Chapters Transcript Video Eat Right, but Which Type? Diabetes, Weight Loss and Diet Back to Symposium Dr. Alex Bonnecaze encourages a patient-centric approach to treating diabetes and obesity. So our next speaker is Dr Alex Vanoc Oz who practices endocrinology at pioneers medical clinic in Pinehurst north Carolina. I'm laughing because I asked him like five times how to pronounce his name. It's Monica's. Um he graduated from the University of Washington School of Medicine and completed fellowships in both and technology and obesity medicine which is rare. There are not very many obesity medicine fellowship so he really is an expert. He did both of those at Wake Forest University School of Medicine. And his areas of clinical interests include lip ideology, male hypogonadism and obesity medicine. So Alex, we are so excited to hear you speak. You can go ahead. Thanks so much and fantastic talk to Dr Harris. I'm excited to be here and today I'm talking about diabetes and diet each eat right but which type I have no relevant disclosures. So, my objectives for today, I want to first go over kind of the 2021 American Diabetes Association standards and diabetes care guidelines regarding dietary guidance of diabetes. This is a very complex guideline and they have a specific chapter just focusing on dietary recommendations. I'll also go over and dive into some of the popular dietary strategies and their respective data primarily relating towards the data for diabetes. And I also want to kind of wrap up with several case based scenarios and practical approaches that we can use in clinic to kind of help our patients with dietary choices weight loss and to help control their diabetes. So we'll try and put it all together around the end. Yeah, So the 2021 standards of medical care and diabetes by the A. D. A. It's broken down their dietary chapter into the following sections and thats consisting of the effectiveness of nutritional therapy, energy balance, eating patterns and macro nutrient distribution. Including kind of specific discussions on carbohydrates, proteins, dietary fats. They also discuss specifics regarding micro nutrients and supplements which I'll talk about in addition to having um specific guidelines on alcohol intake, sodium intake and also non nutritive sweetener and sugar sweetened beverage use. So the first section of effectiveness and goals of nutritional therapy there are two major points I want to highlight. So I'll read these and then kind of emphasis what they're getting at. A lot of this document focuses on an individualist medical nutrition therapy program as needed to achieve treatment goals provided by a registered dietician or nutritionist, preferably one who has comprehensive knowledge and experience in diabetes care. It's recommended for all people with Type one or Type two diabetes, pre diabetes or gestational diabetes. And that individual theme will keep coming back and I'll keep explaining why that's so important. They also recommend for all patients with overweight or obesity and diabetes. We should target at least 5% minimum weight loss for all of these patients which from the prior talk you can understand how that makes such a huge difference in their outcomes and how they're doing even to lose 345% of their total body weight. And they have distilled these goals of medical nutrition therapy down into kind of four really sustained a bullet points and these goals are number one to promote and support healthful eating patterns, emphasizing a variety of nutrient dense foods, an appropriate portion sizes to improve, improve overall health and achieve and maintain body weight goals, attain individualist glycemic blood pressure and lipid goals and delay or prevent the complications of diabetes and again, putting that emphasis on the individual aspect of it. Since we all have many different preferences. Number two to address individual nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful foods, willingness and ability to make behavioral changes and existing barriers to change. Number three to maintain the pleasure of eating by providing non judgmental messages about food choices while limiting food choices only when there is an indication by scientific evidence and for to provide individuals with diabetes the practical tools for developing healthy eating patterns rather than focusing on specific nuances with micro nutrients, macronutrients or single foods. I think to summarize that. I love that they're focusing on an individual, culturally sensitive, personalized approach. Not everyone is going to be eating the same thing and that's okay, that's what a lot of this talk is going to be about. You'll see a lot of commonalities with that regarding eating patterns and macro nutrient distribution. They again emphasized there is no single ideal dietary distribution of calories among carbs, fats and protein for people with diabetes. I think that's kind of surprising for some people to hear that a lot of people think we have to go down on the carbs because it is an effective strategy, but there is no absolute macro nutrient distribution that's recommended. So therefore meal plans. Again, they're saying should be individualist while keeping total calorie and metabolic goals in mind. And I think this gets back to the concept of if we can create a caloric deficit in a sustainable way for patients, most patients will lose weight and then by virtue of losing weight, kind of improve their at a at a velocity based complications such as Type two diabetes. So that can really make a big difference. And it's great to hear them kind of taking that stance. They also mentioned how a variety of eating