Empowering Wellness Journeys: Dr. Jim LaValle’s Integrative Approach to Blood Sugar and Health

Kelly Engelmann: Welcome to the Synergee Podcast, where myself, Kelly Engelmann, and Lori Esarey shed light on powerful tools and topics that nourish your body,

Lori Esarey: and most importantly, feed your soul.

Kelly Engelmann: Welcome Synergee listeners, we are so privileged today to have with us Dr. Jim LaValle. He is a clinical pharmacist. He’s an author of over 30 books and they are rich and deep and wide. He has been on faculty at the George Washington University Integrative Medicine Department for many years. And the way Lori and I got to meet him was actually through A4M. He’s responsible for a lot of the curriculum through A4M and we became groupies we are early adapters, and followed him around to all if we knew Dr. LaValle was lecturing, we were in that class and we got to know our friendly A4M staffers really well so they would let us sneak into classes when we weren’t supposed to be in that class because we needed to hear what Dr. LaValle had to say, and Dr. LaValle, I remember my very first encounter with you where I stood in that long line that we get in after, a lecture to ask a question. And I got up to ask my question and I was completely speechless. I couldn’t get my words out, like nothing would come out and you were so patient with me. You just sat there, you helped me find my words and I knew then that you were just an incredible human being. So we are so honored to have you here today to share all of your rich wisdom with us. 

Dr. Jim LaValle: Thank you so much and, if you’re a good teacher, you need to be a good listener and you’re supposed to pull things out of your students. So I think that they had to pull something out of you, but it worked out. It was all good. 

Kelly Engelmann: It worked out for a few lectures I was a little bit shy, I would write notes to Lori and I would just hand them to her. And I would say just ask this, I’m not even going to try today, I don’t feel good. So the fact that we’re sitting here having a podcast and we can actually have a conversation, I think it’s progress. 

Dr. Jim LaValle: That’s absolutely wonderful and you didn’t even need to be medicated. 

Kelly Engelmann: I really actually my team told me I should have a mimosa, before the podcast. I chose not to, because I didn’t want to be sleepy or giddy or any of those things. But yeah they told me to medicate. 

Lori Esarey: I just want a second that I am incredibly grateful to have you on here today, and yes, we have sat in hours and hours of lectures and you have been extremely gracious with your time and I just want to thank you for carving out time, today to talk about some of the most important things that Kelly and I get to see in our clinics, but is at the heart of its blood sugar metabolism and so much more because we know it’s not just glucose, it’s a far bigger picture than that, so we’re going to dig in today and challenge you a little bit and it’s good stuff, you probably won’t be that challenge but we’re going to challenge you as much as we possibly can because these are burning questions that we have and we want to know if you’re seeing it and what are you seeing so, I’m looking forward to digging deep with you today so thanks so much for being here. 

Dr. Jim LaValle: Oh, my pleasure let’s go. I’m excited.

Kelly Engelmann: So before we get into questions, we really want to know your backstory, what’s the story behind the story? What drives you to be involved in this functional space to the depth and breadth that you are?

Dr. Jim LaValle: I was always into it at an early age, I had cousins importing dietary supplements from Germany and selling them to physicians in the like 1970s. But what really influenced me was my grandmother was a fingerless, totalist, blind diabetic. My father was diabetic. All my Italian aunts and uncles were diabetic. My grandmother used to feel my face with her little amputated little fingers to see how I had grown now, which kind of scares you when you’re 6 years old. But the fast forward to that was, I just got out of pharmacy school. I’m in the roughest neighborhood back then, I was big, I just won a national qualifier and bodybuilding so we’re gonna put this guy in and rub his neighborhood in the Midwest because nobody’s going to rob him. And that is no joke. And they boarded and had all kinds of steel curtains for this store, right? It was a Kroger store and at about five till nine at night, a woman comes in and gives me her prescription for diabetes medication, I can’t believe we’re going to talk about glucose because this is what’s driven it all for me. She gives me that medication. I go and fill it. She comes back. I look at her grocery cart. I just looked at her. I saw my grandma and I said, can I show you around the store? Wasn’t supposed to do that by the way. I wasn’t supposed to leave the pharmacy, but I showed her around the store, showed her some better options, she was very grateful things that she could afford to change. Next two weeks in the roughest neighborhood in the greater Cincinnati area, over a dozen people come in wanting the grocery store tour, and a rubbish neighborhood now, but here’s what ends up happening I go to the president of Kroger’s I say, I want to tag foods for low sugar for diabetes, friendly heart health, I want to test people for blood sugar. I want to test their lipids, cholesterol health with shopping at Kroger’s 1983, I’m doing this. And he looked at me. I got into the president of Kroger’s, which is, I had a ponytail on an earring back then. I was like, how did I, he said, how’d you get in here, boy? He’s I’m not going to do that, I’m not going to tell some of our biggest food vendors that their foods don’t qualify. Just get out of here, right? So he throws me out and I go to my marketing area manager who was a pharmacist and I said, look, I want to tag foods, I want to bring people in have wow events. And I went through the whole store and tagged foods individually. We tested found more diabetics than anyone in the country. We sold more glucometers, and it pioneered food tagging within Kroger’s which created 2. 7 million impressions a month, about eating healthier. That was 1983 and what it did, I still get pretty choked up about it, every time I tell that story, when people ask me, what really got me going was. You never know who it is, you’re going to reach out and touch and how it’s going to make a difference. Like she was a Medicaid, inner city, man, there was no reason for me to take that effort and being a young guy out of school, I didn’t know any better, I just hey, I’m gonna try and help you. And that’s what fueled my career, I realized that you can be a service, it only takes 1 person to impact millions of lives. 

Lori Esarey: Wow.

Dr. Jim LaValle: Is why every person, why I go to A4M is there’s somebody in that room, that I’m going to speak to, that’s going to change millions of lives and I’m positive of it. And that’s what drives me. 

Lori Esarey: And that’s 1 of the reasons why we truly love you, because that speaks through you every time you talk and, our stories, although I can’t say that I’ve seen that come alive in a grocery store setting for me, but I’ve seen that come alive in the clinic, it’s almost like this tsunami effect for change, right? With one person, your story really resonates with me deeply because I’m that Italian family. That is my story diagnosed it, 25 years old with diabetes yet I was a marathon runner and none of it made sense. And, like we’re going to talk about today, what we know today about the significance of glucose control. We did not know then we were seeing it, but we didn’t have the data, we didn’t have the research. And now we do, it’s just crazy, but congrats on that change and just what that did to get you where you are today. 

