#553 T1D Mom is a CDCES

October 4, 2021Scott Benner

Drew is a D-Mom who has become a CDCES.

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Scott Benner 0:00
Hello friends, and welcome to Episode 553 of the Juicebox Podcast.

Today we're gonna be talking with Drew. She has a newly minted CDC he acid the end of her name. She's a mom of three, and the mother of a child with Type One Diabetes. You're gonna enjoy our conversation if you don't, for money back guarantee. While you're listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan. or becoming bold with insulin.

I'm way ahead of the music here. Oh, jeez, way ahead. I need to fill this time. Yeah, Hey, take the survey for the T one D exchange please if you're a US citizen, or a US citizen who is the caregiver of a child with type one. Anyway, if you have type one diabetes, and you're from America, T one d exchange.org. Ford slash juice box, fill out the survey help people living with type one diabetes, and support the podcast. That's it. I'm gonna tell you about the advertisers here in a second, and then we're gonna get right to drew

this episode of The Juicebox Podcast is sponsored by the Dexcom g six continuous glucose monitor. Head over to dexcom.com Ford slash juice box to learn more where to get started today. The podcast is also sponsored by Omni pod makers of the Omni pod dash, you may be eligible for a free 30 day trial of the Omni pod dash. Go over and find out at Omni pod.com forward slash juicebox.

Drew 2:01
Hi, everyone, my name is Drew. I'm married. I have three boys. It's my oldest son, that is my type one. I work as a nurse practitioner in a busy maternal fetal medicine clinic. And I'm newly certified as a CDE or now known as CDC. He is a certified Diabetes Care and Education Specialist.

Scott Benner 2:28
Oh, I don't understand why they make things more difficult. But that's interesting enough. I mean, honestly, what did you just say? A c, d c e s?

Drew 2:37
Yes. That's now the term instead of CTE CTE is now the old lingo. But I still use it because I like simplicity as well.

Scott Benner 2:47
Yeah. I told Jenny that one day and she's like, I'm a CD. And I was like, Okay. I could argue with it. I so Okay, so I, before we started recording, I told you that I had the worst time trying to find our correspondence and didn't do well, finding it. But as you're saying what you're saying it's coming back to me. So let's start with reminding the host why you came on the show?

Drew 3:11
Yes. So on your Facebook site, you had asked for people to message you if they were working on getting their CDE or had just obtained it, remember and wanted someone on the show. And so my husband is the one that emailed posing as me saying yes, I'll come on. I'm a new CD. So that's why I'm here.

Scott Benner 3:39
Drew, how many people do you think I'm corresponding with who aren't really who they say they are?

Drew 3:44
Oh, maybe if they're like, my husband,

Scott Benner 3:48
was he? Was he just like, Did he say Joseph jewel definitely want to do this? I'll just send this out there, or was he trying to prod you into doing it?

Drew 3:58
No, he said to himself, Oh, she definitely needs to do this. I'm gonna sign her up. She'll do it. And I don't like public speaking or speaking in group. So he probably knew I wouldn't do it on my own. But with a nudge and backed in a corner, I would

Scott Benner 4:16
love that. I love that you're here. I'm not certain how I feel about your husband's manipulation. And but I but at the moment, you're just talking to one person, so you're doing really well. Okay, thank you. Yeah, it's like we're on the phone. You and I are girlfriends. And now we're going to talk about what it was like to do everything. So let's get a little background first. So you're a D Mom, how long have you been How old was your oldest son when he was diagnosed?

Drew 4:42
He was diagnosed two years ago at 11. And now he's 13.

Scott Benner 4:47
Okay. And two years ago when he was 11 What did you do for a living?

Drew 4:53
I was a nurse practitioner. I have always worked in a ob Jen clinics. But at that time two years ago, I was in an anesthesia pre op clinic so I was still touching diabetics. I'm not as in as big a way as I do now. But if people would come in for surgery, I would tell them what to do with their devices or what they needed to do to change their insulin to be ready for surgery day. Okay, so that's what I was doing. When my son was diagnosed. Gotcha.

Scott Benner 5:29
not to get too far off the topic real quickly. But as you're talking I'm realizing besides Drew Barrymore, I don't think I know another woman named drew except for you now. Is it? Okay good. I feel special. Yeah, well, yeah. Is there is it a name that I'm just I don't recognize as like are there like a lot of famous Drew's that I would know when I just don't know. We're not really.

Drew 5:51
Um, I have never met another girl named Drew. So I always say, My name is Drew like Drew Barrymore. And everyone wants me to say, is that short for for Drusilla? Or another name, which Drusilla sounds horrible. So thankfully, it's not as

Scott Benner 6:08
true. So

Drew 6:11
yeah, that's a name. But it's not mine. So we're good.

Scott Benner 6:15
I don't want to come down on any drusillas but that makes me think of Godzilla, just in case you're looking for an insight into my mind there. Yeah, Drew's not so was it? Is it like one of those like Arden's and androgynous named like there are only that when we named Arden we looked on the registry for the United States there were only nine slightly over 9000 people named Arden in the US, and well over half of them were men. So Wow, I feel like drew might be a similar name like that.

Drew 6:47
I like unique names.

Scott Benner 6:50
My dear. Okay, I'm a I'm a fan okay. So you and I are going to get along swimmingly. So your, your, your son's diagnosed, he told me a little bit about the diagnosis and how it went.

Drew 7:03
Yes. This is one of my like, biggest regrets that I feel like I'm still trying to heal over okay, because, um, leading up to his diagnosis, he's 11. He's independent. I'm not watching him get his own water or go to the bathroom, right? And his complaints are abdominal pain. That's all he could say My stomach hurts. My stomach hurts. And I was watching him lose weight, but he was also active. So I felt like I was brushing that off looking back to easily brushing that off. And then it got bad, quick, right as he's going into DK a. It was the week of Christmas. And there are lots of activities at school, and he was so excited for them. And one morning before school, he comes to me crying, and he hadn't cried before over his stomach. And he's like, My stomach's really bad today. And he's crying. And I hugged him. And I felt like I was hugging a skeleton. And I my son's name is Ethan. And I said, Ethan, you're so skinny, what's happening? And I had him get on my scale, before I even realized that he lost 20 pounds, which is crazy. He went from 86 to 66 pounds. And he said, but I'm okay. I really want to go to school because there's activities at school for Christmas week. And holiday week. And so stupid Moo, let him go to school. I went to work. I call this doctor right away. And he said, Oh, yeah, get him into me. And I said, Great. So my husband is the one that picked him up from school and took him to the doctor because I'm at work. And the doctor didn't know what it was. And I wasn't using my brain either, I guess, and did labs and said, Okay, these labs will come back tomorrow. Is it there overnight, and so I get home from work that day. And I just, of course, feel sick about it. Like, he's going into DK he's very sick, right? I so I keep asking my husband over and over What did the doctor say? And my husband just kept repeating. He doesn't know we got to wait for the labs tomorrow. We've got to wait till tomorrow. I'm like, okay, and I just remember I didn't sleep. I stared at him all night. We sent him to bed and I was like, wait, I don't feel good about that. So I made him sleep with me. My 11 year old son slept with me. And I watched him go to the bathroom seven times that night. And I was like, What in the world And I knew right then I was like he has diabetes.

