HbA1c: What's Optimal, What's My Data?
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- Опубликовано: 31 окт 2023
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Papers referenced in the video:
Age-related changes in clinical parameters and their associations with common complex diseases
pubmed.ncbi.nlm.nih.gov/26623...
Predicting Age by Mining Electronic Medical Records with Deep Learning Characterizes Differences between Chronological and Physiological Age
www.ncbi.nlm.nih.gov/pmc/arti...
Glycated haemoglobin A1c as a risk factor of cardiovascular outcomes and all-cause mortality in diabetic and non-diabetic populations: a systematic review and meta-analysis
www.ncbi.nlm.nih.gov/pmc/arti... 
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Another great example of if low is good, lower is better, being a fallacy. There a plenty of sights urging HbA1c should be below 5, which the data shows is false. Excellent presentation.
I would say sometimes. I used to believe that was the case with u-shaped curves also. Then, a doctor I respect said that sometimes it's because your body has another issue that may be overutilizing that marker. Cancer, as an example, could be overutilizing blood sugar. The best bet is if you are out of range, you should investigate more.
@@Santa-ny1ypdefinitely agree...plus CKD LOWERS blood sugar
@@Santa-ny1yp this is the same argument for why the medical consensus target for LDL should be below 1.8 mmol when lowest all cause mortality is an LDL of 2.5 and lowest CVD mortality is 2.3 without statins and 2.1-mmol with statins. My experience is many of the most respected doctors defend the dogma most vigorously regardless of the bast data. The undiagnosed cancer trope consuming cholesterol is also dogma with little good statistical evidence to back it up.
Find my comment. There's NOTHING shown here in the video or in the study itself that would support your claim!
100% agree. It is impossible to be under 5.0 on A1C if you get a good amount of strenuous exercise.
I think it might not be survivor bias, but very old people eat less. My grandma barely ate at all before she died.
5.1% is quite good. We find that short walks after meals helps to keep HbA1c low. The association with increased mortality risk for HbA1c below 5% may be due to the lowered HbA1c values in old age, as presented in the video
I am 76yo and mine is 5.1%. I am a runner.
HbA1c is an integrated measure over the lifetime of RBCs and as such is changed by many things, such as blood sugar levels, RBC lifetime, glycation efficiency etc.
Continuous glucose monitoring is a better way to establish actual average glucose levels. If you use CGM and measure HbA1c and absolute reticulocytes/reticulocyte index that gives better insight into this system.
A short RBC lifetime results in a low HbA1c which I would argue is not a good thing. There is also some evidence of higher reticulocytes being less favourable.
I would argue that we want low glucose and also long RBC lifetime with retained function across that lifetime. Those are in conflict in HbA1c.
Got diagnosed 6 months ago hba1c 9.8 now it's 5.4 no exercise just some weight loss and diet
Nice job @jasonbrice9921!
Great work!
Great analysis and overview of HbA1C vs All-Cause-Mortality risk. 👍
Thanks @aljosarojac8575!
The famous warning by my introductory statistics class professor: "Association does not prove causation." come s to mind. I suppose I have been brainwashed to think that keeping blood sugar low reduces glycation, and glycation is bad, and HbA1c is a function of the average blood glucose level over the last 3 months... all point to having a lower HbA1c as being better.
Obviously the meta analysis data doesn't seem to fit that, but WHO are the people with the low HbA1c levels? I'm not sure what conditions might cause someone to have a very low HbA1c, but if (this is just made up) cancer or type 1 diabetes or some other conditions, if common enough, are being mixed in with "healthy" people with low HbA1c, this analysis would need to be adjusted, I think.
Were you able to find out if the people with low HbA1c were heterogeneous in some way as I speculate above? Sorry that this is just speculation and not an answer, but this is the first question that comes to my mind when seeing this, especially after hearing so much that lower HbA1c is optimal.
Really enjoying your N=1 studies!
Nice, thank you.
Thanks. Interesting.
Just speculating, perhaps in old age the lifespan of RBCs is shorter so there is less time for them to be glycated, hence the decrease in glycated hemoglobin.
Interesting, thanks @Battery-kf4vu, I hadn't considered that!
Yeah but tge peak is so pronounced and sharp…leaning towards survival bias
I don't see how the lifespan of RBCs would shorten just because of the "host's" age and I'd speculate you've got it backwards. To the best of my knowledge, glycation, as well as fructation, reduces their half-life.