Dr. Jim LaValle: 40 years now. It literally took me on a journey of 40 years of being in this business and started writing right away and left pharmacy and went into more clinical pharmacy and, got all my other certifications and degrees. It’s been quite the journey, what’s interesting when you cross the 60 threshold, I’ve well crossed it. You start looking back and going, man, what a ride. I see examples, we’re talking about diabetes and one thing I want to people understand is it’s never too late, my father was 79 years old when he was diagnosed with a duodenal adenocarcinoma, very rare. But he was diabetic, poorly controlled diabetic since the age of 38, world famous chef, top 100 chefs in the world, right? They do a Whipple surgery, so if you’re listening on the podcast, a Whipple is the biggest GI surgery, they may take out the lower third of your stomach and your duodenum and they take off the top part of your pancreas. He didn’t have pancreatic cancer, but typically a surgery like that, somebody lives three or four years, right? Somebody 79 years old getting that kind of surgery. He came to live with us and, the 1st thing I said to him was a pop, because little Italian. Literally, a little Italian, I said, hey, pop, guess what? Party’s over now.

Kelly Engelmann: Welcome to my house. 

Dr. Jim LaValle: We’re going to eat my way. And I’m going to tell this to people want to understand he wasn’t given much hope, right? He lived an additional 13 years, he lived to 91 years of age. By improving his diet and doing strategies to control glucose more efficiently, understanding the underlying mechanisms in him. That was causing him to have this inflammation, cancer signaling, glucose issues. And he championed it at age 79, he had to do it I could point the way for him, but he did it. And he got to see his grandson grow up and he got to go and enjoy, hanging out at the senior center and then the VFW. And so that’s why it’s so important for us to talk about this because, glucose disorders, principally diabetes, it’s our number one health care crisis, I don’t care what anybody says, it’s number one it’s at the top. 

Lori Esarey: Agree. 

Kelly Engelmann: Yeah. So what do you think is driving that? Tell us some things that you think are key things that are driving the tsunami effect of poor regulation of glucose. 

Dr. Jim LaValle: How many hours do we got?

Kelly Engelmann: I know, right? 

Dr. Jim LaValle: I wrote a textbook called Diabetes and Cancer Epidemiologic Evidence and Molecular Links.

Kelly Engelmann: What year was that? 

Dr. Jim LaValle: That was like 2000 and 6 or 7 when I first identified, like the mitochondrial effect, of glucose regulation where, so if we boil it all down, let’s start from the inside and go out. If you boil this all down, really what happens when you’re a person with diabetes. You end up no longer making energy packets good in your body anymore. Every cell in your body now is only making two packets of energy instead of 30 plus, you make a bunch of waste product called lactic acid. The lactic acid turns yourselves into acidic environment. Now that in acidic environment, it has to sell, has to survive. And so it induces changes in your genes that allows you to survive in an acid environment, the problem is those changes, end up triggering cancer in many cases and that’s why people with diabetes feel fatigued, put more fat on their muscle, I always say, people with diabetes or why goo five, they’re great. Why do man, they got marbled, marbled muscle because they’re inefficient. At storing nutrients and storing glycogen for energy, and they are super efficient at storing fat. And why does that happen? Why does the mitochondria become a problem? Back in 2000 and 1. I started writing about this, that there were various factors related to it so the 1st, 1, you can’t get around it. It’s diet. And I know everybody now is on the paleo vegan FODMAP fruitarian carnivore diet, and I’m not sure how you do that, but I’m pretty sure they’re on it. So I think there’s a lot of things that get missed, diet doesn’t have to be that difficult, sure as people get more sensitive to diet, you have to restrict them for a while, but then, you work on building them back up.

Kelly Engelmann: That’s right. 

Dr. Jim LaValle: But diet is key. We ate, so he said, what was one of the big things? We eat really energy dense foods here. So energy dense foods with not a lot of micronutrients in it. We eat too often, we eat too late. We eat too much. We eat too often, too late, too much, we never allow our body to go into cleanup mode, known as autophagy. And then we get under a lot of stress and we don’t get enough sleep. And that’s just the start. So right there, that’s number one, what revolves around food is inappropriate eating times. If you’re Italian you know this one, right? You eat breakfast at seven. You have lunch at noon, you eat dinner at five with your family and if you’re a good little Italian boy, you get something at seven but after that, the kitchen’s closed and I better not find you in there. That’s the way traditional cultures would eat basically on a 12 12 schedule anyway. If you go to France, I don’t care where you go.

So anyway, that was important. And then I think it starts to get into food selection, too many carbs, too many carbonated drinks, too much sugar. So people think they’re supposed to drink a green drink, they go and buy a green drink and it’s basically pineapple juice with some green food coloring, that makes 88 grams of sugar, you may as well drink two Cokes, shotgun, a couple of Coca Cola’s, at least you’ll get the caffeine. That is such a big issue. People, I think because of the amount of stress they’re under, they’re wanting that serotonin hit.

Lori Esarey: One of the things you said, though, is you referred to diabetes, and I want to go back and just clarify because do you really have to meet criteria in traditional medicine of diabetes to have all of these things happening?

Dr. Jim LaValle: No.

Kelly Engelmann: Tell us about that. Let’s tell them on a journey of like how this whole cascade presents itself clinically for a patient. 

Dr. Jim LaValle: Sure. That’s what that whole book was about was we mapped out every cellular step. So let’s start with just the fact of if you’re under stress. If you’re under chronic stress, how do I know if I’m under chronic stress? Do you feel over committed? Do you feel anxious? Are you craving carbs or sugar? Do you get home at night and all you can think about is mowing through a row of cookies, or I’m going to munch on a chocolate covered pretzel with bacon and caramel and sea salt, right? It’s the thought of hedonic urge. So stress triggers that need for reward, so that’s one step. But more importantly, when you’re under chronic stress, before you’re long before you’re diabetic, look, when you look at the Kaiser Permanente study from what, 2015 for every point over 84 was a 6 percent risk of being a person with diabetes, and then once your blood sugar was 90, you were damaging your micro capillaries. And that you’re solidly in the normal range. If you’re walking into a doc’s office, most of the time they’re going, Oh, Hey man, you’re at 92, you’re all good. Oh yeah. You’re 35 pounds overweight, you’ve got a lot of visceral fat, you’re prehypertensive and your lipids are high. All a byproduct of your sugar being off, which we’re going to get through why that happens, but Hey, you’re not diabetic. 