Scott Benner 10:03
I and as I'm getting older, I've got to be losing testosterone because you almost made me cry twice while you were saying that and I've heard these stories so many times I thought I was immune to it. Oh, my God, you. I'm sorry. That's terrible.

Drew 10:18
hugging a skeleton was like the worst thing

Scott Benner 10:21
ever. It was just not me. You told me how much he lost him. My eyes filled up and I was like, Am I gonna cry? Like we've only been doing this for nine minutes. And Drew's got a boy's name. I should be okay. But I wasn't. It's not a boy's name. You're gonna make me cry. It's just gonna happen again during this hour. Be careful.

Drew 10:40
I hope it's happy from here on out. Oh, my gosh, in the morning,

Scott Benner 10:45
I'm bed wash Good God, you you made it overnight? Or did you just like take him right then in there?

Drew 10:50
No, so still stupid me. I I we wait until the morning. And essentially, we take him in the morning. And of course, he has type one. And I remember getting there and like watching him come to life with just IV fluids, right? Because he's so massively dehydrated, and then keep coming to life with insulin. But I remember the doctors coming because you know, in my brain, I've already figured it out. I figured it out last night watching and pee a million times. The doctors come in, and they're like, you know, I'm sorry, this is what's going on. He has type one. And I remember smiling and saying like, thank God, like, there's, I'm familiar with this disease. And I know he can live with it and thrive with it still, and he's gonna make it like he doesn't have cancer. And a death sentence is where I was in that moment. So yeah, I was thrilled. And they're like, looking at me, like, do you really understand what we're saying? And I'm like, I do I do. And I'm, thank you.

Scott Benner 12:00
No kidding. Well, I guess good that, you know, right? Like, because to be, this is gonna sound strange, I guess it's good that you need to be grateful that it could have been other things. You know, because that does give you some instant perspective, that, that some people might lack in that moment. Okay, so I'm gonna, I want to say first, and I'm certainly not in charge of making you feel better. But you know, these things, they happen so gradually, that even people who understand what's happening, don't say it. And, you know, you have to really think back to when, you know, a friend or yourself is lost 10 pounds, and they come up to you, and they're like, hey, and they're gonna stand in front of you, like, waiting for you to say, Wow, you look great. You know, and nobody ever notices. And nobody ever notices when you live with somebody, they don't notice, if you gain weight, they don't notice if you lose weight, they, you know, I've had, you know, I had trouble with iron that that made me, you know, just my personality completely changed. And the people around me could finally see it. But it had to get pretty obvious first, and I couldn't tell what was happening. It's that it's that incremental change, like when it happens quickly, you're like, Oh, I just broke my arm. This is obvious. But the rest of the stuff, just your body does such a good job of trying to keep you alive while it's slipping away from its whenever it's balanced point is that, you know, it's just really difficult to see. So I hope you don't torture yourself much longer over this. Although is the torture? Did it make you want to help other people with diabetes? Like how did you At what point in this process do you say to yourself, I'm going to go back to school, get more education become a CDE that is now a CD and a couple of other letters?

Drew 13:56
Absolutely, my son played a big part in that. And I ended up transferring to another department a month after he was diagnosed, which is where I am right now, in maternal fetal medicine. So we do very high risk pregnancies. Everybody's coming in with a diagnosis. And because it's so high risk, at least half of my population has some form of diabetes. So yes, that with work and my son, I knew I needed to have I couldn't get enough education. I wanted more education to be able to take care of everyone better.

Scott Benner 14:47
Are you just a caregiver at heart? Have you always sort of felt like that?

Drew 14:53
Yes, I knew from a very young age that I wanted to go into nursing. So it's a good fit.

Scott Benner 14:58
Yeah, even personally. Though like, do you find yourself? Are you consumed with making sure everybody's Okay, not just health wise, but I have that it's a burden sometimes, like, somebody looks unhappy, or, you know, they're having an issue and it feels like my issue that I'm pretty sure I'm going to die soon from the stress. But But I don't know. I'm not sure if that, do you feel like that like somebody has a problem at school and now that's in the back of your head, and someone else has a problem with a friend, and that's the back of your head and you kind of just you're keeping track of everyone's level of, I don't know, contentment?

Drew 15:36
Yes, I do have that caregiver role in and burden sometimes Yes,

Scott Benner 15:40
it sucks. I mean, it's nice for them, but they don't appreciate it. That's the part that sucks worse. Like, at least at least, at least if you do it you like you think once in a while, someone might look up and go, Hey, thank you. But that doesn't never almost ever happen. And not that I'm doing it for somebody to say thank you to me. But it would make it easier if I thought someone was noticing it. But I guess that's sort of the job, right? Is the you just sort of quietly nudging people in the right direction and saying things that make them kind of pay attention to the stuff you think like, oh, like, look over here, this is important to maybe that is just the job. And then you get to sit around the rest of your life when you're really old and be bitter, or happy? I guess no. I mean, you're gonna pick one, like, I'm going for happy, I'm going for Look how well everyone's doing. I had a hand in this, that makes me happy. But I've met a couple of ladies, and I have to throw myself in this because I'm basically a mom, that, you know, they just they're like, ah, they spend their older years just like now I'm by myself. And that kid's got the fruits of all my labor. I'm trying not to be that person. I don't think I am. But I've seen it happen. Okay, so you're a lovely person who's trying to help people. Now, don't you 100% Welcome. You're on the show, because a lot of people contacted me and said that they wanted to know what the pathway was like to becoming a CD. And I didn't really know. And you are uniquely qualified to take us through that journey. A because you've done it but more maybe because you've done it more recently, too. So at that moment, you're in your nurse practitioner, and you decide I want to be a CD because you back then you thought that's what they were called. And what did you do next? Like what are the steps you had to take?

