Scott Benner 12/2/20 Scott Benner 12/2/20

#414 Durban Shirley

South Africa Represent

Shirley is a T1 from South Africa and she's here to talk about type 1 diabetes care.

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:07
Hello, friends, and welcome to Episode 414 of the Juicebox Podcast. On today's show, Shirley, who is a type one herself also works in the healthcare industry, helping people with type one diabetes in South Africa. We'll find out about Shirley, her type one, and what care looks like in South Africa. While you're listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. Please always consult a physician before making any changes to your health care plan. are becoming bold with insulin.

I'm delighted by your accent, we're gonna have a great time. This is going to be the highlight of my day off. Well, you don't hear yourself right you sound you just think I sound fun.

Unknown Speaker 1:07
Yeah, no, I sound normal.

Scott Benner 1:09
We all do. This show is sponsored today by the glucagon that my daughter carries. g Volk hype open. Find out more at G Vogue glucagon.com forward slash juice box. This episode is also sponsored by the Contour Next One blood glucose meter. And you can find out more about that amazing meter at Contour Next one.com forward slash juicebox. And don't forget to add your name to the T one D exchange at T one d exchange.org. forward slash juicebox.

Shirley 1:58
Hi there. My name is Shirley. I am a South African. I live in Durban. And I'm a type one diabetic. I've been diabetic for 17 years.

Scott Benner 2:09
17

Unknown Speaker 2:10
Yes.

Scott Benner 2:11
Wow. How old are you now? I'm sorry.

Shirley 2:14
I'm 37

Scott Benner 2:15
Oh, I just did the math. And I know how old you are when you were diagnosed?

Shirley 2:20
I was older 2020

Scott Benner 2:23
were you in school at that time? Or were you finished?

Shirley 2:27
I was finished school. I was in university. So I was in second year of university.

Scott Benner 2:33
Big surprise far from home.

Shirley 2:36
Not too far from home. I went to university about 45 minutes from home. So I didn't stay at home. But yeah, not too far.

Scott Benner 2:44
And when you're diagnosed, what's the is it classic signs? Or did you have a strange finding?

Shirley 2:51
Um, yeah, to be honest, I had all the classic signs, but kind of didn't really even think I would be diabetic. So I didn't think about it at all. But yeah, like when I look back on it pretty much all the classic, or the classic sides?

Scott Benner 3:07
Yeah. Did you go to like a physician on campus? Or did you tell your parents and go to a private position? How'd you handle that?

Shirley 3:17
No, I went to my private GP so that our general practitioners family doctor, so yeah, came home and went there. But I went about two weeks into having all the symptoms.

Scott Benner 3:32
South Africa is interesting because living in America, the only thing I can tell you about South Africa is that Charlize Theron is from their tree, that is literally my only pull for that at all. I'm interested in, in understanding a little more about the breakdown of the country. Is it? Like? Is Africa, like, three different places? on one continent? Or how does? How do you feel when you when if you had to describe it to me, how would you describe the whole continent to me?

Shirley 4:05
So the whole continent, I mean, we're like, South Africa is like the bottom of the continent, the southernmost tip. And I mean, there's plenty other African countries on the continent, we're just one of them. Yeah, so I mean, I personally haven't traveled to any other African countries, but South Africa Yeah, we, we like the southernmost tip of Africa.

Scott Benner 4:31
Which is it's, you know, not that it's crazy that there are countries within a continent, but you understand the naming system throws me off. Because because there's Africa, like it would be like if if I lived in South North America, that's how it feels to me. And yeah, I suppose Yeah, you suppose you're like, shut up read a book.

Shirley 4:54
I mean, cuz I suppose you guys yeah. I don't know. Yeah, I'm not very Good with geography. So

Scott Benner 5:01
no. And I don't want to turn this into a geography lesson either I just want to, you know, kind of suss it out for people listening, that South Africa is unto itself its own place. It's it's just the Yes. Right? And

Shirley 5:14
yeah, own country, just part of Africa.

Scott Benner 5:17
Right. Right. And there are a ton of countries within Africa that, and it's a huge continent, it really is. Yes, I've now come to believe the map might not be correct. Scale wise, when you look at it, it's possible that land masses are much larger and smaller than I think they are. So I try not to wrap my head around that too much. Unless that's wrong. But anyway. So you're off at school diagnosed, you come home to your parents, they take you to your GP. And it's 20 years ago, so or excuse me, 17 years ago? What's management like? And is the technology much different in South Africa than I would find in America? Other places?

Shirley 5:59
Um, okay, well, I suppose like on diagnosis, our I started on insulin pins, and just your normal basic glucometer. Um, I've been on an insulin pump for about nine years now. And then I started a CGM end of last year, so about six to eight months on a CGM. So we have technology, I mean, we have stuff available. But it's not easily accessible due to funding. Yeah, so most people don't access technology. As much as you see in other countries, just due to funding privately, our what we call our medical aids, they don't actually fund technology, you have to fight quite hard to get it funded. And then in our public health system, you can barely even get a glucometer. So there's no technology in the public health system.

Scott Benner 6:58
So for a person living there that's not financially able to just run out and buy something for cash, and maybe is on the lower part of the of the spectrum. They maybe can't even get a glucometer

Shirley 7:12
Yes, so I work in public health. So I work as a dietitian in a in our public health setting. And your access for diabetics in that setting is it's like shopping to be very honestly, also, it's very difficult to access, if you comment, if they do get one, there's only one top that you can use, because they only will provide strips for one type of glucometer. And if they get that they get a maximum of 50 strips a month, which really is not helpful to anybody. So yeah,

Scott Benner 7:46
that's really something. How do those people manage them? You're taking me back to a number of years ago, I spoke in the Dominican Republic. And when I was when I was asked to come down and talk they, you know, they said to me, like, can you, you know, take what you do and bring it down here and translate it for people who are living, you know, at the poverty line. And you know, and I was like, Yeah, sure. So I put this whole kind of, I don't know, talk together where I was, yeah. And then I got there and saw what they meant by poverty. And I realized that even what I was saying, didn't imagine what was actually going on. You know, 50 strips, like, what do I do with 50 strips take really good care of myself, like, seven days a month,

Shirley 8:31
or? Yeah, so I mean, like, so 50 strips equates maybe to one maximum two tests a day. Yeah. So if you work it out, or they could do peer testing over certain periods of time. But I mean, to be honest, so like, what I listened to you on you listen to on your podcast, it would be very difficult to translate that back to my patients that I see as a dietitian. And yeah, so in our public health system, there's also like really no diabetic education at all. So they see a doctor, they get given something, whether they talk to they get put onto medication, if they tap one, they might go to a higher level hospital for if they're, especially if their child, and they'll have some sort of education there, and they'll have insulin. And then yeah, so And yeah, it is just the lack of education is the biggest. I mean, it's, I think, a bigger problem than even getting the 50 test strips because most of the patients we interact with, they don't really actually even understand what they have or what diabetes is or what's happening inside their bodies. So for them to control their diabetes is it's very difficult.