Kelly Engelmann: But let’s put you on a statin.

Dr. Jim LaValle: But let’s put you on a statin. Exactly. And maybe something for your blood pressure, but y’all want a little low sartan or something, a little Isidro, whatever, but, when you’re under stress you start making more inflammatory cytokines and nobody would have known what that name was before pre COVID now, everybody understands the term cytokine storm. Inflammatory molecules getting thrown off in your body too frequently due to the upregulation, of cortisol in your body stress and then, as you think of as stress progresses, the more you stay in fight or flight, the more you sustain fight or flight, the more you train your body, to be in sympathetic stress, I’m making more adrenaline. And when I start making more adrenaline and my cortisol levels are high. I start releasing more interleukin 6. Now there’s two things that start to happen with it. One is interleukin 6 and TNF alpha, both of them. Hit the insulin receptor and basically turn off the insulin receptors. So you have something called insulin receptor 1 IRS 1 and IRS 2, and these 2 kinds of insulin receptors that are hanging out, trying to make you efficient at burning blood sugar. When you get under stress, or you make a lot of inflammatory cytokines, you could make inflammatory cytokines to an environmental exposure. Or maybe somebody that works out too much, or maybe it’s a mold exposure it’s something within your house that caused the problem. Whatever the reason, you make these inflammatory compounds and now your body goes from literally the insulin receptor being able to open up, and accept the insulin that has been released so that your glute for transport, can take in glucose and make all those beautiful packets of energy, 30 plus packets of energy, right?

When you make too many inflammatory compounds, that doesn’t happen. And instead you go through GLUT1, predominantly. And there’s other things that are going on, you’ve got increase in hormones and you’ve got hunger and appetite hormones, there’s a lot of stuff that’s happening at the same time but when you get down to it, metabolic inflammation or meta flammation, drives your insulin receptors, not firing. And now the glucose passively absorbs into the cell and when it passively absorbs into the cell. You go through aerobic glycolysis, you start making a lot of lactic acid. It’s almost like becoming a gas burning SUV or just you’re sucking gas, you’re a two mile gallon person instead of a Prius, right? 

Kelly Engelmann: And what that feels like to a patient is what fatigue, achiness, stiffness. I just don’t feel well, right? 

Dr. Jim LaValle: They don’t have any energy, right? What’s the number one thing? Look, 50 percent of our population is going to be obese in the next 10 years. Even with the advent of all the drugs, because we’re not really teaching people a lifestyle. It’s not just about injecting or Manjaro. It’s how do I maintain my lean mass? And so people will complain, and we’ve seen this, right? If you all you do is tell a person with diabetes, say, I want you to eat better and exercise, they’ll go, thank you so much. I didn’t know that. They don’t feel good enough to exercise. And the other part is, it’s even when you’re really good at explaining it to them. The problem is on the way home, they’re running out of energy already. And so they have 3 choices. They can stop at the broccoli shop, but there aren’t many boxes shops. They can stop at the bakery. Which is a bakery on every corner, or they could stop at the liquor store. And a lot of liquor stores, or there’s fast food. And so their metabolism is driving for the quick hit of energy. So 1 of the biggest things that I think we’ve just never really gotten right in health care is. How important it is to manage people from the inside out. When people have energy, they can make better decisions. When people have energy, they think clearer, meaning when your mitochondria is functioning well, because when your mitochondria don’t function well, now all of a sudden I’ve got more inflammatory compounds. The insulin receptor doesn’t work. Your thyroid hormones get lazy. You can’t make neuro chemicals like you’re supposed to. And how often do we hear this guys? I feel achy. I’m tired. I feel like I’m pushing a thought through jello. I’m 40 pounds overweight. I have no self esteem or sex drive. And, oh, yeah, I’m gassy, I’m bloated, I’ve got constipation and or diarrhea. 

Kelly Engelmann: Every single day.

Lori Esarey: Every single one of them. And, we often will say, and our listeners are used to us speaking in this language, it’s control blood sugar control everything. And that statement, do you believe that control your blood sugar? You have the potential to control everything, or?

Dr. Jim LaValle: I think that’s the cross road, right? When you think about it, what causes people to die early are 2 hormones. Cortisol and glucose, or glucose, insulin, and then cortisol, and they’re interrelated, right? When cortisol goes up. Insulin resistance goes up because cortisol makes you keep your blood sugar up because you think you’re going to fight a white tiger. Right? And those are the 2 things that age people. Everything else swirls around it. I am on 100 percent agreement with you that everything revolves around glucose. Your lipids revolve around glucose. If you’re making small particle lipids and lipoprotein little way, and they put lipoprotein B, it is in a crest or deficiency. You got to get your glucose under control and it’s interesting people are like, yeah, but do I really have to eat healthy all the time? I’m like what kind of questions that? Eating healthy is an opportunity. The opportunity is for you to take care of yourself. Enjoy the food that you’re eating but understand its impact on you right? And coming from a my wife being a dietitian, my father being a chef me being a clinical nutritionist, we came to this happy medium of understanding how to really enjoy it with him in the house. How do you enjoy food dad, and it tastes good and keep your blood sugar down at the same time and you can do it. I think the other big issue that revolves around this. Let’s face it, this thing’s, hey, 12 times a day, it’s telling me to breathe.

Kelly Engelmann: Right? Like you needed something to tell you to breathe, but we do. 

Dr. Jim LaValle: It’s pretty scary when you think that our system is so sympathetic dominant, so cortisol driven that we’ve all become a culture of shallow breathers. That our diaphragms are stuck. That we’ve got higher hernias and we’re told we have gird. When in fact, we’re under this excess sympathetic tone, and we have to have a stinking watch tell us. Hey, don’t forget it. Now, here’s the thing it’s cool I don’t know if you guys notice this. Sometimes I get blue before the alarm goes off. So I got to breathe a little earlier than that, but 12 times a day, I get to do a breath, a lot of times I’m changing color. But, and then the other one is what I do like about this, is heart rate variability, but heart rate in particular. If your heart rates in the seventies, you know what? You’re running from a white tiger. 

Lori Esarey: We are so glad you brought that up. 

Kelly Engelmann: Yeah. We were just talking about that before you got on, we’re like, we’ve got to ask him about this. 

