I am honored to connect with Dr. Mark Cucuzzella today. He is a Professor from West Virginia University School of Medicine, and a retired Air Force Reserve Lieutenant Colonel who practices Family Medicine and advocates for evidence-based policy and education.
Dr. Cucuzzella has a fascinating background! He spent forty years as a humble yet seriously dedicated athlete, competing in over a hundred marathons and ultra-marathons. In this episode, he shares his perspective on shifting the paradigm to a low-carb diet, the impact of that on metabolic health, needing guideline Centrals for low-carb diets for patients, and hindrances to changing the narrative within the traditional allopathic medical model. We also talk about low-carb on a budget and food insecurity.
I hope you enjoy listening to today’s conversation with Dr. Cucuzzella and find it beneficial. I look forward to reconnecting with him next year for a second podcast! Stay tuned for more!
“Our medical industry has no incentive to make people well.”
– Dr. Mark Cucuzzella
IN THIS EPISODE YOU WILL LEARN:
- How the unconventional treatments Dr. Cucuzella received from an innovative orthopaedist motivated him to become a doctor.
- How working with obesity in the Air Force led Dr. Cucuzella to understand that nutrition is fundamental to metabolic health.
- The significant shifts Dr. Cucuzzella has seen in his patients and himself over the last thirty years.
- Why Dr. Cucuzzella focuses on getting people with diabetes off their medications.
- The art of deprescribing.
- What is MODY?
- Some of the barriers to the acceptance of promoting lifestyle management for addressing and treating metabolic disorders.
- Why should obesity and food addictions be treated as medical conditions?
- Some tips for doing low-carb on a budget.
- How to support teenagers to make better food choices.
Dr. Mark Cucuzzella is a Professor from West Virginia University School of Medicine and a retired Air Force Reserve Lieutenant Colonel. Mark practices Family Medicine at WVU’s Jefferson Medical Center and directs their Cardiovascular and Stress Testing lab. An advocate for evidence-based policy and education, Mark is a founding member of The Nutrition Coalition, the Low Carb Action Network, The Society of Metabolic Health Practitioners, and The Hypoglycemia Foundation and is a scientific advisor for Diet Doctor.
As an athlete, Mark has competed for 40 years, achieving a streak of 30 consecutive years running a marathon in under 3 hours. He has finished events up to 100 miles. He lives in Shepherdstown, West Virginia, where he owns a small community running store and directs running races and camps for youth and adults. His book “Run For Your Life” summarizes the science and the soul of running, nutrition, and physical activity to help you maintain a vigorous life.
Connect with Cynthia Thurlow
Connect with Dr. Mark Cucuzzella
- On his website
- Run For Your Life (Dr. Cucuzzella’s book)
Chasing Cupcakes: How One Broke, Fat Girl Transformed Her Life (and How You Can, Too) by Elizabeth Benton
Cynthia Thurlow: Welcome to Everyday Wellness Podcast. I’m your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
Today, I had the honor of connecting with Dr. Mark Cucuzzella, who’s a Professor from West Virginia University School of Medicine and a retired Air Force Reserve Lieutenant Colonel. He practices family medicine and he’s an advocate for evidence-based policy and education. I had the honor of meeting him earlier this summer. We both spoke at an event. He has a really interesting perspective about the paradigm shifts to low carb, the impact on metabolic health, the need for Guideline Central’s for low carb diets for patients, the impediments to changing the narrative within the traditional allopathic medical model, low carb on a budget, as well as food insecurity. I had a really amazing conversation with Dr. Cucuzzella. I know you will find it incredibly beneficial and I look forward to reconnecting with him in 2023 for a second podcast. Welcome, Dr. Cucuzzella. It’s so nice to reconnect with you.
Mark Cucuzzella: Yeah. It’s so great to be here, Cynthia. Privilege and it was awesome to meet you a couple months ago in the great state of Virginia.
Cynthia Thurlow: [laughs] Yes.
Mark Cucuzzella: Not too far from me. I’m in the other Virginia though.
Cynthia Thurlow: Yes. No, it’s wonderful. And so, I think let’s start the conversation. You have such an interesting background. You have a military background and you were a serious runner. You were very humble. When I met you, you were talking about your humble running practice. It’s a serious running practice. Over hundred marathons and ultra-marathons and it’s next-level dedication. [laughs] So, let’s start there.
Mark Cucuzzella: Well, maybe that was my path into becoming a healthcare practitioner. I think anyone who is a competitive athlete across country at University of Virginia right up the road from you. A sad week this week at [crosstalk] with a lot of the violence now that is infested college campuses. But yes, I went there for college. I think anyone who did a collegiate sport, basically, you do whatever you’re doing until you break and you try to fix it and you repeat, but that was the way it was. That was the culture, and myself, and all my teammates, you’re always hurt and trying to figure out how to get out of that. We had a mad scientist doctor, who was this really innovative orthopedist. His name was Daniel Cole and he had a practicing– He treated all the national level runners in America at the time. He would go into his office and he’d spend an hour with you, Cynthia. That’s weird. Most people get 10– [crosstalk]
Cynthia Thurlow: [laughs] Five minutes if you’re lucky.
Mark Cucuzzella: Inject them cortisone into your joints or something. No, he was the guy on Back to the Future. He’d look at you and watch you run on a treadmill. He’d put these little shoe inserts in his waffle iron and he had this big pool and kind of like a big hot tub in his office and he’d have runners in there with a tether running. I asked him why he did that, and he’s like, “Well, that’s what they do with horses.”
Cynthia Thurlow: [laughs]
Mark Cucuzzella: Run] in the water. There’s no impact. I was really fascinated, because it was the first time in my life, I felt someone connected with me and cared about me. This guy really cares about– Follow up. He’d call you, “How are you doing this?” I’m like, “Wow, I want to do that in some capacity.” I followed around a little bit of my fourth year of college and he wrote me a letter for medical school. Maybe that was why– it helped me. It’s hard to get into medical school and it wasn’t the best of students. I did pretty well but everybody does. But somehow, I got into UVA medical school with thoughts of being an orthopedist, because it was all I knew as an athlete, it was being broken and getting fixed. But then, I was really fascinated just by all aspects of medicine and physiology and health.