Actually, if there's less RBCs around they might glycate faster and die faster. Whatever effects plasma quality would also play a role. Also, according to AI:
Age-related changes in mesenchymal stem cells (MSCs) can impact the availability of red blood cells (RBCs) through their effects on hematopoiesis, the process of blood cell formation.
Imbalance between osteogenesis and adipogenesis: With age, there is a shift in the differentiation potential of MSCs towards adipogenesis (fat cell formation) and away from osteogenesis (bone cell formation)
. This can lead to a decrease in the number and function of osteoblasts, which are involved in the production of factors that support hematopoiesis, including RBC formation1
. As a result, the availability of RBCs may be affected.
Functional and spatial heterogeneity of MSCs: Aging is associated with an increase in the functional and spatial heterogeneity of MSCs, which can lead to changes in their supportive role in hematopoiesis1
. This heterogeneity may affect the production and support of RBCs, potentially leading to a decrease in their availability.
Impact on hematopoietic stem cells (HSCs): MSCs play a crucial role in maintaining the function and self-renewal capacity of HSCs, which are responsible for the production of all blood cell types, including RBCs
. Age-related changes in MSCs can disrupt this supportive role, leading to a decline in HSC function and a decrease in the production of RBCs
Inflamm-aging and myeloid skewing: Aging is associated with a state of chronic low-grade inflammation, known as inflamm-aging, which can affect hematopoiesis and the production of RBCs4
. Inflamm-aging can lead to an imbalance between myeloid and lymphoid cell production, with an increase in myeloid-biased HSCs and a decrease in lymphoid-biased HSCs4
. This myeloid skewing can impact the availability of RBCs, as myeloid cells are involved in the regulation of erythropoiesis, the process of RBC formation.
I reduced my a1c from 5.2 to less than 4.8 by switching to a low fat high starch diet. One can also reduce a1 c from a low carb diet but the glucose tolerance test will worsen meaning that the insulin resistance is worse you just aren't eating carb s.
Totally wrong, mine went down on carnivorish lots of fats and proteins and a bit of carbs
Insulin resistance is not worsening on low carb, quite the opposite. You just become more fat adapted and most likely metabolically healthier.
So you've essentially ditched fructose and improved your "insulin resistance"?
Ditched fructose, started fasting, improved my mitochondrial health through exercise, RLT, diet including fixing nutritional deficiencies to improve electron transport chain (complex 1,2) once fatty liver was gone, so was insulin resistance. It’s not Keto, just fat adapted approach and more relaxed with carbs now, it’s not an issue anymore. It should not be if you are healthy and sensible.
You posted before actually listening to the video didn't you?
Not sure about using averages. Average means alive but not necessarily healthy. I am assuming that as people get older they lose control of their blood sugger and become more and more diabetic so there HbA1c increases. I think a 5 is associated with a fasting Gl level of 100 which is health.
My HgA1C shot up 0.5 mg/dl in 6 months by replacing regular protein bars, sweetened with sugar, with keto friendly protein bars, sweetened with alcohol sugars.
The meta-analysis did control for illness causing low A1C:
"Lastly, since many confounders were controlled for in most studies when computing HR, the external validity of our estimates of all-cause mortality, cardiovascular mortality and risk of cardiovascular events, in both diabetic and non-diabetic populations, could be reinforced."
Like most epidemiological studies It has to be taken with a grain of salt as there could be undiagnosed illness or other unknown factors causing low H1C.
70-80 range drop = Metformin? They throw "Met" like candy starting in that age range.
This is fascinating and far from what the "standard of care" is.
Thanks for this Michael! I enjoy all of the hard work and valuable in depth analysis you put into all of your videos. This particular vid has inspired me to post the comment below.
I wonder how many of the people in the above statistical analysis with an a1c under 5 are rigorously dieting and exercising? If sugar consumption in that group of people is at an estimated average daily intake(lets say 50-80 grams per day) or even higher, and most in that same group of people live sedentary or not very active lifestyles, the low a1c might just be a smoking gun for some other unusual systemic health issues that spill over and are symptomatically expressed through the endocrine system(or directly from the endocrine system).