Lori Esarey: Yes. So I want to go one direction first and then go back to that cause this is really important. So we’re speaking about wearables right now. So whether that be an Apple watch or whatever lots of wearables out there. How do you feel about the onset of people wearing continuous glucose monitors? Are you excited about that? Are you, is that been a positive thing?

Dr. Jim LaValle: Been a mixed bag for me. I think in general, it’s really good. Because it makes people more aware. 

Kelly Engelmann: Yes. 

Dr. Jim LaValle: To me, blood sugar is about awareness. People don’t understand, oh, I just ate 24 servings of rice because I went to a Chinese restaurant and they give you a bucket of rice. And gee, what is that doing to my blood sugar? I think that’s real important. 

Kelly Engelmann: And not only what it does to blood sugar in the moment, but for 3 days, you could be dysglycemic from that 1 excursion to your point, do I need to eat healthy all the time? What are we really trying to do? 

Dr. Jim LaValle: You’re so right, and it’s not just I’m eating a high sugar food, are you eating a food you’re having a reaction to. So you’ll notice when people are eating a food that they may be having a sensitivity reaction, not a full blown allergic reaction. Two things will happen. One, their heart rate goes up. Two, their glucose can spike. And of course, what a lot of people don’t realize is the number one thing that causes heart disease, is postprandial hyperglycemia.

Kelly Engelmann: Yes. 

Dr. Jim LaValle: We’re all worried about, oh, are you taking Lipitor or not? Are you taking an ACE inhibitor or not? Drug for the audience, a drug to help people with managing their blood pressure. And the reality is you’ve got the most powerful preventative tool, that you can have to prevent heart disease, our number one killer. Is your fork. 

Kelly Engelmann: Yes. 

Lori Esarey: True. 

Dr. Jim LaValle: It’s your fork. And then it’s what selections I’m making and so I like CGMs because of tracking that, I’ll tell you when I didn’t, here’s what’s interesting cause I was a huge, I’m still a huge fan of CGMs, I’d use them all the time. But I’m in a military. I was educating them. I’m doing work with Fort Bragg and the department of defense on special forces and they said, we tried using CGM, but we need to get blood sugars every 2 minutes because we’re trying to find out blood sugar and cortisol in response to a round that like a sniper would shoot. And I was like, wow. I never thought of that, because of the instantaneous duress, how does an individual respond to that? Say, for example, a race car driver, maybe or anyone that could have really intense the rest from moment to moment, and I was like, wow, that just took my understanding and desire to learn about glucose and stress hormones and cytokines to the next level, because, I just was so happy with the normal population that I worked with. And now I was thinking, oh, wow, I’m going to have to correlate. Where their instantaneous heart rate HRV is with where their blood sugar and their stress hormones are so I can understand it like with another dimension added to it. So anyway, that’s the only reason I had a little bit of a pause on. For 99 percent of the people I see, yes, I love them and then all of a sudden I got punched in the nose when I was down there a month ago. We couldn’t use them I’m like, Oh, okay. 

Lori Esarey: If they would only monitor insulin and cortisol besides blood sugar, wouldn’t that be amazing but maybe that’s in the future. I love that you said that too, because one of the things that prior to the ability to get on Libre view, which is the cloud version of being able to look at more than just what their scans are, we able to really focus on that variability where now we can see some degree of variability.

Dr. Jim LaValle: That’s where the magic is. Where you can really start to investigate. Why is that there at that time of day? What were you eating? What were you doing? What was going on? 

Kelly Engelmann: So Dr. LaValle, can you clarify just for the audience, the postprandial hyperglycemia, what that’s doing to the glycocalyx and the endothelium? Like, why is that the big driver of cardiovascular disease?

Dr. Jim LaValle: So when your glucose goes up really high, there’s a couple things that happen. One is you do release more cortisol. So the more you drive up your blood sugar, the more you drive cortisol production. And the more that you drive that glucose up and then if you have a dramatic insulin response you’re going to, you’re going to release more insulin. 

Insulin is essential, but it creates a tremendous amount of inflammation, in your tissue. And so the glycocalyx, of course, which is the furry lining of the endothelium is the way I like to put it, right? It’s the endothelial lining that we now know has a brush border due to the great research by Dr. Hans Zink, incredible research. You start to create what’s called more shearing stress on the glycocalyx, so you basically damage it so that now lipid particles, first of all, get inside the protective barrier. But secondly, when you’re under inflammation, you make more monocytes, and when you make more monocytes, you trigger more macrophages and there’s, M2 macrophages and M1 macrophages. M1 macrophages, are inflammatory. And they attack that lipid, they got through the damaged glycocalyx. And see, the thing is when you’re really insulin resistant, when you’re making more insulin, your glucose is higher, you make BB sized, LDL cholesterol, right? That’s why we measure particle size. And I try to use that as an example, if you think of the inner lining of your artery as a tennis net and you try to throw a softball through a tennis net, then go through there. But if you throw a BB through the tennis net, it gets through there a bunch and the more you’re insulin resistant, the more you make BB size cholesterol. Toxic metals will do it. High stress will do it. There’s different things that will create that low estradiol in a postmenopausal woman will do that, and that bb size cholesterol gets in there, the macrophage attaches it, hits it, you basically rust that cholesterol. If you think about it, you have an enzyme called myeloperoxidase. And it rusts that cholesterol, it causes calcification. Now the real problem is the interim stuff known as the vulnerable plaque that also gets produced during that. And then that is the stuff that can break off and cause embolisms and all that kind of good stuff. But the postprandial hyperglycemia basically lights a stick of dynamite in your chemistry and the net result of it is, you blow little holes in your glycocalyx, the inner lining of your artery, which then allows the lipid to get in there. And then the immune system, which is turbo charged because of that insulin resistance is triggering that. And you got to remember, this can happen just due to stress. If you’re under stress, your hypothalamus will tell your sympathetic nervous system, to signal through the enterochromophore cells, the enteric nervous system to release corticotropin releasing hormone. So when I’m insulin resistant, I’m making this excitatory chemistry. Now I release all this corticotropin releasing hormone, and now let’s go to the next level of why your blood sugar goes up. Now your gut gets permeable. That’s the next piece, you have elevated interleukin six. You’re making more corticotropin releasing hormone, and now the tight junctions of your gut get broken. And those broken tight junctions allow for bacteria to go through. For food that now is undigested because under sympathetic tone, you don’t digest well and oh, yeah, there’s this little thing I don’t know if you guys have ever heard this or not, but I think you’re supposed to chew your food before you swallow It’s really weird. But when you eat your food, it actually digests and I’m just catching on to this now. I think that’s gonna be the next thing on our watch, it’s gonna be time to chew.