Drew 17:24
So I looked at the website to see if I was qualified. And it did show that it it's somewhat easier to get qualified if you're already a nurse or a dietitian. That's usually the easiest pathway. There's other qualifiers there's even a unique qualifiers pathway, which I don't really know anything about that. But me being a nurse already made it very easy. Okay, especially with having diabetes experience.

Scott Benner 17:57
So your your initial education and work life made you a good candidate, and what and what was your initial? Like, what did you do? Like, what did you go to college for? And how did you pull your career together?

Drew 18:14
I have my bachelor's degree in nursing, and then I also got my master's degree. So that's how I'm a nurse practitioner. And the qualifications, if I'm remembering correctly, correctly, we're having a bachelor's degree, and then being a nurse or a dietitian or a list of other things, but those those two are the most common. And then you also it's not simply having that you also have to prove that you've been involved in diabetes education, and then also have continuing education and diabetes.

Scott Benner 18:54
And so alright, so if I'm coming out of like high school, and I'm going to college and I want to do this, become a dietitian, is one way and yeah, and then after that, get involved in diabetes care. And be very involved in don't just like blow past somebody with diabetes one time to go, Hey, you have diabetes, I've touched you. That's not enough. Like you have to be involved in diabetes care. And then you had to get into a program to become a CDE. And how long are those programs?

Drew 19:30
So I took a nine week class to prep me for the CDE exam. So that's the only thing I lacked in order to qualify to take the exam, okay, because I had the the bachelor's degree, I had the diabetes education. So it was a nine week class, which I did welcome because I had experience on type one. I had experience and gestational diabetes, but I really lacked a lot of the type two. So I felt like I needed that to really be able to pass this exam. So it was a valuable and eye opening class.

Scott Benner 20:15
Okay, so yeah, and I'm googling so it looks like there's something called. Well, there's diabetes educator.org, there's cbdc e.org. There's a couple things that pop up when you Google, a CDE exam. And the practice tests and so yeah, you say you took a nine week. So you basically, for a CD, you had an IU and an MCAT coming up. And you you took a crash course a nine week course to take that test? Correct? Yes. And that was really valuable for you.

Drew 20:48
It was valuable in helping me with the type two stuff that I was lacking. But the other value piece in it was being able to participate with other classmates and discussion posts every week, and seeing the absurd things they posted. About like type one, and just the misunderstandings that you and I are already familiar with.

Scott Benner 21:17
Let me ask you a question. And I'm not looking for smoke to be blown anywhere. I genuinely want to use this as a measuring stick. I barely got through high school. I have no college to speak of. If I took the CD, E, E, C, D, E, what do they call it now? c d, e e s, right? If I took the CD? What? If I took the damn test? Obviously, I'm How would I do on it? Do you think you listen to the podcast? How would I make out?

Drew 21:54
I think you would do well.

Scott Benner 21:56
Like pass it. Maybe Really? Keep in mind, I can't remember what they call it anymore. And you've told me five times. So it's possible I have the recollection of a gnat. But I mean, like, Is it is it basically like stuff that you learn? Taking care of someone with diabetes? Or having it? And then there's that extra level of nursing stuff that I would obviously not know anything about? I don't think but is that the mix? Or is it more just like diabetes related facts?

Drew 22:33
You know, a lot. And if you're a good test taker, you would probably pass just using simple that action. But it's, it's insulin, right? What we already know, it's nutrition, and counting carbs and exercise and behavior techniques. And there's type two stuff in there, like the oral medications that I really had to brush up on gotcha,

Scott Benner 23:02
I want to be clear, I have no intention of becoming a nurse, a dietitian or a CDC in a couple of extra letters. That's not going to happen. But I just was wondering, like the level of what was in the test, like I'm not obviously asking you to tell everybody what's in the test. But I was just curious that if it's something that's like super technical that even like a person like me would just get in there be like, I don't know any of this, or if it is more nuts and bolts stuff about diabetes, and you answer that question. So thank you very much. So now Okay, so you take the test, you pass, which congratulations. And then what's next is to find a job.

Drew 23:40
No, I stayed in my role. So I'm still in the same role. I'm still functioning as a nurse practitioner in my maternal fetal medicine clinic. Because our clinic is so high risk, we have different champions in our clinic. So some specialize in cancer related to pregnancies, some in blood disorders, and we also have a diabetes champion. So the results already a physician that was considered a diabetes champion, so I've kind of come on board as a diabetes champion in my clinic.

Scott Benner 24:23
Okay, and now that gives you time with people with diabetes to so now you're touching more people with diabetes? Do you have to build up hours then? What do you just have to keep a certain number of hours like every year, how does that all work?

Drew 24:37
To maintain my certification? Yes. I have to continue to touch diabetes, like providing education, and I have to continue to get continuing education hours so with at least half of my patients having diabetes I'm I'm eating Like getting that requirement.

Scott Benner 25:02
And it's not. It's gonna sound crazy, but you can't get like bonus points for having a kid with type one, right?

Drew 25:12
Sometimes I use that to my advantage. I feel like more of an expert when I live with it day and night,

Unknown Speaker 25:18
I would think that you would

Scott Benner 25:21
be more immersed at home. But I don't know. But it's just the way I imagined when you run into people in a work environment. You're seeing them for how long? Right? A few minutes, half hour? If you're lucky,

Drew 25:34
and minutes, Max.

Scott Benner 25:37
Okay. So what's the um, so knowing what it's like at home, and knowing what it's like in a work environment? what's lacking in the work environment? Like Where could that be improved for people? I know that's not a question you might have been ready for.

