and welcome to the latest edition of Telehealth in Hawaii. I'm your host, Vikram Acharya. I'm the Chief Executive Officer of Cloudwell Health and all virtual telemedicine-based provider located in Hawaii. We have an excellent show for you today. We have two physicians that are leaders, researchers, and authors, Dr. Sanjeev Chopra and Dr. Martin Abramson. How are you both today? Hi, thank you for inviting us on the show. Oh, Vikram, I'm on top of the world. Well, thank you for being on the show. Absolutely, I'm honored to be on the show. Dr. Chopra and Dr. Abramson are the authors of Conquer Your Diabetes, a wonderful book around the prevention, control, and remission of diabetes. To get things started, Dr. Chopra, tell me a little bit about yourself, where you're from, your role at Harvard Medical School, and we'll go from there. So I'm a hepatologist, specialist in liver disease, a professor of medicine at Harvard Medical School, and I had the privilege of serving as the faculty dean for continuing medical education at Harvard Medical School for 12 years. I was born in India, schooled by Irish Christian brothers, and then did medical school at the All-India Institute of Medical Sciences in New Delhi, and then came with my wife, who was my classmate, to America in 1972, and I've been in Boston since 1973. I'm passionate about teaching and writing and speaking, and I'm also privileged to serve as the editor-in-chief of the hepatology section of Up to Date, the largest electronic textbook to subscribe to by 1.5 million physicians in 195 countries. I've lived in Boston since 1973. I have a beautiful family, and I'll have two incredible inspiring granddaughters who live in New York. Excellent, excellent. Dr. Abranson, walk me through your background. Yeah, so like Sanjeev, I'm born outside of the United States. I was actually born in a little city called Bulawaya, which is in Zimbabwe, and I did all my schooling there before leaving Bulawaya to go to Cape Town, South Africa to study medicine. I studied medicine there, did my residency fellowship training and research training in Cape Town, and then was head of the endocrine unit at the University of Cape Town and Crutuscure Hospital before I was recruited to what was the Beth Israel Hospital in Boston in 1992. And I came here to set up a program in diabetes for the hospital. I trained as an endocrinologist and then focused more of my efforts on managing people with diabetes and developing diabetes programs for people. Beth Israel and the Deaconess Hospital subsequently merged and that merger led to a relationship with the Jocelyn Diabetes Center, which is a prominent diabetes center, probably the most prominent in the world. Started, it's the oldest one, started by Elliot Jocelyn in the late 19th century before insulin was available as a treatment for diabetes. And because of that merger with the Deaconess and the relationship with Jocelyn, I transitioned into the Jocelyn Diabetes Center where I was first the head of the adult diabetes section and then I was the chief medical officer for just over 10 years before transitioning out of that role and coming back to Beth Israel Deaconess Medical Center where I continued to see patients with diabetes. And for 25 years, Sanjiv and I have worked together. We've run the Division of Continuing Medical Education in the Department of Medicine at Beth Israel Deaconess Hospital. We've become close friends, brothers, colleagues. And this opportunity came really when COVID struck. In all credit to Sanjiv, he said, Martin, let's try to book on diabetes. I'm a diabetes physician. He's a hepatologist. We both like to teach. We're passionate about teaching. We're passionate about lecturing and we're passionate about the things that we do. So it was a natural fit that the two brothers worked together to develop this book. Actually, Vikram, Martin and I together with another colleague, Richard Beezer, could have an annual Howard Medical School CME course on diabetes and its complications. Martin gives several talks, Richard gives several talks. I give a keynote on microbiome, man in medicine and then talk about non-alcoholic fatty liver disease which often related to type two diabetes and obesity and afflicts an estimated 70 to 100 million Americans. Very impressive. So we have Dr. Chopra is a hepatologist, a liver doctor. Dr. Abramson is an endocrinologist. How is diabetes for the non-clinical audience linked between endocrinology and the liver? We'll start with that. So there are a number of liver conditions leading to cirrhosis, chronic hepatitis C which afflicts 170 million people in the world, non-alcoholic fatty liver disease which we think may afflict up to a billion people in the world, alcoholic cirrhosis which is a very prevalent disorder throughout the world and then a condition that's called celiac disease where there is an association between type one diabetes and celiac disease. There's also a condition called hemochromatosis which is the most common genetic disorder known to man. Most physicians or medical students when asked what's the most common genetic disorder and probably say cystic fibrosis. In reality, it's hemochromatosis, a genetic disorder in which there is avid absorption of iron from the gut and then it gets deposited in the liver, the pancreas, the brain, the heart, the skin and it leads to in advanced stages diabetes cirrhosis, very high risk of primary liver cancer. This condition is sometimes called bronzed diabetes. So four or five links between liver disease and diabetes. There's other links because the liver is the source of glucose storage and glucose production. And so under normal circumstances, we all know that if we don't eat, our blood glucose levels will not drop too low. The reason for that is the liver has taken the glucose in that is available and distorted as glycogen which is long chains of glucose. And if you don't eat, the glycogen gradually breaks down to maintain blood glucose levels in the normal range. Similarly, when we do eat proteins and amino acids proteins and amino acids in the liver are changed to glucose and then glycogen. So the liver is a hugely important organ in terms of maintaining glucose levels in the normal range. In type two diabetes, which is the commonest form of diabetes affects 95% of people with diabetes. There is a condition called insulin resistance. Whereby the insulin that is produced in the pancreas is just not effective enough to do its job. And the job of insulin is to push glucose that is in the blood into the cells where it's used for energy. So under normal circumstances, if you eat a meal all the carbohydrates get broken down ultimately into glucose, which is in the blood it begins to rise, the pancreas produces insulin which then takes that glucose and pushes it into the cells where it's used for energy. The liver is a site of what we call insulin resistance. And interestingly enough, paradoxically enough when people in people with type two diabetes the liver thinks that the body is devoid of glucose. And there is an increased production of glucose by the liver even when you don't eat even in the fasting state the liver overproduces glucose and that leads to high fasting sugars. So physiology is intricately linked in terms of glucose control, the deposition of glycogen the ability of what's called gluconeogenesis but it's also fascinating that the most common general surgical procedure right now and it's a sad commentary