Lori Esarey: Maybe it should be because we’re all in this fast pace, run from the tiger, slide into first base, don’t even sit down to eat. Don’t even stop to smell our food while we’re preparing it. The list goes on, right? 

Dr. Jim LaValle: I still remember. If you guys have heard me talk, you’ve heard the story, maybe not. But I remember sitting, I was at a phytopharmacist talk in the 19 late 1980s, I was teaching there. I’m in the airport at 6 am. You guys heard this one from me? Do you know this story?

Kelly Engelmann: I don’t think so. 

Lori Esarey: Oh, I know. 

Dr. Jim LaValle: Oh, you’re going to love this one all right, here we go. So at 6 a. m. and I’m just staring out at across the way from me early just got off a long day of lecture. Next day I wake up, get on a plane and I see a kid fold a piece of pizza in half. And he’s got a Pepsi and he takes a bite of the pizza 6 a. m. He swallows, he takes one bite. One chew swallows, like I saw the point of the pizza down his throat, like his Adam’s apple, but it got stuck. Because he had to do that. And he grabs the Pepsi in order to volume force the pizza down. And one of my mentors, Dr. Alexander Wood in Richmond Hill, Canada, I used to go up to Canada, get trained a lot by him, he started the nature pass school in Ontario, Canada, actually. He used to tell me, if you do not get people to chew food, you will not correct their digestion. We didn’t give ’em all the glutamine, all the aloe, all the SBI powder, the bovine serum immunoglobulins. We’re gonna hit ’em with Retseptide and KPV and M-O-U-S-E. And we’re not gonna teach ’em, right? We’re not gonna tell them, Hey, by the way, I need you to chew your food, so we can get you out of these immune reactions that go on once you break the integrity of the gut. So people with blood sugar always have blood sugar issues. Even when they’re in their nineties. Look at their skin, they’re growing fungus. Their tongue is broken down, it’s geographic. That means the mucosal barrier is broken down, it’s coded. They’re not diabetic yet. I just had a case. I literally just had a major executive, huge investment banker. Can’t lose weight, a 99, literally a 99 blood sugar, so he’s right at the edge. Nobody’s telling him, Hey buddy, you’re already diabetic, you just don’t know it. That’s basically in my opinion, once you’re at 99, you’re already there. Especially if he’s got a 15 insulin, his blood pressure slightly elevated is, his red blood cell magnesium is low. He’s got bad lipid particles. All these things are adding up. And I said, stick your tile for me. Coded cracked. It was just, people don’t understand that when you don’t control your glucose, all aspects of homeostasis in your body like I’m a big believer in homeostasis. 

Kelly Engelmann: Yes.

Dr. Jim LaValle: I don’t think we need to turbocharge people. We need to balance people’s chemistry, right? 

Kelly Engelmann: Absolutely. 

Dr. Jim LaValle: And when you do not. With glucose regulation off, there’s no possibility of balance. 

Kelly Engelmann: So we’ve thrown around some numbers, right? I want to go back for the listeners just for them to anchor this in. You go to your primary care, you have your yearly exam, they give you your blood sugar numbers. Fasting blood sugar 75 to 85 is optimal. 

Dr. Jim LaValle: Ideal. 

Kelly Engelmann: Ideal. Yes. Anything over 85, even one point above 85, you’re tiptoeing into dysglycemia, right? And so the good way to see that is to get a continuous glucose monitor on it, just train yourself for a while, see what’s happening because you may be surprised. And oftentimes people will have very low blood sugars, because they’re pouring out all this insulin and they are in a sympathetic overdriven state and they’re not yet insulin resistance, but they’re headed there. And so they’ll be the ones that have low blood sugar, and they’re not even aware that they have low blood sugar. 

Dr. Jim LaValle: That is so true and I think the other one is they don’t understand that if you have low blood sugar, it means your postprandial spike is even higher. 

Kelly Engelmann: Yes.

Dr. Jim LaValle: So you’re actually in a very damaging moment of your metabolism when you are a I was hypoglycemic. I remember, passing out. I would train. I would come home. I thought it was good to eat whole wheat muffins made with honey. And so I’d eat eight of them. 

Kelly Engelmann: Of course. 

Dr. Jim LaValle: And then I would wake up drooling on my couch. Wondering where the last half hour went and so it’s so important for people to, they have to understand when you get hungry, when you get lightheaded, when you get sweaty, but you go and you get your blood test and your doctor says, oh, you have a 68 blood sugar that you should be saying, Oh, that’s a problem. 

Kelly Engelmann: That’s a problem. 

Dr. Jim LaValle: That’s a big problem. 

Kelly Engelmann: That’s a problem. The other number we threw out was, or we didn’t really talk about a number, but what you said, you made the statement for postprandial hyperglycemia, very high blood sugar. But I have a feeling you’re very high blood sugar is very different, than conventional medicine very high blood sugar, so I think we should put a number to that. Like what? And I know we can’t put an absolute number, but.

Dr. Jim LaValle: Thank you, thank you for asking. I don’t like postprandial blood sugars over 125 actually. 

Kelly Engelmann: Same. 

Lori Esarey: That’s what we take. 

Dr. Jim LaValle: I’m very picky. I really don’t like them over 125 at 1 hour? And at 2 hours? I want them starting to ascend to normal ranges. 

Kelly Engelmann: Yeah. 

Lori Esarey: So you look at degree of variability, right? So if they started out pre meal at 85, we talked to them about keeping that variability. 85 to 1 15 would be a sweet spot.

Dr. Jim LaValle: Perfect. No, I couldn’t agree with you more. No, I know sometimes I sound sarcastic, but my humor comes out of being ruthlessly compassionate. I care about people. But it’s like people will spend more time researching their next refrigerator, car, house, purchase outfit than they do their health. And you know what? You don’t get to enjoy any of that stuff when you don’t have your health. And so, start to learn one of the most basic things you can do. I’m so glad you guys focus on this cause it just is still way under. People that are doing Ozimbic, right now. Don’t even understand what’s going on with them. They just know I shoot it in me and I lose weight, but you’re losing. I’m not on the camp that you lose all lean mass, if you look at the human studies, you lose the same amount of lean masses, if you’re on a low calorie medically induced diet, it’s equivocal. You lose 20, you lose about 30 percent of your lean mass. That’s the bottom line now, if you go too strong on that drug, you can increase that, right? You can accelerate the lean mass loss. But my point being is, they don’t even understand why, how did I get here? So I’m doing a big program with a group called lifetime. 