I had a military scholarship and family medicine, which is general medicine, primary care, which had a branch called flight medicine, which was operational medicine. It was a specific field in the Air Force and I rotated in that field and I liked it. I was like, “This is fun.” The orthopedic side was much more fixing things that were broken, but that side of medicine was much more like, you do a lot of stuff and you’re trying to keep people well and it was a lot of orthopedics, but not the operations when people were broken. It was a lot of the nonoperative sports injuries. That was the start of my career. I did active duty for about 10 years and then separated from active duty. Stayed reserve for 29 total years of service, but then went to university Colorado on faculty and ended up out here to be closer to my family. It’s been a good move. I live in a beautiful little town called Shepherdstown, West Virginia. But that’s the short story of how I became a doc.
Metabolic health, I started working a lot with obesity in the military and discovered just by listening to troops who are able to lose weight and keep it off. You go to bases and you’re doing these presentations, you’d ask a question, Cynthia, to the audience who are in the audience and these are usually people being remediated for not passing their fitness test, so they don’t want [crosstalk] [Cynthia laughs] to be the guy who’s going to yell at us to run more, this doctor runner guy They don’t really want to be there, but they’re mandated. They’re marginal on their test and there’s always been one person who raised their hand at one of these base gym seminars who lost 50 pounds and kept it off. “What did you do, Aaron Smith?” It’d always be some version of the same. It was got rid of all the sugar. Did paleo. 10, 15 years ago, paleo was not the aisle in Whole Foods of processed paleo food. It was eat plants and animals, like something you’d gather or kill. That was the original– They would even occasionally tell me to cardiology for so many years– 15 years ago, to tell a doctor, “I did Atkins,” [chuckles] they’d be afraid I was going to yell. “Yeah, I did this thing called Atkins. I know you’re going to tell me, I’m going to get a heart attack.” “No, no, it’s cool.”
So, that led down a rabbit hole of diabetes. Most of my practice now is diabetes reversal, trying to take people off medications. It’s using methods similar to yours. Understanding the food and timing of food, but there’s so many levers there. That brings me joy as a clinician because people come back and they’re better. It’s like, “Wow.” With medical students, I have one with me today, and he’s like, “That was fun.” People get better. That doesn’t happen. They come in and they’re sicker, more meds. No, people can get better.
Cynthia Thurlow: I think it’s something as someone who worked in cardiology and prior to that I was an ER medicine, we used to count the amount of medications that patients were taking and we had a few that were in the 40 to 50 range. Medications, not supplements. I think in traditional allopathic medicine, we’re not taught much about nutrition and lifestyle medicine. We’re really focused on symptom management with medications. There’s no criticism from my end in terms of the many very talented clinicians I’ve worked with over the years, but those of us that are putting together the pieces about how critically important what we eat, how we sleep, how we manage our stress, do we exercise, that is so impactful. The work that you’re doing, if you’re getting people off of medications, that should be applauded. That should be the standard of care, as opposed to my patients in cardiology that every year, we were adding more medications, more antihypertensives, more diabetes medications, more cholesterol-lowering medications.
Oftentimes, shaming them and saying, “You need to eat less and exercise more.” You and I both know that doesn’t work. Or, “Count your calories till the end of time.” It doesn’t take into account the hormonal dysregulation. And so, over your 20 plus years as a clinician, what are some of the significant changes that you’ve seen? I know that you’re doing profound and impactful work, but what are some of the changes you’ve seen in your patient population over all, over the last 20 years? What are some of the changes? I think from my perspective, a lot of what I saw shifting was, as you said, 15 years ago, paleo was nutrient dense whole food and now, you’ve got keto, paleo, junk food. You’ve got plenty of vegan junk food, let’s be honest, because we’re so focused on these hyperprocessed, hyperpalatable foods.
Mark Cucuzzella: Yeah, gosh, where has it gone? I graduated med school in 1992. So, it’s been 30 years of practice. I honestly believe anyone did– If you were overweight, that was probably in some way on you and this wasn’t metabolic hormonal dysregulation. We had this calorie balanced equation. We would all profess to that and tell people that, but nobody ever got better. For me, maybe it worked because I was a runner. I could probably eat whatever I wanted to eat, but I was highly active. But I ended up also about 11 or 12 years ago developing a condition called maturity-onset diabetes of youth. So, that was my personal wakeup call when I’m getting my military physical. I looked like this. I’m running, but I’m waking up at [2:00] in every morning needing to eat. My glucose was plummeting, but I didn’t know what I’d had. I had an intact second phase insulin response, but not making what’s called a first phase insulin response. So, I eat something carby and my sugar would spike really high 250 range, but then two hours later, I would crash, wake up in the middle of the night needing to eat. It went on for about maybe a year, maybe even two years. But I thought that was just the way it was. “Well, I guess I’m running a lot, I need to keep eating like this.” I was actually losing weight and I’m eating probably 8,000 to 10,000 calories a day, insane amounts of food. Yeah, it just happens. Dudes don’t go to doctor, right? [crosstalk] cardiology.
Cynthia Thurlow: [laughs]
Mark Cucuzzella: The only time they show up is when they’re having an event. They don’t come in for prevention, but if you’re in the service, every so many years, you got to line up for your lab tests and you’re mandated and that’s how things could be identified. So, I had a diabetes level blood sugar and they put me– was that [unintelligible [00:10:42] and they gave me an early gen what’s called a CGM, a continuous glucose monitor. It wasn’t something you could see from your phone like I have now. You can download it later. So, I wore that for three days. I knew nothing about blood sugars or C peptides, or insulin resistance at the time. They showed me what was happening to my glucose and I’m like, “Holy cow.” But fortunately, at the time, because of the work with obesity I was doing for the Air Force, I’d read all Gary Taubes and Eric Westman. So, I knew that eating a well-formulated low-carbohydrate diet was not going to give me a heart attack. I immediately switched the food pyramid upside down overnight.
Not many patients are willing to do that, but if your career is on the line, you’re going to do it. Mine was, because if you’re diagnosed with full diabetes or on medications, you’re medically discharged. You’re like, “Okay, I know the only way to regulate blood sugar without medication is to not eat sugar.” But I think every human should understand that it’s a human right for us as clinicians to give people choices. Like you mentioned, Cynthia, every time they come in, they’re on another med for their blood pressure, for their lipids, another anticoagulant. The more meds someone is on to manage a condition, are they getting healthier, are they getting sicker?
Cynthia Thurlow: Yeah.