but it is bariatric surgery for weight loss. And people who want to go bariatric surgery can have remission of their diabetes. It's the one surgical procedure that's linked to longevity. Two years out after bariatric surgery patients are taking many, many less medications or low doses and it pays off. Two years later it pays off for the cost of the bariatric surgery. So that's in terms of the diabetes. What happens to the liver disease? One of these people have significant fibrosis or scarring of the liver or even cirrhosis of the liver. And two thirds, the liver fibrosis including early cirrhosis is reversed after bariatric surgery. It's an incredible story. We should get there to the stage where we need bariatric surgery. And one of the game changers will be a new medication which in recent studies in a phase three study patients on the high dose lost 52 pounds. And even on the lower level, 52 pounds. Yeah. You know drugs that cause six, eight pound weight loss, 52 pounds and with the intermediate dose it was like 45 pounds. And with the lowest dose it was like 33 pounds. Phenomenal. Let me just add into that because what Sanjeev is saying is absolutely correct. But let me tell the people listening here that if you lose weight absent of bariatric surgery and it's not easy, but if you do lose weight, weight loss is what drives the improvement in the liver scarring and the fibrosis and so on. Now this new drug that Sanjeev mentions is a sort of one step up, slight step up of a drug that is already available. And they belong to the class of drugs called GLP1 receptor agonists or incrotons. These are newer drugs that came about. So it's a fascinating story how these drugs came about because the first of these drugs that came about came about through a discovery that the saliva of a healer monster, which is basically a lizard that lives primarily in Arizona and parts of California too, contains an enzyme, contained a product that actually stimulated insulin secretion in human beings. And this was almost a serendipitous discovery. And then they then discovered that if you take what is called an analog of this enzyme, you can actually lower glucose levels through stimulating insulin secretion, through blocking another hormone called glucagon, which opposes the action of insulin also produced in the pancreas, by actually slowing the emptying of the stomach and also blocking or suppressing the overproduction of glucose by the liver, which is what happens when people are insulin resistant. And we've seen advances in this original product to medications that can now be taken by injection once a week that have significant impact on weight loss. These drugs can cause significant weight loss. And this new one that Sanjeev mentions is actually what we call an analog of two natural hormones produced in the intestine of humans when food enters the stomach. One is called glucagon-like peptide and the one is called glucose and insulinotropic peptide, GIP and one is GLP-1's GIP for short. And this new drug has actually got both of those hormones in one, which is, it's a drug called tizepotide, which is approved by the FDA but will be on the market very soon. But other drugs that are just GLP-1s can cause significant weight loss and there are a number of those on the market already. I think it's also important for the listener, especially our patients, to appreciate that they don't need to lose all that excess weight. And if they lose five to 9% of excess weight, they can be marked improvement in their diabetes, in their liver disease, in their blood pressure control, in their triglycerides, cholesterol, all of those metabolic parameters can improve remarkably. That is true. Over the course of the pandemic, you mentioned you wrote the book during the course of the pandemic. Are you seeing many more patients with onset of diabetes during the post pandemic at this point in time, because a lot of people have not gone to the doctor, they haven't been as active. You're seeing increased rates of this in your practices? Well, the prevalence of diabetes has continued to increase. So in the United States, in the world, we're now seeing that 13, 14% of the adult population now has diabetes. That's been an increase over, it's been a continuous rise over the past 10, 20 years. I can't say that if in the last year there's been a blip up even further, but certainly we've seen increasing prevalence of diabetes continuously for at least 20 years now. So Vikram, that's an excellent question. I think what did happen during the pandemic, speaking as a liver specialist, is that there was a significant increase in alcoholic hepatitis and alcoholic cirrhosis, and also in worsening of non-alcoholic fatty liver disease. I think for many of us, unfortunately, food is comforting. And if you're sitting at home and you're stressed and you're not traveling and you're not going to the gym, maybe we're eating too much and we're eating the wrong foods and we're drinking a little bit too much alcohol. We had an incredible surge in people on the liver transplant list in our country. And now non-alcoholic steatohepiditis with cirrhosis and liver failure and alcoholic cirrhosis are the one and two indications for liver transplantation in our country. It used to be chronic hepatitis C, but we now have miraculous drugs. You take them by mouth and we have a 95 to 100% cure rate for chronic hepatitis C with pills taken for eight to 12 weeks. And it doesn't matter if they have cirrhosis. It doesn't matter if they have co-infection with HIV. It's really remarkable. It's the only chronic viral infection in human beings where we can use the radical term cure. There's no trace of the virus in the blood. There's no trace of the virus in the liver 20 years after you've eradicated the virus from the blood. So very remarkable, but sadly alcoholic liver disease and non-alcoholic fatty liver disease are on the rise. We have three year olds in our country with fatty liver. We have 16 year olds with fibrosis with scarring. We have 25 and 30 year olds on a liver transplant list with non-alcoholic fatty liver disease cirrhosis and end stage liver and complication. Go ahead, Doctor. Vikram, now you carry on. Now, if I want to check my liver and you mentioned some of these conditions, if I want to see if my liver function is okay, what types of tests can I get? Where can I go? Who can I speak to around this as well as diabetes? Check it out. Very good question, Vikram. I think the primary care physicians routinely will check what are called under the rubric liver function tests, LFTs. And we measure two liver enzymes that deal with liver necrosis. So if there's significant injury to the liver, these two liver enzymes go up in the blood. They're called ALT and AST. Then we check the bilirubin. We check something called alkaline phosphatase. We check albumin, which is a protein made by the liver. And we check the platelet count and something called prothrombin time. Sometimes INR in people on anticoagulation liver disease, we prefer protime. So the liver is the factory that makes all the clotting proteins. So if there's significant liver disease, the protime will go up. If there's significant liver disease, it's a synthetic factory making clotting proteins, but also albumin. The albumin will go down. The platelet count goes down because the spleen on the other side, the liver's on the right side, the spleen on the left gets enlarged and it shoots up the platelets. But also thrombopoitin, which stimulates the production of platelets is made in the liver. So it's a very simple panel of tests that is routinely done. The only plea, and it's happening slowly, is that the upper limit of ALT, which in most laboratories is 40, and AST also 40, needs to come down in men. And if it's 36 or 37, it's not normal. Even though it may look normal under the range. And those patients can have significant liver disease.  