The 3 Biggest Mistakes Diabetics Make

Okay, so I want to start with a patient. I'm not going to use her name, obviously, but she came in. Now, this was maybe three weeks ago. She came in with an A1c of 6.3, pre-diabetic, you can say. She was frustrated, right? Because she would have been pre-diabetic maybe for four years, and every single one of those four years, her A1c went up by a tenth, like 5.96, 6.1, 6.2, and now 6.3. And she said to me, I will never forget this. She said, Dr. Ergen, I walk two miles every single day. I never miss. I eat salad. I don't know what else you people want from me. She was really mad. Now, here's the thing. She wasn't lying. She wasn't one of those patients who tells you that they eat perfectly, and then you look at the CGM, and it's a roller coaster. Well, she was actually doing what she said she was doing. She was just doing the wrong version of the right things, and that is what this video is all about. Three mistakes. I see them constantly in my clinic in Port St. Lucie, Florida. Three mistakes that almost every pre-diabetic and diabetic makes. And before anybody clicks off, if you are already diagnosed, and if you are type 2, if you are on metformin or Jardians or a GLP-1, this video is more important for you, not less. Everything I'm about to say applies harder once you're diagnosed, because now you're trying to hold ground instead of just prevent something. Same three mistakes, bigger consequences. And the frustrating part, the part that really gets me, is that people are, or these people, I would say, are really trying. Now, these aren't people who don't care. These are the people who care the most and are getting the least out of it. So let's fix that. Mistake number one. Unfortunately, some of you do not understand what exercise intensity means. All right, so this is the big one, right? This is the one that I fight with patients about the most. You do not understand exercise intensity. Now, let me be very careful here, because I know how this sounds. I am not telling you walking is bad. Walking is fantastic. If you are currently doing nothing and you start walking two miles a day, that is a genuine, real improvement in your health. Your blood pressure gets better, your mood gets better, your mortality risk goes down. I am not knocking walking, but here's what I need you to understand. Walking a mile, but two miles, at a conversational pace, on a flat Florida ground, that is a very, very mild stimulus. And your metabolism, your muscles, they adapt to that stimulus in about maybe three, maybe four weeks, and then nothing else happens. You hit the wall again. You know what the problem is? Your body is smarter than you think, and it's very efficient. It adapts to whatever you demand of it, and then it stops changing. That two-mile walk that felt like something when you started after six months, your body has completely absorbed that. It is baseline now. It's like, it's like paying the minimum on a credit card. You're not going backwards, but you're not going anywhere either, and that's my patient. Four years of exact same walk, four years of a slowly rising A1c, and what actually moves the needle, right? What is it? Let's talk about that. So what the data actually says. If you look at the diabetes prevention program, some people call it DPP, right? This is the landmark study. We're on 3,200 people with pre-diabetes, and this is the one every single guideline is built on. Lifestyle arm got 150 minutes a week of moderate activity plus 7% body weight loss, and the results get quoted as like 58% risk reduction from, you know, progression to diabetes from pre-diabetes, which is true, but I want you to hear the absolute numbers because that is what actually matters for you as a person. Relative risk can be kind of a little bit deceiving. Now in the placebo group, about 11 out of every 100 people developed diabetes per year, so 11 out of 100. Now in the metformin group, the lazy guys who just want to take metformin and do nothing about their lifestyle, about 7.8 out of 100. In the lifestyle group, that was 4.8 out of 100, the guys who do moderate intensity exercise. So going from doing nothing to doing structured lifestyle change dropped it from 11 down to about 5 per 100 per year, and that is real. Now that is about a 6 in 100 absolute reduction every year, and that's great, enormous, because it's like a compound interest. It adds up, but, and this is the part that nobody tells you, that 150 minutes in DPP was supervised. It was progressive, and moderate meant real brisk, meaning you're breathing hard, meaning you could talk, but you cannot sing. That is not a stroll around the block with the dog stopping at every mailbox. And then look at Daking, the Chinese study. 20 year and 30 year follow-up. Lifestyle intervention. People still had lower diabetes incidence decades later. 