patterns can be considered for the management of type two diabetes to prevent diabetes and individuals with pre diabetes as well. So again, focusing on, there is no one size fits all template, which is great to see now. They also mentioned until the evidence surrounding comparative benefits of different eating patterns and specific individual strengthens. Health care providers should focus on these key factors that are common among all patterns. Number one emphasizing non starchy vegetables And I think a large part of that is the fact that these are relatively calorically poor foods and they're very satiated, you can eat a whole bowl of Broccoli, maybe have 40 or 50 calories and be quite satiated. Whereas if you're eating the foods, they're saying to avoid such as the minimal the processed foods, refined foods with sugar, you can put away 500 calories with barely having any effect on society. So that's why they emphasize these really non starchy vegetables that have good satiation, not going to create in a setup for caloric excess and then also choosing whole foods over processed foods to the extent possible. And I think that just makes good common sense in terms of you're going to be able to create more sustainable um eating habits that way, they're not going to be in a cork excess regarding carbohydrates. And this is kind of a divergence from prior year recommendations, they have these three bullet points specifically, they stayed carbohydrate intake should emphasize nutrient dense carbohydrates sources that are high in fiber and minimally processed eating plan should emphasize non starchy vegetables, minimal minimize added sugar, fruits, whole grains as well as dairy products. They also state that people who have diabetes and they prescribed a flexible insulin therapy program, they need education on how to carb count and how to dose their insulin around modification to meals such as fat and protein consumption and should have education on how to use their mealtime insulin dose ng they also note that if people are using a fixed insulin dose, consistent pattern of carbohydrate intake with respect to the time and amount while considering the insulin action time can result in improved policy mia and reduce the risk for hypoglycemia. One thing that is very important about this is nowhere in the statement. They say you have to eat 45 carbs per meal or 30 g of carbs per meal. I think that a lot of patients are still going to diabetes classes and being taught they have to eat x amount of carbs per meal. And I think that's a really important point because not only is that an outdated approach, it directly affects their glycemic control and ability to lose weight. So I'm hammering home that there is no recommended amount of carbs per meal in the 2021-88 guidelines. This has to be individualized. So one of my favorite things is I like to ask the patient do they ever feel like they're eating to prevent a low. I had a gentleman not so long ago, sugars looked okay when I reviewed everything, but he kept saying, well, you know, I had to eat this granola bar, eat this because otherwise we'll have a low. And he was on a regimen that was more than he needed. So I'm always asking the patients trying to figure out are we feeding the medication or are we feeding the patient? And so we really need the patient's medication to work for them. We shouldn't be working for the medication. So I think that's something we can do better at again if a patient's having to eat it's not, the answer is not eating more food around the insulin. We can go down on the insulin and we can get rid of the cell phone area which we should be. Hopefully do it anyways. So I think that was a really nice thing to see in the guidelines and something that I think is still coming up to speed in clinical practice regarding proteins and fats. They have several comments on here specifically with protein. They just mentioned how protein can have somewhat of an insulin response even without increasing the glucose. So they kind of limit their advice to just if you have a low probably don't treat a low with a carb that's really rich in protein. I think that the big takeaway is just knowing that ingesting protein does have some insulin response. And regarding fats they do emphasis a mediterranean style eating habit that is essentially just avoiding saturated fats and having mainly poly and mono unsaturated fats can be considered to improve glucose and reduce cardiovascular risk. We also they also mentioned considering foods rich in omega threes and I'll go into that a little more later, micronutrients, alcohol and sodium just like dr Harris was saying in the last talk we have a lot of patients on supplements and herbs. And I routinely see people coming in on herbal medications that are not only probably not effective which the A. D. A. Guidelines say we don't have evidence for that but they're also potentially harmful. Some of these herbs can inhibit or induce cytochrome other ones can um act almost as endocrine disruptors. So a lot of times I'm always asking about supplements because a lot of people don't necessarily consider them medications a lot of times they're taking them and it is impacting their wallet and then maybe also a safety issue. So I I try to sell patients essentially limit to you know maybe a multivitamin if they want to take that in terms of supplements. Maybe like a protein real replacement. That's that's great. I'm a big fan of those but when you get into some of the more esoteric supplements and herbs I think you have to be very careful and screen for those regarding alcohol. They do recommend limiting alcohol consumption and particularly