Wonderfully Made

Diabetes

Three Angels Broadcasting Network

Program transcript

Participants: N. David Emerson

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Series Code: WM

Program Code: WM000427


00:36 Hello, I'm Dr. Emerson,
00:38 Medical Director at Eden Valley Lifestyle Center
00:41 Today, I want to talk to you about diabetes,
00:44 and the insulin resistance syndrome.
00:47 We start with a story about Toni.
00:49 She was a patient who came in our practice...
00:52 She actually wheeled into our practice in a wheelchair.
00:56 Now, you wonder why a wheelchair?
00:58 Well, she didn't have multiple sclerosis, or polio
01:01 BUT, at 5 feet 3 inches, she weighed 325 pounds.
01:05 She weighed more than she could lift.
01:08 This is one of the effects of diabetes type 2 which she had.
01:12 She was on large doses of insulin,
01:15 about 44 units of insulin per day.
01:18 A normal pancreas only produces about 30 units per day
01:22 in a normal person, but she was requiring even more
01:25 than in a normal person would require.
01:27 We're going to find out why shortly.
01:30 She also had high blood pressure.
01:32 She was on 2 blood pressure medications,
01:33 and her blood pressure was still poorly controlled.
01:36 She had high cholesterol, and was on a
01:38 medication for that as well.
01:41 She was tragically blind from her diabetes.
01:46 This is one of the complications from diabetes...
01:48 diabetic retinopathy, and was not reversible at this point.
01:53 So, she was coming there for help, and the question is...
01:59 "What should I tell her?"
02:02 Well, I could tell her the diabetes is genetic
02:05 and there's really nothing you can do about it, except
02:07 continue to take medications the rest of your life
02:09 and wait for further complications such as...
02:12 heart attacks, stroke, kidney failure necessitating dialysis
02:16 or an amputation from poor vasculature to her
02:19 lower extremities... and I could tell her that she was doomed
02:25 to carry the weight for the rest of her life...
02:27 that she'd need to take medications for her cholesterol
02:29 and her high blood pressure for the rest of her life...
02:31 Or, I could tell her about God's Plan for a healthy body.
02:35 A plan that many times can eliminate the need
02:38 for medications and improve and reverse the disease process
02:46 So, what exactly did I tell her?
02:49 Well, first the question is... "Is diabetes genetic?"
02:53 Well genetics can increase your predisposition for diabetes.
02:57 BUT, if you make the right choices,
02:59 you can avoid getting diabetes.
03:02 Now, we look at the Pima Indians, in America,
03:05 as well as the Pacific Islanders
03:07 They both have a very HIGH rate of diabetes today...
03:09 However, this was NOT always true.
03:12 At the turn of the century, a German endocrinologist
03:15 went to the Pima Indians and screened them for diabetes.
03:21 This was in 1901, and out of the whole tribe,
03:24 he could only find 1 diabetic.
03:27 Today, in the Pima Indians, diabetes is rampant.
03:32 Back in the turn of the century, they were on a plant-based diet
03:39 and they didn't get the diabetes that they're getting today
03:43 on the western diet.
03:44 Dr. Murdoch, an endocrinologist at Loma Linda, says
03:47 "Genetics can load the gun, but the environment...
03:51 that is the choices WE MAKE is what pulls the trigger. "
03:54 So, if you make the right choices,
03:56 even though you have a predisposition for diabetes,
03:59 you may not get it.
04:01 Now, diabetes has increased dramatically recently.
04:06 I remember in medical school, studying about diabetes type 2
04:10 wondering if I'd ever SEE it.
04:11 NOW, just about everybody I know either has diabetes
04:15 or knows someone that has diabetes.
04:18 Between 1958, and 1994, a span of 36 years,
04:23 the prevalence of diagnosed cases of diabetes
04:27 has increased, not just 5 or 10% ... it's increased 500%
04:32 and recent surveys show no sign of it decreasing or slowing down
04:40 Well, have our genetics changed in the last 50 years? No
04:43 Have our eating habits changed? Yes
04:46 Can what we eat cause diabetes?
04:49 That's an important question.
04:52 Can what we eat actually cause type 2 diabetes?
04:55 Well in 1927, Dr. Sweeney asked a similar question
05:00 and he did tests to investigate.