When you see an ALT and AST of 22, 24 in a woman, it's fine. In a man, 28, 30, 32, it's fine. But if it's in the so-called upper limit of normal, it's not normal. And the majority of those patients will turn out to have non-alcoholic fatty liver disease because it's the most prevalent chronic liver disorder. And then what can we do? We can encourage them to lose weight. We can tell them to get vaccinated for hepatitis A and B if they don't have protective antibody. We encourage them to drink coffee. Coffee drinkers have the least amount of scarring with naffin. We tell them it's appropriate to take a statin. Most people say, oh, you have liver disease. You can't take a statin. In reality, that's not true. I'll have a greater proclivity for getting liver disease and short-term statin use, multiple studies, all the statins who know the risk of developing primary liver cancer. And then we can encourage them to enroll in clinical trials. So 12 years ago, there were 12 clinical trials in our country. This year in 2022, we have 435 clinical trials going on on non-alcoholic fatty liver disease. So the majority of these people will do well, but we can intervene at a point in time before they progress to get cirrhosis and complication. Dr. Abramson, if I wanted to, as Dr. Chopra articulated around liver function test, for diabetes, what types of preventive measures can I take? So first of all, I wanna tell people listening that if you have diabetes, there's a lot you can do to improve your glucose control to potentially go into remission if you have type 2 diabetes. And there's been huge advances, not only in the diagnosis of diabetes in terms of the ease of diagnosis, but also many, many advances in treatment, notwithstanding the fact that a healthy diet, especially limiting carbohydrates and exercise, go a long way towards maintaining good control and facilitate weight loss. But to diagnose diabetes, all you need is one test called a hemoglobin A1C. And the hemoglobin A1C is a test that can be done at any time of the day, because it's a test that reflects your average glucose over the preceding three months. It was a test originally developed in the 1970s to assess adequacy of glucose control in people who already had diabetes. And it was used then to monitor people every three months and determine how well they were doing with regard to their glucose control. Because it's become a much more standardized test now, we have used, we can now use this test to define or to diagnose prediabetes and diabetes. And hemoglobin A1C level of less than 5.7% is considered normal. Anything between 5.7 and 6.4 is considered prediabetes and 6.5% or higher is considered diabetes. In addition to that, you can do a glucose test, a laboratory glucose test from a blood sample. And we have criteria for what is normal, what is prediabetes and what is diabetes. And that should be done either in the fasting state or sometimes we even do it after giving somebody a glucose load, which is what we call a glucose tolerance test. Those tests are very rarely used today for routine diagnosis of diabetes. They are very commonly used and it's part of routine practice to screen women who are pregnant for a condition called gestational diabetes, which is defined as diabetes developing during pregnancy and which usually goes away after pregnancy but identifies a woman who is at risk for the development of type II diabetes and also a woman who is at higher risk for the development of cardiovascular disease later in life. So those are the simple tests to diagnose diabetes. It is now recommended that anyone 35 or older should be screened for diabetes and the screening should be started at any age if you have risk factors, if you are overweight or obese and have additional risk factors for diabetes, such as a family history of type II diabetes, a history of gestational diabetes, as I said, a woman who has a condition called polycystic ovarian syndrome, people who have high blood pressure, people who have abnormal cholesterol levels and people who are in certain ethnic groups because there are certain ethnic groups in this country where there's an even higher prevalence of diabetes. African-Americans, American Indians, Asian-Americans as an example. And the Hispanic population. And the Hispanic population. It's mentioning that the hemoglobin A1C is a really remarkable blood test. It gives average of the blood sugar. It represents the average of the blood sugar over the preceding three months. Right, Martin? Three months? That's correct. It's a three-month test measure. And as I say, that was originally developed in the 1970s to as a way of telling people how well their glucose control has been on average because of blood sugar at only one point in time, only tells you what your sugar is then. Nobody really, now we've got things that measure your glucose 24 hours a day without having to prick your finger. They are these continuous glucose monitoring devices which have transformed the way people look after themselves. And I think altogether another topic for another discussion on another day. But the one other limitation of hemoglobin A1C is in people with hemoglobinopathies, for example, sickle cell disease. We wrote the book because we believe in the three eyes that when we have patients, we need to inform them or doctors or colleagues, inform, inspire, and integrate. Three eyes, form, inspire, integrate. And there are amazing stories in the book about people who have conquered their diabetes, lived to the age of 92 years, taken 120,000 injections of insulin during their life. It's just unbelievable. Pilots who lost their license because of type two diabetes and they were taking insulin and they showed working with Martin, one patient in particular that we talk about in the book and he was endorsed the book that he could regulate his blood sugar, tight control, save for him to fly airplanes, commercial airplanes, got his license reinstated. Really remarkable. All the different diets and nutrition, there are at least three patients with type two diabetes who on intermittent fasting have come off insulin, including one patient who had been on insulin for 25 years. So we incorporate a lot of stories. We have checklists with a list of vaccines, the promise of stem cells. There are a couple of patients now who with stem cells appear to have been cured of type one diabetes. So, you know, Walter, the French philosopher once said, every man is guilty of all the good he did not do. And so Martin, I felt, you know, this is an amazing time we live in. It's the 100th anniversary of the first dose of insulin given to a young boy, Leonard Thompson in Canada. Let's write this book. Let's inform, inspire and help people integrate this new knowledge and wisdom. There's one more I, there's one more I that I always add to Sanjeev's three and that's improve the lives of people with diabetes. And this book is intended to improve the lives of people with diabetes as well because there's a lot of positive vibe in the book and it's all true stories. So people with diabetes don't, you should never give up hope. There's always ways that you can look after yourselves, improve your lives and you'll feel so much better for it. That's the important thing. So our patients inspire us and we wanted to pass that message on to the rest of the world. Absolutely. Someone may get diabetes, but there are ways to manage it. There's ways to control it so you can live a healthy and normal life. And throughout this discussion and the book, our audience can learn about it and adapt their lifestyles. If they have diabetes or if they're pre-diabetic, the living a fulfilling life. And it's very unique to have physicians, physician leaders, authors, researchers beyond the show. And I can't thank Dr. Chopra, Dr. Abramson enough for being on the show and contributing and improving the health and wellbeing of the population. I thank you both for being on the show. 30 minutes is not, definitely not enough and we need to have it back. We'll have to do another 30 minutes another time. We're going to do that really soon.  