they have some other condition that I so associate with food sensitivities, that’s when I do it. The gut, the stool analysis, again, what is their gut like? Is it healthy? Have they had a lot of antibiotics? How obese are they? What have their diets done?
With the gut, we’re looking for beneficial bacteria, dysbiosis, yeast overgrowth. I am not fan right now of that zonulin test done through a certain lab. I have not been happy with it. At this point, if I want to do leaky gut, I do like the lactulose, mannitol test. I think that is clearly functionally telling me what is getting through the gut. But the antibodies, again, like, for example, you can have antibodies to diabetes but not have it. Same with Hashimoto’s. I don’t like that antibody test from that one lab. I’m much more into, functionally, is someone showing leaky gut? Are they sucking in that lactulose? That is not okay. Then I know. That’s the test I prefer. Go ahead.
Dr. Kara Fitzgerald: Let me just ask you before we move on, the food sensitivities. I’m assuming you’re looking at IgG?
Dr. Mona Morstein: Yeah. I have used Alletess forever, for well over a decade. I think it’s an amazingly accurate test. It’s IgG but you want one that does subsets one through four, does all of those. Now, you have some Docs that say you also have to do IgA or this. You know what? If you’ve got a good lab that does IgG, you’re going to get your results. Again, if you keep pulling foods out and out and out, what do people eat?
The other thing is that, let’s face it, we have the top 10 food sensitivities: gluten, dairy, eggs, corn, soy, almonds, coconut, tomatoes. Everything else really is a leaky gut. You pull those off for a month, heal their gut and you can add them back in right away. Right?
Dr. Kara Fitzgerald: Mm-hmm (affirmative).
Dr. Mona Morstein: It concerns me that a lot of people don’t know how to interpret food sensitivities. People have to avoid 40 foods for three years. It’s ridiculous. For me, I’m very content with just IgG with a good lab. I get the foods that I need. It’s not too many. When I work my protocol, it really helps them out.
Dr. Kara Fitzgerald: Right. We’re going to circle back to your protocol. One more question on labs. Nutrients. You mentioned vitamin B and what else?
Dr. Mona Morstein: I do want to say one other lab to consider results is environmental testing.
Dr. Kara Fitzgerald: Yes. I want to talk about toxins as a separate question.
Dr. Mona Morstein: Oh, okay.
Dr. Kara Fitzgerald: Nutrients, are you looking at nutrients?
Dr. Mona Morstein: I am not very pleased with nutrient testing companies either. I don’t really want to spend $700 and another test … Do any of us really know what that test measures? I’ve had problems with that cheaper test where the patient came back B12 deficient. But then I tested serum B12 and methylmalonic acid and it was perfect. I’m not really sure.
For me, I do diet diaries. First visit, they’re doing … Well, I’ll give them a seven-day diet diary, and I will see everything they eat and drink for seven days. Yes, I mean, I have a nutrition degree. I was chair of nutrition. I feel very confident that any naturopathic or integrative physician should be looking at diets and knowing foods and nutrients to really pull out what they have in their diet and what they do not without having to spend a lot of extra money on it.
Now, I do measure of course the vitamin D. I do think if they have neuropathy … We can do serum B12, methylmalonic acid, folic acid, homocysteine. We can do D, iron. We could do red blood cell zinc. These key nutrients can … red blood cell magnesium. That can be done through their labs where their insurance pays for it and these are some of the key nutrients that we really care about, right?
Dr. Kara Fitzgerald: Right. Absolutely. Yeah. Yeah. I’m with you. I know. I think we can get a good insurance-covered workup from a standard lab. Yeah. You mentioned toxins in the beginning as a major player. I think you were citing that 2006 Lee, et al., study about the association of persistent organic pollutants in diabetes in your book.
Dr. Mona Morstein: Yeah, absolutely.
Dr. Kara Fitzgerald: That’s a great, great seminal paper. Folks, I will link to it. It’s just really one of my … It’s just one of the strongest papers. It’s interesting how it didn’t generate the buzz you would have expected. Just talk about that again. You touched on it earlier, the process. Well, let me just ask you this. Talk about it. What are you thinking about clinically with your patients and how you’re dealing with the likelihood that POPs are playing a role and how you work it up?
