0:00:00.0 Kimberly Ellis: Alright, everyone, let’s go ahead and get into our last instalment of the crash course to diabetes management. Just to recap, my name is Kimberly Ellis, also known as The Diabetes NP. And we have been going through what diabetes management is and what that means for the nurse practitioner. So, today, we’re going to be wrapping everything up and really putting a button on everything. And so I’m gonna take you through some different conditions and different things that you need to know to continue to manage your maintenance care for your patients, just things that you should know when you’re dealing with a person with diabetes. So, first thing I wanna get into are the complications of diabetes.
0:00:58.1 KE: Now, this is very important, guys. This is one of the areas that’s the core goal of diabetes management. Everything that we’re doing is to prevent the complications. Because studies have shown us that once people start developing complications, this really affects their quality of life. And so one of our goals, which I’ll be honest with you, if I really think back on when I went through school, be it undergraduate, even graduate school, sometimes as providers, we could just get so focused on the treatment and we really are not looking at the patient as a whole. Well, the Standards are very clear as well as the many, many different publications that we’re wanting to really maintain the quality of life for our patients.
0:02:00.5 KE: And so it’s not just about getting them to go, it’s not just about them reaching a number, we want our patients to have a full quality of life, and part of that is preventing complications. Anything that you’re gonna read is gonna talk about trying to prevent or stop complications in their tracks. So, if there’s already some type of complication developing, that we don’t want it to get worse. So, what are those complications? They are divided into two different categories, macrovascular and microvascular. So, let’s go over what macrovascular is, right, quick. So, basically, and you see the word there, macro means large, so these are diseases of the large blood vessels. So, what you’ll see here is your coronary artery disease, you’ll see your peripheral artery disease, you’ll see your cerebral vascular disease as well, so your stroke.
0:02:57.1 KE: So, we’re thinking about our heart, we’re thinking about our extremities, the arteries that give our extremities and the arteries that fuel and nourish our brain. So, these are your large blood vessels. And so microvascular are your diseases of the small blood vessels, so this is where you’ll start seeing your retinopathy, these are your eyes. This is something that we all know, people with diabetes definitely need to be going in to get their eyes checked regularly. Many times, you’ll see many people with diabetes going in more than one time a year, especially if they have developed cataracts, if they have developed glaucoma. We really need a ophthalmologist that is astute in treating those with diabetes, so they’ll know how to really observe and treat the blood vessels in the eyes.
0:03:58.2 KE: We also have nephropathy, our kidneys. This is a huge thing. As we were talking about medications, and as you learn more about medications, you always wanna protect the kidneys because the kidneys… That’s our filtering system. It affects our blood pressure. We are trying to ultimately… We’re wanting to keep our patients from chronic kidney disease and we’re definitely trying to keep them away from dialysis. So, we’re trying to prevent that. And then you have your neuropathy, diabetic neuropathy is probably one of the most common neuropathies that you’re going to see. And of course, this is your numbness, your tingling, any type of nerve dysfunction that people with diabetes would have. And clearly, if you think about it, this is a huge part of their quality of life because people lose their feeling in their feet. And if people can’t feel their feet, people are not gonna be able to feel if they got a nick on their foot, they’re not gonna be able to exercise and have physical activity and just be able to have the mobility that they want, so these are…
0:05:08.5 KE: As you can see, these are very heavy-hitting complications that we have to start early and really be proactive against, this is something that as you are having your patients with diabetes, you’re always going to be addressing this, always. This does not go away. You’re always following up on the complications of diabetes.
0:05:30.8 KE: So, now let’s move into hypoglycemia. Now, hypoglycemia, y’all, this is a huge thing. This is one of those things that we’re going to, again, we’re going to be addressing with every encounter with our patients. It’s very important that you’re… Not only that you’re fully aware of what hypoglycemia is and how it manifests in a patient, but you also need to be highly educating your patients over hypoglycemia. This is considered a safety measure.
0:06:06.1 KE: So, if you are a nurse practitioner that works in a hospital, before that patient leaves, they need to know how to identify and treat hypoglycemia. People out in the community, they need to know how to identify this in themselves, because when it comes to… When you’re looking at hypoglycemia and you’re looking at hyperglycemia, the one that needs to be addressed the soonest, the quickest, the priority is the hypoglycemia. This is what sends people into commas, this is what sends people into a quick death. And so this is by far the one that we need to be on top of. You should have literature about this, you should be very aware and know how to treat this. So, let’s get into that a little bit. We’re gonna go through this little blurb right here. So we know what the symptoms are.