Yep, coffee drinkers have a low risk of developing diabetes. That's the next subject we're going to get into fairly soon. But for now, I thank you both. Thank you for being on the show. Thank you, Vikram. We're going to do it again soon. I look forward to it. Thank you. Thank you. Thank you so much for watching Think Tech Hawaii. If you like what we do, please like us and click the subscribe button on YouTube and the follow button on Vimeo. You can also follow us on Facebook, Instagram, Twitter and LinkedIn and donate to us at thinktechhawaii.com. Mahalo.


What I'd like to do today is give it a little bit of an overview of my thoughts on over-the-counter hearing aids, direct-to-consumer products for those with hearing loss. I've spent a lot of my career actually thinking about this topic and developing innovations in this area. Back in 2000, I left GN Resound and helped start a company in Silicon Valley whose goal was to develop products for people with hearing loss who won't wear hearing aids. So we worked to embed hearing aid technology in mobile phones to compensate for hearing loss in streaming music through servers. And finally, we ended up developing what you would today call a hearable back in 2004. A little bit later, the lab I led developed a self-fitting tool for people to adjust their own hearing aids in a very easy-to-use way. And just a few years ago, I found myself providing guidance to the FDA, to the FTC, to members of Congress around hearing aids and the role of audiology in the hearing loss services. So I've been talking a lot about OTC and where our field is going. And I often find that I get similar questions from a lot of people with respect to OTC. So one obvious question is from everyone, particularly people outside of our field, why aren't hearing aids helping the tens of millions of people who have hearing loss in America? Or why is it that such a large percentage of people with hearing loss don't have hearing aids? Or why are hearing aids so expensive for people who need them? And now with OTC imminent in the US in terms of being made legal, will OTC hearing aids replace audiologists fit hearing aids? And this is a concern for people within the hearing aid industry, both audiologists and hearing aid manufacturers and others. And so my response to all of these questions is really that these are the wrong questions to be asking. They're based on a false premise. It's based on the concept that everyone who has hearing loss or everyone who has difficulty is a candidate for hearing aids. And everyone who has a hearing aid who is fit by an audiologist is the candidate for OTC hearing aids. Both of these assumptions are false. So hopefully you'll understand my position on this by the end of this brief talk. So what is the right question to be asking here? Well, what are the unmet needs of the different segments of the population of people with hearing loss? So this is critical in terms of understanding what treatments and what solutions are right for what people. This is fundamental in any company that is going to be successful trying to understand the unmet needs to understand what solutions are needed for them. And then based on those unmet needs, who actually has a need for OTC hearing aids? So that's going to be how I approach this. What are the unmet needs of different segments of people who have hearing problems? So if you consider all the people who have auditory dysfunction, you can segment them in some very simple ways. You can segment them by whether or not they have a measurable hearing loss by the audiogram. And there are people who have normal audiograms but still have hearing dysfunction. So we do have those two categories. But then you also have two categories and whether or not the person perceives that they have hearing difficulty. So this gives us four different categories here of the population to think about in terms of unmet needs. So let's consider them one by one. There's top left one, people who have normal audiograms. They don't perceive that they have a hearing difficulty. They have some auditory dysfunction.  I don't know how to find them. I don't know how to address them. So let's just ignore that segment of the population. Let's consider the top right here now. So this is a group that has a measurable hearing loss of greater than 25 dB PTA. But if you ask them, they say they don't have any difficulty. So this is a challenging group. We know they have a hearing loss, a traditional sensory neural hearing loss. But they seem to be doing fine. It could be because their lifestyle doesn't produce any auditory demands or able to compensate well. They don't notice it. This is going to be a really challenging population to consider to say that they have any need at all for a hearing aid. OTC or audiology fit hearing aid because they don't have a perceived need. Now maybe you could expose them to devices and get them to understand the need, but that's going to be a real challenge, marketing challenge. So for the sake of this talk, I'm going to ignore this population as well because I think they're a really, really difficult group to address. And I think we have other opportunities for solutions for people who do have unmet needs today. So now the bottom left here. These are people who have normal audiograms, but say that they have hearing difficulty. So there's a lot of people who walk into audiology clinics saying they need hearing help. But when you measure their audiogram, it looks normal. And what do you do?  It's not fine. There's a reason they showed up. I'm going to talk about this group right at the very end because they're not necessarily candidates for hearing aids, but they're candidates for other solutions. Finally, this group in the bottom right. These are people with a measurable hearing loss by the audiogram. And if you ask them, they say they have hearing difficulty. We can split this into two groups. Those who accept professional help and those who accept the use of hearing aids as a solution. And then those who, for whatever reason, are not seeking any help. They're not wearing devices. They're not going to see professionals. So let's consider these two groups as separate segments. So let's consider this group right here. This is the segment that everyone who's in the field knows and understands really well. So this is the population with the measurable hearing loss. And they know they have hearing problems. And they want to see a professional to get treatment. So what do they want? Well, all of us can list what their needs are. This is just a small selection of those. Improved speech understanding. Improved sound quality. Less listening effort. But these are all things that hearing aid companies, device manufacturers are producing and developing innovations year by year.  