Dr. Mona Morstein: I think we can assume everybody has environmental chemicals in their fat cells, lead in their bones just today just because we know from cord blood in infants, in newborns, they have over 200 chemicals in their cord blood.
The idea is what was the exposure … We all just get exposed but do they work in any industry or job that even gave them more? You have to ask every patient. Do you have exterminators? Do they spray outside? Do they spray inside the home? Do you have a lawn guy? Are you spraying Roundup around your home? What is their personal exposure? Do they have sensitivity? Can they not walk down the detergent aisle? Does perfume give them headaches? How just really overtly toxic are they that they’re showing symptoms or not?
I do do heavy metal urine testing for a main environmental but there’s now newer labs that … Great Plains is coming out with a good urine test. I’m starting to play with that. But we have to deal with this in a number of different ways because people have to get these chemicals out to be able to really help reduce their insulin resistance. The idea is I have handouts on just … I give them. We go over the environment and how their home has to be very green and very clean. I refer them to the really organic exterminators in town that are green and not just doing the chrysanthemum pyrethrins made from a flower, the fake green people.
Then I try to get them into saunas. We sometimes have to do an actual detox protocol with them, but at least they have to start cleaning their home, getting supplements to help detox. We have to make sure their livers and kidneys are working well. I have to get them sweating. We have to just start opening their emunctories. Make sure they’re pooping daily and just start working on these levels to ensure that not just to begin with but also we know scientifically as people lose weight, they will release chemicals and that could be, I feel, that could be one of the problems where people lose weight, lose weight, lose weight and then reach a plateau and they can’t lose weight more. I have concerns that it’s because of these chemicals now being so in their system. If they’re not peeing and pooping and if their liver isn’t supported, if they’re not sweating, then these chemicals maybe then just re-initiating the insulin resistance. It’s a whole process with patients working with these chemicals.
Dr. Kara Fitzgerald: Let me just summarize this. You’re assuming everybody has got a toxic burden, which is logical. Then you’re doing some kind of an intake to find out how severe it might be in an individual just given their presentation and…
Dr. Mona Morstein: Where in their own homes and workplaces …
Dr. Kara Fitzgerald: ……..What’s going on.
Dr. Mona Morstein: Yeah. I have a guy who’s a Type 2 diabetic. His office is right next to the machinery shop. Then you might need a HEPA filter or you might need things just even in your own office or you’ve got to take some extra liver support. You’ve got to really be protecting yourself if you’re just every day you go to work and you work in a building or a factory where you’re getting an exposure.
Dr. Kara Fitzgerald: Are you recommending everybody go to organic, use glass and those basic kind of…
Dr. Mona Morstein: Yeah, those are also my handouts that I have. No plastics is the number one bolded thing to do. Not to cook in, not to carry, not to store plastics. Especially here in Montana where you leave it in your car, and you’re thirsty and you get back in. Oh, it’s a little warm. I’ll drink it. No.
Dr. Kara Fitzgerald: Yes, yes.
Dr. Mona Morstein: Yeah, plastics. Then definitely organic. I say organic to be honest as it’s available and affordable. I have cards of the Clean Fifteen, Dirty Dozen of any food that is okay on a low carb diabetic diet. Like leafy greens, all leafy greens must be organic. They are at the bottom of the most toxic vegetables. There are just some things everybody has to get in organic.
Dr. Kara Fitzgerald: Yeah, absolutely. If you’re open to sharing some of your guidelines with us, we’ll post them. Incidentally, folks, we’ll also post Dr. Morstein’s website and some of the other links, a link to her book and just any of the papers we mentioned on here. We’ll circle back and try to corral that material together.
Dr. Kara Fitzgerald: All right. Let’s talk about diet because you are the founder of the Low Carb Diabetes Association. I got a hint at where we’re going to go. Give me the high level view of what you’re doing with the diet…
Dr. Mona Morstein: What’s interesting is that, I don’t know if you just saw, but this week …
Dr. Kara Fitzgerald: Yes.
Dr. Mona Morstein: The article that came out.
Dr. Kara Fitzgerald: Yeah, the Ludwig
Dr. Mona Morstein: Diet. What I think is interesting about that is that…
Dr. Kara Fitzgerald: Give a snapshot. Give a snapshot of the study first.