05:03 He took several medical students,
05:05 and he was able to induce a diabetic state with a
05:09 high fat diet in just 2 days. How did he do this?
05:13 How did he accomplish this?
05:15 Well, first he tested them for diabetes,
05:17 with a glucose tolerance test.
05:19 He gave them 75 grams of sugar
05:22 and he watched how high the sugar went.
05:24 The sugar rose from below, say 100, which was normal.
05:27 It rose, stayed below 150, and then it slowly came back
05:31 to normal... down below 100.
05:33 This was a normal response, they did not have diabetes.
05:37 Now, what was happening in this process,
05:41 when they took the sugar into the body.
05:42 How did the body regulate sugar?
05:44 As the sugar goes into the intestines,
05:47 it dissolves and goes into the bloodstream,
05:49 and the blood sugar rises.
05:51 The pancreas senses that, releases insulin,
05:54 and insulin acts like a little key.
05:56 It goes to all the cells in your body,
05:58 and it unlocks the doors to the cells.
06:01 The sugar then leaves the blood,
06:02 goes into the cells, and gets burned
06:04 and that brings your blood sugars down.
06:06 And that's the way it's supposed to work...
06:08 And that's the way it was working with these
06:10 medical students.
06:11 Then he tried his experiment.
06:13 He gave them 2 days of a high fat diet,
06:15 that's olive oil, butter, mayonnaise made with egg yolks
06:18 and 20% cream... then he re-tested them.
06:22 He gave them the 75 grams of glucose,
06:26 and in 4 out of 6 of the patients,
06:29 the blood sugars rose, and they ran between 150 and 200
06:34 before coming back down...
06:35 That's called insulin resistance.
06:37 The blood sugars were going higher than normal.
06:40 It's a prediabetic state.
06:42 In the other 2, at 2 hours, the blood sugars
06:45 were still above 200, and that's a diabetic state
06:48 ...That's the criteria we use to diagnose diabetes.
06:51 What actually had happened?
06:54 What was causing them to be in this state?
06:56 Well what happened was, the fats that they were taking
06:59 from these foods, these animal products was going into
07:02 the bloodstream, and plugging up the keyholes-
07:06 those insulin receptors.
07:08 So NOW when they took a sugar or starch,
07:10 their blood sugar went UP, insulin was released,
07:12 and couldn't get in the keyholes.
07:14 The door stayed shut, and the blood sugars rose
07:16 because they had nowhere to go...
07:18 and this is insulin resistance...
07:20 and it eventually leads to diabetes.
07:24 Well, at the time of Dr. Sweeney many people surmised that
07:29 because the blood sugars are elevated,
07:32 maybe the real problem is too much sugar or starches
07:37 which break down into sugar...
07:38 Maybe too much sugar and starch in the diet.
07:41 Was this what was the problem?
07:45 Well, he decided to do a preliminary test to check for it
07:48 He took some more medical students who were usually
07:52 eager subjects, and he gave them 2 days of a very high
07:56 sugary diet... lots of high simple sugars,
08:00 and complex carbohydrates such as sugar, candy, pastries,
08:03 white bread, baked potatoes, syrup, bananas, rice, oatmeal,
08:08 and then he re-tested them.
08:10 When he re-tested them,
08:12 he gave them 75 grams of glucose.
08:13 He watched how high the blood sugar rose...
08:15 started below 100 which was normal...
08:17 It rose, and stayed below 150 and came back to normal.
08:20 This was a normal response...
08:22 They did not have insulin resistance.
08:24 So, simply put, the sugars, and the starches
08:29 were not able to induce this insulin resistance state.
08:35 So, up to this point, the simple message is
08:38 "You can make someone diabetic with lots of fats and oils,
08:41 particularly the animal products,
08:43 and you can cure, or reverse this process in early diabetics
08:47 by eliminating those fats and oils. "
08:50 And also, sugar doesn't seem to be the primary
08:54 cause of the primary problem in diabetics.
08:57 Well, in 1973, Dr. Anderson wanted to confirm these tests.
09:03 He is a world authority on diabetes,
09:06 and he essentially repeated Dr. Sweeney's experiments
09:09 and he was able to turn lean, healthy individuals,
09:11 into mild diabetics in less than 2 weeks...
09:14 by giving them a diet in which
09:16 65% of the calories came from fats.