Audiologists are hearing care practitioner. This is critically important for this group. They know they have hearing loss. They know it's a hearing health condition. They want to see a health care worker. And they want good quality of care from that worker. So we know that this is critical and the level of care is important because there's a lot of data that shows the level of care correlates with the satisfaction with hearing aids. This is out of Sweden where the Y-axis shows the amount of care that they got from their audiologist. The X-axis is how satisfied they are with their hearing aid. You see a very strong relationship between the level of care they got and how satisfied they are with their hearing aids months later. At the National Inclusive Laboratories, we also got similar data where three months after their first fitting, we questioned people on how satisfied they were with their hearing aids, how much benefit they were getting. And you see that the more benefit they get is highly correlated with the amount of care and the level of interest that they got from their clinician. So if clinician isn't giving much attention, if they're not giving much care, the benefit they're getting from their hearing aids later on is low.  And this is just like in any field where you seek professional help, the better the help you get, the more satisfied you are with the outcomes. This really should be no surprise. And so for the population that currently is accepting of going to see a professional, this is really important. So the summary, I think, with this group is hearing care professionals will continue to play a very significant role for this group because for whatever reason they want professional help and the more they get it, the more satisfied they are with their treatment. Now, let's consider this group on the bottom right here. They have an audiogram that shows the hearing loss. They know they are hearing difficulty, but they're not going to see a hearing care professional. So what are the unmet needs of this group? Well, there are a couple reports that came out a few years ago that said that the main issues here are accessibility and affordability to care, to treatment. So if we look at a model of behavior, something that's been applied to healthcare behavior, such as why do people not stick to diets? Why do people smoke? This is a very nice framework for understanding what are the reasons why people behave in a certain way. It's called the COMB framework for capability, motivation, opportunity that influences behavior. So if we think about the behavior of not seeking a hearing care professional, when you know you have a hearing problem, what are the reasons behind that? Well, accessibility and affordability would fall under opportunity. Now, I would question whether these are really true because if you go online, you can get a lot of people who will mail you a cheap hearing aid to your doorstep tomorrow. So is accessibility and affordability an issue? Let's say it is, let's put it on the list. But what the framework tells us is there are a lot of other considerations to think about in terms of why people are rejecting audiologists. So what might those be? Well, stigma, people are just lazy. They don't have confidence that the solution is going to help them. There are people around them who are supporting them and telling them to do the right thing. Or they just want to do things themselves. They don't want anyone else's help. There's a variety of reasons why people may choose not to get a hearing aid. And these can be defined all under that COMB structure. At NAL, we've done a lot of research into what it takes to be successful with self-fitting hearing aids. And to tell you what, it takes a lot of ways that you can fail in getting someone to be successful with an OTC or a self-fitting hearing aid. We did a study of 60 adults, gave them all hearing aids that were designed to be self-fitting, gave them the instructions and said, okay, let's see how you do. And what we found was only about one in four were able to be successful in fitting themselves. Another half were able to be successful if they had professional help assistance. And then another third just weren't successful at all. So getting someone successful with a hearing aid device is not easy as any professional knows. Market Track 10 recently published earlier this year has a lot of data on attitudes towards hearing care professionals and self-fit devices. Looking at the different tasks that are necessary in order to get to a self-fit device, over 3,000 people who have hearing loss, some with hearing aids, some without were asked, their level of comfort in doing things like selecting the right technology, fitting it themselves, learning how to use the features. And about half the people were comfortable and about half of them were not. So there's a bunch of people out there who say, you know what, I think I can do it myself. But a lot of people are like, you know what, I think I'd rather get some help with this. When the population was asked whether they would prefer to get over-the-counter product themselves or go to see a professional if they were to get another hearing aid, those who are current hearing aid owners, almost 90% said, you know what, I'd rather go see a professional. Probably not surprising because they had a good experience. Those who have hearing loss but are not hearing aid owners, about 60%, 56% said, you know, I would probably look at a hearing care professional, but almost half said, you know what, I think I would give these OTC devices a chance and see how they go. So, you know, again, there are different segments of different attitudes towards devices here. When asked whether people with hearing loss when asked whether they think a professional provides value in terms of your success with the device, hearing aid owners, 90% said, yes, of course, they provide value. And again, non-hearing aid owners, it was about, you know, 50%, 60%. I think it was 66% said, you know, I think a hearing care professional does that value. The other said, you know, probably not, I could probably take care of it myself. So again, different segments, different attitudes and different beliefs that are going to drive different behaviors in terms of whether people seek professional fit devices or not. So if we look at the Combee model, there are a variety of reasons why people might choose to go and get an OTC device instead of seeing a professional. If they're socially acceptable, if they get support from others, again, if they're affordable, if they have activities that are being limited because of their hearing in terms of capability, if they feel that they're able to select the proper device, if they're able, if they're capable in terms of fitting themselves and managing any apps or technology that goes along with it. And then if they are motivated to do so, they believe that the devices will help them if they're not concerned about stigma, if it fits their lifestyle and so on. So there's a lot