Lifetime has 180 facilities across the country. 2. 5 million members. And our big thing is, we’re creating longevity centers within there to take care of their customers within their facilities. And, of course, everybody’s a GLP1s, is it bad for fitness industry? Is it good? Of course, it’s good if you teach people how to eat lean protein, understand stress, understand that their eating window, correct for their chemical issues so that they lose fat.

Kelly Engelmann: It’s a tool to be used within a process of changing your lifestyle.

Lori Esarey: It’s a tool in the toolbox, it’s not the tool. It is a tool, toolbox. But you’re exactly right because they expect it, just give this to me and I’m going to drop weight. But no one’s corrected and they’re not talking to them about correcting gut microbiome, monitoring blood sugar, eating lean and clean, teaching them even what constitutes a nutritionally, nutritional dense diet. 

Kelly Engelmann: The other aspect of that is when we’re offloading all of this fat especially the visceral fat, it’s extremely toxic. So I find that oftentimes they become very nutritionally depleted, because they’re not building up metabolic reserves. And so you can, I’ve seen some pretty significant train wrecks with people coming in, losing their hair, just not feeling well on therapy, despite the fact they’ve lost 50 pounds.

Dr. Jim LaValle: I think the whole thing about visceral fat, is when you start to look at all of the metabolic actions going on so when your blood sugar is off here let’s teach people about the 1st thing. If your blood sugar is off. Look down, and if you can’t see your feet through your waist, you have a blood sugar problem. Now, how else to put it? I want you to be technical with anybody. The reality is when you gain weight, visceral fat and belly fat, right? And then there’s other ways, right? You could have low thyroid and you gain it around your thighs and there’s all that stuff, but we only got so much time. So the reality is, okay now I have that visceral fat. What’s that mean to me? It means you’re going to die younger than if you didn’t have it because you release compounds that lead to heart failure, you release a compound called resistant, which triggers ventricle mass increase, which is basically, my heart’s not pumping efficiently anymore and people with this have left ventricle failure more than normal people, and so before you’re even a person with a big label on your head that says you’re diabetic, you’re training yourself to have all of the comorbidities, you’re training yourself to have a destroyed endocalypse so that your four six and eight micron micro capillaries collapse and now you have peripheral vascular disease. You’re training your brain to not use glucose, so now you develop dementia, right? You’re training the heart to end up failing. It’s really, I don’t know it’s devastating. I got to tell you, being from an Italian family. And I came back to my family reunion and I’m a half breed, right? So I’m the 5 11 Italian in a 5 foot 5 world, I feel good about myself. Like I’m the big guy, I’m tall. And then I go to the NBA teams I work with and I feel I’m really talking again. But, I just look around and everybody’s short and everybody’s overweight and everybody’s diabetic and everybody’s got heart disease. And I think now it’s not even as cultural. It’s not cultural within an ethnicity. It is what we have adopted as Americans.

Kelly Engelmann: Right? 

Lori Esarey: And what you just said a few minutes ago is that not only do you die sooner. The life that you live is not full of vibrance, right? So quality of life is, it’s less than desirable.

Dr. Jim LaValle: Let’s face it, drive around. Next to the donut shop. It’s set up this way, next to the donut shop and the liquor shop is the dialysis center. So if you stop and you drink enough liquor, I only have a little bit of wine, what’s a little bit of wine? Do you have a little five ounce glass? You’d have a goblet. Most of the time it’s the goblet and then it’s the refill. That’s going to throw your sugars off sorry, guys. You guys know that folks listening, sorry, wine’s good for you, but not that good for you and so, we’ve adopted these whole lifestyles that lead people into dialysis and I gotta tell you, I don’t think people need to go in before they become a diabetic, they should ask if they can walk into a dialysis center and look around. Because my father had to go to dialysis his last year of his life. So at 90, poorly controlled diabetic for 40 years, we did the best we could. But the last year, the kidneys just started going. Right? His quality of life went from going to the VFW center, cooking for the veterans of foreign war, going to the senior center, hanging out, going to the casino. Getting on the tour bus with the other retirees, to every other day, having to go to dialysis and spend half a day at the dialysis center and the day in between dialysis, as you guys well know, is recovery. And then by the time you get through your weekend, when nobody wants to treat you, you got an extra day without the dialysis, you feel extra punky by the time you get back into dialysis, and we people just think that those centers are there empty and they’re full of people, that were insulin resistant through their life and diabetic that’s 90 percent of the people that are in there. Very few of those people were in there due to some kind of traumatic kidney injury. It’s that’s not it. It’s you’re obese. You had bad blood sugar, you had big postprandial hyperglycemia, which why that damages your kidneys, right? It is that you’re releasing a ton of adrenaline. The arteries to the kidneys get squeezed down and now the blood flow to the kidneys is reduced, and you lose your filtration rate, and when you lose the filtration rate meaning your blood can’t pump through your kidneys, now that allows for more old oxidative damaged compounds to hang out and damage your kidney tissue.

Lori Esarey: And I’m super glad you mentioned that. Because now we have the ability to look at kidney disease predictively using Cystatin C. If we could just get others to use that, right? But kidney disease doesn’t just show up either, if they’re surprised wow, I have kidney disease. No, you’ve been working on that for a long time.

Dr. Jim LaValle: Yeah, just like your heart disease, just like your depression, just like your colitis. Most of the time you’ve had to work at this. And it’s really interesting, I try to give people analogies. And I say you could be 100 feet away from the Grand Canyon. And you take your next step. It’s not a big deal, but if you’re at the edge of the Grand Canyon and you take the same length step, it’s a lot bigger deal. And the problem that we have is that people are walking to the Grand Canyon of their illness and then there’s that 1 last step and now it’s yes you have kidney disease. Yes you’re diabetic. Yes you have heart disease. Yes you have cancer. Yes you have an auto immune disorder, which always ends up blending in with people with diabetes, right? How often do you see that, in a context and not just type people with type one diabetes, which is obviously autoimmune, but people with type two diabetes, their immune systems on fire.

Lori Esarey: Right? And that’s if they’re lucky, to actually know that last step, because heart disease is silent until it’s not.