Dr. Mona Morstein: This study was using low carb diets in Type 1 pediatric patients and showing how it’s so helped control their glucose without the highs and lows of a standard diet causing brittle “diabetes.” What’s fascinating to me and frustrating is that if this had been a drug trial, if this drug had controlled their diabetes as well, they would have said, “We got to start using this right now.” Since it was a diet, they’re like, “Well, this was a great study and the diet was magnificent, but we just need more studies. We can’t recommend this for all people with Type 1 diabetes.” That’s where we hit our heads against the wall in this regard.
Dr. Mona Morstein: For Type 2 diabetes, Drs. Feinman and Bernstein, there’s a very key study that came out with 26 medical doctors and the researchers that a low-carb diet needs to be the initial treatment diet for diabetes. This was in a peer review journal. Dietary carbohydrate restriction as the first approach in diabetes management. The low carb diet is very validated by many, many studies at being able to control diabetes. Diabetes, as a one sentence definition, is you’ve lost the metabolic capacity to process carbohydrates. This is the key diet.
Dr. Mona Morstein: On the other opposite extreme, there were a couple of good studies on what’s called the MaPi2 diet which is actually really a macrobiotic, high carb, almost no fat, vegan, very low protein diet that also showed immense, immense improvement in all lab and body indices of diabetes. You do get some people saying, “No, it’s got to be a high carb, low fat, plant-based diet.” But in reality, for most, I would say the low carb is really the key diet to start and use with patients. That’s my promotion.
Dr. Kara Fitzgerald: Yeah, absolutely. I would assume compliance might be a little bit better with a low carb management.
Dr. Mona Morstein: That’s true. It’s true because even in the macrobiotic study, this was on men, they were fed this diet. They didn’t prepare anything. In terms of being able to socialize or go out to a restaurant or live with your family, a low carb diet is so much more usable in that regard than a macrobiotic type diet.
Dr. Kara Fitzgerald: Well, listen, if you can give me the citations on those papers so we could throw them in the show notes, that would be great. Why do you think that particular diet was successful? Because they seem like they’re diametrically opposed.
Dr. Mona Morstein: It does seem like they’re diametrically opposed. I don’t know. I tried to figure this out. I do think Dr. Jo Pizzorno who’s an amazing ND and of course he’s one of the leading NDs on environmental chemicals and even in insulin-resistance, but he did this great talk at 2014 AANP Conference on cellular acidity, not serum acidity because that doesn’t change, but intracellular acidity. That too much intracellular acidity, which is caused by animal protein, the sulfur amino acid proteins which are animal proteins and too much salt, can certainly increase insulin resistance.
Dr. Kara Fitzgerald: Fascinating.
Dr. Mona Morstein: You just wonder if there are some people that have that … I’m just theorizing. But what I’m trying to connect it, if we’re really reducing everything that could produce say intracellular acidity and that is a huge aspect of some people’s production of insulin resistant tendency, maybe that helps them.
Dr. Kara Fitzgerald: That’s pretty fascinating.
Dr. Mona Morstein: I’m just pulling those … Also we do know, now the ketogenic people may not like to hear this, but too much saturated fat can produce insulin resistance.
Dr. Kara Fitzgerald: How does it do that if you’re very low carbohydrate and your insulin levels are extremely well controlled? I mean, what’s the mechanism?
Dr. Mona Morstein: Well, if we’re just getting too much saturated fat, it’s starting to interfere with the cell’s recognition of insulin even if it’s a relatively lower insulin. Certainly we do know that omega-3s are needed in the cell to produce insulin sensitivity and so-
Dr. Kara Fitzgerald: Are you talking …
Dr. Mona Morstein: In the cell wall.
Dr. Kara Fitzgerald: Okay. In the cell membrane. Okay. Okay. Yeah. It’s the ratio. If the ratio of saturated fats in the membrane to the poly and saturated 3s in particular is too high, then you’re setting yourself up for problems.
Dr. Mona Morstein: That’s what it seems.
Dr. Kara Fitzgerald: Good. Well, that does make sense. That does make sense. I mean, then it becomes a really rigid membrane but it’s not.
Dr. Mona Morstein: Exactly. You see this with depression and with other cells in the body.