For many years now, my sugar derived caloric intake is restricted to 25 mg per day(from small amounts of fruit). My a1c hovers in the 4.8/4.9 range. If I were to include more sugar in my diet(around 60 grams per day) and exercise significantly less my a1c would go up to around 5.2. That would fit in nicely with the optimal healthy statistical group cited above. But wait a minute, I said I would be eating more sugar and exercising significantly less? Would I be healthier with more sugar in my diet and exercising much less? I tend to think not. My egfr would drop down 20 points and other numbers on my blood work would be less impressive.
For me to assume that because my a1c number fits the statistical analysis cited above will lead to a healthier, longer life is ad hoc. I would need more health and lifestyle data from the a1c under 5.0 group to draw any applicable references to my own diet/lifestyle. I understand that if this data were available, Michael would have included it, so I have to work with the info at hand. Based on what I know, how I feel, and other data from my own blood work, I will continue to work at maintaining an a1c under 5.0 through diet and lifestyle choices(not that I'm saying Michael is suggesting we do or don't anything with this data analysis lol)
In this study, a1c is considered clinically low if it's under 4. www.ahajournals.org/doi/full/10.1161/circoutcomes.110.957936
From an old LEF article: "For those interested in optimal metabolic control and longevity, reducing blood glucose to an ideal range (between 70 and 85 mg/dL) along with achieving hemoglobin A1c less than 5% are important goals"(the papers are cited at the bottom of the LEF article).
I’m also a person with low 4.7 A1C due to diet and exercise. I consider it good, not bad;regardless of what these data show. I think that most people with this low of A1C have eating disorders or comprised absorption of the foods they are eating.
@mime454 I concur. We can't draw definitive conclusions from the above analysis. I recently increased my exercise regimen to seven days per week and cut out my desert cheat day on the weekend. My last round of blood work after implementing those diet/lifestyle tweaks took my a1c from 4.9 down to 4.8 and my egfr went from mid 80's/90 to102! My Lp(a) went down moderately as well. Liver enzymes stellar. If I were to set new goals based on the data above I would set out to consume more fructose or calories and exercise less. I speculate that if I were to implement that silly regimen my a1c would go up to 5.2/5.3 and my egfr would probably drop to the low 80's along with a higher Lp(a). No bueno.
COULD THE RAISE IN ALL CAUSE MORTALITY WITH AN A1C BELOW FIVE BE DUE TO THE FACT THAT CERTAIN PATHOLOGIES LOWER BLOOD SUGAR LIKE CKD OR TYPES OF CANCER...SARCOPENIA
Definitely
Probably the best level of discourse on comments I have seen across all biohacking channels.
I like those big data graphs too. It is a shame the first one did not have many data points in the 90s and above and the young. It looks like, men averaging higher A1C is another candidate for the explanation of why there is reduction in male centenarians relative to female.
It would be interesting to do a study like these with a population with very low obesity, like Vietnam. And maybe the other extreme as well, such as one done on the population of some Polynesian island.
i look at HBA1c values every day in my job. Learned a lot from your presentation. Analytical and presentation skills really are top knotch, tks Sir
I really appreciate this channel, love how it's a complex endeavour and Michael style of presentation too. But to claim that the data shows an ideal range of A1c above 5 is anything but too analytical or top notch and nobody seems to pick up on that mistake. I'd hope more critically thinking viewers would contribute with corrections and someone looking at HbA1c "every day" with some insights. But it's sadly not happening.
If you think it's a mistake that 5-5.3 is optimal, please post some papers with a larger sample size than those presented in the video.
@nootri The data is what it is. How you feel about it may not be all that relevant.
This is not about my feelings. The graph presented does not support the claim anywhere. Even the claims of the study that somehow 5-6% is optimal is wrong. They worked with ranges that are too wide.
@@nootri Actually it does support the claim, at least from an epidemiological perspective, which has considerable limitations. Unless you're prepared to add nuance to your claim that something is wrong, it's about your feelings.
mmm. So, what would be the mechanism for a 4.8% HbA1c being riskier than 5.1%? And isn't there data which shows that as you approach prediabetic (5.7%) risk gets higher for CVD?
Do you ever change your meal timings? Fasting/eating window to influence overall health or hba1c?
After years of experimentation, it's pretty much set. I haven't noticed an impact on biomarkers, but sleep quality is better with a shorter eating window.