of things that you have to get right in order for OTCs to work for someone. And conversely, there's a lot of reasons why people are not going to see professionals. And I think they're really nicely described by the factors in this model. So in summary, for this population, there are a lot of challenges to get this population to accept OTC hearing aids, and it's not just accessibility and affordability. There's other things that you need to be successful in order for this population who are rejecting professional care to get them some form of self-help solution. So we'll see how well companies do with that challenge when OTCs become legal within the US. Finally, let's consider this bottom-left group here. These are people who have normal audiograms, if you measure them, with the Houston Westlake procedure, but they proclaim that they have hearing difficulty of some sort and are looking for solutions. So what are the unmet needs of this group? Well, they typically complain about difficulty with speech and noise. They want a solution that is just dead simple to use. They want something that looks really good because they are a very high-demanding group. They're not going to stand for any side effects, whether it's inclusion, discomfort, other things. And then, obviously, for this group, it has to be reasonably priced. I'm not going to pay thousands of dollars for a solution for this. So there are a lot of products on the market already for this group. And they work really well. This was a data from a product that evolved from something that I worked on a long time ago. Showing on the bar on the left is the benefit that a traditional hearing aid provides for speech and noise. The middle bar shows the benefit for speech and noise that a hearable can provide. Just wearing a hearable on your ear. And then the far right bar shows the benefit you can get with a remote microphone connected to a hearable. So they can improve speech and noise. That is without a doubt. You can fit them. They can provide hearing help. But that's not the only need that needs to be met. Otherwise, everyone would be walking around with a hearable. There are over 25 million people, adults in the United States, who fall into that segment of people with a normal audiogram but hearing difficulty, particular speech and noise. So why aren't there 25 million people walking around every day wearing hearables? It's because of those unmet needs. It's not just about putting in good directional microphones for speech understanding improvement. The cosmetics have to be really good. It has to be really easy to use. You can't have occlusion. You can't have discomfort. And you've got to hit all of these. And I would say so far, it hasn't been a manufacturer that has done every single one of these features for people. So and there are other needs as well. If we apply a combi model for this group, other factors will surface in the behavior of why someone would choose to wear a hearable or not. So the summary for this group is it is a very large group out there underserved. They don't need a hearing aid because they have normal audiograms. They do not need amplification. So hearing aids are not for them, but they need a device that can help them with speech and noise. And the challenge is really about that usability, the cosmetics, social stigma, making it easy and acceptable. And this, I think this is an opportunity for hearing care professionals. I think there are people walking through the doors of clinics every day who have normal audiograms, for whom hearing aids are not a solution, but these could help. And I think it's in the best interest of the public, the hearing dysfunction public. And professionals worked this into their portfolio of treatment solutions for this segment of the population who have a hearing need, but it's not a traditional one that can be meant by traditional hearing aids. So in summary, when you think about OTC hearing aids and think about hearables and think about traditional, professionally hearing care, professionally fit devices and services, rehabilitation. It's not one size for everyone. You have different segments with different needs and you have to understand which segment a person is in order to understand which treatment is appropriate for them. And these are very large populations we're doing well with that segment D. People in segment C and E need our help. There are people trying to develop solutions for them. And but it's a big opportunity to expand the role of hearing healthcare for people who need it. So that's my thoughts on OTC and hearables and these emerging market segments in a nutshell. My contact info is there if you want to follow me and I'm happy to take any questions if you have any.


Good morning, weasel.  Thank you. Thank you. We're good We're here in South Dakota South Dakota to coffee time truck stop So I didn't film anything yesterday For me Yesterday was the day after our whole federal election, which we won't get into here. I took a day off Filming so you didn't miss much. Don't worry. Pretty much all I did yesterday was I spent I Spent all day pretty much picking up this load that I have behind me.  I had to tarp it In the cold wind it took Yeah, most of the day And I'm taking it down to Lincoln, Nebraska. So we made it down here to South Dakota. We got to go the rest of the way Excuse me was six hours down to Lincoln From there we go over to St. Joseph, Missouri We pick up some steel and we head over to the great and the beautiful Alberta gotta deliver that steel to Calgary, Alberta. Somebody over there needs steel from over here So where are the people to bring it to them?  It's gonna be fun It's gonna be a little bit of a new scenery also from Missouri to Alberta Because we're taking a different route again than we usually do similar to that route We took a few, what was it about a month ago? Where we went and saw that massive big truck stop there in Nebraska Through Montana and all those states over there.  So it's been An interesting couple of days But we're ready to get back to trucking and exploring our continent here We live in a beautiful beautiful part of the world and one of the most favorite parts to me of my job I'm one of my most favorite parts. Sorry. I'm still waking up. My English isn't good yet One of my favorite parts of the job is exploring and seeing everything Because you know, you can hear about it. You can learn about it But once you see it you really see it feel it experience it. It gives you a whole new appreciation for For the land that we live that we live in both Canada and the United States. I live in Canada, but you know Technically I live a lot of my life in the US. I'm just not a citizen here But they are kind enough to allow me to come and visit Quite often so I'm down here almost as much as I am up there Great people down here. I love visiting the United States So I'm gonna go in and grab my coffee here.  