09:20 He then wanted to confirm the sugar question,
09:25 or find an answer to the sugar question,
09:27 so he decided to give them not just a LITTLE bit of sugar
09:29 but he gave them a pound of sugar a day...
09:33 That was, you know, 5 pounds of sugar is about that much...
09:36 A pound would be about that much sugar...
09:38 a huge amount of sugar on a daily basis.
09:41 He tried this for 1 week, 2 weeks...
09:43 He went actually 11 weeks, and at the end of 11 weeks,
09:48 he was not able to produce even 1 mildly diabetic individual.
09:52 All the glucose tolerance tests were still in the normal range
09:55 And he concluded that, again, sugar doesn't appear to be the
09:58 primary problem in diabetes.
10:01 Dr. Bronzo asked a similar question about sugar.
10:05 He took subjects with mild diabetes,
10:09 and he changed them from a diet containing 45%
10:13 simple sugars to one containing 85% sugars.
10:17 He was unable to produce diabetes in those,
10:23 and actually, with those mild diabetics, the blood sugars
10:26 actually dropped... the fasting sugars dropped.
10:29 So, again, we can induce the diabetic state with the
10:34 fats and the oils, and we can help to eliminate that state
10:37 by eliminating the fats and the oils.
10:41 Sugar is NOT the primary problem in diabetes.
10:45 Well, let's move out of the laboratory into real life.
10:50 Let's try Dr. Sweeney's experiment on NOT just
10:53 a few subjects in the laboratory
10:56 but let's go to a whole island!
10:59 Prior to World War II, the natives of the
11:03 small Micronesian island of Nauru
11:06 had a very low incidence of diabetes.
11:09 They had excellent health.
11:12 Their diet consisted mainly of bananas, taro which is a root,
11:16 breadfruit, coconuts, some fresh fish, vegetables.
11:20 Consumption of canned foods and frozen meats was
11:26 essentially nonexistent... They didn't have it then.
11:28 After World War II, however, they found phosphorus
11:34 in the bird dung... that had been deposited over
11:36 hundreds of years there.
11:38 This was a product that was in demand in the world
11:42 and they came and they mined it...
11:45 And they became the richest per capita nation in the world
11:49 just after World War II.
11:52 What do you do when you have money?
11:53 Many people will buy the western diet,
12:00 and start importing the foods... and this is just what they did
12:02 The consumption of canned and frozen meats
12:04 fish, sodas and oils increased dramatically.
12:07 Fat intake increased, fiber intake decreased...
12:10 Many meals would include 2 or 3 meat dishes per meal.
12:17 Eventually in the 80s, those over age 15,
12:23 1 out of 3 was diagnosed with diabetes.
12:26 Obesity, atherosclerotic complications
12:29 became very common.
12:31 The other islands in Micronesia were also affected
12:36 After World War II, the U.S. Navy,
12:40 toured the Micronesian Islands,
12:42 they felt an obligation to address the medical needs
12:46 of those islands after freeing them from the occupation
12:49 during World War II...
12:51 so they wanted to find out what the problems were.
12:53 The USS Whidbey toured those islands and surveyed them,
12:58 and they found that, yes, they had bacterial diseases...
13:00 They had venereal diseases, parasitic diseases,
13:04 but they had no diabetes, high blood pressure,
13:07 obesity, hypertension... these were not issues for them.
13:12 When I went to Guam in the 90s,
13:15 we served at a little Seventh-day Adventist clinic
13:18 on the island there...
13:19 By that time, in 1992, diabetes was rampant.
13:24 It was their #1 problem.
13:26 Heart disease was their #2 problem,
13:28 and we were frequently flying patients to Hawaii
13:30 for their cardiac catheterizations,
13:33 and further examinations.
13:35 We went to the "Nutcracker Suite" at one point
13:39 at the gym there, and when we went in the gym,
13:42 we got a sense of the preferences in Guam.
13:46 Food preferences... we saw a huge banner on the side
13:48 of the gym saying, "SPAM THE FLAVOR OF GUAM"
13:53 So their dietary changes had changed dramatically
13:56 in 50 years, and so had their medical problems.
14:01 Countries that have maintained a low fat, high fiber diet
14:05 such as the Africans, some of the Asians,
14:07 some of the Polynesians, still have a very low incidence of
14:12 diabetes, hypertension, and heart disease.