@@conqueragingordietrying1797 Did you eat 3x per day with shorter window or more than 3x per day with shorter window ? If you eat 3x per day with shorter window then how you manage it ? Breakfast at 10 am, lunch at 2 or 3 pm and then dinner at 5 or 6 pm ?
Well, I reversed my prediabetic stage from 6.2 to 5.4 - 5.6. I wish to get it a little bit lower ( may be via fasting?). I managed it by quitting any added sugars.
One can increase his insulin sensitivity with a low fat nutrition plan. Intramyocellular fat from ingesting oils and fats, especially satuarted fat, causes insulin resistance. There are papers on this in the early 2000s.
sorry to disagree. I have been on high protein/fat and low carbs for last 5 yrs with my wife and we are both the same number for years at 5.2-5.3. more research is required but i will stick to my strategy for now at 68 yrs old
Insulin and A1C go down on low carb.
I have yet to see proof that fat in the muscle is the result of fat intake. If that was the case nobody trying to lean out with keto would escape at least an initial rounding up.
Once aged or metabolically deranged, lipids and their derivatives accumulate both within and between muscle cells, inducing mitochondrial dysfunction, disturbing β-oxidation of fatty acids, and enhancing reactive oxygen species (ROS) production. This leads to insulin resistance, as well as enhanced secretion of some pro-inflammatory cytokines, promoting the development of sarcopenic obesity, which in turn means less muscle, more fat.
Lysosomal dysfunction plays a significant role in the context of sarcopenia, it and impaired autophagic flux can contribute the accumulation of lipids in enlarged lysosomes, impairing their function and exacerbating cellular injury and inflammation.
This dysfunction can disturb the balance between muscle protein synthesis and degradation pathways, contributing to muscle atrophy, a hallmark characteristic of sarcopenia.
You can get here faster if you damage your mitochondria and cell membranes with a high carb, low fat, unsaturated fat rich diet.
@@Always-xl9db Insulin will go down, but AC1 may go up because there is not a lot of circulating insulin to keep it lowered.
I think brain needs large amount of glucose with corresponding O2. It is possible that at low a1c, energy intensive GNG is constantly forced to supply glucose- GNG is energy intensive vs Glycogenolysis.
The higher mortality rate below 5.00 may be result of more load on GNG to supply glucose that becomes thermodynamically and kinetically less efficient process.
Along the GNG line of thought, liver failure would be expected to lead to less glucose output, and a potential mismatch for maintaining circulating glucose levels. That could also explain the increased ACM risk for HbA1c < 5%, i.e. liver dysfunction--less circulating glucose (< 70), less HbA1c.
Constant load on liver via GNG is an inefficient process- Besides it will activate Pituitary dialing down thyroid, activating adrenal or HPT/HPA axis besides Gonads- Many hormones would be wacked.. Glucose homeostasis is the primary job, extremely complex, and Gods Biochemistry is perhaps too complex for humans!!
As known, GNG is messed in T2D resulting in glucagon pumping despite insulin signal. Besides T2Ds, anyone having messed insulin/glucagon/Somatostatin pulsation can have low ( or high) a1c with corresponding hypothalamus activation. Would love to see perfect people or younger generation lowest possible a1c when compensatory machinery kicks in.....
Can we fairly say HbA1c also reflects glycation level in general ?
I'm not sure-I haven't seen any studies comparing it to GlycanAge-if anyone's come across that data, please post it!
Glycated albumin could be better, as albumin is the most abundant circulating protein, but I haven't seen that as a commercially available measurement.
Ignoring the contribution of fructose caused glycation, which isn't measured by hbA1c yet likely impacts the half-life RBCs is a confounder that nobody accounts for in this studies...
the problem with large number of people is comparing healthy to sick people. It would be nice to have a group of healthy people (definition to be discussed) to compare what could be optimal, but it could be difficult. I am happy to be still in the optimal range at 68 yr old along with my wife eating more a meat based approach. It would be interesting to find a person willing to parallel your approach using a meat based strategy. in any case, all your videos are useful to map a strategy
It's a population-based average, the larger the sample size, the better. For example, it's hard to argue with the meta-analysis data, which included 46 studies.
There are many roads to optimal health, it doesn't have to be my way, but I think we should all be regularly testing biomarkers as a roadmap.