Scott Benner 9:50
Well, okay, so let's talk about that for a little while. Is Is it like that for other disease states? Diabetes particularly ignored.

Unknown Speaker 10:04
I'm

Shirley 10:06
sorry, I mean, so like from South Africa, so we do have a high rate of HIV positive patients, they have a different sort of access. I mean, they do have access to medications. And then they go through like a sort of simple education process as well, before they are initiated onto their abs. So there's a lot of focus in our country on things like HIV and TB, because we have a high population group that are both HIV positive NTP. So it does kind of fall by the wayside. There's also quite a big focus, like on maternal health, things like breastfeeding, where they are like programs in place. But yeah, I do. Like personally, for me, I find diabetes is sort of neglected, was a fine patients often playing because they uncontrolled, they've got all these complications. But nobody ever took the time to actually educate them and help them to control their diabetes.

Scott Benner 11:08
So from an institutional perspective, not from where you work, but from, I guess, government down is the idea. People get sick, and that's it, they're lost. And then the rest of their life is just dying faster than they would have.

Shirley 11:27
I just think there's, yeah, I mean, I just think there's just a lack of understanding, there's just a lack of, yeah, I mean, I think there needs to be some sort of definite program put into place to help with it. And it's not like necessarily that everyone is going to be dying, but they would probably have a shorter lifespan due to complications if they do become diabetic, right?

Scott Benner 11:54
Okay, I think I have my head wrapped around this pretty well. And so there's no educate the education piece is probably First, if you stop and think about leaving people who are diagnosed here who don't know, the first thing about type one or diabetes in general, they can run back to the internet and find out but that's not lacking in South Africa, right? People could go online and learn is there just no person or entity there with a voice that they can go to?

Shirley 12:26
Now we do have organizations. So I mean, we have like a diabetes, South Africa, there's a few different organizations. So I mean, there are resources, people could go on to the internet to learn for themselves. But also a lot of our patients Can't I mean, they may not be financially able to access internet, it's gotta pay for it. And also, sometimes literacy and education levels are low. So yeah, they may not really take that initiative to access education, because it's just not a priority, I suppose.

Scott Benner 13:00
And then their bodies become accustomed to the higher blood sugars, and they don't feel badly at first, and then they don't know they're really in trouble until they are and then that that whole cycle begins.

Shirley 13:10
Yeah, so I mean, for me, like in my institution, I'm seeing mainly older, like more type two diabetics, we do have like a sort of an age group of a younger adults type one diabetics. But pediatrics, so the younger children, so under the age of 16, they will go up to a higher, like a tertiary facility. So I don't see a lot of young top ones, but we, we do deal more with our top two diabetics, and just the common, mostly obese, high blood pressure, diabetes, often high cholesterol. So it's like a whole host of problems that they already have. Yeah, so we we deal mainly with type two diabetics, I suppose. And messaging. Okay.

Scott Benner 13:57
When you do that, just let's talk about the type two for a second, where do you start when you're trying to help them? Like, where's what's step one?

Shirley 14:06
Yeah, it's very hard. I mean, we tried to give them sort of a brief explanation on what diabetes is what's happening, you know, why they need to see a dietitian, okay. Like, for me, like they get referred to us as a dietician. But they've had no prior education. So the prior education, if they had that, they might see the value of a dietitian. But without having that. The I don't suppose there's not always that link between the value of seeing a dietitian because they don't really understand why they need to be there. So I think it's more starting off with just brief explanations on what diabetes is, what's happening inside the body, why our food is important, how it works inside the body, and then giving week I mean, we really do give basic dietary information at the level. We always With I mean, I wouldn't I don't do things like carb counting, etc, unless I have a more motivated patient who has some prior knowledge and wants that extra information. But a lot of them. It's very basic, basic dietary information, small changes that we can make to try and help them out. Do you see? Do people return for fall? And by the way, do

Scott Benner 15:23
you have a Star Wars droid in your home? That's it. There's a very like, electronic sound that that what is that? Is that?

Unknown Speaker 15:30
It's not fine. Oh, okay. I'm

Shirley 15:32
silent.

Scott Benner 15:33
Don't be sorry. I was like, she's got a robot. She's pretending that it's not great. But she has one now. My question was, do people continue to come back for help? Or do you see them once and then they disappear? And then my follow up to that is, how many people do you think you get through to in a way that changes their thinking and focuses them on what they need to do, and how many people are just trying to get by?

Shirley 16:01
Um, in terms of follow up, they don't always have follow up with us. It really depends on the dietician that sees them if they feel necessary for a follow up. Sometimes it's one self cancelling, and then a lack. Like, depending if the doctors see them, when the doctors see them, again, if the blood sugars are still high, because it's always blamed on the diet. They may be referred to us. But yeah, that's just dependent on who's seeing them what the situation is. So they may or may not have follow up with us. And then you're in terms of getting through to the patience. I mean, there's plenty that you do get through to the contrary, put it number two, it is plenty that you'll see a little light bulb click. And that I mean, I'm not saying they're going to have perfect HBA when sees results, but it might help them in some way.

Scott Benner 16:53
Sure. So your days mostly and with you feeling like you use your days and and you feel like you've you've accomplished something for people, mostly

Shirley 17:03
some days, some days not. So see. So that I mean, think in the states is very different for dietitians, they kind of specialize in certain areas. So we don't specialize we literally go to work and see anything that walks through the door. And we spend time in the woods as well. So we do both in and our patients. So I mean, I can have a day seeing diabetic patients overweight, we know. It really just depends what comes to us on that day. So my sole focus is not only diabetes, right?

Scott Benner 17:36
Well, how did you say you said you have an insulin pump? How did you find your way to it? Do you have some sort of assistance or coverage or the finances to be able to do it?

Shirley 17:47
As a dietitian?

Scott Benner 17:49
No, I just mean is that as a type one, like when you said you have an insulin pump is I'm trying to understand like here, people have insurance or don't have insurance.