educating that patients can have a delayed hypoglycemic response after alcohol consumption. I think we've had quite a few patients where maybe they're on insulin and they've had an exaggerated hypoglycemic event if they're drinking. And then also keeping in mind that alcohol does have seven calories per gram. And so getting into our theme of weight loss. You know a lot of patients may have frustration with weight loss but a glass or two of wine per night is significant caloric intake as well. That can make a big difference. And in terms of sodium the recommendations are saying the same for all adults basically limiting that to 2300 mg per day. Now they have a statement as well talking about sugar sweetened beverages and non nutritive or artificial sweeteners. Obviously a hot topic, it's going to come up a lot and it's its own talk all in itself. They recommend screening for sugar sweetened beverage intake and educating on the harms of these um and promoting alternatives. I think that this is an important point because I don't know if everyone routinely asks about sugar sweetened beverages and I think before I moved to the south I might ask, oh are you drinking sodas? And so of course I'm not drinking sodas. But you really have to realize a lot of people don't consider drinks like 100% fruit juice or a fruit smoothie or half and half sweet tea. They don't necessarily think of that as like a sugar sweetened beverage, especially if it's something they grew up on. So I asked generally about things like soda, any sweet tea, fruit juices. Um I had a patient that was doing a lot of fruit smoothies and what I calculated it was probably 100 and 50 g of liquid sugar they were drinking. So a good sugar sweetened beverage history. It can be really effective for both glycemic control and weight loss regarding the data on artificial sweeteners. There there really is mixed benefit. I'm sorry. Mixed data in terms of their effect on society, they're clearly better than sugar sweetened beverages. So I think sometimes people may say oh I've heard diet soda is worse than the regular soda. That that's not true that that we can definitively say I've had many patients where as a baby step we're trying to switch from four sodas a day to a couple of diet sodas and they all lose weight and do better the A. D. A. Specifically they kind of talk about using artificial sweeteners as a bridge to just going off of them and transitioning to water. Um I think that you know I do have patients on a diet sodas or artificial sweeteners as a tool. Long term maybe some patients might have an increase in satiety. Um But a decrease in society if they kind of have that sweet craving and they want them to eat more. But I think big picture they can be used as a helpful tool. Um But they basically say the use of non nutritive sweeteners may have potential to reduce overall calorie and carbohydrate intake if substituted for caloric sweeteners and without compensation by intake of additional calories from other food sources for those who consume sugar sweetened beverages regularly. A low calorie or non nutritive sweetened beverage may serve as a short term replacement strategy but overall people are encouraged to increase it to decrease both sweetened and non nutritive sweeteners and use other alternatives such as water but in a perfect world but in reality you know, if you have to have a diet soda now and then I think you're still doing okay. So the next section, I want to just give a brief overview of popular dietary strategies and there are way more than these four. But these are kind of the main ones discussed in the A. D. A. Guidelines and also the ones that we have kind of the most data in terms of diabetes. So just a brief definition of these. The mediterranean style eating plan is generally defined as high in vegetables, low in saturated fats and higher in the non saturated fats like olive oil, avocados, fish. Um Hi and whole grains, legumes, nuts and you're limiting animal protein and saturated fat. Low carbon keto has many different definitions and there's all kinds of different spinoffs of keto and low carb that are very popular and trendy in general, a lot of people consider keto under 25 g of carbs per day. It's usually very high in saturated fats but as we'll kind of discuss briefly, there's a couple different styles that exist vegan and vegetarian. These are plant based strategies. They're pretty self explanatory and still very popular and intermittent fasting is something that's been very popular over the last few years and the emphasis with this is more so on when you eat as opposed to how much you eat and I'll talk about the pros and cons of all these. So regarding the mediterranean style eating plan, the two major trials that we have for this and primarily diabetes patients are direct and prayed amid direct basically looked at low fat versus low carb versus mediterranean type of eating pattern and it found that the A one C. Was lowest in the low carb group. However, they considered low carb to be 28% of calories from carbs. So a slightly higher definition than many plans. But plasma glucose was lower in mediterranean style patients than when compared to the low fat group. I think the strongest study we have is pretty med which looked at basically mediterranean versus lower fat eating plants. At four years, participants, participants on the mediterranean plans had improved by seeming control and we're on less diabetes medications. They additionally showed that these Mediterranean style diets rich and nuts and olive oil reduced the incidence of cardiovascular disease in both patients with and without type two diabetes. I really