Mark Cucuzzella: Yeah, and they actually die sooner. The data on at least glucose lowering is that the more glucose-lowering meds you’re on, the sooner you will die, no matter what your sugar is, because your diabetes is getting worse. But we published a paper a year ago with authors from four continents on medication reduction and type 2 diabetes. If you go into the literature as a med student, resident, attending, we’re hammered every day with industry articles on how to prescribe more advertising direct to consumers, but medical students have never had a talk or have never read a single paper on how to de-prescribe, which they really should. If there’s an art and a science to that, just like we all learn clinical experience about how to prescribe beta-blockers for heart failure and you just make mistakes, but they have to understand some of the basic pharmacology principles, but then they have to see patients and start trying it and have immediate contact with patients, if you’re de-prescribing.
You can’t say, “Come back in three months. Stop all your meds.” No, not at all. You’re going to have monitoring that they do at home and they communicate with you, glucose, blood pressure. It’s 2022. We have the technology to give better care and it’s not time consuming. There’s quick touches to be able to, “Okay, keep lowering your insulin. You can stop your insulin now.” Then, they’re good. Then, it’s actually pretty easy. When they’re not on insulin, they don’t get hypoglycemia, not at risk. But think [crosstalk] paper in the show notes for clinicians, it’s just algorithms of how to take meds away just like we would learn how to put them on first line, second line. We get hammered with that stuff every year. Some new society guideline with this fancy algorithm. Ours is actually pretty simple.
Cynthia Thurlow: I actually read the Guidelines Central last night and it is really well put together. I think for anyone that’s listening, even when I talk about just the strategy of intermittent fasting, I tell people, if you’re on blood pressure meds, or cholesterol meds, or diabetes medication, you have to have a touch point with your healthcare practitioner, because very likely, you’ll need to make adjustments and I don’t want it to turn into you lose 10 pounds and then you’re passing out in a store or you’re becoming acutely hypoglycemic. And so, just touching back on MODY, because I think there’ll be a lot of questions about what is MODY. It’s a mutation in a gene. And so, it’s something that’s inherited. Did a member of your family or was there anyone that you’re aware of in your family that– [crosstalk]
Mark Cucuzzella: We have type 1 in my family and it’s sporadic, but essentially what that– So, 95%, maybe 98% of diabetes in America is insulin resistance hyperinsulinemia. Meaning, you’re making too much insulin to overcome the resistance. When you can’t make enough insulin to overcome the resistance, you have high sugar and they say you have diabetes. But essentially, you’re making too much insulin until you can’t make enough to keep up. Then, you have the other side of the coin where you don’t make enough insulin. Technically, that’s a type 1 variety. The MODY, maturity-onset diabetes of youth, or LADA, latent-onset diabetes of adulthood. So, these are late-onset conditions where you don’t make enough insulin. So, I think that’s the simplest way for someone listening. My body’s massively insulin sensitive. So, this little squirt of insulin that I make for my physiology keeps me okay. But for someone who is insulin resistant, it wouldn’t touch it. They would be on medications.
You keep your body highly insulin sensitive and you actually don’t need a lot of insulin. We see this in type 1s. I have a lot of type 1 patients. The ones who are super fit, exercise, they don’t need to inject a lot of insulin. Very low amounts and they’re very stable. The exercise actually is this backdoor method of glucose disposal. When they’re exercising, if they’re on a pump, they’re going to shut their pump off. They could even be taking carbohydrates while they’re exercising, because they’re disposing of that glucose through the exercise mechanism. You can upregulate your glucose disposal up to about 50 times by– That’s a magic thing for anyone who is a type 2 diabetes patient. You have high sugar here, takes some insulin, stuff it into the cells or you can go for a walk and lower– We did a trial published about a year and a half ago on using continuous glucose monitors in helping new diabetes patients just understand their diabetes by food and exercise. We didn’t give them a lot of coaching. We just let them long. And immediately, they saw, “Carbohydrates increase my sugar. I’ll stop that. The exercise is really good.” Two-thirds of those patients, they were new diabetes patients never been on meds. Two-thirds of them in four months met their criteria for not having diabetes anymore.
Cynthia Thurlow: That’s incredible.
Mark Cucuzzella: They’re like, [crosstalk] They’re like, “Wait a minute, two-thirds of patients over four months, not intensive coaching, just putting a little monitor on their arm made their diabetes go away.” Now, will they sustain that the rest of their life? I believe they will if they keep eating that way, but it’s not a diet. That’s their physiology. For them, they had to be at 30 to 50 grams of carbs and walk an hour a day, and their sugars were beautifully good. Majority of them lost significant weight too. A1C reduction was like 1.8 average. No medicine. They felt better. They got healthy.
Cynthia Thurlow: That’s incredible. What do you think are some of the biggest impediments to acceptance of front lining lifestyle for treatment and addressing of metabolic disorders like type 2 diabetes, which is a lifestyle mediated disorder?
Mark Cucuzzella: Yeah, it’s a nutritional syndrome of carbohydrate intolerance. It can be reversed. You’re in medicine. Our medical industry has no incentive to make people well. It’s pharma, procedures, hospitals. They give us RV use, how much am I billing per patient, incentives based. If you have a for-profit healthcare system, there’s no incentive to make people not customers anymore. I don’t think there’s any ill will in that. It’s just the way it is and the system we’ve created. I don’t think doctors want to make people sicker. But we’re not taught or trained in this. It’s highly disruptive to the status quo. What I do here is not universally accepted. It’s accepted highly in my peers who understand it, who send me patients, but then you have others who think, if you eat meat, you’re going to get a heart attack, which we know from the literature’s absolutely not true. But people have entrenched belief systems that we carried with us from our training, maybe our culture, thought leaders, or opinion leaders. So, I think we’re the experts disagree, Cynthia, the ignorant are free to choose.
Cynthia Thurlow: [laughs]
Mark Cucuzzella: We need to give patients opportunity. “Well, let’s get you off of sugar. You have a problem with sugar. Let’s just do it for two weeks. You tell me how you feel. Well, I’m worried about– check your cholesterol, check all these things. Everyone’s worried about these things, right? Well, check them.” “They’re better. Everything about this is better, including your labs and you feel good.” I think give people permission to do something, and take ownership, and let their numbers, they will let you know. “I think your cholesterol is going to go up or something, but let’s see.” Now what does that matter for you, if your HDL goes up and everything else is fine? So, I think we just need– But it takes time. I think we don’t get enough time with people. You’re trying to do these 20- to-30-minute visits and electronic health records that are very burdensome. The system we work in is very intervention, pharmaceutical driven, not lifestyle driven. I have tons of patients on medicines. I’m not like a medicine denier. Cholesterol bad, [unintelligible [00:19:57] on lipid lowering, the ones who did it– blood pressure lowering, yeah, we need to use every tool in the toolkit. But for lifestyle driven disease, which is diabetes, high blood pressure, cardiovascular disease, osteoarthritis, you name the organ system, so the primary treatment should be lifestyle and then use.