Shirley 17:59
So basically, in our country, you we have private health care which you can pay for, or if you cannot afford to pay for private health care or choose not to then you access public health care. And so with my job, they do subsidize some of my private health care coverage. So like you guys have medical insurance, we call it medical aid, I suppose it's it's similar, but it is different. And yeah, so from my brief understanding of how yours guys works, I think it's linked more to who you work for, and what kind of insurance they offer. Yeah,

Scott Benner 18:40
so private insurance, your you get through your employer. Normally, you can buy it in cash, but most people get it through their employer, their employer subsidizes some of the cost and you pay the rest. I don't know what people pay in general. I do know what RS is. And it's, you know, for for people, I think we probably pay. I'm guessing here, but I bet you it's about $6,000 a year for

Shirley 19:08
that. Yeah, so as it's similar, the medical aid is a similar concept. employers don't have to subsidize it, just to get subsidized. And because I'm subsidized, I use the medical aid that they recommend. But if I do have the choice to use any medical aid I want, I can use any one I want. But they will only subsidize the one that they recommend. And then within the medical aid, there's like different options. So you can pay for different sorts of coverage. And I pay about five and a half 1000 Rand a month. So I don't know what that equates to in a year. I have no idea. Yeah. But your monthly pay about five and a half 1000 Rand. Yeah. All right.

Scott Benner 19:57
Well, I'm going to tell you while I figure out how Much Aranda is worth.

Unknown Speaker 20:02
It's not worth very much at the moment.

Scott Benner 20:04
But what I was, what I was gonna say is that is that, aside from the money that we pay out of, you know our check every month that comes from the company that gets held back for the insurance. The first $3,000 we spend on healthcare a year is what they call out of pocket. We have to pay that through. So I guess if I'm being honest, if nothing goes oddly wrong in a year, gee Volk, hypo Penn has no visible needle, and it's the first premixed auto injector of glucagon for very low blood sugar and adults and kids with diabetes ages two and above. Not only is chivo hypo pen simple to administer, but it's simple to learn more about, all you have to do is go to G Vogue glucagon.com forward slash juicebox g vo shouldn't be used in patients with insulinoma or pheochromocytoma. Visit Jeeva glucagon.com slash risk. People with diabetes need an accurate and reliable blood glucose meter. It's a staple of your care. And the Contour Next One is easily the most accurate, easy to use, easy to handle meter that my daughter has ever used. It's small, but not too small, has a bright light for nighttime checks. And of course, the test strips allow you a second chance. So if you should not get quite enough of your blood sample and need a little more, you can go right back and get it without messing up the accuracy of the test. It's very handy, super easy to hold easy to use, fits well on your pocket or your purse, or wherever you carry your supplies. Contour Next one.com forward slash juicebox. Go there find out more about the Contour Next One meter, and a host of other things that contour has for you. There's test trip programs, and you may even be eligible for a free meter. This website is worth your time to pick around. For many people the Contour Next One meter is cheaper when bought with cash than when it's purchased through insurance. You should look into that too. And you can do that right at the link. Don't let your blood glucose meter be that thing that the doctor gave you because they had one in a drawer where a salesperson left one in their closet. Get a good one, get an accurate one, get one that's a pleasure to use Contour Next one.com forward slash juicebox. The T one D exchange is looking for type one adults and type one caregivers who are us residents to participate in a quick survey that can be completed in just a few minutes from your phone or computer. After you finish the questions. They are simple. I did them in about seven minutes. You will be contacted annually to update your information and to be asked further questions. This is 100% anonymous. HIPAA compliant does not require you to ever see a doctor or go to a remote site. This is your chance to add to Type One Diabetes Research right there from your sofa super easy to do. Go to T one d exchange.org. forward slash juicebox and click on join our registry now. After that simply complete the survey. Past participants like you have helped to bring increased coverage for test trips, Medicare coverage for CGM, and changes to the ADA guidelines for pediatric a one segals it's exciting to imagine what your participation may lead to T one d exchange.org. forward slash juicebox there are links to all of the sponsors right there. In your podcast player shownotes. We're at Juicebox Podcast comm when you click on the links, you're supporting the show. Thank you very much. And I want to get you back to Shirley now. I think we're all grateful that I haven't made any surely surely jokes so far. And let me just give you a little teaser right now. I'm not going to that's pretty proud of myself, as you may imagine.

And it's pretty regular year, it must cost us about $9,000 in cash to to have health care and for context. That is 152,120 Rand.

Shirley 24:38
So our like our medical aid works differently. So like the medical aid I'm on I'm on the highest option, and then it's within the option they break down so you have like in hospital care and they pay X amount for different things and then you're out of hospital care like you'll have a chronic benefit. I have like an optometry benefit. So, paying out of pocket more comes for things that they don't cover. So with your diabetes under your chronic, or the medical aids, we'll have what we call a chronic disease list where they cover certain chronic illnesses. And within those chronic illnesses, they have what are called prescribed minimum benefits. And those prescribed minimum benefits are what they have to cover. So for example, for diabetes or type one, they have to cover my insulin and my test strips. And then they'll also have a essential drug list and specific insolence and etc, will be covered. If you go for incident that's maybe not on that drug list, then you'll probably have a co payments. And then in terms of insulin pump CGM, they are not readily covered at all. There's no sort of funding for them within the medical aid, you have to try and fight for it.

Scott Benner 25:59
If if they were. Do people generally have cell phones to use as receivers for a CGM, or would they need a receiver from the CGM?

Shirley 26:10
No, there's access to cell phones.

Scott Benner 26:13
And before I'm just gonna blurt this out before I keep moving just for context, one US dollar is just about 17. Okay, so just so people have context. So if I had a CGM, I might have a cell phone to use it with and what kind of pump do you use? I'm sorry.

Shirley 26:31
So I currently use an accucheck pump. I don't think you guys have it in the States. It's a it's a combo. It's quite accucheck combo. And yeah, it's, well, my pump is now four years old, so it's just out of warranty. So hopefully, I will be able to upgrade to a newer system. It's just basically, the one I'm using is just a pump. It comes with a glucometer, which connects to the pump via Bluetooth so I can control the pump with the glucometer as well. Okay,

Scott Benner 27:00
so you take a blood test and it shows up on your pump. And do you do you have a CGM yourself? I'm sorry.

Shirley 27:06
So yes, I have started using a CGM. At the end of last year I'm using the at the moment the Medtronic Guardian Connect, because it's what I was able to get funded via medical aid at the time.