like the mediterranean style plan. I think that it has some of the best data. So when patients don't have a strong personal preference, this is kind of the style that I'm a big fan of. So I think it has some really nice data to support it. Ketogenic diets. There are many different types as I was saying. And they can look and be in all different shapes and sizes. Generally, people who do Keto or eating less than 50 or 25 g of carbs per day. Um the typical macro nutrient composition can be everything from 5% less of carbs 10-20% protein and 75-85% fat. I've seen some people do much higher percentages of protein and lower fat. There's some concepts of what's called dirty keto, where people are doing nothing. The cheese and bacon and really high fat meats. There's people that do kind of more of a mediterranean keto where things like salmon, avocados, cheese, but the leaner cuts of meats and things like that. So there's a lot of different shapes and sizes of what keto truly is because of that. We haven't really had. I think a lot of really great data because people have so many different definitions of what it is. Um I think the two things as clinicians for us to be aware of one, there's a group of patients that can have really variable LDL responses to a true ketogenic diet in some circles. They are referred to as lean mass hyper responders and they can have really dramatic increases in their LDL when they increase their dietary saturated fat. So I've had a few patients where the real deals went up to the three or four hundred's when the Duke ITo after it was previously normal. So those are patients to kind of watch, you know, just to make sure they're not in that category. There also is just a lack of long term data, but we do have one small type study where an eight year perspective cohort revealed patients on low carb. High fat were more likely to develop progression of coronary artery calcium. So we just need more information. But I think if someone's gonna do keto we should probably do more of the healthy type of low carb options instead of just tons and tons of bacon. Now the A. D. A. Does make a statement specifically on low carb and they have this kind of disclaimer basically saying. In addition to in addition very low carb eating plans are not currently recommended for women who are pregnant or lactating Children, people who have renal disease, people at risk of disordered eating. And these plans should be used with caution in patients taking an S. G. LT two inhibitor because of the potential risk of ketoacidosis and I think specifically regarding the renal disease. That's a good point because the KD GO nephrology guidelines do mention for patients with diabetes patients who have diabetes, kidney disease, they should limit their excess animal protein and kind of focus more on plant based proteins in those populations vegan and vegetarian. So these are both very popular and we have a couple large meta analyses looking at these and diabetes. two of the large meta analyses looked at um Diabetes patients eating on these plans and concluded at about an average of a .32.4% reduction in a one C Plant-based eating plans also resulted in weight loss of around two kg, decreased LDL and decreased waist circumference somewhat surprisingly, they didn't see a major effect on HDL triglycerides or blood pressure in these groups, compared to the control. There was also a very interesting meta analysis of around 180,007 day adventist patients. Um this is a group of patients largely based out of Loma linda California. It's one of the blue zones, if people are familiar with this largely a vegetarian eating pattern. Um and they have a reputation for their their lifespan is much longer than many of their populations. And they found in those patients compared to non vegetarian controls. There was an overall 40% reduction in C. A. D. 29% reduction in cardiovascular events compared to non vegetarian controls. Kind of a challenging study to do. They tried to eliminate other can founders as best they could, but I think that was one of the nicer studies showing that there probably is at least some benefit to doing a plant based or plant plant centered diet In a minute fastening, obviously incredibly popular. There's a lot of different ways to do this as well, but it's the concept of only eating during a specific window and the ways of executing this can vary everything from doing a 6-8 hour eating window or alternative day fasting where maybe you don't eat for two days and then you eat for one day. There's a lot of different patterns. Several studies noted weight loss with fast of 16 hours or more per day but noted no significant differences in a one c. One study did find there was similar reductions in weight a one c. and medication use versus traditional dietary strategies. They did have a study of men with three diabetes and those on a six hour eating schedule had improved insulin sensitivity, superior beta cell responsiveness, lower blood pressure and improve satiety compared to those doing a 12 hour eating window. I think an important caveat to this is eating disorders such as like night trying eating syndrome or binge eating disorder. There are a lot more common than I think people realize. And patients that have those types of eating disorders probably not a good idea to do this because if you have an issue with binge eating and you're limiting your window to five or six hours, not only would you be able to eat in a caloric excess in that time, you may even be exacerbating some of those binge eating tendencies and making it harder to have that under control. So I generally try and screen for binge eating in anyways