14:15 But, as their diet becomes westernized,
14:17 they develop our problems as well.
14:21 Well, remember Dr. Sweeney's experiment
14:23 with the 6 medical students...
14:24 A high fat diet was able to turn them into early diabetics
14:29 in just 2 days.
14:30 What if you took a whole nation and gave them the same
14:33 high fat diet... What would you expect to produce?
14:36 You think diabetes would become rampant?
14:38 Yes, you would expect that,
14:41 and that is what we're finding in America today...
14:43 And that's why the large increase in diabetes
14:47 that we see is occurring.
14:49 Well, up to this point, we've seen that fat causes
14:56 insulin resistance by plugging up the insulin receptors.
14:59 We've seen that insulin resistance leads eventually
15:01 to diabetes.
15:02 Is insulin resistance a NEW concept...
15:05 or is this something we've known about for a while?
15:08 Actually, it was first discovered in 1935
15:10 by Sir Harold Himsworth, physician at the
15:14 University Hospital in London.
15:17 What he found was that the insulin requirements of
15:22 the diabetics changed based on how much fat they were getting
15:25 If they had a high fat diet,
15:27 he would have to increase their insulin doses to cover it
15:29 If they were on a low fat diet, he could reduce the insulin
15:33 doses that were needed to control their blood sugars.
15:37 In 1964, Dr. Felber again demonstrated the effects of
15:42 high fat on insulin resistance.
15:45 He found that on a high fat diet,
15:47 nondiabetics' insulin levels raised by 35%.
15:52 Now why would this occur?
15:54 Well, what happened was, when you're on a high fat diet,
15:57 the insulin receptors become plugged up with insulin,
16:00 the pancreas says, "You know the normal 30 units of insulin
16:03 a day that I'm normally secreting is not working...
16:06 I've got this insulin resistance what am I going to do?"
16:10 "I'll do the only thing I can do, I can release more insulin"
16:14 So the pancreas would release more insulin,
16:16 overcome the insulin resistance bring the sugars down,
16:19 but at the cost of higher insulin levels...
16:21 And that's why the insulin levels on a high fat diet
16:24 increase, and in this test they increased by 35%.
16:28 When subjects on the high fat diet were tested by Dr. Felber,
16:36 they also fell into the diabetic range.
16:38 Later, studies done on animals confirmed...
16:43 in over 34 animal studies that
16:46 "Yes, a high fat diet does induce insulin resistance"
16:50 The drug companies that make medication pills for diabetes
16:57 they have to test their drugs on diabetic rats
17:01 Do you think the drug companies are aware of
17:03 this insulin resistance problem?
17:05 Well actually, they are because
17:08 to test the drug on diabetic rats, they have to
17:10 get diabetic rats...
17:12 Now, last I checked Wal-Mart does not sell diabetic rats!
17:16 ...So where do they get their diabetic rats?
17:18 They have to make them diabetic.
17:20 And they know how to make them diabetic.
17:22 Very efficiently, they take a normal rat, and they feed it
17:25 a diet 60% lard, and in several weeks they've got diabetic rats.
17:31 This is a reproducible effect,
17:34 and it's a very dependable effect and can
17:36 guarantee them their supply of test animals.
17:39 Since then, also 15 recent human studies have also confirmed
17:45 that a high fat diet causes insulin resistance.
17:49 So, up to this point in time, insulin resistance had been
17:54 reported basically with high fat diets.
17:57 Major fat sources were either high saturated fats,
18:00 or hydrogenated fats, or polyunsaturated fats.
18:03 Work after 1986, started to look more specifically at
18:06 what fats were more harmful than others,
18:09 and they've also found that the prediabetic state,
18:18 the state just before diabetes,
18:20 caused problems as well as diabetes itself.
18:26 People may say, "Well, the doctor says I'm not diabetic,
18:30 but I just have some insulin resistance,
18:33 or I have an impaired fasting glucose. "
18:36 "Am I at risk?"
18:38 What they found was that, yes, you ARE at risk.
18:41 Individuals with insulin resistance, or syndrome X
18:43 had a markedly increased risk of heart disease...
18:46 and this was found in a
18:48 prospective epidemiological study of 970 men with
18:52 no heart disease who were followed for 22 years
18:55 in the presence of hyperinsulinemia.