Scott Benner 27:19
Okay. Wow. All right. So how about insulin? Is everyone that we've talked about this, despite their financial situation? Is insulin available to all of them who need it?

Shirley 27:33
So yes, insulins available. So in private? Well, let's start. So in our public health care system, it's your your older insolence are like atrophy and profane the human insolence. They really only have access to those. I think you guys like and I've seen it termed as the insulin you get from Walmart. Okay. It's the same. It's the same.

Scott Benner 28:00
Feel good to hear that we're

Shirley 28:01
having a healthcare system. Geez.

Scott Benner 28:04
Gotcha. All right. So what we consider here to be older insulin. Yeah, is what's common there. And

Shirley 28:11
available to everyone your private sector. I mean, you can access Lantus levemir you're Pedro, you're Nova rapids you're humalog I think we have a tour Seba is available now as well. Yeah, so in private you can access I suppose your newer insolence if you wanted to have them as that

Scott Benner 28:39
right and what do you use?

Shirley 28:41
I'm using in my pump I use Nova rapid but I mean since diagnosis when I was diagnosed, I used Lantus and I used I've used a p drive us to Malaga, and I've used Nova rapid as my rapid acting. And then yeah, am I longer acting? I used land just when I was diagnosed.

Scott Benner 28:57
Okay. So, um, for your care, like what are your What are your goals? A one C, is that how you measured you measure more like your variability your up and down? Do you just shooting for what your finger stick says? How do you go day to day?

Shirley 29:15
So yeah, I mean, I do use HB one C, since I've had a CGM. I have been able to look more at like my time and range and those things as well. Um, yeah, I mean, my agency has ranged a think it generally was in the sixes last year, clammed up into the sevens. And then since I bought the CGM, I have reduced it down to 5.8%. By Yeah, just by having all that extra data, it really does help to make changes and to just see what's happening throughout the day, not etc.

Scott Benner 29:54
What changes did you make did you start with food or were you pretty comfortable with your diet and it was more about insulin?

Shirley 30:01
More about insulin Amina. I don't really follow a diet, but I'm pretty comfortable with my so called diets. I kind of eat all the food, but more just about insulin. I've been able to just tweak my basil a little bit as well. So that's helped as well. And then yeah, I do exercise quite a bit. I still kind of battle with that with dropping low during exercise. And but yeah, also playing around with like your extended Bolus is on your pump, which you can see better when when you've got a CGM. You can see how they're affected. And then, yes, Pre-Bolus Singh. I've been much better at that as well, since I've had a CGM. It's a big deal.

Scott Benner 30:43
That's probably where you got the point out of your a one C was the Pre-Bolus. Yeah. Oh, wow. That's so it's very interesting, because I have the feeling that I have talking to you about what's happening in South Africa around care is how I feel when I'm doing the podcast. And I think this podcast really is reaching just people. You know, I mean, fully reaching just people who have the technology to take advantage of the data. And for everyone else listening, it's probably feels like, I don't know, like something they can't it's out of their reach? And is there a way since you've been listening? Is there a way to take the the conversations on the podcast and what you've taken out of it? And give it to people who don't have the technology? Or is it just not? Is it not possible in your point, in your opinion?

Shirley 31:36
Um, I think it could be possible. It's a little bit difficult. So I mean, like, the patients, I see a lot of them also like English is not their first language. So sometimes, the context might be difficult for them back not having English as their first language. And yeah, and then I just yeah, I think they also saw, I mean, most of my patients, if they're on incident, they unset doses, nobody teaches them to adjust doses or anything like that. And if they're not testing, it's very difficult for them to adjust doses and make changes in their doses themselves. So they're not really given that kind of freedom, which in a private setting, it's completely different. Because we do have, I mean, most of the patients in private setting will be doing things like carb counting, they'll be able to adjust their doses themselves, they have access to better sorts of insulin. But in the public setting, it's a little bit difficult. I mean, I can give basic messages across but not Yeah, there's not a lot of I don't think a lot of the information would translate very easily for them.

Scott Benner 32:52
So many people there are managing type one, in a way that is more reminiscent of 40 or 50 years ago, in America, the idea of just I'm going to get up in the morning, give myself some insulin, make sure I eat at the right times, if I get dizzy, I'll eat something like it's it's that simple.

Shirley 33:12
Yeah, so I mean, like in my patients that we see, so a lot of top twos is also a bit hesitant to put patients on insulin. So there'll be sitting with her HB, one sees there are knock the oral dose of Metformin and maybe one other oral medication. And they probably really need insulin, but they there's a resistance that doctors don't seem to want to stop the insulin, and then also patients resistant as well. So because a lot of patients won't want the incident. Yeah,

Scott Benner 33:44
yeah. Is there trouble with refrigeration, that the two people have that concern that they can't keep the insulin?

Shirley 33:51
And I think like, that's not one of the major concerns. I just, I think it's fear sometimes as well. So I mean, because they often they're gonna say, oh, you're going to get an injection to take home, there's no like education around it. Or you take it, what do you do? They're kind of just given the stuff. And then they go home. And a lot of them, even if they're given the insulin, and they go home, they don't take it because they don't really know what to do with it. And nobody's taught them.

Unknown Speaker 34:19
Wow, that's sad, isn't it? So yeah, I

Shirley 34:23
mean, there's like, there's really as two different levels of care is that the public health care, but in privates, it is completely different. It's more along the lines of what you guys would experience in America, just with a little bit less access to the technology that's available.

Scott Benner 34:40
I you know, I don't you know, from my limited interaction with type twos and I do have some, I don't know that that sounds that much different than what a lot of people with type two diabetes here experience either it's, it's limited education, a small understanding. A feeling like you don't want to use insulin. I've heard people say insulin felt like giving up. A lot of people say that here, you know, like, like they have it in their head that they can diet their way out of there type two diabetes. And if they're going to use insulin, it feels like they've given up on trying, which is, of course, you can dye it and use insulin at the same time. It's not a one doesn't preclude the other. But I get the idea. I understand it, it is such a strange. I mean, honestly, most health issues that require more than take this pill in the morning and take this pill at night, comes down to can you get the patient to put themselves in the doctor's shoes and make the the kind of the bold idea that I'm going to be in charge, now I'm going to take care of this, I'm not going to lean on the doctor, the doctor has given me you know what he's got, I'm going to go find out the rest, I'm going to start paying attention to my body, seeing what happens making adjustments on my own being a little, you know, aggressive and not scared. I don't know that it's, I don't know that it's a fixable thing that you just, you know, turn a dial or, you know, send some instructions out to every dietitian in South Africa. And suddenly it's, it's fixed. It's, it really does live with the person who has the disease, but it's got to be someone's job to impress upon them beyond a shadow of a doubt that this is the only thing they should be focused on until they figure it out. Because otherwise it's just gonna it's just going to impact the rest of their life.