Drew 26:01
I feel like overall, I work in an educational institution. So I work with very smart people. But even the smart people I work with, don't understand the full scope of type one, because it's so big. And like we all talk about, unless you're an endocrinologist, you get one paragraph on type one diabetes in school. Right? And so I can come home every day, and tell my husband, can you believe this happened? Can you believe that habit, I can complain about at least one thing every day, even in saying that, I still think I work in a pretty good place. And so I take those little instances of Oh, my gosh, I can't believe this happened. And I'm trying to make change in my work environment, like providing more education to the staff, to the patients, to the community to just improve care and improve awareness. Yeah,

Scott Benner 27:13
I would imagine I'm sorry, I would think that, um, the issue would be that even if you, even if you do that, if you just find better and better ways of helping people, it still happens in a room with the door closed and nobody else sees it. So the only thing that's going to happen is you become the popular CD. Because people it gets around that, you know, it goes well with you. But But the people you work with don't get to know why. And that's, I don't know, like I realized that you can't it just feels frustrating. I don't know if I'm misunderstanding, but I just yeah, you don't I mean, like if you do great, that's amazing. You do great with the people who you are with, but that that message doesn't expand for some reason.

Drew 27:58
I'm trying to work on that expansion. So for example, this month, I am giving a lecture to my fellow nurse practitioners that I work with on something simple, like CGM. I'm doing CGM. And so I'm trying to get them more comfortable with it, with reading it with understanding it. So they can be more comfortable with then recommending it, reading it giving recommendations having discussions with patients. So I'm trying to, to broaden my knowledge. I'm trying to give it to other people.

Scott Benner 28:38
Yeah, well, that's lovely. I just, you know, the other day, I had to run out to pick something up. And I got a message from a person through social media person I didn't know they asked me a question. And I found myself thinking, I have a 10 minute ride home. I can talk to this person for nine minutes, right? So I get on the phone, I asked her a couple of quick questions, we have a nice chat. At the end of the chat. The person says to me, this is the most comfortable I've been talking to anybody about Type One Diabetes since my kids been diagnosed. And they were talking about their doctors like, and I just got off the phone. Like I was grateful that he felt good about it. And I'm hopeful that I said something that might be valuable to him. But as I got off the phone, I think how can that be true? Like how can a 10 minute conversation with a person leave you for the first time feeling good? Because I didn't tell him that much. I explained a couple of simple ideas and some things to look for. And they kind of gave him a pat on the button. I was like, you know, go get them that kind of thing. Like how is it possible like a physician can't do that? Is it just that they don't live with it? And therefore there's some aspect of it that's lost still to clinical.

Drew 29:55
I agree with that. It is really clinical To them, even the thought of more than just food impacts blood sugar is lost to the majority of providers. Really? Yes,

Scott Benner 30:14
that's terrible. I, I just I get too many notes from people were like, you know, we got diagnosed, and my CD told me to listen to the podcast. And I'm like, imagine if I was a mechanic, okay. And I made my living being a mechanic and you came into me, and you're like, hey, my car doesn't run, right? And I said to you, yeah, I could fix that for you. But instead, why don't you go listen to this podcast that will explain it? That's not even a good idea personally, for the doctors like why why would the doctor not want to be the, the center of where you get great information from? Like, why would they want to farm it out to somebody, like try to imagine being a doctor. And the best option you have for a person is to tell them to go to another source, other than you, but you should be the source. And and how that doesn't make you as the physician go, Oh, hell, I should stop sending them to listen to the podcast, maybe I should listen to it like, well, I don't know why that doesn't. That is just seems counterintuitive, just on a professional level to me, like diabetes aside of it, like I would want to make myself the kind of mechanic where you were like, you know what, I could probably figure this out on my own. But I'd rather go to Scott, he's the best mechanic I've ever heard in my life. Like, I don't even I can't. Do you understand what I'm saying? And do you have any insight on why that would be?

Drew 31:34
Um, I appreciate having several different lenses and my provider lens is, we have so little time to spend with patients. So why not give these tools for your tool belt? That you can go home and do and spend as much time on as you want to?

Scott Benner 31:54
Okay, I don't I don't not understand that I do. I've just been able to, I don't know, like it's it doesn't take that long to explain it to most people, is the thing that throws me off. I think I think in a 20 minute, I believe that in 20 minutes, if you came into a room, and 20 minutes later, I could let you leave with enough information where you'd feel a little emboldened. And you could kind of safely make some changes for yourself and find a better place. But but that's the truth is is that that doesn't exist is overtly why the podcast has the popularity that it has, like if that existed for most people, I'd be talking to myself, because no one would need this, they wouldn't come here. And I don't know that I don't I'm not trying to put myself out of business. But I guess I kind of am like I would write I'd rather see people feel well, and confident and actually be healthy than to be lost. So much so that they're looking for I mean, really think about what we're saying through a podcast, like, imagine a health scenario where you're like, Well, let me go hunt down a stranger who has access to the internet and a microphone like that. So it's a pretty big drop, don't you think? Or at least it should be. But apparently it's an elevation and even That's weird. And for the providers listening in at this point. There are a lot of providers listening to this podcast, I know because I can, because of how much correspondence I get from people are like, hey, my doctor told me to listen to this, they listened to it, or the notes that, you know, I just got one the other day that said, the doctor kind of like looked at me and said, You listened anything to help you with this. It was like that. And the person goes, Yeah, maybe podcast, the guy goes juice box. And then the patient says, Yeah, and then doctors I listened to I mean, what are we doing? Like, you know, like, at some point like install like stop pretending and just get in on it. Like if you're a provider, and you're listening to this tell people this stuff, don't send them well. Let me stop myself send them back to me Still I need the downloads, but like you could be telling them to and you know, and a lot more people than I could reach. So I don't know it's the whole thing is very frustrating to me. And I don't want to get you in trouble with where you work because it sounds like you work at a great place. But those were frustrations kind of exist everywhere. No matter the level of quality institution that you reach. It seems like unless you get that special endo or that special CD who has it and knows how to talk about it.

Drew 34:37
True.

Scott Benner 34:40
This is this. I don't know you told me you're

Drew 34:42
the same frustration.

Scott Benner 34:43
You told me you weren't gonna make me sad anymore.

Drew 34:48
Well, I'm trying to make a difference where I

Scott Benner 34:50
live. Okay, so So let's do that for people then. What do you think? The answer is on the patient side do they need They come in armed with the correct questions, or do you think they really do need to go find other tools, and the doctor is a place where they check your blood work and write your prescriptions.

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And I don't mean that in a bad way actually. No, that might sound like I do but I don't like

Drew 39:28
I cannot be all the above. Yeah, I feel like you can make diabetes simple, right? Give them the basic tools, but it can also really be vast, there's a lot of it and I feel like diabetes humbles me every day because I'm learning something new. Like there's so much it has so many legs and arms. So I think both like for the basics At the very least those questions and need should hopefully be fulfilled by the provider. But there's also great tools like your podcast where you go into so many different things. And I love even beyond the treatment and management that you engineered cover just speaking with individual people and hearing the different perspectives, because even that is valuable, too.