Dr. Kara Fitzgerald: Okay. That’s a really good point. Listen, this is off, just my own curiosity. I don’t know if you’re going to remember this from 2014. But how he did he say you would assess intracellular acidity? Out of curiosity.
Dr. Mona Morstein: He did say that a random urine and even saliva does not pick that up.
Dr. Kara Fitzgerald: Oh, pH. He’s using pH.
Dr. Mona Morstein: He thought that potentially a 24-hour urine pH might be helpful. Yes.
Dr. Kara Fitzgerald: That’s great. Okay. Okay. What kind of carb count are you looking at when you’re doing the low-carb diet?
Dr. Mona Morstein: Generally I’m striving to have people have less than 45 even ideally maybe less than 40 grams a day.
Dr. Kara Fitzgerald: I’m assuming most of those carbs are coming from veggies. Are you doing any fruits?
Dr. Mona Morstein: Well, fruits are very individual. Obviously, we start off by not having fruits. Now, by fruits, of course I’m not talking about avocado, cucumbers, olives or even some tomatoes which are “fruits” but none of us consider them “fruits.” If we’re talking about fruits, if they want to try, if they’re pretty well controlled and they just … I will say try a quarter cup of berries at lunch, not breakfast, not supper, lunch. Then we just need to see what does their blood sugar do? We really can’t do a lot. If we’re going to do fruit, it can only be berries, a little bit at lunch. You have an apple, that’s 20 grams of carbs. The banana is 34. These are just not going to be fitting in a low-carb diet.
Dr. Kara Fitzgerald: What are the carbs you’re going to tell them to eat?
Dr. Mona Morstein: Well, carbs I’m telling them to eat would be pretty much, like you said, the vegetables, nuts. Nuts will have some carbs in them. Otherwise, that’s pretty much it.
Dr. Kara Fitzgerald: That’s it. The carb allowance. I know. It goes quick. 40 grams of carbs-
Dr. Mona Morstein: Watching out with the nuts, at least they … Making nut pancakes or nut bread, nut granola. This can add a really pleasant variety to the diet that people enjoy.
Ketogenic gets all the name out there but in reality, my patients, most of them don’t want to do a really strict ketogenic. They want to be around 30 grams, 35 and get nut breads in and get this in. They still do very well but that ketogenic, it’s just meat and cream and a little veggies. A lot of my patients are not really interested in taking it that far.
The other thing we have to realize is that with any low-carb diet, ketogenic or a more omnivore type ketogenic, it’s going to ruin the microbiome. We have got to give fiber powder at least 4, 10 grams a day because without that bran, without that grain fiber, it is going to negatively change the microbiome.
Dr. Kara Fitzgerald: Good. I wanted to move on to talking about some of your interventions. What kind of fiber are you recommending?
Dr. Mona Morstein: Well, I don’t really care what fiber powder it is per se. Particularly though I like ones that do have a little bran in them, oat bran, rice bran. But if they are getting in ground flaxseeds or psyllium or you want to get some apple pectin … I don’t particularly care. Honestly, yes, I do care because I think bran, that’s the number one thing that we’re pulling out of the diet when we’re pulling out the whole grains. That is the food of the beneficial bacteria and they turn it into short chain fatty acids which is the food of the colon. Short chain fatty acids systematically, when they get absorbed, they’re anti-inflammatory. They’re very helpful and so we just have to realize that willy-nilly pulling out the grains, these have consequences in our microbiome.
Dr. Kara Fitzgerald: Okay. Good point. Some of the essential nutraceuticals you’re prescribing to your Type 2 diabetics.
Dr. Mona Morstein: I will always start with a good multiple vitamin because we’ve just got to make sure that every single day they get all the vitamins and minerals that a body needs to run well. Then I will also put every patient on fish oils and at least a thousand EPA, 750 DHA, at least that a day. Sometimes I will double it for patients.
Dr. Mona Morstein: Look, I have a diabetic product that I think is the best. It’s called, if I may-
Dr. Kara Fitzgerald: Yup.