30 years later, they had fewer cardiovascular deaths. That is how durable this is when you do it right. The two things that you are missing, right? So what's actually missing from your two mile walk? Two things. Number one, resistance training, and I cannot say this loudly enough. Your skeletal muscle is the single largest glucose disposal site in your entire body. Somewhere around 70 to 80 percent of insulin mediated glucose uptake happens in muscle. So if you are insulin resistant, and if you are pre-diabetic, you are the most powerful thing you can do is actually to build a bigger glucose sink, right? And here's the mechanism that I love. This is the part that gets me excited. Muscle contraction translocates GLUT4 to the cell membrane, independent of insulin. It is a completely separate pathway. AMP kinase mediated. Your muscle pulls glucose out of your bloodstream during and after contraction, whether your insulin is working or not. Well, obviously, if you're type one diabetic, have no insulin, that may not always work. You have to have a little bit of an insulin there. So you are literally bypassing your insulin resistance. And that effect from a single heart resistance session lasts 24, sometimes 48 hours. So if you lift Monday, Wednesday and Friday, you have essentially covered your whole week in improved glucose disposal. Two to three days a week. Compound movements, squat, hinge, push, pull, carry. Doesn't have to be a gym. Bands, bodyweight dumbbells in the garage, whatever, right? And it has to get hard. If you finish a set and you could have done 10 more reps, that set did not count. All right. Number two, intensity spikes. So zone two is great. That steady nose breathing, conversational cardio, that is mitochondrial biogenesis, that is fat oxidation. So keep that going. But you need some sessions where you go hard, where you're at 85 to 90 percent of your max heart rate for short bursts. Obviously, if you have cardiovascular disease, heart attacks and strokes, you got to take it a little easier and then gradually go up there. If you're having chest pains, obviously, that's not going to be good. Getting a clearance from your cardiologist is always a good idea as well. But the low volume HIIT, high intensity interval training literature, basically, on this is really striking. Gabala's group, Little, Gillett, these guys, you can get meaningful improvements in insulin sensitivity with total workout times under 10 or 15 minutes of actual hard effort. Not because it burns more calories, it doesn't. It is because of what it does to your mitochondria and your VO2 max. And VO2 max, by the way, that is the strongest single predictor of all-cause mortality we have. Stronger than smoking status, stronger than your lipids. You do not raise VO2 max by walking, unfortunately, on two flat miles. The practical fix is that what I actually want you to do, well, keep the walk, don't take it away, I'm not saying that, but add hills, add a weighted vest, add speed intervals, walk hard for 30 seconds, easy for 90, repeat eight times, lift two to three times a week. That's non-negotiable. This is the most under-prescribed intervention in all of endocrinology. Post-meal movement, this one is free, right? There is a nice 2022 meta-analysis, Buffy and colleagues, basically showing that even two to five minutes of light walking after a meal meaningfully blunts the postprandial glucose spike compared to sitting. So just two minutes after dinner, just don't sit down. Even walk around the kitchen, do the dishes, standing up, 10 squats, why not? One hard session a week, you can do that as well, where you're genuinely uncomfortable. 10 minutes of intervals, that's it. And progress, whatever you did in January, you should be doing more of or heavier by April. If your workout hasn't changed in a year, your body hasn't either. Mistake number two, you have no idea sometimes how powerful vegetables are, okay? So this one, and honestly, that one frustrates me more because it is so fixable. You're not eating anywhere near enough vegetables, not even close, even though you think you are. And I don't mean eat your veggies. I don't mean the little pile of iceberg lettuce next to your chicken. I'm talking about five to eight servings a day, every day, five to eight servings a day, every day. Should I repeat? As a therapeutic dose for you. I don't like vegetables. I only like meat. All right then, good luck. Let me repeat that word. It's therapeutic. I want you to think about vegetables the way you think about a prescription. You don't like it? Guess what? You're gonna take it anyway. Prescription. Who likes prescription? But if you need it, you have pneumonia, you better take it. Does it taste bad? All right, well, suck it up. Same thing for vegetables because at the right dose, they behave like one. What a serving actually is, by the way. Let's do a quick housekeeping here because everybody gets this one wrong. One serving is roughly one cup of raw leafy greens and half a cup of cooked vegetables, okay? So, or a half a cup of chopped raw, okay? So, five to eight servings. That might be two and a half to four cups of actual cooked vegetable volume per day. To make it practical, you can just fill half of your plate with salad, pretty good