All right, let's don't take a look at this here I was gonna take a look at this here So there's my load. It's like a brick wall that I'm Pulling my I don't know why they stack it so high they could stack it lower and use the whole Trailer but they decide to stack it up like that in the center of the trailer and it acts like a huge Parachute behind me and I use a lot more fuel because it catches so much wind, right? That tarp is it was so windy. I was lucky enough to have another driver who was tarping there helped me out a little bit That's the little oops looks like I'm gonna have to grab another bungee Bungie that in there supposed to be in there Okay, well, I'm gonna complete my pre-trip here and everything gonna continue doing what I got to do We'll get back on the road just Keeps on going remember such a wet autumn or wet fall before I Mean, I know we had a lot of snow and rain the year on end of 96 so we had the flood of the century in 97, right? I wonder what next spring is gonna be like Because the river is up in Manitoba all the water from here flows pretty much into the Red River of the North, right? Just off to our left and That all flows up north to Canada It's the only river in North America that flows north it goes into Lake Winnipeg and from there it drains into the Hudson's Bay But all this water here a lot of it anyways not all of it But a lot of it goes up to Canada up to Manitoba where I'm from and our rivers up there are pretty high I Think I just read an article this morning saying that the Red River in Manitoba. There's about ready to Rise over the banks. I think it's crest is what they call it, right? That's at fall time We got to get a whole winter of snow in yet, and that's all got a melt in spring So it'll make for a very interesting spring next year I'm glad we're kind of up on higher ground Don't really have to worry about flooding much and we don't have a basement either We just have a crawl space So the water would have to be exceptionally high and most of Manitoba would have to be underwater before our floorboards would even Start to get a little wet There's a lot of people who live in what we call the flood basin around the Red River Up around you know, Santa Gath south of Winnipeg because the floodgates go up and Winnipeg gets protected We built a massive floodway that takes water around the city but They saved the city at the expense of the small towns and agricultural communities south of Winnipeg So whenever they put those floodgates up Essentially what it is it's a dam it dams the river so it goes over and spills into the floodway But that means all those towns flood there. So I don't know what it would be like but Having to worry about flooding every I just remember sandbagging in 97 and that was a crazy flood that year But yeah, we're here in South Dakota still this is the scenery today. What do you guys think of it? It's nice, isn't it? So Dakota great places great faces or is it great faces great places? One of those one of those South Dakota So I've been running as hard as the law will allow me today. I thought that I had to get to St. Joseph by End of day by end of business day to pick up my load turns out the load's actually on a preloaded trailer and That trailer is gonna be waiting there for me and I can pick it up anytime of day 24 hours a day They'll leave the paperwork where I can find it I can just go hook on tie it down and get going whenever I get there So that is awesome.  I show up with an empty trailer leave my empty trailer take the loaded trailer And then they put you know, it's a cycle then So not every shippers like that, but this one's really nice I talked to them in the office there and they were they were super nice and good mood So they go home at 2 o'clock must be nice However, I can pick my load up 24 hours a day. Don't matter. So they know I'm gonna be there late tonight I'm gonna get to my my receiver for this OSB board around like four o'clock they go home at five So I'm gonna get there just in the nick of time And then I got about three hours to get to st. Joseph Eight I'll probably be in st. Joseph like around between eight and nine tonight I'll probably be there for a couple of hours tying it down And then I will just go a little ways down the road and go to bed somewhere But we got to be in Calgary for next Monday. I'm filming this on Wednesday Look at lots of times only two and a half day drive. So Wednesday, I'll get loaded tied down and then tomorrow will start So we got Thursday Friday Saturday, so we have four days to go two and a half days of driving That makes sense So I can take my time. That's good No rush Omaha Omaha, how many of you are from Omaha? How many of you have been to Omaha? Never actually been in the city. It's actually a pretty big city. It's a TD bank over there. That's a Canadian bank Oh, look at that. It's pretty big building to TD. I didn't know we did we had banks down here I knew TD was in the US, but It's kind of weird though, right? What would a Canadian bank be doing in the US? Or maybe it's a US bank just but it's just called the Toronto Dominion Bank Well, I know. What do I know? I know that I'd love to explore the city so much to see, you know all I get to see is like Sights from the freeway. I never get to actually explore that often So I'm gonna be turning off onto interstate 80 here In three kilometers I'm gonna have to get into the right lanes there. He wants to get into the left lane. I want to get into the right lane Okay, he didn't see my signal. My signal was on first At least he let me in now When you put your signal on and then someone you know backs off to give you room to Move over and then someone else from the other lane on the other side moves in and takes the spot That was made for you Doesn't that annoy you? Quite a bit warmer here already. Look at the trees. The trees have barely even started changing color here That's a little bit Truck must check in before entering gate. So you want me to check in here? I Don't want to block the gate though. So I'm gonna go Yeah, it says do not block gate Okay, well, I'm gonna go and park over here off to the side then Then go in and check in Good thing looks like there's nobody else here, so it's just me they claim I can get around here It's about five o'clock Just just about an hour to get all un-tarped and cleaned up and unloaded just like I thought Always getting better at estimating how long things will take you make it around no problem So now we're on our way to St. Joseph got to pick up that steel load and we're not gonna be able to take the scenic route through Montana, unfortunately Apparently I have to cross at Emerson, Manitoba so goody for me a I Guess we'll head up that way not very scenic, but I'm just gonna wait for this forklift guy to do whatever it is He's doing there Said I don't have to crowd him too much getting around this corner. I think he just took the The wrapper off of that Lumberbees that would came from British Columbia in Canada. He's gonna leave room for me Much easier that way Some of these yards that we deliver to are so tight and so so narrow But it works as long as everything is kept neat and in order It works So we've got about two and a half hours to St. Joseph now and Then to tie that down that'll probably take me about three hours there Unless if I like hurry might be two hours But I usually take my time with those loads because I go overboard.  I don't know what I'm saying Off we go on the next adventure Oh, well at the border of Nebraska and Iowa here They got something going on in two three four five cranes. I Wonder how they don't all hit each other They're all so close together It's our whacking each other they can start having crane fights sort of like sword fights with cranes this Wonder which one would win a whole bunch of them So obviously building a new bridge here probably gonna be pretty cool and pretty nice once it's done We're just going over the border here, and we're stopping at the pilot how to grab some fuel again Keep beating that fuel You grab the fuel and some D F fluid diesel exhaust But I think you guys in Europe call it ad blue.  