0:07:04.1 KE: One of the things that I think is a good way to think about hypoglycemia, this is an easy way to remember it. Just think about when you yourself are hungry, how do you feel when you’re hungry, you haven’t been able to eat yet? And you may not feel sweaty, you may not get confused, but how many of us feel dizzy, how many of us get grumpy? The word is hangry. You’re hungry and you’re angry. Well, that’s what that is. You get a headache. I know for me, when I have not eaten, I’ll get a headache. And so basically, hypoglycemia in the person with diabetes is that times 10. Now, right here says the symptoms are limited… They’re not limited to just the shakiness, the irritability, the confusion, the tachycardia, and that’s why I said here, think about when you haven’t eaten and how you feel. Now, one of the things that I don’t think is often talked about, we oftentimes just talk about hypoglycemia as just this overarching theme, as just an umbrella, but there are levels to this.
0:08:05.6 KE: So, your level one hypoglycemia is anything that’s less than 70. A patient is considered to have hypoglycemia if they are falling below 70. And this goes for everyone. Yes, you can have hypoglycemia unawareness, but it is classified as hypoglycemia level one if you’re anything less than 70. Now, anything… Any time up to 54. So, 69 up to 54 is considered level one. Level two is anything that is less than 54. And once you hit level three, anything that is considered where a person is not able to treat themselves and they need assistance, which a lot of times, it will… They could be 62, and some people feel like they need help, maybe they need help with injecting the glucagon, that’s what is considered level three. And speaking about glucagon, it says here, the Standards say that you should automatically prescribe glucagon to anyone that you see that has level two or level three hypoglycemia.
0:09:25.2 KE: So, one of the big things that you will need to know and really have on your radar when you’re dealing with your patients is trying to anticipate who is at risk. Now, I’ll just be honest with you. Typically, the non-insulin type 2 diabetic, they’re not so much going to have hypoglycemic events necessarily. I mean, they can. Don’t rule it out. Don’t think that you can’t see it, but typically the person who is on insulin, whether they’re type 1 or they’re type 2… Clearly, if they’re on a sulfonylurea or a meglitinide, because these are medicines that make the pancreas squirt out more insulin. So, more insulin, clearly in the presence of more insulin, there’s gonna be a risk for hypoglycemia, and then you also wanna keep in mind those who have hypoglycemia… It says their awareness, but I meant to say unawareness, that’s a typo on my part, but unawareness. And so basically, this is when you have a person that their body does not… They cannot feel when they are in a state of hypoglycemia.
0:10:39.0 KE: You know, having hypoglycemia and those symptoms that come with it are actually a protective measure. And if we cannot feel that, that’s basically giving us a warning sign that, “Hey, something needs to happen because our body is needing X, Y and Z, and we’re not getting it. We need glucose. We don’t have it. You need to do something.” Well, if you don’t feel those different symptoms, then you… That’s very dangerous, because then you wouldn’t even know.
0:11:08.2 KE: You wouldn’t even know that you needed to eat something, you wouldn’t know that you would need to inject glucagon, and there are many people out there that do have unawareness. Typically, you’ll see people like this that have had long standing hypoglycemia. Sometimes if people have an autonomic dysfunction, because this is an autonomic type of function that’s going on, but people who have other issues that may cause their body to not be able to give us those signals. Also, people who have rather high blood sugars that run pretty high, if they have… A lot of times those people do have hypoglycemia, and here’s a tidbit. When it comes to… I’m sure for anyone who has practiced, if you’ve been in clinicals, you might have come across a patient that will tell you, you know, “I can’t let my blood sugar get too low.” You know what I’m saying? Or, “I start to feel shaky at 140. I start to feel… “
0:12:16.9 KE: I have seen so many patients that will tell me like… Will you set a goal for them and you say, “Okay, I want your blood sugar to be before meals 80 to 130,” they’ll say, “Well, I can never get there because I’ll start to feel shaky.” Well, typically, that’s because they probably are dealing with some type of unawareness, and that’s probably because their blood sugar probably on average runs up into the 200s and the 300s. So if someone is having such, if that’s the number that they start to feel the hypoglycemia symptoms, chances are, their blood sugars are running high. And I hope that makes sense to you guys.