amount, twice a day at least. That should cover most of it. Most of my pre-diabetic patients, when I actually walk them through a food recall, I'm getting one, you know, recently there's this whole huge recalls going on. But don't just turn to potato. Potato does not count here. Now, why cruciferous vegetables, especially now? All vegetables are good, right? But I want to spend real time on cruciferous because these are in a completely different tier. Like broccoli, broccoli sprouts even better, cauliflower, brussel sprouts, cabbage, kale, arugula, boccio, radish, watercress, collards, mustard greens. And here's what's special. These plants contain glucosinolates, especially glucoraphanin. And when you chew or chop them, an enzyme called myrosinase converts that into sulforaphane. And sulforaphane is one of the most potent naturally occurring activators of NRF2 that we know of. Now, what is NRF2? Like what the hell, dog? What are you talking about? Well, here's what I'm talking about. NRF2 is your master antioxidant and detoxification transcription factor. So what it does, it turns on glutathione synthesis, right? So phase two detox enzymes, the whole system. But here's the part that is directly relevant to you. And there is a really elegant paper from Axelson and colleagues published in Science Translational Medicine in 2017. They did a computational screening looking for compounds that would reverse the gene expression signature of type 2 diabetes in the liver. And sulforaphane came out on top. Then they tested concentrated broccoli sprout extract in patients with type 2 diabetes for 12 weeks. Fasting glucose went down. Avancy improved. And the effect was largest in the obese, dysregulated patients, the ones who need it the most. But the mechanism is beautiful, right? Sulforaphane suppresses hepatic gluconeogenesis, which is glucose production in your liver. It downregulates the key gluconeogenic genes in the liver. So the genes that tells your liver to make more glucose. That is the same general target metformin and berberine hits. Your liver dumping glucose overnight. That is why your fasting sugar is 110. Then you didn't eat anything or 130, 140. You didn't eat anything for 10 hours. You're like, what is going on? That's your liver. Now, sulforaphane goes at that directly. Now, how to not waste your broccoli? Now, when you prepare, you have to prepare right. And almost everybody destroys it. Now, myrosinase is heat sensitive. So if you boil broccoli to death, right, you get essentially no sulforaphane. You get fiber and some vitamins. That's it. Now, steam it lightly, three to four minutes until it's bright green and still has a bite. That is the sweet spot. Enough to kill the enzyme that competes for the pathway. Not enough to kill myrosinase. Chop it and let it sit 10 minutes before cooking. Let the reaction start. The mustard seed trick, I'll tell you. If you overcook it, sprinkle a little mustard seed powder, I would say, on top. Mustard seed carries its own myrosinase and rescues the conversation. So same with raw radish or arugula on the side. Now, broccoli sprouts have anywhere from 10 to 100 times the glucoraphanin of mature broccoli, right? So that's why broccoli sprouts is better. A handful on a genuine salad is a great intervention. And it's not just sulforaphane. The rest of the vegetable story matters too, right? Fiber, for example, in the Epic Interact data, the higher serial and total fiber intake in the Epic Interact data, higher serial and total fiber intake tracks with substantially lower type 2 diabetes incidence on the order of a quarter lower risk in the highest intake groups. Viscous fiber, right? Slow gastric amputee. These fibers really does that. Slows the gastric amputee, blunts the glucose curve, and this is the important part, feeds your gut bacteria to produce butyrate and other short chain fatty acids, which, by the way, are great because they stimulate GLP-1 naturally and PYY from your L-cells in your intestines. You are, in a very real sense, making your own endogenous ozempic or manjaro with fiber. Now, magnesium, right? We talk about this as well. Dark leafy greens are loaded with it. And magnesium is a cofactor for the insulin receptor's tyrosine kinase activity. So you literally cannot signal insulin properly when you are depleted. The dose response meta-analysis also suggests something like a 15% lower diabetes risk per additional 100 mg of daily magnesium intake. And most Americans are frankly deficient. Now, talk about dietary nitrates, beets, arugula, spinach. They get converted to nitric oxide, which improves your endothelial function and blood flow and better perfusion of skeletal muscle. Basically means better glucose delivery and disposal. Let's talk about the food order. Now, this one is also free. It just needs a little organizing. It works. That costs you nothing, right? Meal sequencing. We talked about this before as well. Now, Shukla and colleagues showed that this, you know, in a study cleanly, same meal, same calories, same macros. But if you eat the vegetables and