Scott Benner 40:34
Yeah. And that's obviously something you can't get from a provider that I think is a big piece of this. I'm not coming down on people, like I just it is, it's obviously the way it is. And I'm trying to figure out if it just has to be this way, and outside tools or just an obvious need. Or if there's a way that a provider can be more like, let me use an example from a conversation I had recently that was private, right? I'll just keep everyone's details out of it. How can a provider of type one diabetes care? Look at a Dexcom graph and see that every night, around 11 o'clock, there's a high blood sugar that results in a low blood sugar at 1.1 am and come to the conclusion that the answer is to lower the basil rate at 1am. Like how can that happen? How could someone not say, Well, obviously, what we need to do is stop that initial spike so that you don't make a correction so that you're not low later at one. How can they say we're going to let all these problems happen in the past, that lead to the spike that lead to the crash. And the only thing we're going to do about it is put a band aid over the crash site so you don't crash too hard. And then that low basil rate causes another high blood sugar overnight. And it just perpetuates and goes on, like how many times do you have to look at that graph before your bank? That's not the answer. Like is it? Is that asking too much of some people?

Drew 42:00
Apparently, because I see that a lot, too. Okay, but that's what I'm hoping to fix.

Scott Benner 42:05
I appreciate that. Are you telling me that it's possible? I'm smarter than I think I am that? Because I think of myself as a moron. Like, maybe that's the problem. Maybe it's my self esteem that's making this problem? I'm sorry, if people are laughing right now. But like, honestly, like, I have that thing inside of me. Like if I can figure this out? I can't imagine who couldn't figure this out. Because it just seems obvious, but maybe it just seems obvious to me. And it's not obvious to people, maybe I need to rethink the way I think about that. Because I just don't, I don't know, you know, it just feels like somebody comes to my house every night throws matches on my patio. And the way I handle it is by having a bucket of water by the front door, instead of putting up a fence. It's a weird analogy, but like, that's how it seems to me, like we're constantly trying to medicate the the end result instead of trying to figure out how to not to get to that result. And that to me is, I mean, if you're a physician, and you're listening to this, and that's what you're telling people like, please stop doing that. Because these people live in just abject anxiety, their entire lives, just waiting for the next bad thing to come instead of feeling empowered to stop the next bad thing from ever happening. And I don't know, it makes me upset now I'm upset. And you're so nice. Dammit. Sorry. No. She's so alright, so are you seeing it? Are you? Are you able to make those kinds of impacts for people? Or do you need to find a new job where you can do it? Are you able to do it where you're at right now.

Drew 43:40
I'm able to do it where I'm at right now. I feel very supported in my role and making an impact. I'm also on committees and hospital wide. So we work on educating patients more and even in the community like school nurses. So I'm in a good role. I am very blessed to be where I'm at.

Scott Benner 44:07
So you brought that up twice now. So institutionally, that is the path to change. Correct? Being a thought leader? Yes. Okay. And how does that happen like you, but how do you go to somebody and say, I think I understand this on a deeper level than the institution does. And I want to be the one to talk to people do you have to prove it first and then do people come find you or do you have to go find them?

Drew 44:35
I'm well supported by my bosses, and they support evidence based practice. So I have to use, of course, ADA and jdrf and a cog and other governing bodies to see what they say but they allow me to make an impact.

Scott Benner 45:00
Are there things you do management Wise With Your son that you can't talk about at work?

Unknown Speaker 45:10
Sometimes,

Drew 45:13
sometimes I bite my tongue, I'm trying to think of a good situation. A lot of times I don't though. One of the most frequent things I see if somebody is low, like, low is in 65. We freak out, and we give them like 45 carbs or something insane. And every time I'm like, What are you guys doing? Oh my gosh, stop giving them a buffet of food.

Scott Benner 45:44
See, I say 65. Drew. And I think that's 15 points from being perfect.

Unknown Speaker 45:50
Like, right, that's how I

Drew 45:51
see five and stable. I'm like, well, who?

Scott Benner 45:55
Even that right, you're like, oh, man, I'll just nudge this up a little bit and get back to work. I will. Obviously that's we're in agreement about that. But it's, it's how it strikes people. That's the problem. They see it and they can't diagnosis, diagnose it as Look, this is a stable 65. This is not an emergency, but then they treat it like it's an emergency. Like, if you were 65, and your CGM had an arrow down, I'd be all for eating 45 carbs, because I wouldn't know what to do either in that scenario, but till, especially with the technology to be able to look at it and go, Well, this is a very stable blood sugar. I mean, the first thing I would do is just I would double check it with a finger stick. And then I'd be like, Alright, you know, really is 65 maybe have four carbs here. Let's see if we can't just turn this into a 75 and stable. But I was just wondering if there was actual rules, I guess is the word I'm just simple word I'm looking for that would stop you from saying something like this, somebody like is they're just like, Look, you're 65 feed them. That's what we do here. And but then why not explain the rest of them the difference between stable and falling? And I don't get why that that next sentence, like I find that most problems in life, is because we don't talk about what comes next. We don't say okay, well, this is 65. But it was 65 and following. So you treat it this way versus 65 and stable that you would treat this way. Like why not just go to that little extra effort? Is it because they don't know it? Because it's not laziness, right? Like, there's not a CD standing in front of me that goes, I understand this. Just don't feel like telling it to you. That's not the case. Right?

Drew 47:31
Right. In those moments I'm educating. It's like, Okay, now we're going to have some rebound. hyperglycemia Are you going to be around when she's 250? after this? It's just, I guess, hard to educate everybody unless you're getting them all together. And it's a more formal event. Because just because I tell Mary Sue, doesn't mean Mary Beth over here is going to realize it and she'll do it again, the next person that comes across so.