Dr. Mona Morstein: It’s called Diamend. It’s made from Priority One. You got to give Gymnema sylvestre, an alpha-lipoic acid, and benfotiamine and some bilberry. You’ve got to give a little extra zinc and chromium, vanadium. You got to give a little liver support. You’ve got to give a little green tea … turmeric. It’s good to find one product that has therapeutic doses of all of these antioxidants because, look, what are we doing with Type 2 diabetes? We’re trying to replenish nutrients. We’re trying to maximize cellular functioning. We’re trying to need antioxidants. We need anti-inflammatories because if their blood sugar is high, it’s going to cause oxidative damage. That’s the pathways that initiate the diabetic eye and kidney and nerve and endothelial damage. We’ve got to be protecting their body. We’ve got to start with these vitamin, minerals, oils and then diabetic protections.
Dr. Mona Morstein: The Gymnema sylvestre can reduce their cravings for sweets. It can also help regenerate pancreatic beta cells. Probably most patients may be deficient in D. Dose D as they need. Everybody needs to be on fiber powder. You might want to choose at least temporarily a probiotic if you need. Klaire has one, a metabolic formula for people that have a metabolic syndrome-type condition. I mean, that’s a good start because if you get one product that has the alpha-lipoic acid, and the benfotiamine and the gymnema and the turmeric, you’re covering many, many bases of what we are needing to achieve in our patients.
Dr. Kara Fitzgerald: Yeah. What about some, just out of curiosity and your opinion and experience, botanicals that have been really pushed as effective but may not rise up?
Dr. Mona Morstein: Oh, well. My diabetic product also has berberine in it.
Dr. Kara Fitzgerald: Yeah. Yes. Lots of vitamins.
Dr. Mona Morstein: We’ve got a thousand milligrams of berberine and gymnema, bilberry, turmeric. If we’re thinking of top botanicals, these are green tea extract. These are ones that come up in the study as protective and have good clinical effects on people.
Dr. Kara Fitzgerald: Yeah, it’s a nicely designed product. Again, we’ll link to it in the show notes so people can check out. It really is a nicely designed product and I know you’ve got a good background in botanicals so I appreciate that.
Medication. Talk about that. Are people going to be coming to you wanting to get off meds? I’m sure people are wanting to taper and reduce or stop insulin. There’s some medications you like, some medications you strongly recommend not initiating or stopping. Give me the high level view on that.
Dr. Mona Morstein: Yeah. Medication, obviously, with Type 2 everybody everywhere starts with Metformin. Now, because Metformin, it doesn’t cause weight gain, water retention, cardiovascular disease like other drugs do, it mainly stops the liver or mainly reduces the liver’s production of glucose. There’s a little, little bit of maybe insulin resistance help, but mostly it’s working in the liver. Its main side effect could be upset stomach, but if that happens, you can switch to Metformin ER, which for most of the patients takes away the stomach upset. Don’t worry about Metformin. It’s a good drug. It’s safe and it can help patients innately get their blood sugars at least under better control so their insulin resistance goes down and they can start losing weight.
I like the GLP inhibitors, the glucagon-like peptide 1 inhibitors. Generally now, it’s a once a week injection that decreases appetite, increases glucagon. It slows down the stomach digestion, so we have a slower excursion of glucose into the body, also shown help to lose weight, doesn’t gain weight, one shot a week. It got associated with pancreatitis, but I’ve never seen that. I don’t think it’s a very common thing at all. If they have a medullary or they had nodules on their thyroid, probably don’t want to give it. That would be my second drug that I would use.
The sulfonylureas cause secretion of insulin from the pancreas, associated with water retention, weight gain, hypoglycemia, particularly glyburide is the worst in that regard. Now the new ones, the sodium-glucose transporter-2 inhibitors, these also cause weight loss. They prevent the kidneys from reabsorbing glucose, and the kidney can be responsible for 25% of glucose in the serum. It’s a pretty big thing.
Are there concerns that it can cause what we call a euglycemic ketoacidosis where even in Type 2 patients they can wind up with the ketoacidosis crisis even if their blood sugars aren’t really that high? That’s not very good. We’re not so sure that it also isn’t harming the kidneys long term or causing other problems, but it is a one-a-day drug and it can cause … It causes people just to pee out more glucose. That can set them up for vaginal and genital yeast although that doesn’t tend to be chronic although some people get thrush. I’m not sure where that connection is. It has some side effects but it’s again another one where at least we might have some weight loss. You have to watch it with blood pressure. There can be some low blood pressure problems because they’re losing a lot of fluid, too.