18:58 Now, again, higher insulin levels mean that the pancreas
19:02 is working harder to overcome insulin resistance...
19:03 So it's in evidence that there is insulin resistance present.
19:06 In those people, they had higher risks of heart disease
19:11 and death from heart disease.
19:13 This was illustrated in a prospective epidemiological
19:17 study of 970 men with no known heart disease
19:21 who were followed for 22 years.
19:23 The presence of hyperinsulinemia was associated with
19:27 increased risk of a major coronary event,
19:29 either death, or nonfatal heart attack.
19:31 Now, they measured the insulin levels...
19:34 That's the most sensitive test to determine
19:36 if you have insulin resistance.
19:38 What happens is... The first thing that happens is
19:40 the insulin levels rise, and keep the blood sugars controlled
19:44 Only when the pancreas can no longer compensate
19:46 adequately, do the blood sugars rise.
19:48 So they had evidence of insulin resistance by the fact that
19:51 the insulin levels were higher,
19:53 and those higher insulin levels showed insulin resistance
19:56 indeed was present, and increased their risk
19:58 of heart attacks, and death from heart attacks.
20:01 Studies showing the prevalence of diabetes with age
20:05 showed that by age 65, 45% of Americans had
20:10 either diabetes, prediabetes, or undiagnosed diabetes.
20:14 That's almost half!
20:17 So, if a patient says, "You know I'm at risk for diabetes
20:22 because one of my parents has diabetes,
20:24 actually statically, one of your parents probably should have
20:29 diabetes if they're over 65...
20:32 As almost half of the population has diabetes or prediabetes.
20:38 In 1988, Dr. Raven coined a term called "syndrome X"
20:45 What he found was that diabetes doesn't come alone...
20:50 It doesn't come by itself...
20:51 that this insulin resistance not only causes high blood sugars,
20:54 but ALSO causes high blood pressure,
20:58 causes an elevation of triglycerides,
21:00 it lowers the good cholesterol, the HDLs
21:05 and it can cause obesity.
21:08 This addition of obesity was added somewhat later.
21:13 If you have 3 of any of the following parts of the package,
21:18 you have the insulin resistance syndrome...
21:22 And this includes either a fasting blood sugar above 100,
21:26 abdominal obesity...
21:29 For men, that's the waistline above 40...
21:32 or for women, above 35.
21:34 If you have hypertension, that is a blood pressure
21:38 above 130 or diastolic above 85, that's another factor.
21:43 Or if you have high triglycerides...
21:45 that the fat in the blood.
21:46 If it's above or equal to 150, or if you have a low HDL
21:52 below 40... any 3 of those puts you in the syndrome X
21:58 category and puts you at increased risk for heart disease
22:03 How common is syndrome X?
22:06 Well, the young from ages 20 to 29,
22:09 have a very low prevalence, 6.7% but middle-aged
22:14 people from ages 60-69, the prevalence is
22:17 very high, about 43.5%
22:21 Just like the previous study on insulin resistance
22:23 prevalence of syndrome X generally increases
22:26 with the amount of time on the American diet.
22:28 The prevalence of the syndrome X in 4,000 Scandinavians
22:32 varied based on their glucose tolerance tests.
22:35 If they had a normal glucose tolerance test,
22:37 the risk of having any 3 of those 5 symptoms
22:40 was less than 10%.
22:42 If they had an ABNORMAL glucose tolerance,
22:44 a prediabetic state, it rose to 50%.
22:47 If they had diabetes, they had an 80% chance of having
22:51 3 of those 5 symptoms.
22:54 In subjects with the metabolic syndrome,
22:57 the risk of heart disease and stroke was increased 3-fold.
23:01 Heart disease mortality was was markedly increased
23:04 up to 12% versus 2.2%, compared with subjects that
23:08 did not have syndrome X.
23:11 Well, can I give syndrome X to rats?
23:15 Now, we know that we can give insulin resistance to rats,
23:18 but can I give them this whole syndrome X metabolic picture?
23:21 Yes, we can...
23:23 They did this on a test with rats.
23:26 They fed them a HIGH fat diet, 32% lard, 18% corn oil,
23:32 27% sucrose, with 23% casein which is a milk protein
23:38 and in 4 weeks, they had 35% DECREASE in insulin sensitivity.
23:43 By 8 weeks, they had a 60% drop in insulin sensitivity
23:47 on the same diet...