0:12:52.3 KE: So let’s get into the dawn phenomenon, we’re gonna get to talking about some hyperglycemia that goes on. Many people get the dawn phenomenon and the Somogyi effect confused, and so we’re gonna go over both of them. But what I would like to say initially about the dawn phenomenon is that at some degree, everyone, whether you have diabetes or not, experiences a dawn phenomenon, and again, it’s actually a protective measure that our body puts us through. So let me paint the picture for you. When we’re sleeping at night, we get into a state, our body literally shuts down, it goes on auto-drive. Well, about 2 or 3 o’clock in the morning, our body starts to arouse us, and how it does this is it releases certain hormones in our body: Cortisol, growth hormone, I wanna say we even… What’s the other one? I can’t think of it right now… Adrenaline. A lot of these different hormones are starting to release in an effort to start to arouse us and to wake us up. And about 6 o’clock, there’s enough hormones for many of us to arouse, we start to come out of that deep sleep.
0:14:21.0 KE: Now, for the person who does not have diabetes, after a while, our body normalizes it and we’re able to get back in, because if you think about these hormones that are released, think about what they do and how they can affect your glucose level; cortisol, growth hormone, these are all hormones that in a state in your body will cause the glucose to be higher. For the person who does not have diabetes, they’re able to compensate and move on about their life. But for the person who has diabetes, they’re not able to compensate and regulate those hormones and those hormones end up staying in the body. Hence, why in the morning, you’ll have people that have early morning increased blood sugars. It also is known as the dawn effect. But like I said, at about 2, 3 o’clock in the morning, that’s when everybody’s body, everyone, your body, my body, everyone’s body, people who have diabetes, people who don’t have diabetes, our bodies, this is a natural course that our body does, but people with diabetes are just not able to regulate.
0:15:35.6 KE: So how do you treat that? For one, take medication or insulin at bedtime instead of dinnertime. And there’s some education that’s gonna have to go on there because people who are on insulin, a lot of times, they can be afraid that they’re gonna hit hypoglycemia if they have their insulin at bedtime. And of course, this needs to be somebody who you have definitely identified, which we’ll talk about a little later, you have definitely identified that they have early morning high blood sugars. But you would want to instead of putting the insulin or the medication at dinnertime, you’ll want them to do it at bedtime so it can coincide when those blood sugars are high. You can also tell them to eat dinner earlier in the evening, so then that means that their blood sugar can stabilize, so they’re not going into the night with this high carb meal that’s gonna shoot their blood sugars up and then that’s gonna make their blood sugars go up in the early morning.
0:16:40.6 KE: You can also tell them to get some exercise after dinner. There’s a rule of thumb that for every minute of exercise, you drop your blood sugar one point. So if somebody exercises for 30 minutes after their meal, after their dinnertime, they can drop their blood sugar by 30 points. And in some cultures, in some countries, we just don’t do this in our country, a lot of times in our country, we eat, we sit on the couch. But there are many different other countries and other groups of people around the world that that’s just the natural thing that they do, they have dinner and then they go on an evening stroll. Well, that, we have seen that their blood sugars are much, much lower than ours here in America.
0:17:23.7 KE: But you can tell them to go ahead and get some exercise after dinner, take a walk around the neighbourhood, go to the park, even just getting out, playing with their kids, playing with their grandkids, whatever, just being active, getting some moderate exercise, that will bring that blood sugar down and to help that blood sugar from having a rise in early morning. Also, advising them to avoid snacks that contain carbs in bedtimes ’cause all you’re doing is adding on to that blood sugar. So these are some things that you can do, simple things that you can do where you would just change up their routine, if when you have identified the dawn phenomenon.
0:18:01.0 KE: So, let’s talk a little bit about the Somogyi effect. This is actually a rebound effect that happens that… In… Let me start again. This is a rebound hyperglycemia in response to hypoglycemia. What happens here, typically the patient has taken too much insulin before they’ve gone to bed, and the body is trying to compensate so it releases the hormones, similar to the hormones that I talked about in the dawn phenomenon, to increase their blood sugar to go up.