when I'm dealing with patients with weight loss. But if they have a history of that, I tend to avoid intermittent fasting. Now. I wanted to just kind of give some practical tips. I went through some guidelines went through some evidence about different diets, but I wanted to talk about is someone that does endocrinology and obesity medicine, what are some practical dietary tips that we can use in the clinic. Um and I think one of the most important things is we have to meet the patient where they are a few years ago when I was in training I would try and get all this advice and I thought it was being so helpful but I think sometimes it overwhelmed the patient and it made them just want to not come back. For example, if you're trying to give someone that has no dietary experience and they've never done much with nutrition and you're trying to say you have to eat 1654 calories a day and way out every meal. A lot of people get overwhelmed and so I think you just really need to have the again individualized goals and make things simple. Try and give them maybe a goal or to say we're going to try and give up soda and sugar sweetened beverages and then in two weeks we'll work on another goal. So making it in manageable chunks and then also being encouraging and providing the goals in a way that they're not going to feel like they're coming short and just always kind of emphasizing are we meeting the patient where they're at and then continuing to make that progress. I also think it's important that we ask patients where they're shopping and screen for any potential food insecurities because that can be a major issue. I like to use a lot of portion controlled options at least kind of get weight loss and diabetes control improved, such as meal replacements. Like a lot of people like premier protein shakes or something similar to that. Not only are they helpful in creating caloric restriction, but they can really kind of helped get the scale moving for folks and something that I don't think everyone may realize things like healthy choice or premier protein. Many places like walmart will actually take the snap assistant stamps for these products. So I've had patients with food insecurity were able to get them some weight management options that are affordable with their current plans. So that's been very helpful. Okay. Um, food journaling is also a really good strategy. I tend to tell people write it before you bite it rather that's using my fitness pal and entering it before they have their meal or writing it on a piece of paper. I like pre journaling because I think that it allows the patient to be kind of an active participant in their food choices as opposed to if I'm gonna eat a bag of chips and then write down, I ate a bag of chips. I feel kind of bad about it. I can't do anything about it. Maybe I'll try better next time. Whereas if I have to journal that I'm going to eat a whole bag of potato chips. It's going to at least make me think twice about it. So I find that can be effective. And as we said previously screening for the sugar sweetened beverages again, just a very short slide on portion controlled options. Again, a lot of people have trouble with cooking or they're not comfortable with things. I've had people have meal plans consisting of 22 meal replacement shakes to portion frozen meals or meals consisting of lean protein and vegetable and vegetables and then several food based snacks. So there's a lot of different ways to do this and to kind of help patients get um going with different dietary recommendations. Okay, so I just have a couple of quick cases and then I'll wrap things up. So case one we have a 57 year old man with a history of type two diabetes presenting for follow up. He has currently been taking some magma tied one point a weekly metformin 1000 twice a day and flip aside five mg of breakfast. Historically he would drink 1-2 sugar sweetened beverages per day and snack on processed foods. After your last visit, he became very motivated to improve his diet and eliminate, he eliminated all sodas and has increased his vegetable intake. You review his glycemic log which is markedly improved and he has several lows on a few days, which of the following is the next best step. You tell him that you have to eat 40 carbs per meal. No, you had a bedtime snack. So he doesn't go low, no, continue the current regimen. I'd say no. And then d asked if he feels he sometimes eating to keep up his sugar. This is a case that I had and basically we obviously just stopped his clip aside that he had been on for years he was eating to kind of keep his sugar up from that and so took away the clip aside, he was able to lose a couple pounds and he felt better and it was a win win situation that was safer and overall had a better outcome case two. So we have a 38 year old woman presenting a clinic for further management of type two diabetes and obesity. She reports she has done multiple fad diets which have been unsuccessful in the past previously. She has described challenges with depression and feels sometimes she goes to food for comfort more than once a week. She will get take out and need very large portions later. Feeling shame about overeating, which of the following eating patterns may be suboptimal given her history. And this is basically to highlight what I was talking about that this type of situation where if a patient has binge eating disorder, you would want to avoid intermittent fasting. Um just because it can kind of exacerbate that and they wouldn't have a lot of success with that pattern. So I tend to just scream for that before encouraging something like intermittent fasting for the sake