protein first and save the carbohydrate for the last, you get roughly, you know, 30 to 40% reduction in your postprandial after meal glucose excursion and much lower insulin. So same food, different order. That's pretty much it. So eat your salad first, then protein. Then if you have to have rice or potato or bread, go with it, I guess, at the end. Now this works at restaurants, right? It works at Thanksgiving and it works everywhere. So where a supplement fits, that's also a discussion. I want to be honest here. Even my most motivated patients struggle to hit eight servings every single day and real life happens. Now we always tell patients you do what you can, but nobody's perfect. So sometimes we throw in the mix of sugar and the super berberine. It is a dehydra berberine formulation, right? Compared to berberine, it matters because plain berberine has terrible bioavailability and wrecks a lot of people's GI tract. Dehydra berberine, on the other hand, absorbs several fold better at lower doses and mechanistically, it is an AMP kinase activator, the same energy sensing pathway that your muscle uses during exercise. So it slots in the right alongside everything we just talked about. Better hepatic glucose handling, better insulin sensitivity. SugarMDS.com, you already know the website. Now I use it as a bridge, right? It's not a replacement of your lifestyle. It's not a replacement of medication either. Now nobody has ever out supplemented four cups a day of actual vegetables, but if you are at the two cups and climbing, well, this helps hold the line while you build the habit. Mistake number three, you are unfortunately letting stress and bad sleep undo all of it. And you say that I can't change it. I can't change my stress. I can't deal with it. It's what it is. People just give up. I saved this one for last because this one is the one that people really dismiss the fastest and it might be the most powerful of the three. You're letting chronic stress run unchecked. You don't know how to unwind. You're treating sleep as optional. Everything else is more important. And I get the eye roll, right? All right, doc. All right. I heard it before, right? You know, when a doctor says manage your stress, it sounds like throw away, like, you know, whatever. Like we ran out of real advice. So let me give you the actual physiology and tell me it is soft. What cortisol is doing to you, right, is a counter-regulatory hormone. It's entire job is to raise your blood glucose. That's the point of it. It stimulates hepatic gluconeogenesis, which we talked about, the glucose production. It induces insulin resistance in your peripheral tissues like muscle and fat. It drives fat deposition specifically into the visceral compartment, which is the metabolically nastiest fat that you can have, because it drains straight into your portal vein and floods your liver with free fatty acids and inflammatory cytokines. So when you are in a chronic, low-grade stress state, the job, the marriage, the caregiving, the finances, whatever it is, you have a hormone running 24 hours a day whose literal function is to raise your blood sugar and make you insulin resistant. You cannot out-broccoli that. You cannot. The sleep data is honestly shocking. And sleep, okay, this is where the data is so strong that it should be in every guideline in bold print. In Lancet Journal, this is a classic one, in 1999, they took healthy young men, restricted them to four hours of sleep for six nights. Not the sick people, young, healthy, metabolically normal men like me. I'm still young, right, 40, 42, 42, you know, okay. After six nights, if I did that, for example, six nights of very little sleep for those men, what happened? The glucose tolerance dropped by about 40%. Their glucose clearance rate fell dramatically. Some of them had glucose curves that looked like early diabetes. Now from sleep loss alone, remember? Then in 2012, Annals of Internal Medicine, they had another study, four nights of four and a half hours of sleep, whole body insulin sensitivity dropped about 16%. And when they biopsied fat tissue, adipocyte, which is the fat cell, insulin sensitivity, had dropped about 30% in four nights, just four. And the appetite side, I would say, for example, sleep restriction, when they looked at it, leptin dropped about 18% and raised ghrelin about 28%. So what happens? You get hungrier. You're less satisfied. And specifically, you crave carbohydrate. This is not willpower. This is the neuroendocrinology. You're being chemically pushed toward the exact foods that are hurting you. The one thing that you might be missing entirely is this. I have to say this because I catch it constantly in my clinic. Just remember this, right? Sleep apnea. If you're pre-diabetic or diabetic, carrying central weight, snoring, waking up unrefreshed, needing to urinate two to three times at night, waking with a headache or a dry mouth, you need a sleep study. You have a big neck, you need a sleep study. Now, home test is fine. It's pretty easy now, but untreated sleep apnea drives