0:18:38.8 KE: Now, one of my mentors who is a triple board-certified doctor and she’s an endocrinologist, that’s one of her certifications, there are talks that the Somogyi effect really is not a thing, but they still recognize it because there is some idea that there is the… That it really is not a true phenomenon, but again, there is still just debate over that. I wouldn’t say just throw the whole thing away, you do need to know what it is, just in case you find somebody that has this. But typically what’s happening is that they’re taking too much insulin prior to bed, and then they’re dropping their sugars because of that, and then because of that, those hormones are released, that then shoot it up, but it’s a rebound hyperglycemia in response to hypoglycemia.
0:19:31.2 KE: So how do you determine which one is which? So the blood sugar level is low between 2:00 and 3:00, you can suspect the Somogyi effect. If it is normal or high between 2:00 or 3:00, it’s likely the dawn phenomenon. So what this would look like clinically, if you’re trying to figure out… You know, a patient comes in and how they’ll present a lot of times they’ll say something like, “You know what, I get up in the morning and my sugars are in the 200, in fact, I even had a 300 one time.” Okay, that’s a lot of times the common way that they’ll come in and say to you. So then you’ll… Of course, you’ll go through your little spiel of questions. “So what did you eat you? Did you eat… Did you have a large meal?” That’s typically one of my first questions that I ask, “What did you eat for dinner that previous night?” And let’s say they say, “Well, I only had a salad, we had a baked potato, but it was a small potato,” and they’ll tell you something that it’s not like they were out here eating pasta, they didn’t go to the Olive Garden, you see what I’m saying? They didn’t have a dessert with pasta.
0:20:45.0 KE: It’s something that you’re like, “Ah, that shouldn’t have shot your blood sugars up to 300,” and then of course, you’ll have to ask, “Did you take your medicine?” ’cause you always have to, you can’t assume. “Did you forget to take your medicine or did you take it a little too… ” You start to investigate what’s going on. Well, if everything is falling in line and you’re still wondering, why would you get 250 or 300… 300 for your blood sugars, then you can start to wonder, “Okay, what’s going on here?” You would then advise your patient, “About 2, 3 o’clock in the morning, I want you to take your blood sugars for me, and I want you to do this over the next few days, okay? Once you get that, just get up, take your blood sugar, have it at your bedside, write it down, you can go back to bed.” Many patients, if they’re older, they’re probably getting up around that time to go to the bathroom anyway, but it’s only for a couple of days, just let them know that. And then have them call it in to you, and that is when you can be able to determine if it’s Somogyi or if it’s dawn.
0:21:46.2 KE: So then… Since we’ve just been talking about hypoglycemia issues, let’s talk about when it’s crisis, when it’s an emergency. Now, this is another… We’re gonna talk about DKA and HHS. Now, these two, similar but different. So I’m gonna do a slide by slide for you, so let’s first start with the diabetic ketoacidosis. So basically here, this is where there is some type of insulin deficiency, and because of that, quite naturally your blood glucose levels are going to be higher, they’re not gonna be in the cells where they need to be to be used as energy. And so the body is still going to need energy, and what the body does is that it starts to break down fat.
0:22:32.3 KE: Well, we know as a by-product, we know as a by-product of breaking down fat, you get ketones. Ketones are present. You’ll also get what we call acetone breath, that fruity breath, Kussmaul respirations, and this is something that develops fairly quickly, less than 24 hours, and they’re gonna have classic symptoms of diabetes. So your polyuria, your polydipsia, they’re gonna be ill, they’re gonna feel very ill, they’re going to look and feel horrible, honestly. You typically will see this in your type 1s, because there’s this insulin deficiency, you have insulin deficiency, so when you think about it, that’s your type 1s.
0:23:21.7 KE: Well, let’s put that up against your Hyperosmolar hyperglycemic syndrome. So you typically see this one in your type 2s. You typically will not have ketones and if you do, it’s gonna be very, very small. May not even register. But typically, when you’re trying to distinguish between the two, think of one has ketones, one does not.
0:23:48.3 KE: Now, with this patient, you’ll have this with a patient that has probably been undiagnosed and they’ll be between the ages of 55 to 70 and get this, typically, residents that live in nursing homes. And most of these patients it’s a gradual thing for them, but they’ll also experience the classic symptoms as well, and the most common clinical presentation for patients with HHS is altered sensorism, so this can oftentimes be misdiagnosed as a stroke. Think about that y’all. If you’re having a patient who’s 55 to 70, it’s frequently in nursing home residents, don’t you see how this can really easily be misdiagnosed as a stroke, but a lot of times there’s a lot of… You will see a lot of cognitive deficiencies, you’ll see people who were able to speak and they’re not really speaking anymore. You see people that are having lots of sensory issues, they’re not able to feel, and they’re having numbness and tingling even around the mouth. And so you can see how this could be mistaken for a stroke. Okay.