Shirley 36:27
Yeah, I think so. Like in our setting. There's also like, a lot of misinformation given. I mean, I do also understand some of us, like in our clinics, and even in our hospitals, that doctors nurses are really short staffed, they don't always have the time to sit with a patient. I do understand that. But I mean, as like, patients get told they can't eat red apples, they can only eat green apples. They mustn't eat a banana ever again. And it is an illness Jakob diabetes that's very much related to sugar. So they a lot of patients will feel well, they'll tell me they don't need any sugar. But they don't understand

Unknown Speaker 37:11
that hydrates

Shirley 37:12
and how they impact the blood sugar levels. So they kind of get this sort of like brief, like, don't eat sugar kind of message and take this pool and you're going to be fun. And that's it. Yeah, that's Yeah, it doesn't go further. The education part doesn't really go further than that.

Scott Benner 37:33
It's interesting. Do you have water ice there be like, slushy ice that's got flavors in it.

Unknown Speaker 37:41
Yeah, yeah. So there's a piece a giant

Scott Benner 37:43
organization here. You know, I don't know how far across the country but on the East Coast, it's a massive and they sell water ice at these little stands. And part of their sales pitches. It's fat free. And I always I'm like, Yeah, I mean, right? Until you put it in your body and your body goes, Oh, sugar, what should I do with it? Hmm, I'll turn it into fat. And it's the same idea with like, Oh, I don't need any sugar. You know, there's barely any sugar and bread. Okay, you know, and then the carbs, of course have, you know, they don't understand is really difficult to I don't know where that understanding has to happen. Like, as you're talking. there's part of me that always thinks, what if you just draw a line and start over, and everyone who's above a certain age, you're just gonna miss them. And there's nothing you can do about it, but at least you could fix how it happens. Moving forward, like, do you spend more time in, you know, lower level schooling, you know, with younger children, explain that to them. But don't just say, hey, sugar turns into fat or, you know, bread could be carbs, like you don't just do that you say, and 10 years from now, when a friend of yours or you develop type two diabetes, this is going to be really important information to remember like, do you give them a little extra honesty? And, and so that it sticks in their head? Because you know, I'm watching my daughter downstairs this morning doing geometry. And you know, she's thinking, when am I ever going to use this to my life? But if somebody said, Listen, this geometry you're learning today, this is going to save your health. 10 years from now, really remember what you're being told here. Remember to come back to it. I this is I don't know if this is gonna sound connected or not. Do you have children?

Unknown Speaker 39:29
I don't have any children. Okay, first of

Scott Benner 39:31
all, good job. Kids, dogs. It's a lot of problems. But I find myself thinking I should have started a diary. When my kid was born, and every time I thought of something, wow, he's gonna need to know this one day. I should have written it down. Yeah, because I find myself learning things about life. Sometimes it's medical, and sometimes it's not. And I think well, now I know this He should get to stand on the shoulders of this idea, not have to figure it out for himself. And you know, sometimes when it's not medically, you know, related, you think, Well, you know, it's good to figure things out on your own a little bit. But if you're really going to make a leap in something, you can't start in a hole, you have to start, you know, someone's going to prop you up a little bit. And with medicine, it's just, it's super important. It's what I see with the podcast, you know, people come in completely lost, and the podcast supercharges, their idea of what's going on, and it does it quickly, so that they suddenly are lifted up, and then they can, they can start, you know, at least they're playing on a level playing field all of a sudden. But if you give someone diabetes, and then give them all of the physical problems that come with it, especially, you know, mental tiredness that your body feeling wrong, like you know, all the stuff that you could be dizzy, all the stuff that could come with it. And then on top of them, tell them now live through this every day. And don't forget to pull the pearls of wisdom out and don't forget them and don't forget how to, you know, apply them. It's, it really seems impossible, without, without help without somebody to stand, you know, someone's shoulders to stand on. I don't know, it makes me I really I keep thinking about it. Like there's a way to handle it. I've been having type two conversations with people privately recently. And I just think there has to be a way to do for people with type two diabetes, what the podcast does for people with type one diabetes. And I think it's doable. It just

Shirley 41:31
yeah, I think it is. I mean, I mean, if I look at our context, and like the patients I work with, so a lot of its low income patients, and in terms of diets, they tend to eat a high starch, high carb diet, just because it's your foods that are easily available, accessible, that cheaper. And so I think, like from my side with the information I give, if I can relate, because they only feel like sugar affects their blood sugar levels, and they're not adding sugar, or, you know, they're not eating cakes, or sweets or whatever. But often, yeah, just to try and relate to them, that starch will also affect their blood sugar levels, and they will eat very big portions of starch. So I think it's little things like we get them to cut down on their starch portions, and trying to include more vegetables in their diet. So I mean, it really is like, basic, healthy eating, and I will for myself, I never apply it just to the patient, and encourage them to apply it to their whole family, because it's beneficial for everybody in the family, and it's not specific information. And then on the other spectrum, and our private health care. I mean, you do also get people's perceptions that a lot of people only low carb or no carb. Yeah. So it really just depends where you are in society as opposed if you're low income, middle income, high income, and what your perception on diet is, as well. So yes, it's, it is a little bit difficult, even in private, because those patients have more access to information technology, stuff on the internet, and they don't really see a value of a dietitian sometimes as well, because they just gonna follow whatever. fad diets or etc. that's out there at the time and what works for them, right?

Scott Benner 43:27
Whatever, Google and Instagram, tell them to do. Yeah. Oh, my goodness. Well, that's

Shirley 43:33
for myself. I mean, I've never eaten a low carb diet, I eat carbs, I eat everything. And a lot of people like try and push that onto me. And I'm like, Well, I don't really see the need for it.

Scott Benner 43:44
You're, you're doing difficult, you're doing terrific. What was do you know, back in when you were younger, what your agencies were like in your early 20s.