of time. I'll go through here. So I think this is my last slide, so take home points. We talked about a lot, but I think one of the things to take home from this is the biggest thing is individualization. The best even plan is the one that your patient can stick to you while maintaining the desired caloric intake. One of the best ways to do that is encouraging non starchy vegetables in emphasis on avoiding sugar, sweetened beverages and limiting highly processed foods. And weight loss is essentially at its most basic concept by creating a caloric deficit which is complex, but we do have to create a caloric deficit, not specifically altering a certain macro nutrient. And I think that it's important that we're not keto doctors were not vegan doctors, we need to be just doctors for our patients and have a patient centric approach realized that there's many different preferences and cultural patterns with diet and we have to kind of meet the patient where they are to make their preferences kind of work for their success. Um very importantly, to no minimum carbs per meal for those with diabetes, we have to adjust the medication around their positive lifestyle changes, not not make them eat to keep their sugar up on insulin and consider utilizing strategies. We talked about like the portion meals meal replacements and food journaling to help with their dietary strategies and I think most importantly just providing a supportive and encouraging environment when a patient loses two or £3 tell them you're proud of them, give them that support. I think a lot of people are very hard on themselves when you can be an encouraging member of their care team and really help with them with that motivation. I think it makes a lot bigger difference than some of us realized. So that was my talk and thank you guys so much for listening. Here is a picture of my wife and me in Alaska where I'm originally from and here is my husky rocky that I have about a million pictures on my phone of so I just wanted to share those and that we can take questions. Great. That was a great talk Alex, thank you so much and of course like diet is such a hot topic. We have so many questions for you. So first off, I just want to ask one quick quick on that you sort of address. But you mentioned no minimum amount of carbs per meal. Um Do you recommend in patients with diabetes? Any minimum amount of grams of carbs per day in general? Like is there a zone a danger zone that you try to avoid? Yeah, that's a good question. Um The short answer is no, I mean I've had some people that want to do keto with like diabetes and I've had patients taquito with diabetes and yeah, it's different than what we think about. I think that I don't have a minimum amount most. I don't encourage them to specifically do keto or low carb, but I actually don't have a minimum safety number in my head. I mean, I think if they're on an anti if they're on a medicine that has um predisposing them to hypoglycemia and then we see that they're fasting, glucose is clinically declining, then I'm like, whoa, we need to get rid of those medications that are doing that. But I've had some people that have success on 100 carbs a day less than that. I don't push them towards it. But I've had people have success with everything from 50 carbs a day to 300 carbs a day. So I guess the answer is no. Okay, that's great. You touched on intermittent fasting and there's some questions about that. Is there concern about lowering the metabolism or some type of starvation response? Yeah. My personal thought is, no, I mean, I don't think, I think that there's a lot of I had this question in clinic yesterday. I think a lot of people sometimes confused metabolic adaptations with this mythical starvation mode. I don't really believe that just because you have your calorie shifted to a window, you're going to have this shutdown and metabolism. I think, yeah, if you have someone go from £380 to £220 by virtue of losing that much weight, there will be some changes in your metabolism of course. But I don't think intermittent fasting there is no my opinion of starvation motor, I would say. No, I wouldn't have concerns with that. Okay, great. Thank you. Another big question. Um, what are your thoughts on how Covid has affected weight and diabetes? Yeah. So I think we do have real substantial data that patients who have diabetes and obesity are definitely at much more risk of these complications from covid. And I think a lot of it is, um, one it's a relatively immuno compromised state and to I think that maybe people are alluding to with all of us having to stay home. There's stress, there's a lot of things like maybe we're not as active, you're working from home. I think it's definitely exacerbated it. I've seen a lot of patients in general and rape clinic, um, their weight's going up there snacking at home, there may be having nervous, they're eating the snacks live at home. Is what I tell people, like if you're working from home and you have an angry phone call or something, you can walk to your kitchen and stress seat. So I generally have seen it become worse. Probably saying is that what you kind of noticed or Absolutely, but myself too, I feel like such a hypocrite when I'm doing telehealth, there are days. I like, I think I get less than 1000 steps in, totally. Absolutely agree. I feel exactly the same. Yeah. Well, awesome. Thank you so much. That was a great talk. Published Created by Related Presenters Alex Bonnecaze, MD EndocrinologistPinehurst Medical ClinicPinehurst, North Carolina Dr. Alex Bonnecaze practices endocrinology at Pinehurst Medical Clinic in Pinehurst, North Carolina. View full profile