Dr. Jim LaValle: That’s right. Yeah. 

Lori Esarey: Oftentimes, unfortunately they’re first wow, something’s wrong, is a big event. 

Dr. Jim LaValle: Yeah, I always try to get people to go, it’s what’s the 1st symptom of a heart attack? 50 percent of the time, instant

Kelly Engelmann: death, right? 

Lori Esarey: That’s right. 

Kelly Engelmann: Dr. LaValle, can we go back to talking about the GLP 1s? Because one of the things that we do, and I know that you’ve talked about this for many years, but evaluating resting heart rate, whether you’re doing that with an Apple Watch or whether you’re doing that with an Oura Ring or some other wearable, but trending that. And we’ve been using those devices in our practice for many years, trending patients. And we’re seeing about a 10 point increase, in resting heart rate on GLP1s. And so what is that? What is that a vagal nerve issue? Is that a hydration issue? What is that? And is there a way to override that?

Dr. Jim LaValle: Yeah so a couple things. One is, it’s called a baroreflex response and it’s because of the, it’s strange, but your heart rate will temporarily go up as you start to regain control of glucose and insulin. Called the baroreflex. You brought up a couple other things that are super important. Hydration is so important. And then if you’re not, I still have this issue when we just give drugs to people. If they’ve got real high cortisol and they’re really stressed out and we’re not really even addressing that, we can’t really appreciate that data like exchange in our body between cortisol and doing a G. L. P. 1. We’re still learning about all of it. What I like about G. L. P. 1. so if I wanted to really raise a hand to it, right? Raise a glass of true green juice, to our GLP1s. One, is it down regulates neuro inflammation and improves dendritic differentiation and neurons. So you get better dendritic pruning, with GLP1s that means you’re sparing that type three diabetes effect.

Kelly Engelmann: Protecting the brain guys, protecting the brain. 

Dr. Jim LaValle: Yeah the microglial cells are getting downregulated. You’re getting better dendritic pruning, you’re rebutting your neurons better that’s one. Obviously the data on it for heart disease risk is pretty solid, right? We know by no kidding, because if I’m controlling glucose better and I’m reducing my inflammatory signaling, of course your heart disease risk is going down. Even though, I know you guys know this, the number 1 risk for an acute myocardial infarction is in blood sugar. And it isn’t smoking and it isn’t being obese. You know what it is?

Kelly Engelmann: It’s not moving your body.

Dr. Jim LaValle: It’s autonomic nervous system. 

Kelly Engelmann: Oh, wow. Okay.

Dr. Jim LaValle: Autonomic Nervous Dysfunction is the number one. 

Kelly Engelmann: I wish you hadn’t said that. Take it back, please take it back. 

Dr. Jim LaValle: You know what? When I learned that I was like, worse, but I never thought of it because when you lose heart rate variability, you’re losing it because of excessive stress, excessive insulin, heightened noradrenaline, adrenaline signaling, and that’s what causes the disorder in the endothelium in the end, right? And then you get the incoherence of your brain, keeping synchronicity with your heart, right? And then let’s go out, circuits blow, acute event happens, right? So when you think about that whole piece, heart rate variability. So are you seeing this now? I wish I could talk to you guys all the time, because I love how passionate you guys are in practice, I wanna come be your patient. Know I would be loved. 

Lori Esarey: Oh my goodness. 

Dr. Jim LaValle: You taken care.

Kelly Engelmann: My gosh. 

Lori Esarey: He’d be more speech. 

Kelly Engelmann: I don’t know if my autonomic nervous system could handle that Dr. LaValle. 

Dr. Jim LaValle: No, I’m serious. You guys, that’s so easy to see, but now you’re seeing people that are training too hard for their age. 

Kelly Engelmann: Yes.

Dr. Jim LaValle: They’re actually overworking their nervous system, because they want to train, if they were to get a 25 year old trainer who wants to train them oh, hey, I just learned his school, workout, that these pro athletes use I’m a 60 year old. 

Lori Esarey: Listen, my practice is in the number one retirement community in the U S. And that is, I will tell you more often than not my patient, and getting them to understand that is so hard. 

Dr. Jim LaValle: I’m glad you’re seeing that because I’m seeing it a lot. And look, I just had a full body, like OMA scan which is they measure your marbling and your fat, right? So I just had full body, I had decks and I had clearly scans, I did all this stuff and the guy looked at me and he went, how do you maintain how lean you are? He goes you’re almost, you’re in the top 1 percent of the top 1 percent, in maintaining lean mass at your age, being going on 64. He said, how do you do it? How much are you training? And I looked at him and I said, it’s how much I don’t train. How I worked out in my twenties, when I put on a lot of mass and was a world class bodybuilder. Different than how I trained in my 40s, different than how I trained in my 50s, certainly different than how I trained in my 60s. And when you start to understand this little wearable watch and that CGM, between the 2 of those, you can predict everything that’s going on in someone’s chemistry. Pretty much not the environmental burden, right? Not the lead, mercury, arsenic, the pesticide stuff. Another topic, another day. But basically you have, there is so much and I remember having a 62 year old retired CEO, she sold her company. Uber wealthy, but now she doesn’t know what to do with herself, she’s going to orange theory twice a day. She brings in her papers to me showing her heart rate. She had her heart rate up and she came into me, here’s what she came into me for guys, anxiety. She had a heart rate of 200 and 2 when she was doing, this is a 62 year old female, she should not be operating at a 202 heart rate, at all. I don’t encourage that in anybody. But nobody told her. And there’s this drive to be productive instead of a drive to have a goal of longevity. Which incorporate yoga, incorporate stretching, how about walking instead of worrying about doing interval runs? How about, some way to work out? Don’t overdo it. And how about a rest day, where you do nothing? 

Lori Esarey: Exactly. That’s right. 

Dr. Jim LaValle: Maybe you go shopping and really take care of the food you’re supposed to be getting. And maybe you start to hide, you do the other things you need to do on those rest days so that you, what you said, creating a lifestyle that promotes health.

Lori Esarey: Yes, for sure. We do have to get back to HRV, right? We have to do that, I know it’s gone a little bit long, but we have to ask this question. 

Dr. Jim LaValle: Oh, good. 

Lori Esarey: You mentioned HRV. And I know you Kelly and I are both wearing Oura Rings, we’ve done HRV monitoring in other ways. But 1 of the things that we’ve seen with GLP is actually a drop in HRV. And I’m trying to figure that out. I need to understand that because what you just said is improving blood sugar, should improve HRV. But I’m not necessarily seeing that in my GLP1 patients that are doing better overall in other respects. 