Shirley 43:56
Um, I think they were relatively fun. I think the highest agency I had was about a 9%. And I was battling and after that. That was when I started. Well, I was interested in getting insulin pump. And I think after that I've got an insulin pump. So like, I think they've mostly ranged in the six senses and sevens, maybe blow eights and luck from what are the one I can remember is b 9%, which was the highest it had been and then you're just I needed to refocus and look at something different to help with the management.

Scott Benner 44:35
He used the word a second ago, I didn't hear you said you were battling something. What were you battling?

Shirley 44:45
I can't remember. He said

Scott Benner 44:47
I was battling. And then it sounded like you said like, when a spider man's like photos or something like that. I couldn't tell what you said. Like you swallowed a couple of letters and I couldn't hear them and I was like, Oh, Okay, nevermind, I thought you're gonna be like, oh, That was just this, but I don't know if it was, um, I really don't know.

Shirley 45:04
I'll listen to what I said, I sorry, I can't even remember.

Scott Benner 45:07
Don't, don't worry, listen, right here, when I'm editing the show, I'm gonna go back and play it again and again for people, and we'll figure it out together instead of it instead of, you know, it'll be fun. It'll be fun, you'll listen back one day and think, oh, that's what I was talking about. It's really, it's very interesting that you have been through so many different insulin types. And that you're kind of, you know, you have to mishmash your, your technology around like, you have to get a Medtronic, you know, CGM, because it's what's available that you're using a pump that, you know, obviously, we don't have here any longer. Is there a way to attract companies to South Africa? Like, is there just not enough of a patient population there? Is it a distribution issue? Do you ever do know why some companies don't exist? In some places, they're their products.

Shirley 45:56
Um, so we have access to so obviously, electronic is here, that is the main company. The accucheck pump is still available here. And then we do have access to tandem and Dexcom as well. So that is available now as well. Okay.

Scott Benner 46:14
It's just not it's just not financially reasonable, and nobody will back it up with coverage.

Shirley 46:18
And no, there's people. Yeah, I mean, I'm sure that people using it, the Dexcom. The sensors are a lot more expensive than your Medtronic sensors. So yeah, but there are people that definitely use it.

Scott Benner 46:32
Gotcha. Okay. I just, I mean, it's, it's one of those ideas, like, I don't know how many, you know, what percentage of people you end up, pulling out of the out of the hole. But if you threw a Dexcom on everybody, they have at least a chance to figure out what was happening to them. Even you know, especially type twos, honestly, the way you describe them, I know that more and more type twos are using glucose sensing technology, but that's for them, you know, to see what a banana does, and not just and not just have somebody tell you, you can't have a banana anymore. You know, to see what how, what impacts medications have and where insulin would be helpful for them. If you know dieting is not working for them. Hmm. Yeah, I don't know. It's a problem, obviously.

Shirley 47:22
Yeah, I mean, the other thing we do have access to as the freestyle libri. And there was talk of people trying to motivate for that to be brought into the public healthcare facilities for the diabetics. But I think it's a very long shot to get that into our system, but it is available properly.

Scott Benner 47:45
If you wanted to, do you know the political ramifications? Like if you wanted to petition someone to consider something like that? How do you How would you do that they're

Shirley 47:59
not 100% short in public, but at the moment, in our private sector, there is a group of people and I have participated where we've started a CGM for all campaign. And we are trying to engage with the medical aids to fund CGM for type one diabetics,

Scott Benner 48:20
that would be wonderful if you could do that. I, I don't know. Like it's, it's, I've lived as a parent of a child with type one in both worlds I've used not the really old insulin, but I've been, you know, just fast acting, slow acting and needles and me and a little meter. I've done that for a number of years. I lived through the beginning of CGM, where it was, you know, they were definitely finding their way in the first, the first year, or the first iteration of it was, I mean, still better than anything I'd ever seen. But nowhere near what it is now. And what I'm assuming it's going to be as the generations keep pushing forward. And this is the way to do it. There's there's no doubt like this is this technology is is the gold standard for understanding what's happening inside of your body and making great decisions that keep you healthy and, and and let you live, you know, the the life you're supposed to say it's really devastating to hear, especially with the you know, there's going to continue to be an explosion of type two diabetes, and to know that for most people in in place in a lot of places, not just there, but here in other countries, that it's going to be, you know, that's what their life's gonna turn into is either an uphill battle or, you know, an exercise and ignoring things and hoping it doesn't hurt them, which is of course, not going to be the answer.

Shirley 49:45
Yeah, I mean, it definitely. It's a very hard thing because I mean, it is a lot of diabetes is a patient responsibility. I mean, you don't live with your doctor 24 hours a day. So a lot of your management is Your responsibility and what you put into it. But yeah, I think the starting point to get there is to have a good solid education given to you by the health care workers or whoever gives the education. I think that's the starting point to motivate people. Because if you don't understand anything about diabetes, or what's happening, you don't really have that motivation to do anything about it.

Scott Benner 50:29
Yeah. Now let's even that, as you're saying that I'm thinking, then you have to have a life that you that you want to be healthy to go live, generally mean? And if you're if you're already struggling in other ways, what's the you only mean? Like, what's the excitement for you like, Oh, I'm gonna be healthier. So I can go, you know, do my do my job over and over again, that I don't enjoy that. I feel like it's just, you know, a task and I don't know, it's a it's a bigger idea, like, how do you motivate yourself? In that scenario?

Shirley 51:02
I suppose everybody has their own motivation? Yeah. Something that must keep them going. Whether It's Your family, your job? I don't know. I'm sure everybody must have some sort of motivation in them to keep going.

Scott Benner 51:18
I think so I just I think sometimes it doesn't feel when it doesn't feel doable, then, you know, you know, we talked about this the other day. When you don't, when you can't retreat into your mind and come up with an answer for something, and you don't know who to go ask, then there's that feeling that the answer doesn't exist. Which is, which isn't true. It's somewhere it just you don't know how to get to it. And not knowing how to get to it is about the same as it not existing sometimes? Surely, you're a bummer. Is there anything you're not just kidding? What What made you reach out? Well, first of all, how did you find the podcast?

Shirley 52:01
Think on Instagram, through Instagram, and then I started listening to it.

Scott Benner 52:07
It helped me Was it valuable for you? Or is it just interesting to hear about people with diabetes?

Shirley 52:13
It is very valuable. I mean, the pro tip series that you do, that's really great. And it's also just interesting to hear other people's stories.