Scott Benner 48:04
So where do you make the line between the people who are never going to get it, and the people who don't have the opportunity to get it because nobody will explain it to them. Like, I've been very clear on the podcast, I don't think that like least common denominator teachings a good idea. I don't understand. In a classroom of 20 people with two kids who are going to struggle no matter what three kids, we're gonna need a lot of extra help, you know, 510 kids in the middle, we're pretty average, we're gonna do average, and then there's these five or 10, these five at the top who are getting, like we're ready for, like deeper understanding, and we never delivered to them for the fear of leaving the bottom five behind, I'm not into that I, I think you can help everybody, I think there's a way to give the top of the class, the information that they can absorb while helping the bottom, you know, who might take it up more slowly or not understand everything that's being said, there's a way to help everybody. But I feel like that everything gets just least common denominator. And that leaves a lot of people in confusion. And though and the way I see that confusion, when I talk to people is that they can imagine there something else they should be doing. But because the information they're getting is limiting. It feels like they're breaking some sort of a rule if they even try to follow their own common sense. I know I'm asking a lot of questions that don't have answers, but I'm interested in what you think.

Drew 49:33
I feel like I need to become an educator. Next. I need some more education on educating. Yes, that's really tricky. Tell me the answer to that. How do you educate everybody that when they're all on a different level,

Scott Benner 49:53
I think you have to be so my personal experience by talking from talking to people privately They think you have to be a great HR person, you have to have that like that immediate feel for like the person I'm talking to can take middle ground information, the person I'm talking to can take high end information, the person I can talk to is going to do a little more hand holding. And I make no judgments about any of those people. It's just that they all deserve a different entree into the information. So you as the person who understands it, need to understand who you're talking to quickly, and you can, you can kind of ascertain that by asking some questions, getting a vibe for the response, seeing you know, where, where their level is, sometimes people's frustration is a great way to measure them. So if they're frustrated that they believe there's more, they are more high performers who are looking for better information. And if they're frustrated, because everything feels random, and it's out of control, then those are people who don't even have this simple tools down the understanding of having a good basil rate, how to Pre-Bolus how to understand the impacts of different foods, like the simple stuff that once you get creates the ability, once you create stability, things seem less random, when they seem less random, you can feel more in control of them. So on and so forth, then it builds. So I think it's up to you to accurately and kind of quickly figure out who it is you're talking to.

Drew 51:29
Yes. And it's that's easy to do when talking to patients, and you're one on one, for sure. A harder to do on a larger scale when you're worried about educating all the nurses on this unit,

Scott Benner 51:43
right? To be able to talk the same way to everybody. Yes. So like in my, in my dream situation around this. I don't know where you work. And we're certainly not asking, but I would, I would love to come and talk to the educators and say to them, this is how I've reached people with this information. And this may be something here would help you. Because I would be amazing, right. And I think that's a great idea. Because for whatever reason, there's something about my tone, and tenor and vibe that it seems to work across levels. And I think that's where if you're looking for like, like deep down, things I'm proud of about the podcast, it's that it's that I didn't have to pick a certain person, a certain type of person go, I'm only going to help these people here. Like what I'm going to say is only going to be valuable for these people. Like I wanted to find a way to say it. So it was valuable for everybody. And even the people that you might think of as higher performers in this scenario. They benefit from having basic information that's tangible and easy to digest and understand and put back into practice. It just gives everybody needs that easy basis to start from. You don't have to start with the big words. And you know, like, for instance, this is a great example. You think this podcast is pretty helpful. I can't Okay, I can't pronounce that word that means after meal spike, what is it post? prade?

Unknown Speaker 53:09
postpresidential?

Scott Benner 53:10
Yeah, I don't know that word.

Drew 53:16
That's in my basic vocab?

Scott Benner 53:18
Yeah, I don't know, nor do I care about that word. It doesn't matter to me, like making things seem fancy or, or like they fit in a business setting. I don't I don't do I don't give a shit about that stuff. Like, I think that there's a simple way to understand this. And everyone can build on that simple understanding whether you're no matter where you are in that class, nobody has to be left behind in this scenario. And the truth is, is that when you start with a very basic concept that's easy to grasp the you know that some people just take it and run with it. And some people just come up to speed gently with it. I've seen it happen for everybody. And it's it's not, it's not attached to intellect either. Because I've seen nurses have children with diabetes, and they can't figure this out. And it's something about the nursing brain, I don't understand completely, but there's like it feels like there's rules and you follow the rules and the rules do the thing. And that's nursing to some level and then you get into diabetes, you're like well sometimes this sometimes that is the 65 stable or is the 65 following you have to get into that minutia. And they're like no, no 65 This is the rule for 65 and it takes them a while to break free of that but they do and so I don't know that anybody can't do it. It just has to has to be delivered in a certain way I had you on to talk myself into believing that this could be done and now I just all I did is talk myself into believing that you need other avenues to get the information from drew Alright. Let's not talk people out of being CDs. You feel like you're helping everyone Do you feel that like, this is a valuable use of your time? And you're happy you did this?

Drew 55:05
Yes, definitely. I'm happy. Well, it

Scott Benner 55:08
sounds to me like you're the exact kind of like foot soldier, we need to put in these scenarios. Seriously. Like, we need more people like you who have a grasp of it, and are coming in motivated, because you don't see this as a job as it's a calling for you. Is that right?

Drew 55:24
Absolutely. Yes. Otherwise, I don't know if I could do diabetes. 24. Seven, but it's, it's my life and passion. And it's, it's a good fit.

Scott Benner 55:34
Let's go. I'm glad of that. Do you ever get home and you've talked about it so much in a day, that you neglect things at home? Because you're tired or?

Unknown Speaker 55:45
Um

Drew 55:47
Yeah, I sometimes I get to that point. But I'm blessed with a good husband, that is an engineer, even though he didn't know anything about healthcare going into this or let alone diabetes. He loves numbers. He loves figuring things out. He likes research. He likes fighting with insurance companies. So he's a good partner in crime, and my son being 13 and lifts his weight as well. So even if I'm exhausted, and I take a timeout from diabetes for the night, my son's going to be fine.

Scott Benner 56:27
That's cool. That's excellent. I mean, I can't imagine that you could do it 24 hours a day, every day. Like at some point, you must be like, no one, say the word Bolus again, I couldn't go into another room. Oh, my God. Yeah, I just I would, I would definitely imagine you need some time away from it for your own sanity. And I was wondering when you say you give talks and stuff like that you talk to other people, when you talk to them afterwards, when you're mingling with people? Does it? Is it striking them? Like do you think it's, you think it's landing? And they're, and they're holding on to it? And what do you think they take from it? What do you think? I guess my question is a person who's doing the job by the book, who comes in and hears from somebody who's like, no, I really think you got to think about this, this and this. Do you think that they can go back and put that into practice? Or do you think it just lays on them as like, oh, there's something I should be doing that I don't know how to do.