23:49 Which shows that if the diet is poor,
23:51 and if it's continued, insulin resistance continues
23:55 to increase with time.
23:59 The high fat diet produced
24:02 the insulin resistance as WELL as abdominal obesity,
24:06 with a significant increase in abdominal fat occurring
24:09 as soon as 4 weeks, and continuing to rise.
24:12 Note again that abdominal obesity continued to increase
24:15 with time on that same diet.
24:18 This is the second component of the insulin resistance syndrome.
24:24 So they had higher blood sugars...
24:26 they had abdominal obesity,
24:28 and they also had a rise in total cholesterol
24:32 in the bad cholesterol which is the LDL
24:34 and the triglycerides which is the third part
24:36 of the insulin resistance syndrome
24:39 So, the insulin resistance syndrome CAN be reproduced
24:42 in rats fairly simply with the high fat diet.
24:45 Well, is insulin resistance syndrome reversible?
24:49 And the good news is... YES, it is reversible.
24:52 Can a low fat diet reverse this insulin resistance?
24:55 At the University of Montreal, Dr. Ravinowitz did a
24:58 5- year control trial with 100 diabetics on a 20% fat diet
25:03 He treated the patients with a high carbohydrate low fat diet
25:07 What were the results?
25:08 24% were able to stop using the insulin and returned to normal
25:12 The others reduced their dosage dramatically.
25:16 The patients, of course, preferred the diet
25:18 rather than taking insulin which was pretty much
25:21 the only thing available at the time.
25:23 In 1955, Dr. Singh put 80 insulin-taking diabetics
25:27 an 11% fat diet of natural foods.
25:31 What were his results?
25:32 Well in less than 6 weeks, 50% were off their insulin entirely
25:36 At 18 weeks, all but 12 were off of insulin injections.
25:40 That is 85% were off their insulin.
25:43 In 1981, Dr. Anderson, a world authority on diabetes
25:47 took 13 diabetic patients who were on the ADA diet
25:50 at the time which consisted of 34% fat and 23% protein
25:55 The ADA diet was stopped.
25:57 They started a 9% fat diet with high fiber,
26:01 and a very starchy diet.
26:02 Fifty percent of those taking insulin could stop.
26:05 All those taking pills could stop.
26:09 Currently he finds that 95% of those taking pills
26:12 can be off all pills in about less than 8 weeks.
26:15 And 50 to 75% of those taking insulin can be off in weeks.
26:20 After 1986, not only were some of the fats found
26:24 to NOT cause insulin resistance,
26:25 but some of the fats, in low amounts,
26:28 were actually found to be helpful in lowering
26:30 insulin resistance.
26:31 Saturated fats in the animal products,
26:33 and the trans fats were the worst in terms of
26:36 insulin resistance.
26:37 The polyunsaturated fats in the plants
26:39 actually appear to be helpful in terms of lowering
26:42 insulin resistance if taken in their native state.
26:44 Food components that decrease insulin resistance
26:47 include the Monosaturated fats
26:49 These are the fats found in the olive oil, in the olives.
26:54 Plants containing polyunsaturated fats
26:58 included the safflower, the sunflower,
27:00 and corn and the soybean...
27:02 These were shown to decrease insulin resistance.
27:04 However, one study done by "Vesby" showed that
27:08 even if these good fats are used from the plants
27:12 if the total fat exceeds 37% of the total calories,
27:15 it can become a problem and cause insulin resistance.
27:21 Fiber was found to decrease insulin resistance.
27:24 Whole grains from plants were also found to
27:27 decrease insulin resistance.
27:28 Foods that INCREASE insulin resistance include
27:32 the saturated fats from the flesh and the dairy,
27:35 trans fats from margarines, and shortenings,
27:38 hydrogenated vegetable fats can also cause problems
27:43 and cause insulin resistance.
27:44 Remember 5% of milk, butter, and beef are trans fats.
27:48 Cholesterol was also associated with high insulin resistance.
27:52 So, in summary, we encourage you to work with your doctor
27:56 If you're changing your diet, work with him...
27:59 Let him know what your blood sugars are,
28:01 so that he can reduce your insulin levels
28:03 as your blood sugars drop.
28:05 I wish you God's blessings as you embark on a new diet.
28:09 Thank you.


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Revised 2014-12-17