Dr. Jim LaValle: Yeah, I think it’s interesting. I think that what we don’t know yet is because of the, this signaling of lean mass loss. I think we’re getting some sympathetic tone. Because look, heart rates up, HRV down. And I think it’s initial. I don’t know yet, I am trying to figure that 1 out too but I think it’s, transitory. Because the 1 thing that I try to do so I don’t see as much of it, is I really dose people low on their GLP1s. 

Kelly Engelmann: So do we. 

Dr. Jim LaValle: Started them at 100 if it’s semiglutide, 100 micrograms, I go to 250 and if 250 is good, I keep them at 250. I don’t see as much swing, as the person that’s doing bigger doses. But I think what we’re not getting yet, is what the impact is on the HPA axis, like what’s happening with the hypothalamus pituitary adrenal axis, globally with GLP1s.

Lori Esarey: The jury is out.

Kelly Engelmann: It sounds like we will have you back in a few months and we will have solved this problem. For the world.

Dr. Jim LaValle: Now I’m going to work on it. So you guys have to challenge me on something. I’ll go ahead and get to work. I promise you this. If you have me back, so it’s like me asking for an invitation back, as I enjoyed it from. I will have the answer for you in 2 months.

Kelly Engelmann: I love it. We will do that. So it sounds like, for our patients on GLP1s that we have to make sure that we are addressing their sympathetic overdriven state, from day one, even before, I have my patients go through a four month program before I will even consider a GLP1 to get their lifestyle right. Before, because if we start that right away, it’s addictive to them. They it’s easy. And again, they can eat their sugar and still see some results show up on the scale and it’s very deceiving. So I do believe in getting that foundation really nice and firm before we add that tool to the toolbox. But it sounds like really pushing the accelerator on having them be more mindful, doing their deep breathing, chewing their food, all of the things that we teach, but maybe spending more time in that area and coaching them to that from the very beginning.

Dr. Jim LaValle: Yeah. And the one thing I think I failed to mention is. Making sure they get, I know you guys do this all the time, but just making sure they got adequate magnesium status. Number 1 nutrient associated with development of insulin resistance and diabetes and that could even be 1 of the reasons that heart rates going up, and HRV is going down because you’re pushing the demands on the insulin receptor without possibly having the micronutrients at the cellular level to help with that homeostatic, organization of information so, I applaud you for taking in a responsible approach to GLP1s. 

Kelly Engelmann: We’ve been taught by the best. So here we are. 

Dr. Jim LaValle: Good. No I’m so serious about that because, what’s happening right now is the consumer’s confused. And now you’re having people denied the opportunity of the benefit of GLP1s, because they don’t have an understanding about them and they have a fear now that and it’s because we don’t have enough practitioners practicing the way you guys do the way I do, which is, we want to take care of you as a whole person, clean some things up, apply this as a tool, and then you see success and I’ll bet anything it’s pretty rare that you have any side effects. 

Lori Esarey: Rare. Absolutely and you have a patient that not only feels better, but they are better. And we teach all the time that there’s a huge difference between just feeling better in the short term than optimally just being better. And it’s a lot more work and I think that’s the hard part but at the end of the day, it’s very rewarding work. 

Dr. Jim LaValle: You know what? It’s so funny. Kind of one of my sayings is your health, it’s work, but it’s worth it. 

Kelly Engelmann: Yeah, absolutely.

Dr. Jim LaValle: It’s work, but it’s worth it. Anybody, once again, anybody that takes more time to buy the next refrigerator than to take care of their health, needs to have a lobotomy and get their head readjusted. Hate more time about you and it’s good look, it makes your life more filled with joy. You feel more self esteem. You connect better with your significant other. You’re more helpful to your community, right? All this stuff happens when you can do that. So anyway, it’s good. It’s really good. And I do hope you guys get out to millions of people. The message of the importance of glucose control. 

Kelly Engelmann: Absolutely, we’re doing our best. So before we head off for today, is there anything else you want to put out there in the wellness community? Anything coming up? Any new books, any new promotions that you have going on in your world that we need to know about?

Dr. Jim LaValle: Oh my gosh, I’ve got my new metabolic code book will be out, this year. I have a performance book coming out, looking at lab biomarkers to optimize human performance for more in the, sport performance category. I’ve got a rewrite on my book, your blood never lies. It’s coming out. I just put out 6 eBooks and then I got a bunch of lectures.

Kelly Engelmann: So it’s JimLaValle.Com, right? 

Dr. Jim LaValle: Just go to JimLaValle.Com. 

Kelly Engelmann: Yeah, pretty easy. 

Dr. Jim LaValle: Yeah, pretty easy, go to JimLaValle.Com and it’ll talk about all that good stuff. 

Kelly Engelmann: Sweet. 

Lori Esarey: Great. Thank you so much, for your time. Just spending it with us and there has to be a part two, maybe even a part three, because this is honestly great conversation that people need to hear. This is really good stuff, so thank you for carving out time in your schedule to meet with us like this and I promise you, I’ll keep working on my friend. You did really good today, by the way, Kelly. 

Kelly Engelmann: I kept it together. I kept it together. I’ll see what my Oura Ring told me about my stress level. 

Dr. Jim LaValle: Hey, I’m telling you right now you guys ask, I will come back whenever you want me to. 

Kelly Engelmann: Awesome. 

Dr. Jim LaValle: Always make time. You guys are amazing. 

Kelly Engelmann: Thank you. 

Lori Esarey: We will take you up on it. 

Dr. Jim LaValle: All right. 

Kelly Engelmann: All right.

Dr. Jim LaValle: Sounds good.

Kelly Engelmann: Bye bye.

Lori Esarey: Thanks so much for listening to today’s episode. You can find more information about Synerge at Synerge for Life, that’s S Y N E R G E the number for life. com

Kelly Engelmann: and then Synerge Connect is our Facebook. And then please make sure to follow us on your favorite podcast app so that you make sure you get future notifications of episodes.

Lori Esarey: The purpose of our Synerge podcast is to educate. It does not constitute medical advice, by listening to this podcast, you agree not to use this podcast as medical advice to treat any medical condition in either yourself or others, including, but not limited to patients that you are treating. Please consult your own physician for any medical issues you may be having.

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