Scott Benner 52:22
I'm glad. That's excellent. I Instagram is a is what I was guessing I just wasn't, it wasn't 100% certain out and now you've got me looking. I'm now interested to see how many people listen from South Africa. So I'm going to look real quick, right? While you're here, because that doesn't that can't be that many as what I'm thinking. Because you found it. But yeah. There's a couple of 1000 downloads this year. I guess that's not crazy. Yeah. But that's some people. It's a it's interesting when I see it pop up, because I do look at at the downloads in Africa. And it's interesting, where it'll pop up, moving up into other countries is very sparse. But they're just some countries right through the center that don't even have one download. Did they have no internet access? In that Central African? In that maybe not? Maybe not. Look at you. You're like, I don't know. I'm not leaving South Africa. It's

Shirley 53:19
possible that they don't mean, I don't know what's in Central Africa. Is that like the Congo?

Scott Benner 53:26
Yeah, a little Congo little? Listen, let's talk about something real for a second. How many great white sharks have you seen? And how many people do you know who have been eaten by one? And none? out here?

Shirley 53:38
I've never seen one. I've never gotten shark cage diving to see one. And I don't know anybody who's been eaten bow and I would never

Scott Benner 53:47
go in the water in South Africa. Although it looks beautiful. It's beautiful. Right?

Shirley 53:52
Yeah, I mean, it depends where you go in South Africa. So I mean, if you went to Cape Town, and there was really freezing cold but in Durban we have a much more warmer climates, our waters much nicer and warmer.

Scott Benner 54:09
And, or am I right? Our seasons? Like what what time of year? Is it there for you right now?

Shirley 54:17
So we are I suppose winter. But yeah, I mean, so we are live in Durban. Winters very, very mild. So it's not like if it gets to 20 degrees, we're in Celsius. So if we get to like 20 degrees Celsius, we were all winter clothes because it doesn't get very cold. Yeah, that makes sense. But other areas of the country get colder than us.

Scott Benner 54:40
What about the summertime? Is it incredibly hot, or what's it Yeah,

Shirley 54:45
very humid and hot.

Scott Benner 54:47
humid? I hate the human humans my worst thing.

Shirley 54:51
So don't love the humidity. I actually like Durbin winters. Perfect.

Scott Benner 54:58
Yeah, it sounds like early spring.

Shirley 55:00
65 days of the year,

Scott Benner 55:01
you will take that ICS Have you ever traveled to other countries?

Shirley 55:07
Um, yes, I've been to America. So I've been to New York and Colorado. I've been to Italy, I've been to France, and I've been to the United Kingdom. Wow,

Scott Benner 55:18
that's a lot of traveling.

Unknown Speaker 55:20
Yeah, a little bit.

Scott Benner 55:21
I used to think a little bit you were you've been to four places I've never even considered. I've been places I'd like to be that I've never thought. I wonder if I know you said there's English isn't a first language. And you've heard the pro tip. So let me ask you this. And this isn't me trying to make something happen. I'm just generally interested. If you instead of like you said, it's hard to see patients, because it's so quick. If instead of if instead of a quick, 10 minutes, right, if you put 500 or 1000 people with type one diabetes from South Africa, in a room, and I jumped up on a stage and did a two hour talk about some of those prototypes and got people into the mindset and there was someone there translating for me. Do you think that would move them forward?

Shirley 56:12
I'm not sure. So like, I mean, in South Africa, we do actually have 11 official languages. Oh, dear God. And so we are live in Durban, or what's our provinces kwazulu Natal, our language. I mean, obviously, there's English, but there's also the main language spoken would also be Zulu. And direct translation is a very, there's no real direct translation really, between English and Zulu. So you can't translate word for word. So you're to our talk, take a very, very long time when somebody tries to translate into you, I understand to try to get it out. So I would need someone like you who understands what I'm saying somebody who's speaks the local language to almost have their own

Scott Benner 57:10
understanding of what I

Shirley 57:11
was able to listen to something, have their own understanding, and then disseminate that information.

Scott Benner 57:17
Gotcha. So it for example, if you spoke Zulu, which you didn't say you did, so I'm assuming you don't worry, you would totally be bragging and saying you did. And so if you did, and you really understood the protests, and I showed up and I said something, you could listen to what I said. And then put it into context. Because your brain Yeah, your brain would do the trick.

Shirley 57:34
Yeah. So I mean, I don't speak Zulu fluently. I speak very limited. So I mean, I wish I spoken more fluently. But yeah, so my limited words and things I can string together definitely wouldn't

Scott Benner 57:49
help. It wouldn't help. But But somebody I just I'm trying to imagine like, how do you talk to people like that, and then they'd have to have the technology. So So what I want to kind of finish up by asking you, what of the stuff that you heard in the pro tips. Have you been applying to people who don't have technology? What are you able to tell them?

Shirley 58:12
I haven't really used stack your pro tips much in my week. Okay. So I mean, something I do like to speak to them about if they are on insulin is maybe the timing that they taking the insulin, because it's not often discussed, sometimes they take the insulin home, and they don't actually get told when to take it, they might take it after they've eaten, they might take it just when they eat. So that's something I do discuss. The only other thing I really also discussed with patients is the injection sites, trying to make sure they rotating injection sites, because that's also something that's not really discussed with them, or they're not really told about and, but also in terms of the way we work and like professional regulating bodies. As a dietitian, we are technically only allowed to educate in terms of diets. Everything else is actually out of our scope of practice. So I mean, I do give brief information, but that's just mainly from my own knowledge. But

Scott Benner 59:20
it would have to be an actual physician who said, this is how you use the insulin no one else is.

Shirley 59:24
Yeah, so I don't really speak to them about dosing. I don't. I can't recommend adjusting dosing, I have to set out to go back to the doctor and ask the doctor to look at those things, even though I mean sometimes maybe I could see it for myself that they need to adjust the doses or change something. I can't really give them advice to do that. Gotcha.

Scott Benner 59:49
Wow. What's your favorite Charlize Theron movie quick.

Shirley 59:53
Oh, geez, I don't even know

Unknown Speaker 59:55
unbelievable. You're not following her. She's not watched with it and he's not like your bread. head or anything like that? You guys don't like she made it? I think all right. Oh,

Shirley 1:00:05
yeah, she made it. She seems so like far removed.

Scott Benner 1:00:09
Are all women in South Africa tall and blonde or no?

Shirley 1:00:15
Well, I don't think I'm very tool but I do have blonde hair. I

Scott Benner 1:00:17
don't think I'm very tall. What is not very tall?

Shirley 1:00:21
I'm like 1.6 meters.