@@conqueragingordietrying1797 The issue is the same as with Cholesterol and tau plaque for Alzheimers, though - the levels you see may actually be protective to protect for some third factor that is the one causing death, so that by reducing cholesterol or trying to remove tau plaque, or reducing Hba1C in elderly people who actually need those levels, you actually do more harm than good (remove the natural body response to combat vascular disease or brain inflammation and senescence, or all cause mortality).
@@pureffm With LDL Cholesterol, we know for sure that lower is better because we have a meta analysis of randomized controlled trials that prove it (search for "Association Between Baseline LDL-C Level and Total and Cardiovascular Mortality After LDL-C Lowering: A Systematic Review and Meta-analysis").
I wanna go for a blood work, what are the best markers I should go for? Please. Thank you guys
I wouldn't say best, but we want to be as comprehensive as possible. Starting with a standard chemistry panel + CBS ($35USD) is a great place to start, as it covers many systems.
@@conqueragingordietrying1797 thanks for the reply, I live in Italy so it might be different a bit, should I ask for liver enzymes, cholesterol panel, HbA1c ? Or something more thanks for your patience.
Ask for lipid panel, comprehensive metabolic panel, Kidney function, Liver function test, Uric acid and ratios…A1C, CRP, Vit D, TSH, may be testosterone and stuff….
No worries@@artaxerxes811, I'm happy to help!
Everything on this list:
www.lifeextension.com/lab-testing/itemlc381822/chemistry-panel-complete-blood-count-cbc-blood-test
If you had one choice what would you like optimized, your lipid panel or your hgb a1c?
Ha, I'm not a fan of the 1 choice approach, but if I did, it wouldn't be the blood biomarkers, it would be CR, which in my case may be the most important factor. Also consistent exercise training (2 choices!)...
But, that's too simplistic (for me)...
Losing weight often lowers A1C, and it may not matter what kind of diet it is, as long as there is reasonable fat loss, assuming they had excess fat to begin with. When someone is skinny and has elevated A1C, they probably need medication.
Michael, maybe review the issue of these puzzling U shaped curves with Dr. Gil Carvalho MD PhD ("Nutrition Made Simple" RUclips Channel). His June 26th video on the U shaped Cholesterol curve, "Cholesterol & Risk of Death", illustrates the problem of some U-Shaped curves bby first discussing the cholesterol curve which showed optimum at about 230, which is clearly wrong, but also touches on misleading U shaped curves for BMI, BP, and HbA1c At this point I am not willing to buy into the notion that my 4.8 to 5.0 HbA1cs are on par, or worse than prediabetic values, 5.7 to 6.5%. Similar studies have shown that BMI of 26 is better than 22, later shown to be faulty, and blood pressure being optimum in the hypertension range, another flawed curve.
Hey Peter, for TC (and LDL), that video is in the works. Here's a recently published paper that I'll cover, which goes beyond all the currently published studies for TC and ACM risk by adjusting for almost all co-morbidities, which aren't completely covered in other studies:
www.ahajournals.org/doi/10.1161/JAHA.123.030496
In terms of HbA1c, < 5 might be a problem if liver markers are also suboptiimal. I'd bet that liver dysfunction-->impaired gluconeogenesis would be a part of the low HbA1c story, but I haven't found any papers on that, yet.
In terms of BMI, higher is not better in my case, as much of my biomarker data has improved as BMI has moved away from 26 towards 22. That said, could someone have youthful biomarkers with a BMI at 26? Definitely.
@@conqueragingordietrying1797 Thanks for extremely fast response. I guess I was just bringing up the entire of issue U shaped curves (for a number of parameters) which seem to be at odds with other information. In my case, AST and ALT are in low 20s. Last GGT was good. I usually have HbA1c around 5 to 5.2 but when i took extra care with simple carbs for a while I drop a little below 5%. If I fall off the wagon a bit my HbA1c creeps up a little, but according to the curve shown in this video would be optimum vs were I was. I think you would find the same. On BMI, hope I wasn't confusing. Am not advocating BMI of 26 or thereabouts, just pointing out there were studies that suggested that based on U curve bottoming out around 26. I later saw a plausible deconstruction in which sicker people (and Smolers) were taken out and optimum BMI came in around 21. I don't track food like you do, but have done enough blood work and pay enough attention to my diet to know how they correlate and 5% plus or minus 0.2 is where I settle although
Aren't you inferring causation from association?