But you mentioned what’s another barrier to– I think just the way people are and everyone’s busy and stressed and– so, take a study we did where we put a glucose monitor on new diabetes patients. I think people would have just learned– I think people fall into thirds when they walk into the clinic. Okay, they’ve got diabetes and they smoke and you like suggest, “Well, maybe we can work on this.” But they just went through a divorce, their kid overdosed, they lost their job from COVID, they’re filing for bankruptcy, they’re living off food stamps,
their mother just moved into their house, their life is a mess. They’re not ready yet. Just go on a low carb diet, those folks would not enroll in the clinical trial. It’s fine. When someone doesn’t want to quit smoking today, we don’t bully them or shame them or say it’s their fault. It’s like, “We’re here for you when you’re ready. We understand all of this. I will help you,” compassion. “I will do everything I can to help you. Come back when you’re ready.” We have people who’ve two years later, they’ll show up in clinic. “I saw you on the cardiac lab two years ago, do all the cardiac testing in my hospital. We had a conversation.” It’s wild, like familiar. They’re like, “Yeah, you met me two years ago.” They’re joyful visits.
Then, you have a third that are all in right away. Maybe someone like me, they have skin in the game. Something is real and they’re like, “Oh, gosh, I love meat, eggs, and non-starchy vegetables. I can eat this stuff the rest of my life. I don’t have a relationship problem with food.” They never look back. I bring those patients in to talk to medical students, because then we talk about, “What’s different from them than someone else?” They just did it. It’s a couple of weeks struggle, but they read, they understood the basic science, and they were willing to go all in. The people that will go all in will either do it or you’re done. They’ll get immediately good response, they’ll feel great, they’ll start losing weight, their sugars are perfect. Good. They get it, they’ll never look back.
Then, the third struggle, they’ll have a good week and I’m sure many of your colleagues, and clients, and patients and then it’s like, “Oh, holidays. Hey, this is Thanksgiving week. Oh, man, landmine, landmine, landmine.” They’ll have a lapse, a full relapse and they’ll constantly struggle until they really address that relationship with food. That’s okay. They’re working it and they’re the ones I think really need the support. In our trial, we had some of those. They made some benefit, but they were the ones who when we did post interviews, these were the ones that had they had great weeks and then they would struggle. So, they were constantly waffling. But then, the ones who did it crushed it, because they dropped A1Cs three to four and lost pounds in four months like crazy. So, I think we need to support people. But I think the ones that need the most intervention and time intensity is that group in the middle that need coaching that are vulnerable. [crosstalk] make sense.
Cynthia Thurlow: Yeah. No, it does. I think it really speaks to the type of compassionate care you have in relationships you have with your patients recognizing who’s ready to make changes the people that are not ready and the ones that are going to require significant support. I agree with you that the category of people that have a healthy relationship with food, it’s easy for them. Food is fuel and that’s the mindset. Then the people that I see struggle and I see all women, the ones that struggle the most are the ones that have these– I don’t want to say disordered relationships, but they have complicated relationships with food. Sometimes, they have a really good week depending on where they are in their cycle and they don’t have these profound cravings. Then they get a week before their menstrual cycle and everything falls apart. Their carb cravings go through the roof, they’re less insulin sensitive, they’re not sleeping, they’re more anxious, more depressed. And so, in a lot of different ways, clinicians like we are that are leaning into what types of support and information our patients need.
I would agree with you from Halloween to New Year’s Eve or New Year’s Day, I would argue that is a very challenging time for most people, because what I typically recommend and teach is enjoy yourself on the holidays and then get back on track. But a lot of people feel one day of having dessert, or consuming too much alcohol, or having too much chips, or whatever it is that they’re consuming, all of a sudden, it becomes a landslide. Before they know it, they’ve gained 5 or 10 pounds and they’re discouraged, then really tapping into their mindset and trying to get a sense for how do we reel things back in. I think also being transparent and honest about your experiences, your experiences working with other patients, being very transparent and also recognizing that the degree of support for each one of those groups of people is very different. Additional resources, I’ve become a huge fan of health coaches, because more often than not, they can be in between provider visits. They can be the person to be a lifeline or to be able to provide ancillary support and report back to us. I do think that that it’s been my experience that health coaches in many ways can step in to be that teacher, that coach in the interim in between office visits.
Mark Cucuzzella: Oh, yeah, 100%. I wish the civilian medical sector here, insurance covered and we could train health coaches correctly. A coach is a coach, but you want to make sure that they’re trained just like any clinician. I’ve met people pretty close before. I would let them give advice to people, because if non-patients or just clients that want to get coaching, if they’re getting cognitive dissonance, one person saying, “Red meat is going to kill you. Eat all these grains.” And the other one’s saying, “Well, you have diabetes. No grains.” Yeah, so, I think we all have to huddle together and try to do the right thing for patient. Yeah, little brief indulgences, maybe you’d call that. I think every human should understand, it’s okay to have a planned brief indulgence, but plan that. Okay, we’re going to have pumpkin pie on Thursday. But then, they know that’s not going to set them off into a relapse, but everyone knows that they’re a moderator or an abstainer. There’s some people that one cigarette, boom, they’re back in. An alcoholic, it’d be foolish for us to tell an alcoholic that Saturday’s a cheat day, have a brief indulgence.
I think we have to be careful. Some people can do that and not go off the rails, but if they do that and keep going off the rails, we have to tell them, “No, you must abstain. You have to treat it in the addiction model.” Unfortunately, Cynthia, we do have– It’s real. So many patients have what you described, these carb cravings. It’s a craving as much as any other substance. We have medications now that can help. I think, as a field, we are treating obesity, food addiction diet as– This is a medical condition. We have to treat the brain too. Yeah, so find a clinician who can help you with some of that, because maybe there are times where some medications can help with those cravings.