There’s the sulfonylureas and then there’s drugs. Those work all day. You’ll need generally to take one a day. There are ones that work just at meals that last shorter, but we don’t really want to use those because most people would rather take one pill a day. Then there’s Avandia and Actos, the TZDs which are essentially off the market since the ACCORD trial that showed the increase risk of cardiovascular disease with them. You can prescribe them in this country but nobody really does and they’re still off the market in Europe.
The whole problem with drugs with Type 2 diabetics is that the disease is insulin resistance and actually none of the drugs deal with insulin resistance. The only ones that did were the Actos and Avandia, and they were taken off the market. We actually have no drugs that actually deal with the innate problem of Type 2 diabetes. Mostly what we’re doing with the drugs is just trying to clear the glucose out of the serum and store it in the fat cells and that has consequences that are problematic.
Dr. Kara Fitzgerald: Right. Right. Ultimately it goes back to diet and lifestyle.
Dr. Mona Morstein: Yeah. Ultimately. Exactly.
Dr. Kara Fitzgerald: I know we’re really at the end of the time. I’ve got a bunch more questions I want to ask you, but I’m going to refer people to her book. Again, it’s a great book. It’s over 500 pages. She’s got a huge bibliography and it’s Master Your Diabetes: A Comprehensive, Integrative Approach for Both Type 1 and Type 2 Diabetes. I wanted to spend some time talking to you about diabetic complications but you cover it in your book nicely.
Dr. Mona Morstein: Thanks.
Dr. Kara Fitzgerald: … with good treatment recommendations so neuropathy, retinopathy, nephropathy and other complications. Folks, you can actually look at some of the interventions Dr. Morstein is using.
Dr. Kara Fitzgerald: Just to wrap because it’s essential, talk a little about lifestyle. You touched on high cortisol. We know that’s totally diabetogenic when it’s uncontrolled stress. We know exercise is huge. Some of the things you’re thinking of there to just take…
Dr. Mona Morstein: Yeah, for sure. Certainly exercise and there’s different ways to exercise. Obviously, cardio, resistance, high-intensity interval training. Whatever you’re doing, you just got to get a person out and moving their body and starting at a capacity they can do and increasing it.
Certainly stress management. What we have to understand is that stress can aggravate diabetes, but diabetes can aggravate stress, too, or can be a cause of stress. You can’t eat this. You can’t eat that. You have to check your blood sugars. You’re doing this, good job but your A1C was still a little high. We have to make sure that people feel good about themselves and are dealing with their stress, but that they also have a physician that is a really good, non-judgmental support and motivator for their diabetes.
Now, also sleep. We didn’t get a lot to talk about sleep. If they’re overweight and they say … You’ ve got to ask. Do you snore? They’re like, “Yeah, I do snore.” You should send them for a sleep study. We’ve got to pick up sleep apnea as soon as possible to get that under control. I have another handout on just sleep hygiene at night, how to ensure you’re going to be getting a good night sleep. There are things you need to do.
Those are key lifestyle aspects. The other things of course is living green in that regard, but these have to be big aspects of your discussions with your patients.
Dr. Kara Fitzgerald: That’s a really lovely ending that we need to meet our patients where we’re at, non-judgmentally, support them in the journey, not have their walk towards wellness be fraught with stress and restriction and frankly depression and anxiety and so forth. Really, really important stuff for us today and I appreciate it. Again, send me whatever you can. We’ll pop them into the show notes.
Dr. Morstein, it was a pleasure to talk to you. Thanks for joining.
Dr. Mona Morstein: Thank you, Kara. I really appreciate it. Thank you so much.
Dr. Kara Fitzgerald: Absolutely. And that wraps up another amazing conversation with a great mind in functional medicine. I am so glad that you could join me. None of this would be possible, through the years, without our generous, wonderful sponsors, including Integrative Therapeutics, Metagenics, and Biotics. These are companies that I trust, and I use with my patients, every single day. Visit them at IntegativePro.com, BioticsResearch.com, and Metagenics.com. Please tell them that I sent you and thank them for making New Frontiers in Functional Medicine possible.
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