Numerous factors may falsely elevate or lower HbA1c, including anaemia, iron deficiency, renal failure and pregnancy.
Hi @tomgoff7887, where did I infer causation? I'm always clear about correlations and associations not being causation.
@@conqueragingordietrying1797 Well, if you are suggesting that optimal levels can be identified from observational studies, isn't there an implication there?
I thought the lower the better 🙁
Im 40 yrs old male with 4.7
My hba1c is 4.3. Is it too low?
Based on the data in the video, potentially yes. What do your liver markers look like? AST, ALT, GGT, Albumin, alkaline phosphatase, bilirubin, even BUN
It does nt necessarily mean that your glucose is too low, whatever that could mean. Hba1c is dependent on the time glucose+fructose can act on the Hb. Meaning, it could point to an irregularity in the turnover of your RBC, up to hidden bleeding. If that is ok, and your glucose -fasting, after std. meal - is at the same spot or even higher than your "average", then you have a perfect protection against glycation of Hb. It depends also a lot on food and feeding style
I cannot agree with your conclusions. I hope critical feedback is still welcome though.
"We want to be closer to 5% but not below 5, as that was associated with a higher all-cause mortality" incidence. (With all due respect, that is not risk, especially with both higher and lower %s leading to increase in incidence). But back to the point: The number "5" was a "random" value cuttof. They picked those nice round numbers, 5 , 6, 6.5, 7, based on what? We would need to repeat calculation for 5.1% and 5.3% and so on to see where the real inflexion point lays.
But it's all irrelevant because nor diet, (i.e. fat intake) nor body or visceral fat are taken into acount . The meta-analysis does contain the words fat, obesity or adipose even once! There are others which do.
Instead they tried to extract data considering the following criteria: populations with diabetes or without diabetes, including subjects without known diabetes and even diabetes diagnosis
criteria.
So what I see is cherry-picking and cherry-slicing - if you get my drift.
They even say, "Publication bias cannot be disregarded because,
although 74 studies met the inclusion criteria, only
46 were considered for our pooled estimates, since
the other 28 reported their results using HbA1c
levels not comparable to those of the studies
included in the meta-analysis"
So what's optimal then?
also another issue is that there's a whole lot of different between 4.9 and 0.0@@conqueragingordietrying1797
or in this case sub-4
So you're saying you're not in the optimal range? Give us the honest answer. I agree it could very well be reverse causality etc.
Being right on the optimal range of course biases me to believe or want to believe the meta-analysis.
I agree, they could have used restricted splines to address the question of what's optimal. The fact they didn't account for confounders is a limitation of the meta analysis (which is common for meta analysis). You could probably go through the studies and see what adjustments were made.
I think I remember reading somewhere that Hba1c is not that useful as a biomarker. Anyone knows more about that? Should we maybe rather rely on continuous glucose monitoring?
It is useful for most people. Some people have a longer or shorter lived red blood cells, so for such cohorts, it may be misleading. A CGM will estimate your A1C, so you can compare that to your blood test to see if they are in the same ball park.
But so you think that the lower than 5% hba1c risk population had lower hbawc because of an underlying health condition or poor dietary intake in terms of amount eg. Older people and the sick people have reduced appetite.
I wonder if lower than 5% hba1c from a low carb wholefood diet would show shame results?
Levels Health App has a good blog on this with data and research
My bet would be on reverse causation-then, figuring out if one's low HbA1c is because of poor health (most likely liver function) would be on the agenda.
I'm not sure if low carb consistently = HbA1c < 5%-there are more variables that impact insulin sensitivity besides carbs, including fiber intake.
Does that mean you need to lower strawberry and banana intake? :/
Why do you think that?
@@conqueragingordietrying1797 they are the higher in sugar content doesn’t that throw off hbA1c?
The more important thing is to stay in range imo, no higher than 140mg/dl at any given time.
anything above 110..120 causes trouble and will trigger repair
@@monnoo8221 Got a source for that?
The meta-analysis compares 3 different RANDOM ranges to each other. The claim that the 5% point is a meaningful point CANNOT be made.
I got over 2 minutes of an ad for a 4-minute video. I did not watch it, Michael.
Hi Diogo, I can't control the ads-that's up to YT, but I do offer ad-free videos on Patreon...