Cynthia Thurlow: No. I think it’s interesting that I always say, if you can moderate, that’s one thing. If you can’t moderate, you eliminate. And so, unfortunately, the prevailing dogma on social media or on the web is, “Oh, just moderate.” No, no, not everyone can moderate. I jokingly say, “I don’t eat gluten free cookies, or cake, or any of those things, because one cookie becomes five, a piece of pie becomes two or three.” And so, for me, I can moderate dark chocolate, really high-quality dark chocolate. I can’t moderate things with flour in them. I suspect most people, it’s that sugar rush. You just don’t know it’s the way that your body is metabolizing that food that has a large net impact on why it becomes so desirous. You get that dopamine hit in your brain and you want more and more and more.
Mark Cucuzzella: I think our friend, Vinnie Tortorich, who was also there, I think he’s right. There’s no sugar, no grains. I haven’t touched grains in 12 years and I’m fine, but I do love dark chocolate. It’s so rich that you really can’t overeat. You get one of those bars that’s in five cubes, eat one cube and [chuckles] you can’t– But if I had just more sugar than 85%, I would eat all five blocks and lick the wrapper.
Cynthia Thurlow: [laughs]
Mark Cucuzzella: There’s a threshold of like, “It’s bitter, but it’s good.” But you just can’t. Your brain will not let you. Anyone listening, go try to binge 90% dark chocolate. Yeah, you just can’t. Just like binging hard-boiled eggs, something in your brain will tell you like, “No, I can’t.” Like, “No.” It’s not appealing. Yeah, a lot of these keto products, I think people transfer that sugar addiction into process fat addiction, these high fat processed keto bombs that are highly palatable loaded with sugar alcohols. You can eat thousands of calories that, but it’s keto. You talked about that. No, that’s magical thinking, because you can transfer highly palatable. Any food like that that lights your brain up, if you’re someone that cannot be a moderator, you know that you can’t. Don’t let anyone convince you, “Oh, just go try this stuff. It’s fine.” Usually, that’s somebody who’s not insulin resistant. The people giving this advice online are 25-year-old fitness instructors. They’re like, “Well, I can eat this.” No, that’s fine for you but don’t go be telling these people, postmenopausal females with diabetes in my clinic, like do not follow those people on social media. Their metabolism is not like yours.
Cynthia Thurlow: Yeah. No, or doesn’t fit your macros. That’s always the one that I find not triggering personally, but it bothers me, because people then think, “Oh, It’s a higher carb day, so I can have the doughnuts.” No, you can’t have the doughnuts. [laughs] [crosstalk] Yeah, it’s like, “Does it fit your macros?” It probably works for a 25-year-old or maybe a 30-year-old, but it does not work for middle aged individuals. Because there’s so much hormonal changes that are going on in the body, we’ve got less muscle mass, more adipose tissue, and there’s so many different things that contribute to why we are more prone to metabolic disease as we get older. Now, one thing that– [crosstalk]
Mark Cucuzzella: [crosstalk] just to try it right, Cynthia? If it doesn’t work, okay. You tried it, it doesn’t work. Don’t keep trying it. I’m sorry. You were saying something there. I have interrupted.
Cynthia Thurlow: No, no, no, I was thinking about the fact that it’s probably the study that you are familiarized with talking about nonnutritive sweeteners that came out recently looking at saccharin, and aspartame, and stevia, and a few other things. Was it any surprise what the results were? I’m thinking about a keto company that will remain unnamed, the very nice individuals that their products have a lot of sucraloses in them and trying to explain to people that sugar by any other name is really sugar. If you look at the research on what happens, I think these were mouse models looking at their glucose tolerance, and looking at the changes in the gut microbiome just with the utilization of these products in a 30-day span of time. I keep reminding people that I know well-meaning individuals are in the business to sell products that are cleaner than their conventional counterparts. But we have to get real about our relationship with sugars is one example.
The irony is, I’m listening to Vinnie’s book right now and there’s a whole chapter talking about sugar. To your point that it’s really examining our relationship with sugar. Our brains and our palates really crave sugar. And so, when we have that 90% dark chocolate and the polyphenol count is higher. That are compounds are actually beneficial to us. But what ends up happening is you take something that’s inherently fairly healthy, and you add in sugar, and you add in milk, fat, and all these other things, and then it becomes an intoxicating candy bar that’s really hard to resist, even for people that are metabolically healthy.
Mark Cucuzzella: No, 100%. Yeah, the sugar alcohol’s too– for anyone who’s thinks they can just use this stuff ad libitum it gives people such horrible cramping and ultimately, there’s this toxicity, where people just like, “Yeah, it does not treat your gut well.” But maybe as a wean, when someone’s coming off three big Mountain Dews a day and now, we’re just trying to wean them. So, some people are like the “all-in.” They tend to be military-type people. They’re all in. But other folks, they want a more gentle entry. I think there is a role for these products. But ultimately, the goal– just vaping. You get smoking three packs a day and now you’re going to transition to vaping, but we certainly don’t want you to be vaping your whole life. But if that’s helping you, e-cigarette or something, I don’t want to support those industries, obviously, but if your goal is in three months, you’re going to be off. Everyone has a different plan. We as clinicians, coaches need to work with them but make sure it’s realistic. If they get off the rail, help them get back on. [crosstalk]
Cynthia Thurlow: It’s so important.
Mark Cucuzzella: I haven’t seen anyone never get off the rail. Find me that perfect person and there’s someone on Pinterest or something in there.
Cynthia Thurlow: [laughs]
Mark Cucuzzella: These people are not real.
Cynthia Thurlow: Yeah.
Mark Cucuzzella: You’re following these people, they’re not real.
Cynthia Thurlow: Yeah. One of the things that you talk quite a bit about is how to do low carb on a budget, which I think is really important. I know for a lot of individuals going from a hyperpalatable diet to a less processed one can be overwhelming, because it is more expensive to buy meat. It is more expensive to buy just regular fruits and vegetables, as opposed to their processed counterparts.