0:25:06.3 KE: But I want to show you this chart here. Now, this is from the Standards… No, this is not from a Standards, this is actually from another article from the ADA. And this basically shows you what your labs would look like. So let’s take a look here. So DKA is broken up into three different stages: Mild, moderate, severe. As you can see here, the plasma glucose for all of these are gonna be more than 250, if you were to get a plasma glucose. But look at HHS. This is… Their blood glucose is gonna be over 600, it’s gonna be out of the water y’all, hit out of the park.
0:25:47.4 KE: So let’s look at your pH. Now, we can use our common sense. When you have ketoacidosis, the person is going to be acidic, their pH is gonna be more acidic. So look at that mild, as you go more severe, that pH is getting more and more acidic. But look at the HHS, that pH is moving more basic than what the body likes to be. Of course, you can look at the other labs, your bicarb, you’re definitely gonna have more bicarb than you would in… You’ll have more bicarb in HHS than you would in DKA because it’s more basic. It’s more basic, it’s not acidic. So look at these ketones, you got your urine ketones and you got your serum ketones. As you can see, in DKA, they’re all gonna be positive, you’re gonna have a very small amount with HHS. And so, this is a good chart to keep and just to kind of… Some of this, I mean, a lot of this you would either have to get all the way into it to be able to distinguish between DKA or HHS.
0:26:57.3 KE: So I want to quickly go over the specific types of diabetes. They can be called the zebras, these are some of the ones that are not as common. As I had mentioned in previous presentations, we have the three big ones: You have your type 1, type 2, and your gestational diabetes, by far, type 2 is the more common type of diabetes that you’re gonna see, but there are some outliers. And this, you can go and read more in-depth about this in section two of the Standards, but I did want to highlight specific ones.
0:27:37.9 KE: So, did you know that with cystic fibrosis people have diabetes? This is the most common comorbidity in people with CF. It occurs in about 20% of adolescents and about 40% to 50% of adults. The thing about cystic fibrosis is that, that inflammatory process that’s going on, diabetes makes it even worse. So this is something that definitely has to be addressed with this population. You, depending on where you work, you may or may not come in contact with people that have CF, but if you do, here you go.
0:28:18.5 KE: Post-transplantation diabetes mellitus. This is something that’s very common. I don’t think… Again, if you don’t work with this population, you probably would not know this, but hyperglycemia is very common during the early period of getting a transplant, with about 90% of the kidney allograft recipients exhibiting hyperglycemia in the first few weeks following transplant. Some people that get transplant will always have to be treated as if they have diabetes. Some people after those weeks, they normalize. It’s just all different for people. Now, I will say this, if a person has the risk factors that we use for anybody, so if they are obese, if they have a family history, if they have a history of gestational diabetes, all of those risk factors, if they’re a part of a certain race, cultural group, this does put them more at risk to have this, as well as to continue to have it even after those first few weeks.
0:29:23.4 KE: Let’s talk about LADA, latent autoimmune diabetes of adulthood. Now, this is under the umbrella of type 1. I’ll be honest with you, you’ll hear this term but it’s still considered type 1 and you’ll see this more so because… Okay, with type 1 typically, not always, but we’re used to seeing type 1 diabetes more in younger people. Well, what happens, and what this used to be considered… This used to be kinda considered a 1.5 type. It used to be considered type 1.5. So you had your type 1 and then you had your type 2. And at one point, it was considered type 1.5, because what is happening is, there’s a slow autoimmune destruction of beta cells. They are typically seen in adults. This could be any age of adult. There are people who are 50 years old, they come in, they may have classic symptoms of type 2, but then once you put them on some metformin, they get worse.
0:30:35.3 KE: And so where you’re having any type of autoimmune anything, destruction of beta cells, you have to think type 1. And there’s ways that you can go and get your markers, that you can send people to the labs where they can get their markers where you can see, but this is a whole autoimmune destruction, it’s just a slow progression of it, and that’s what LADA is.