insulin resistance independently of the weight through that intermittent hypoxia and sympathetic activation. I have seen Avon C drop three, four tenths from CPAP alone with zero other changes. And the number of pre-diabetic and diabetic patients walking around with undiagnosed apnea is, in my experience, is pretty enormous. In type 2 diabetes specifically, the prevalence estimates run well over half. If nothing else in this video sticks with you, let it be that one. Get screened. Circadian misalignment is huge. That's another one more layer. It's not just how much you sleep, right? It is when you sleep and when you wake up. The circadian misalignment is important. When you shift people's behavioral cycle out of phase with internal clock, that glucose after meal response, postprandial glucose response, get even worse with the same meals. Some subjects hit pre-diabetic glucose ranges within days. Now, which is why the shift work data, for example, shows meaningfully elevated type 2 diabetes risk, especially for dating shifts. And it is why eating at 10 p.m. is metabolically not the same food as eating at 6 p.m. So your beta cells and your peripheral insulin sensitivity are both under that circadian control and both are worse at night. What's the practical fix? Fixed wake time. Same time every day, including the weekends. What time do I wake up on Sunday? Six o'clock. You don't want to do that? Well, that could be a problem. And that's why people sleep are always messed up. The wake time anchors the entire circadian system more than the bedtime does. Morning lights. 10 to 15 minutes of outdoor light within an hour of waking. You gotta go outdoors, not through a window. This is the single strongest circadian input that you have. And it's free. I live in Florida. I know where you live, so there is no excuse here, really. Most mornings are sunny. If you get rain, it's in the afternoon. So stop eating three hours before bed as well. Late eating, no matter how late you work, is fighting your own physiology. Alcohol, right? I know, but alcohol fragments your sleep architecture, suppresses your REM sleep. It is nothing good that comes from alcohol. It messes up with your CGM, messes up with your liver. Yeah, it knocks you out, it relaxes you, but it doesn't really rest you. You need to get cold, dark, and boring bedrooms. 65 to 68 degrees, blackout. Phone charging in another room, if possible. Get the sleep study if any of these things apply to you, like I told you about. Now, actual stress, right? You have to work on that stress. This is a work for you, not just some vague intervention. Five minutes of slow diaphragm breathing, longer exhale than inhale. You can do 5 to 5, 6 to 6, 8 to 8, whatever. Or actually 6 to 8, you know, 4 to 7, something like that. And parasympathetic tone will improve. And it's important because it is measurable on your heart rate variability. Now, do it before the meals if you want the metabolic version. Now, 10 minutes of walking outside without your phone is going to be huge. Whatever you will actually do daily beats the perfect protocol that you will abandon. Now, supplement support. The two that I use often is magnesium glycinate, especially at bedtime, because it helps sleep onset, it helps muscle relaxation, corrects the deficiency we already talked about, and it's very low risk. It's very high value. Sometimes ashwagandha extract, and this one is one of the few adaptogens with real human randomized trial data. The trials generally show meaningful reductions in serum cortisol and perceived stress scores over 8 to 12 weeks. A caveat is it's a thyroid modulator. So if you have Hashimoto's or you're only with Roxane, I would say talk to your doctor first. I have seen it shift the TSH. So three mistakes. Let me put them back together because they are not three separate things. They are one thing. You are mild exercise that your body stopped responding to two years ago. You are eating a fraction of the vegetables that would actually count as a dose of medication. And you are letting cortisol and sleep that quietly undo whatever progress the first two are making. Now, you want to be clear about the stakes without being dramatic about it. Prediabetes is not a warning label. It is already a disease process. Beta cell function is already declining. Endothelial damage is already happening. The neuropathy and the retinopathy that people think that show up after the diagnosis, a chunk of that damage starts in the pre-diabetic range. And if you are already diagnosed, and if you are type 2, if you are on medication, none of this becomes optional. It becomes the thing that decides whether your dose goes up every year or comes down, or maybe you quit the medication. I have taken people off insulin doing exactly what is in this video. Not everyone, but more than you would think. Thanks for watching today. Remember, we are in Port St. Lucie, Florida, the diabetes, thyroid, and hormone center of the Treasure Coast, and our website is tcendo.com. For supplements, please visit sugarmds.com. Talk to you later.