Mark Cucuzzella: Yeah, we actually published a little book with a grant– we can share, because it’s open access. It’s called Low Carb on Any Budget. I’ll send you that link and you can download the book. I work in rural West Virginia. So, most people don’t have access to garden fresh vegetables 365 days a year. It doesn’t exist. No kidding. If you look at my whole state, 50% of the state does most of their grocery shopping at dollar stores. There’s no grocery stores in these towns. So, you should be able to go into dollar store and make better decisions. You can buy frozen broccoli, you can get canned tuna, you can get ground beef, and you can get eggs, you can get blocks of cheese. You can go into a dollar store in rural West Virginia and eat. It’s not your perfect grass-fed organic farmer market but it’s good. Compared to getting the most-highest purchased item with SNAP, with just food stamps is soda. So, we’re using all these government dollars which are supposedly to address food insecurity, which your health is impacted by your ability to purchase food and people are buying soda and chips.
Yeah, it shouldn’t happen, but there’s too many special interests involved in policy. You and I will not change those laws, probably in our lifetime. So, we can help train teach patients, “Look, you can–” Because everyone has, “Oh, it’s expensive.” No, it’s really not. I have a decent job, but I don’t go purchase a half a pig and half a cow every winter and stick in the freezer and gradually eat off of that in the wintertime. I’m not getting as many fresh vegetables, because they’re shipped up from Peru or something and they’re pretty tasteless. So, I’ll get frozen broccoli, frozen Brussels sprouts, olive oil, and salt. It’s delicious. When summer comes around and it got a lot of amazing local stuff that– Right now, they’re amazing. The kale and the chard, it is magical right now, at least where I live these fall vegetables, and oh, my gosh, yes. So, you still can get that stuff and it’s not offensive.
We developed a program here in [unintelligible [00:36:13] with some grant funding to double SNAP at local farmer markets. You can take your EBT card which is your benefits cards to a farmer market and swipe $20, for example and they’ll give you $40 of market bucks, which can be used on not just the vegetables, but you can go buy eggs, you can go buy sausage, [chuckles] you can go buy cheese, you can buy any local farm product. But a small fraction of our people on SNAP and EBT are going to farmer markets. But the ones who actually are you doing this, they keep coming back. They’re like, “Wait, are you serious? I can double this?” We even triple it with it. There’s another program in this state called SNAP Stretch. If you have children, that $1 on your EBT card becomes $3. They’re like, “No way.” It’s like, “Yeah, a way.”
Cynthia Thurlow: Oh, that’s interesting.
Mark Cucuzzella: Even though the vegetables are a little more expensive at face value, but when you’ve tripled your dollars and then kids learned to like vegetables. They’re like, “Wow, this is actually pretty tasty.” Like an apple from one of those orchards, yeah, oh, my gosh, they bite into one of these local apples and they’re like, “Wait, that’s good. [laughs] Yeah, that’s really good.” So, the programs like that in your community, I think you have to be innovative and work within the barriers that you got between government policy and food access, do you have a grocery store. I shop in all the 100% when I need to shop, because there’s only 1,500 items in all of them, so you don’t get overwhelmed. If you walk into one of these big stores, I get a panic attack. I just want to get some bacon.
Cynthia Thurlow: [laughs]
Mark Cucuzzella: [crosstalk] I’m just like, “Get me out of here.” But all these, you can search and you can go around the perimeter in 10 minutes, you’re out of there and even get that 85% dark chocolate.
Cynthia Thurlow: Yeah. And that efficiency piece, I had to run into, I think it was Kroger. You’re overwhelmed with the color, because the processed food industry makes their packaging, it’s really bright and colorful and enticing, maybe the person who wants to eat it. But trying to find as you said, trying to walk the periphery, I was looking for, I think garbage bags, so I had to go to that site. But you have to walk so far through so many other things to get to what you need, [crosstalk] you feel like, “Oh, I need these five other things.” And then you end up having more of a grocery bill. So, I think that depending on where you are in the United States or abroad, finding opportunities to eat locally as often as you can support local farmers if your budget permits.
Then, finding a reframe for how to feed yourself and how to feed your family, I know with my kids, when they were younger, they’re now teenagers, it was the thank you bite. They always had to try it, they didn’t care what it was, they had to try it. If they really liked a vegetable, we would just buy more of that vegetable. So, if it was broccoli, broccoli was always an easy choice for my kids. Maybe they didn’t like sweet potatoes as much, but I was okay with that. But understanding that kids oftentimes have to try something 20 times before they like it. Their taste buds are more sensitive than ours are, just like everything as we’re getting older things aren’t working quite as efficiently. And so, I have to remind myself, especially with my kids that if they’re sitting down and having a good amount of protein and they’re having some vegetables, I’m happy. I try not to think about what they’re eating at school, because that’s a whole separate conversation.
A lot of the questions that came in for you were, how do I continue to support my teenager and young adult eating healthfully? Because what ends up happening is, if maybe in your home, you have healthy food. But then they go to a friend’s house or they’re at a party– I had my 15-year-old was at a church sponsored function for the weekend and he came home on Sunday and said, “I can’t eat any food. I ate nothing but junk for two days. I’m so sick to my stomach.” He went to bed. [giggles] He was like, “I can’t eat that way. I ate more Oreos than ever eaten in my life” and he’s like, “I don’t want to tell you what else I ate.” I was like, “Please don’t.” But I think that they’re starting to make that connection. So, how do we support teenagers in particular?
Mark Cucuzzella: I think as a parent, I have two, one in college, a senior in high school. You can’t be an authoritative parent of teenagers. If you tried to do that, that will backfire. I think in your home, you model for your kids, develop a good relationship with food. “We’re going to have meat and vegetables.” You just model like, “This is what we’re eating.” Certainly, you set their palates young, because kids’ palates and flavors are being hijacked now at age one with first foods. Robert Lustig is the guy who’s really written neuroscience and all this. You have to create a safe food environment at home. But it’s not difficult. If you’ve never had soda in your home, not having soda in your home is not a punishment. Kids’ brains are programmed before eight, seven. That’s where the programming happens. So, video and screen time, if the kid never was exposed to current screen before eight, seven, it’s not a struggle when they’re 10 to extract the screen. They’re fine. They’ve learned other programming mechanisms to do what they need to do to keep themselves occupied. I think it starts with helping just serve kids human food. Not a little carb, just real food. No sugar-sweetened drinks, including the juices. I don’t think there’s any place for that on human diet, especially for your teen and just develop a good relationship with food. Involve your kids to cook with you.