Oh boy, they had to tear down a couple of really big trees to build this bridge. That's too bad I really wish that when we would develop we would sort of try to leave up as many trees as possible But it seems a lot of the time when we develop they go into the land And they they just clear the entire land from corner to corner to corner, you know, they just everything cleared right down They take down every single Tree and everything again. I'm not a tree hugger, but I'm also I Also don't hate trees. I like them. They take a long time to grow but I Guess I was just I was seeing a development. I went for a walk the other day, and I saw this new development It was new development. He was this new commercial building coming up And it it was a forested lot and what they could have done is just cleared enough trees for their business And they could have had a nice tree didn't business. It would have looked really nice, right? But no, no, no, no, they took this whole like Quarter of a square mile and just cleared everything and then they just chewed up all the trees into sawdust and wood chips I guess they sold those and at least they'll go to use somewhere It was sad for me to see you didn't need to knock them all down Just, you know down a few of them Whatever whatever. I'm like right in the middle We need to keep developing so that I have work to do. I need to bring people steel so that they build some I want them to keep building things But don't be wasteful like leave trees I'm very protective over the trees on our property Hydro our electric company Thanks, thanks Karen always wants to be involved Our electric company a manageable hydro they tried to Re-route our hydro on our property and I told you about this right and they wanted to cut down a whole pile of our trees And it caused a big stink and I forced them to go underground Protecting my trees in that case. I was a tree hugger Those are my trees specifically Look at this. Wow. This is Barely big enough to fit through here. All right, so pilots off on the left here. Let's grab fuel and go get our steel Rolling in a St. Joseph here.  That's all you need to tell me. You don't need to tell me all that All right, then I don't remember coming in this way We're going the great past downtown St. Joseph Oh What are we doing here Karen Okay, so all you have to do is say K next exit for a turn right Well, you're thinking at me yet, too You don't trust me to listen to you do you? Probably because I don't listen all the time. I just tune her out like a good man 69 6th Street This is definitely different route. I don't remember this I don't I haven't been to this shipper in a month or two So I don't know and it's nighttime rolling into town here. So Might just be me might just be me Okay, this is looking more familiar now. Sorry guys Slight right on Karen you have to interrupt me on that. I just realized you guys have got some bugs in your Your line of sight there. I didn't realize that Okay, what turn right here, right, right, right? right Here green arrow pointing right this way Very often I've gone the wrong way Right on Alabama Street Alabama Street, huh? Alabama's okay. Let's 30 miles. Okay. Good. I was going 30 Yeah, this looks familiar now Now I know where we are because this shippers in an old part of St. Joseph Razzle all these buildings are very old and Probably from the a lot of them from the 19th century early 20th century You know one of these neighborhoods that I always like to show you and talk about you know the good old days Back in the good old days in the 1800s and early 1900s Before everything got weird and crazy like wow, especially as of late the world's just gotten really weird, hasn't it? What have we done? Let's talk about that big bug right in front of my camera. Well, why are you why is that bug right there? Right there.   You've stolen my childhood and my dreams with your bug guts Trying to show the good people where we are Wait, don't I want to turn there? Okay How's that that better? this bug deflector That I installed doesn't catch all the bugs catches a lot of them not all So this is my next load and check this out Steel is painted white this time instead of that regular gray and there's there's a strap here already for me Why is there a strap? It's not our strap This is the right trailer, right? Yeah, it's definitely my trailer Check this out. It's gonna be so easy to tie this down Look at this. Is there anything back here? Oh, it's a little bit. Okay. Yeah, you got a little bit of Little bit of something something back here yet I'm gonna put my tarps on top of those and that'll hold that down. Look at that other than that. It's just One cluster usually it's way higher usually it's all the way to the back here I'll be out of here in less than 45 minutes. Okay. I'll get myself an hour because I'm gonna take my time because I'm in no rush I'm just gonna tie this down and go down the road find a good place to park and I'll be that I'm calling tonight after this so I take my time do a good job make sure it's all tied down because you got to make sure like all these little pieces in the Center you have to make sure that each piece Is tight and it's got friction that's gonna hold it in place It's not gonna rattle loose and come out the back right and like these things back here like this The reason I said I'm gonna put my tarps on this here is because of these center pieces in the middle Right, I could put a strap or straps right over it I have to put corner protectors on there and tie it down real tight But you never know these middle ones they might Rattle forward or back you have to slam on the brakes or something you don't want that So I'm gonna put my tarps on top of this then tie my tarps down tight on top of them that way Everything has got a lot of friction and nothing's going to move Yeah, that's my load that piece up there looks kind of crooked though Sometimes they load this stuff a little wonky like that. You see that load there. That's what I'm used to Usually when I pick up stuff here, this is what I'm looking at look at this Chaos and this place my another place I pick up steel in Evansville, Wisconsin That place puts those ropes through remember they put the ropes through so that you can pull your straps through This place doesn't even do that and you're not allowed to climb on the trailer deck here You can get kicked out of the yard and you can't pick up here anymore So you can't put any straps through the center of this or through the middle of this But you're supposed to you know, tie this all of this all the way down Legally that's not possible. You have to have straps going through the center So what they make you do is they you tie it down the best you can just going over the top without getting on The trailer and then you leave here.  But yeah that That's a big load. I'm glad that's not mine. I'm really really glad that that's not mine This is mine Much better much much better. Let's get to work. I Usually walk around it once or twice or a couple a couple times just to get a good look at it Get a good feel for it. You know, I feel my freight gonna feel it in my bones Gotta know what I'm gonna do with it, right? How do I make this freight mine? My freight you're not going anywhere.    Don't worry Taking you with me We're all going for a ride up to western canada