Drew 57:24
I think I'm changing the way they practice, what, and mingling with people or talking with them after I give a talk. The response surprises me that they weren't even aware of what I would consider basic information. So I keep having to go back and think, okay, really start with a good foundation. Before I try to go into anything more detailed.

Scott Benner 57:56
In Do you think that's because I think the one aspect of medicine that that laymen don't understand is that medicine is basically built on a foundation of? Well, it might be this, it's most commonly your problem most commonly might be this, let's rule that out. Oh, it wasn't that well, then its next most commonly might be this, we'll try to rule that out. Oh, that was a great answer. You leave. Oh, that wasn't it? Let's go to the next, the third most less likely thing. And that that's all medicine is really is ruling out? What statistically could be the problem based on your symptoms? And yeah, yeah, right. And I don't know that that's something that people understand. I think people think they go to a doctor. And there's an all knowing all seeing shaman sitting in front of them, and you're like, Hey, here's what's up, my belly button looks like this. And I got a gray hair on my left side and look at my pinky stone. And that guy goes, Oh, that's this. And this is how that gets fixed. And that is just not how it works. And that model is not intuitive to managing diabetes. But those are the people that you're sent to. And that is the way they're trained. And so you're looking for those people to either flex, figure it out and learn how to talk to you about it. Or you have to come to the you have to come to the understanding on your own, that there's more information out there, I have to go find it for myself, this is a very well meaning person who's going to give me my prescriptions and check my blood work and tell me where my ranges are. And I think that even though I might have sounded differently a half an hour ago, I guess that the people, the doctors, the windows, were telling you, Hey, this is good information, go find this information. That is really a kindness because maybe maybe you're asking too much for them to fundamentally change how they've been taught. And what they do. I guess that might be fair. There it is. All right. Yeah. Drew what Do I make you I put you in charge, you get a magic wand? You're in charge. What happens? This seems so outside of your personality, you're pregnant pauses are fantastic. But I put you in charge, what's the first thing you do?

Drew 1:00:22
I'm in charge, where I work of the world,

Scott Benner 1:00:24
I put you in charge of the world, you fix the happiness. You fixed all

Drew 1:00:28
that, you're like that I want to be in charge of the world.

Scott Benner 1:00:32
Well, you fix the other stuff, you're down to diabetes in a clinical setting. Like, I think I know what my first step is, what's your first step?

Drew 1:00:39
my foundation would be more time. I think that truly is what limits providers, there's not enough time to sit down with a person and really do the investigation that you were referring to of how did we arrive at this number? How can we fix this? Because that requires time and talking and investigation. So time is the fundamental issue, I think,

Scott Benner 1:01:02
even for providers who, if they had the time wouldn't know what to do?

Drew 1:01:08
Well, my gosh, they should have some education. Maybe with time, though, though, they'll have more education. And no, I don't know,

Scott Benner 1:01:17
I'm hearing a little Midwestern hope in your voice. Am I right about this?

Drew 1:01:21
I'm in the south. Oh, okay.

Scott Benner 1:01:23
That's close enough. You know what I mean? Like that hopefulness that you got to come up to some of my East Coast, like, there's no way anybody's figuring this out, we're gonna tell them what to do. So my first step would be if you put me in charge, my first step would be, I would, I would take a person who could explain it. And I really do mean the basics, the keys to initial success. And I would go to each provider and give them one on one attention, give them the same exact talk, and have them mimic it back to me parrot it back to me. And then they need to sit with a person who understands it. Watch the advice be given and watch the result happen so that they can believe in it. And then you send them off to try it on their own. And I think then

Drew 1:02:09
thankless of medical school, learn one do one, teach one?

Scott Benner 1:02:14
Did I just make something up that I already know?

Drew 1:02:17
Yes, you know how medical school operates? Now, learn one, do one, teach one. That's what you just said.

Scott Benner 1:02:24
I got to be honest with you. I know that from Grey's Anatomy. But that's not where it came from out of my head just now I just, I really thought like, what would I do if I wanted to make a clone? Like, if I wanted to, if I wanted to make another me in the world, what would I do, I would assume that the person I'm talking to doesn't believe that what I'm saying is going to work. So I would explain it to them, then I would show it to them. And then when they could believe in it, I'd like to see them do it once. And then once they get the result back, then it's the same as the person with diabetes, you just need to build up trust in the process. You know, the you need to build up trust the idea that your basil has to be right, here's how you can make it right, you have to Pre-Bolus your meals most of the time, here's how to know 10 carbs, this isn't equal to 10 carbs that don't stare at a high blood sugar. You know, it really is I gave a talk the other maybe two weeks ago online for touch by type one. There's like 125 people in there. And the responses coming back are over and over and over again, the same from people. Which means makes me think that the information strikes people similarly, and all these people are sending graphs, they're like, look how much better things got. And I was like, it's like, there's the part of me it's like, Yeah, well, you know, we put the insulin in the right place and you're doing what you need to do. And then you get what you expect. And now you're on your way. I think that's the process. I just need one anyone listening, I need one hospital to have me come in and talk to everybody. I want to do a pilot program with somebody and prove it out.

Drew 1:03:57
Anybody I'll fly any that will be amazing continental

Scott Benner 1:04:01
United States I don't want to leave the country. Okay. Imagine I'm in like the Czech Republic. talking through through someone is like, you know, taking my words and like I here's what he's talking I have somewhere where people can understand me, I want to try it first day, no one's gonna take me up on it.

Drew 1:04:21
But why I'm gonna I'm gonna work on this

Scott Benner 1:04:24
because I don't know how to say post press

Drew 1:04:28
pranjal

Scott Benner 1:04:29
and I can't remember when the CD turned in. Like, I don't seem like the person you would ask. But I feel I feel an immense amount of confidence around it. Like I would I would love to. I would love to do that. I would love to even like it doesn't have to be everybody in the practice. Like just pick two people and talk to them, get them doing it in a certain way and then watch over six months watch a one sees for their patients over six months. Like I think that would be fascinating and wouldn't say anything, you know, crazy, it's not like I'd be like, Alright, listen, ground up your cinnamon, and then get your essential oils diffuser out, it wouldn't be like that, it would just be like, you know, here's where you use the insulin. And I think this will be valuable and then let people because the truth is, is that people need to see it so they can believe in it so they can build on their own which ends up being the real value of it, which is there at home making decisions that are valuable because as diabetes keeps flexing and changing, you have to know how to move with it, or it'll just overwhelm you again, I mean, I have a hormonal 1617 year old daughter, and I'm going to tell you that if I could go back and talk to the Scott I was five years ago, I'd be whispering in his ear every day, wait until the hormones come. Like I just every day I'd be telling that guy that like Don't, don't sleep on those hormones. It's it's gonna change everything and the only thing that keeps Arden's agency where it is which is now for seven years in the fives is the ability to stay flexible when the impacts change. So

Drew 1:06:06
absolutely that is our life right now. Ethan has grown like six inches in the last year and so we have fun basil names for pump and one of them is growth spurt and we have other stuff so we're constantly changing between basil rates to keep up with what he's going to do that day.