So, if you do those kinds of three things, model for them, so you can’t be binge eating Cheetos at night and expect your teenager to have kale and pork chops. But I think anyone listening to your show probably has already had some good patterns and then safe food environments. In the cabinet and in the fridge, you always have real food. So, they’re hungry and if you’re going to get a snack, you get a piece of cheese, a piece of salami, what do you snack on? Really, they don’t need–
The culture of snacks is weird. When I grew up, there was no such thing as a snack, the snack industry. So, you’re not creating this culture, we’re going to get in the car. Cars are cafeterias. Now, there’s 18 cupholders in some cars. We’re not bringing snacks to drive a half hour across town. That’s just what people do now. The kid can’t be in the car unless the screen is on and it’s like a movie theater, [laughs] two cupholders per child. You drive half hour to grandma’s and you’re like, “What the hell?” Then, you got to deprogram that like, “No, just don’t go down that path.” Yeah, just develop a good relationship with food, because kids develop bad relationships with food. That’s the worst. So, if somehow you’re authoritative to that child and the child starts restricting, all of us know that that’s probably the worst thing that can happen to a teenager is to get a restrictive eating disorder. They’ll be highly untreatable with high mortality rates. So, we never want to, at all, do anything that could potentially send a kid down that path.
There’s a great book that was recommended to me by Sue [unintelligible [00:43:21], who’s also in Richmond. It’s called Chasing Cupcakes, which I think if you read that book, it just is like, “Oh my gosh, that was me.” Not me personally, but if you read that and you’re like, “That was me and my mom.” It takes you off the hook. You’re like, “Okay, this is not my fault. That was my mom following me from behind, because I was a little bit overweight and forcing me to run at age 12.” Yeah, it happens. These authoritative parents doing this to kids, it’ll crush them.
Cynthia Thurlow: Oh, it’s interesting.
Mark Cucuzzella: [crosstalk] powerful book. You’ll think of things that you may have done or done and you’ll be like, “Oh, I ain’t going to do that again,” because it’s powerful.
Cynthia Thurlow: [crosstalk] Yeah. No, it’s interesting to me over my lifetime. When I did my medical training, I worked on an eating disorders unit just by pure happenstance. That’s where I got placed. We know the cure rate for anorexia as an example is really low, much lower than it is for bulimia or even binge eating disorders. And so, I’ve had multiple friends throughout my lifetime. And their anorexic tendencies, although they might be stable, they never go away. Even navigating, watching friends of mine eat, who’ve been full anorexic and now are still in these restrictive patterns, that mindset never changes for them. And so, I agree with you wholeheartedly that if you do have a child or you yourself are struggling with this to really get the support that you need, because shaming someone that has an eating disorder is definitely not the way to go about supporting them.
Mark Cucuzzella: It’s pervasive in sports too, especially sports– I was a distance runner. Almost 100% of collegiate level distance runners have some degree– because they’re encouraged to be– And that culture is changing a little bit, but it’s still pervasive. They’re encouraged to weigh in and be ultra-lean, because they actually do run faster when they’re lean, but the bill comes due, because then ultimately, they break– But their image of their body and who’s running fast tends to be, okay, the one who’s running fast is the one who’s unhealthily lean, but they might actually be uber fit at that moment. But they’re not healthy and ultimately, they crash and burn. That’s a hard culture to break.
Cynthia Thurlow: Absolutely.
Mark Cucuzzella: New York Times had an article about it last week and people are starting to come out and talk about their experience more now, because they did talk about, “Oh, gosh, my coach was weighing in every week.” It’s like, “Whoa.” They were doing that for us 30 years ago, but I don’t think anyone understood all of this eating disorder stuff then. Now, there’s so much more knowledge about it. The female athlete triad and they call it RED-S syndrome, pervasive gymnastics, any sport that would involve some degree of leanness.
Cynthia Thurlow: Or even belly dancers. Anyone that’s in a leotard, absolutely. Now, when you’re working with your patients and you’re looking at metabolic health markers, what are some of your favorite test to use? I’m sure fasting insulin, probably C-peptide. But what are some of the other testing modalities you’d like to look at? I know when we met over the summer, we talked a lot about the CAC and I think this is important to reinforce to our listeners, things that they can be asking for that are not expensive tests, that are not particularly invasive tests that can give them good information about their metabolic health.
Mark Cucuzzella: Yeah, it depends on the question you’re trying to answer. Every test has its utility. There’s not any set of tests we should give to every single human. Fasting insulin– we’re doing a pediatric study now. Children especially, their pancreas will crank insulin to store fat and carbohydrate in their path to becoming significantly obese before their sugar gets high. An A1C test for a child, by the time that’s up, they’ve been hyperinsulinemic, prediabetic for years and probably, already BMI 40 plus. So, we’ve seen these fasting insulin in these children off the rails, because– levels you’d never see with fairly normal blood sugars. So, I think if you need some kind of convincing that your body is overproducing insulin and the way to not over produce insulin is not eat the foods that will make you need insulin. Draw that test. It’s like a $20 test.
Yeah, hemoglobin A1C will tell you who’s had this condition for a while. It’s something standard medical literature we can follow. I think really you get a continuous glucose monitor, an A1C is one marker every three months but it doesn’t tell you anything about your glucose variability, time, and range. 20 years ago, no one could get these glucose monitors. They weren’t very good, they were very expensive, they were very bulky. Now, the things can
and it’s $75 per month for two of these and you just read it on your phone, but it gives you all this data, real-time data. So, I think you just want to see what your response is to food, and mood, and exercise. You don’t need this forever, but just go play with one of these for a couple months if you have some kind of medical issue. I don’t recommend that– Now, there are people starting to use these monitors who really don’t need them or who are overinterpreting. They’re like uber well people, who will eat a sweet potato and their sugar goes up just a little bit, they freak out. No, that’s fine. The type As are like, “Oh, you have someone to help you. So, you’re not going to put this on you and get stressed out about something that’s not meaningful.” If you have medical illness, diabetes, I think it’s really powerful. If you don’t, I’m not recommending we have every human being on the planet put glucose monitors on.
Now, the CAC or the calcium score is a powerful test to tell you as an individual, do you have any degree of cardiovascular disease that is detected? It takes about probably 20 years before you would develop calcification on your arteries from the process of little bit damage to your endothelial, which is that little lining of the blood vessel to penetration of the small LDLs, and macrophages, and foam cells, and soft plaque, and little plaque ruptures, and then you get a little calcium cap. That’s a long process. But if you’ve got calcium on your arteries, it means you have some risk of a plaque rupture. I don’t want people to be terrified of that if they have calcium, but some folks just want to know where they stand, because they’ve been told, “Oh, everything’s fine. You passed your stress test.” But they’ve got loads of calcium. They’re fully diabetic, so we want to help them, because they still have high risk.