0:31:00.9 KE: Then you have your monogenic diabetes syndromes. These are your genetic defects, and they cause beta cell dysfunction. So you have your neonatal diabetes, which occurs in those babies that are under 6 months of age, also called neonatal or congenital. So think 6 months of age, less than that. And then you have MODY, which is your mature onset diabetes of the young. Now, this occurs typically in your young adults, they’re less than 25 years old, and really they do not have characteristics of either one or two. Again, this is a genetic thing so there’s some gene testing that can happen. Y’all, this is very rare, okay? It’s very rare. You’re probably not gonna be the person to pick it up, you’re probably going to refer this person out and somebody else is gonna pick it up, or maybe they’re gonna come to you already knowing this is what they’re gonna have. But this is just a good idea of just knowing what it is. And typically, there’s many different types of this, of MODY, there’s different subtypes, and there are some types that really do not need treatment at all, no insulin, no medications, nothing.
0:32:22.1 KE: And so again, refer to this Standards section too, it goes through all of these and gives you some more studies that you can go and do your own learning over. Very interesting reading, at least it is for me, but of course, you all know I geek out over this. So just some things to know because you may not, depending on where you work, you may not even come in contact with some of this stuff, y’all. But these are other specific types of diabetes.
0:32:53.5 KE: So, we are at the end. This has been great. I always love teaching over this subject. I feel that the more that we know, the more that our patients will grow. And so I love teaching colleagues about this, and just as much as I love teaching my patients about this. But I do encourage you to continue your learning. This was a crash course. I cannot go over everything, y’all. I cannot. I could not and I cannot. But definitely, and I know this is something that The NP Collective definitely pushes, but definitely continue to be a lifelong learner. There’s so much information that is coming out all about diabetes every single day. I get notifications all the time about new studies that are happening all throughout the industry, and so just commit to being a lifetime learner.
0:34:00.1 KE: One of the things, and I wanna just remind you all, I am leaving the link here for the complete Standards of Care. This is something, again, I cannot say this enough, I know that I have stated before, but every year, read the Standards. Read the Standards. That’s the one thing that you can do that will definitely better help you to manage your patients with diabetes. I know that there are so many things that we have to deal with in the clinic, and diabetes is just one of many, but diabetes is definitely probably one of the hugest diagnosis that you’re gonna have to deal with. So you’re gonna need to know the Standards, what’s out there, you need to stay up-to-date.
0:34:47.0 KE: Also, a great resource that I love is the Association of Diabetes Care & Education Specialists. I love this, I love this organization. I am currently certifying with them to become a Diabetes Care and Education Specialist. They have done so much for my practice and my knowledge. They’re a wealth of knowledge, a wealth, and there’s so many free resources on their website, there’s many free webinars that you can go in that they bring in people all over the world, and so definitely check them out. They have lots of books, they have lots of guides, some you have to purchase, some that are free, but definitely check them out as well.
0:35:34.4 KE: And then on a more personal note, I definitely will want to invite you all to subscribe to my YouTube channel. I have already put out over two years’ worth of content on my YouTube channel, pretty much anywhere between a video to two videos a week, just about everything that you probably can think of, and I’m still working on even more, there’s more to come, and I would love to have you over there on YouTube. I’m able to explain and give you some things over there as well, and it’s free. I definitely want to remind you guys of my diabetes med boot camp. This goes over all of the medications, I get in depth with that, even talk about insulin, get into your injectables, it’s not just orals that I talk about, I talk about all of them, and I update as I go. This course does have continuing education hours, it’s certified through the American Association of Nurse Practitioners, and it’s just a really good resource.
0:36:41.5 KE: Also, another resource that I want to bring to your attention, I had mentioned one of my mentors, Dr. Arti Thangudu. She is triple board certified. She’s an endocrinologist. She’s certified in endocrine and metabolic syndromes as well as lifestyle medicine. She’s also certified in internal medicine. The woman knows what she’s talking about. And me and her both have a huge passion for diabetes. Well, we recorded a workshop over… It was almost 90 minutes where she just talked about diabetes technology, and we just had a conversation. She answered questions, and she went through insulin pumps, she went through CDMs, we talked about self-monitoring of blood glucose. Very, very, very great resource. And so I do want to invite you all to check out these resources. And so again, I just wanna thank you all for having me. This has been fun. And if you have any questions, feel free to reach out to me, I’m on all platforms, Instagram, Twitter @TheDiabetesNP, or you can email me at info@ellisdiabetes.com. It’s been great and keep learning. Bye.