Scott Benner 1:06:26
No kidding No kidding I don't this I don't I could never imagine that that's not the truth. I swear to you It feels sometimes day to day here and you but but it's not I know that might sound crazy to people like oh my god it's gonna change every day I can't do this but you can if you know how to if you know how to look up see what's happening and go okay more basil you know a little more little more push on the meal insulin here like it's and then you see it go back the other way like okay, I'll take the Basal back to where it needs to be it's actually not it's actually very intuitive after a while for me and it's not that intensive with my time or my thought as I thought it was going to be when it started happening you just have to learn to see it as another it's just another variable it's just one you don't see happen because you don't eat the variable that it comes from inside. Right drew? I talked way too much on this one. People are gonna bitch at me like feel it coming.

Drew 1:07:24
I enjoyed talking with you.

Scott Benner 1:07:25
Did you thank you tell the people to leave me alone.

Drew 1:07:30
Oh, no, they're fine. Everyone loves you. True.

Scott Benner 1:07:33
I love I don't know why you're so nice. If I would have booked my wife on a podcast without telling her she would have punched me with an ashtray and we don't even have an ashtray she would have gone back to 1975 gotten a big glass ashtray and come back I hit me you were sweet. Why are you so nice? Let's take my

Drew 1:07:53
chin and visit me at my hospital I'm going to work on this

Scott Benner 1:07:57
Alright, well we'll do that you if you get it, I'll do it. I'm up just you know, but when we stop recording you'll tell me where you're at. But, but first you have to ask me You have to answer my question.

Unknown Speaker 1:08:07
Why are you so nice? I don't know. No, you can't be that nice to say I don't know. pleasant to be nice.

Scott Benner 1:08:17
No, that's not what I mean. Like are you holding a rage inside that you won't let out? And is that through good grooming? like have you were you raised to hold it in? Or do you not feel the rage? Which is it? That's my first question. Do you hold it in or do you not feel it?

Drew 1:08:34
Um, if I'm upset exercises is my outlet. So

Scott Benner 1:08:42
that's a fair statement. I'm gonna pick some were raised to not show anger to people

Drew 1:08:56
that's fair. My mom was always my mom is a very pleasant person. It would never be unhappy in public so I think I got some of that

Scott Benner 1:09:05
but you're not like privately like a raging lunatic like you don't like you won't get off of this and like start kicking your dog or something like that to let it out? Not that anybody should kick their dog no no no no she's not feeling like that burning not at all like I definitely would not kick a dog but the burning like there's no burning like you're like I'm irritated now. Like not at you at the world like these conversations always get me riled up like and so I get I get like oh like I want to do something about it like if you told me right now Scott pack a bag and come here I'm gonna let you talk to these people. I just walked downstairs and be like, I gotta go get like, I don't Yeah, but but but if you got me three days from now and you're like, hey, that I'd be like oh I don't know I don't like traveling. I don't really put right now you've got me. I'm actually warmer now than I was when we started this.

Drew 1:09:58
I saw the first A year after Ethan was diagnosed, I felt like I lived with a grudge on my shoulders. Because when people wouldn't know how to properly treat type ones, it upset me and I would be short with them or correct them in a not so great attitude that I realized that no one's going to come to me asking for better education, I'm not going to impact people, if I get if I live with that, and are so sensitive and upset, because I was very sensitive and was easily accessible for the first year. But now, after that first year, like people don't know they're lacking knowledge, and I need to keep a good attitude so they can really hear me and respect me and be able to come to me, if they have more questions,

Scott Benner 1:10:56
you're the right kind of person or this message that's for certain anyone listening who finds themselves to be like Drew, first of all, congratulations. Secondly, if you're in a position of teaching people with diabetes, I would say this have the nerve to speak up and try to make an impact like if you're in a job right now where you're watching something happen and you just know it's not right but you don't feel like you have a voice there. You know, try try try something to help people because I get to see the other side of it. And when they go home and they leave that practice with no answers, it's a struggle for them 24 hours a day, and it's um, it becomes as impactful emotionally as it is physically and it's just not needed. It's not fair and it's it doesn't need to be that way. So if you have the voice go ahead and speak up. Like drew is and I'm going to keep ranting and raving about it here until until until I get a doctor that comes along and goes I just tell people get your basil right do this do that do this and I tell them how to do it and don't be like God I want that I'm gonna retire done with this alright, Drew I really appreciate you doing this You're very kind

Drew 1:12:07
if you can hold on Thank you for having me on.

Scott Benner 1:12:10
No I was really my pleasure. I didn't know how much I was going to enjoy this talk like I really even that is a weirdness about me like I'm all agitated but I really had a good time talking to you. I don't think people think of things like that mostly but I had a great time even though I'm I'm all jacked up. A huge thank you to drew for coming on the show and sharing her story answering all my questions. Thanks also to Omni pod makers of the AMI pod dash and the Omni pod promise check them out at Omni pod comm forward slash juice box you may be eligible for a free 30 day supply of the Omni pod dash and the Dexcom g six let's not forget them. Dexcom comm forward slash juice box find out the speed and direction that your blood sugar is going see it right there on your phone if you want or using a receiver. Don't forget to fill out that survey at T one d exchange.org. forward slash juicebox. support people with type one diabetes support the Juicebox Podcast.

Thank you so much for listening. I'll be back soon with another episode of the Juicebox Podcast. Hey, don't forget to check out the private Facebook page for the podcast absolutely free to be in 15,000 plus people in it now talking about type one diabetes, management of insulin, all kinds of stuff. You'll find it online on the Facebook. It's Juicebox Podcast, Type One Diabetes