There’s other people that are told, “You have high cholesterol. You need this med,” but they’re well. So, if you have “high cholesterol,” but you’re otherwise perfectly well, cholesterol doesn’t cause heart disease. It might be at the scene of the crime, but it’s not the murder. There’s other things that have to happen. If you’re middle age– I’m not saying 25, because you’ve got a long road to go. You’re my age, for example. You’re 56. I have high cholesterol. My CAC score is still zero. So, I’m okay with that. I’m not going to take a medicine to lower my cholesterol, because I’m really at no risk of a piece of plaque breaking off, because I don’t have any plaque. But if I had a big plaque number– My dad had a heart attack at 85. If you plug me into the calculator, I shouldn’t be on all these cholesterol-lowering meds. But there’s a lot of things that go into heart disease. So, at least for me as an individual, my score is zero. I feel well, and I don’t want to take them, and I don’t need to. That’s in the Heart Association’s own guidelines. If your score is zero, there’s no benefit from a statin, because if your odds of a plaque rupture is near zero, the medicine can’t lower that odds anymore. But if you have a high score, yeah, we need to dig into the weeds.
I order advanced lipid panels for people that have really high scores that can’t easily be explained. Again, these people, these are the ones who concern you, because they’re the ones who are missed. They’re athletic, they look pretty well, they’re not diabetic, and they have calcium scores greater than a thousand. They’d be like, “Wait a minute, where’s that coming from?” While they have high LP(a), that’s a genetic marker, that’s not responsive to statins. Yeah. So, you have to answer that question why that person has that high score. It’s nuanced with some basic principles, we don’t want to do harm and overtreat people, but we don’t want to undertreat people that can benefit from treatment. You can’t just guess. You need objective data to make that determination who doesn’t need treatment. I know that’s two minutes. A lot of stuff and what we spent hours with medical students in the cardiac lab, and pulling up all this stuff, and having conversations with patients about what their preferences are, do you want more testing, less testing?
Cynthia Thurlow: Well, I think it’s really invaluable to hear, because I don’t think there’s enough discussion around the CAC. I think people assume if they have a negative stress test, then their risk is relatively low. The advanced lipid analysis, I can’t tell you how many people have an irregular LDL. They get a traditional lipid panel with triglycerides, total cholesterol, HDL, LDL, and their LDL is greater than 160. The first thing the patient tells me was I was told, “I need a statin,” and I said, “No, you need more information. That’s really what it comes down to.” We need more information to make the best assessment on how to address this. If you’re insulin sensitive, you’re, otherwise, metabolically flexible, get those the advanced lipid analysis. We used to call it years ago, the VAP. I think it’s now evolved into different names, but really getting more information– [crosstalk]
Mark Cucuzzella: [crosstalk] profile.
Cynthia Thurlow: Yep.
Mark Cucuzzella: Lab Cardio IQ, Quest test depending on which lab you can get. The NMR lipid profile from LabCorp gives you what’s called an insulin resistance score, which is really powerful in the women’s health study. 28,000 women, 21 years having the worst quartile of that lab test posed a 7x risk of cardiovascular disease. LDL was 1.3. Wait a minute, [chuckles] why are we looking at this lab test rates. It’s like, holy cow. In that LDL, 1.3 risk, which is pretty close to one, which is even-steven. The only part of that LDL that mattered was small LDL and particle number which travel with insulin resistance. The large LDL particles had not crossed the line. It was one. Again, there’s no good or bad cholesterol for those listening. Cholesterol is all the same. It’s how it’s packaged and what the condition of your arteries, genetics, like a lot of known knowns and unknowns and that whole thing. There’s a lot we don’t know. We knew all this cardiovascular disease would not be the leading cause of death of men and women. There’s a lot we don’t know.
Cynthia Thurlow: Exactly.
Mark Cucuzzella: We practice medicine these days. That’s what we do. We practice that. Hopefully, your doctors are reading and curious. I read every day.
Cynthia Thurlow: That’s really key, being a lifelong learner. It’s something that my parents instilled in me, but definitely to this point, during the course of a year between papers, and research, and books, there’s a lot that’s read. I think for all of us, it’s being curious about the fact that maybe what you learned 20 plus years ago no longer applies or things have evolved. I know that it takes medicine a long time to catch up with the research, but there are certainly people like yourself that are front lining and trying to help change policy, trying to be much more progressive in your approach and patient care.
Mark Cucuzzella: No, I think we’ve covered a lot of ground here. Spent a good hour.
Cynthia Thurlow: Absolutely. Please let listeners know how to connect with you. You’re not really on social media. I was actually laughing about that. If I tried to tag people or tag you on Twitter, you’re not on Twitter. It’s probably a blessing, because sometimes social media can be good and bad. [laughs]
Mark Cucuzzella: Honestly, I don’t have time.
Cynthia Thurlow: [laughs] Yeah.
Mark Cucuzzella: I am at my running store now. I own a little running store, which is a little community place, where we help train people and help them move better and get them walking. So, I spend a lot of time doing other things. I have a website, www.drmarksdesk.com, and there’s a little Contact Us. But I wrote a book called Run for Your Life and I have a website with that called runforyourlifebook.com. I have a lot of resources on there. You can hit contact, you can reach me through there. If you live close to West Virginia, come on out.
Cynthia Thurlow: Well–
Mark Cucuzzella: Yeah, I do have a Facebook page, but I use it more for things. I direct races too, running races. So, it’s just having another way to promote your races and events and things like that. But I think it can suck the life out of you like I’ve just not gone down that road. Maybe that’s a good thing. Read a book at night. Not going to Twitter. [laughs]
Cynthia Thurlow: Yeah. No, no, it’s much safer. But thank you so much for your time. It’s really been an invaluable [crosstalk] discussion and one that I know will be really helpful for listeners.
Mark Cucuzzella: Yeah, and we can do something downstream again too with other topics, Cynthia.
Cynthia Thurlow: I love that.
Mark Cucuzzella: Enjoy the holiday.
Cynthia Thurlow: Thank you. You too.
Mark Cucuzzella: We’ll see. All right. Bye-bye.
Cynthia Thurlow: If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.