Scott Benner 1:00:23
I have no context for that. That's hilarious

Shirley 1:00:26
in my mind now really tell you in feet because I have no context of I only know the metric system.

Scott Benner 1:00:33
I'm gonna find out. Because right now in my mind, right now in my mind, you're like, you're just as tall as like a baby in my mind. So you're like five feet a quarter inches? I gotcha. Okay. All right. You're right. You're not that tall.

Unknown Speaker 1:00:50
Yeah. Okay, so

Shirley 1:00:52
no, we're not all tall and blonde. I was just wondering,

Scott Benner 1:00:56
is there any type one in your family? Like, was this do you? Are there a lot of people who have type one? Are you the only one?

Shirley 1:01:03
Nice so when I was diagnosed? Yeah, I pretty much was the own. Yeah, well, I am still the only one and my dad's family. So my dad's actually Welsh, so he's from Wales. And, and then after my diagnosis when he spoke to one of his sisters back home, and she said she could remember their grandmother taking insulin. So possibly, it would, I think that would have been my great grandmother. So she's about 20 years older than my dad, but she remembers her dear grandmother taking insulin and back boiling the syringes and that kind of thing. Okay. Wow. But otherwise, no, there's

Scott Benner 1:01:47
no the only connection. So you really are on your own to, to do this and figure things out and extra because you're, you're living somewhere. Were you born in South Africa?

Unknown Speaker 1:01:56
Yes. Okay.

Scott Benner 1:01:58
So your dad was from some was your dad for somewhere else or?

Shirley 1:02:01
Yeah, my dad's from Wales,

Scott Benner 1:02:04
Wales. And he made it that to South Africa that started a family there. Which is why you're blonde, but short. Is that right? Is your mom from South Africa? Originally?

Shirley 1:02:15
I Yes. My mom's from South Africa.

Scott Benner 1:02:17
I figured it out already. That's right. You got the blonde from your mom, the short from your dad, am I wrong?

Shirley 1:02:22
No, my mom's actually got dark hair. My dad was the blond one.

Scott Benner 1:02:25
Have you ever considered just agreeing with me? Surely. So it seems like I know what I'm talking about. I mean, really wouldn't have been that way. At the end of the episode, you could have really made me seem like a genius and been like, Oh, my God, it's got you figured it out? It's amazing that I obviously, I'm, I don't know what the hell I'm talking about. But you have, you've painted a really interesting picture that I think people should, should wrap their minds around a little bit that, you know, I see people here. And there are certainly people in America who are in, you know, just similar situations financially and with their ability to get insulin, especially and, and technology for sure. And then there are people who, you know, like us are just, you know, we're able to get this stuff because we have the insurance. I mean, if we lost our insurance tomorrow, it would be out of reach. But it's interesting that the problems don't change from place to place, the idea of you know, not having the right education not having the right understanding, then the tools, it's, it's a, it's a worldwide problem, you would think it would be since it's such a similar problem from place to place, the place you would think it would be something that would be fixable, but I guess in the end, it just really does come down to money. And who's gonna pay for it? So

Shirley 1:03:46
Yeah, it does. I mean, I think every suppose every country in some way has the has similar situation, similar problems. Some people have access, some people don't. So it's not only one place in the world that has the problems. I think we all have similar problems. Right. Um, but yeah, I wish it could be fixable. And I mean, there's I think there's two ways it could be fixed, I think strengthening public health care services. Having programs in place because yeah, programs do actually work in public health care. We have other programs for other conditions and things that actually do work. And yeah, so having a specific program in place could be something that could work for the public health care as well.

Scott Benner 1:04:39
Yeah. I hear crickets in the background. It's very relaxing. Are you outside? No, I'm a Windows just open and just have it just I'm like it's just making me very happy. I'm like, Oh, it's lovely. In my mind, you're in the Serengeti. I know you're not but if you could just let that be like that. I would appreciate it. Thank you.

Shirley 1:04:56
Lions outside my door.

Scott Benner 1:04:58
I've been that you know of Say a bear walking through my town the other day and trust me, that's not something that normally happens,

Unknown Speaker 1:05:06
I think. Yeah,

Scott Benner 1:05:09
I think everybody stayed inside for so long because of COVID-19 that the bears were like, Huh, I wonder how far we could get. How? Let me finish by asking you has Coronavirus been very impactful there.

Shirley 1:05:20
Um, yeah, so we got our first case cases in March, which came from people that had traveled. Well, I mean, those are the cases that were tested and they came back from people that traveled in Italy. But I mean, for honestly, we actually don't, I don't think you know, when it actually into the country. Um, we were put on by the end of March we'll put on to it was meant to be a three week lockdown, very strict lockdown, just essential services. And then basically staying at home you couldn't go anywhere and except about food or access medical care. That was extended for a further two weeks so and then in the beginning of May, I think we went to what we've called level four lockdown, which then we're allowed to exercise between six and nine in the morning. And the our that was about it. And then from Monday, which was the first of June we now and what we calling level three, everybody's gone back to work. And basically they've asked us to stay home as much as possible only go up for essentials. In our strict lockdown. Alcohol was prohibited. So there were no sales of alcohol that opened on the first of June. So everybody flocked out but alcohol and cigarettes have still been prohibited. There's no sale of cigarettes. And yeah, that's that's where we are at the moment.

Scott Benner 1:06:47
I found it odd here that they we made we made alcohol an essential thing. So a liquor store was essential. And they stayed open, but they closed meetings. So like there was no a meeting. So Alcoholics Anonymous meeting sounds like that's not that doesn't seem balanced. And, but it does. It did really tell you like I think they're like oh, we're gonna lock all these people in their houses. We better at least give them booze because

Shirley 1:07:14
we got no booze at all. Well, what you stocked up and people thought it was only for three weeks. So yeah, weren't very happy. Most people have been home brewing their own beer. Um, but yeah, I think sustainability of the lockdown especially in our country financially, we couldn't sustain it. So they have allowed everyone to go back to work now but it's really created great job loss. Terrible major financial impacts on our country. So yeah, we're gonna have to try and recover from that. Yeah. And then in terms of like our numbers, I think we setting on 30 odd 1000 people at least 50% recovery rates so far and I think our death rate something about 2%

Scott Benner 1:07:58
I know I would the unemployment. I don't even think you people know the full extent of it yet. Like there are people right now in America who are home who are like, oh, when this all is over, I'm I'll go back to work except they're gonna go back and their jobs not gonna exist because the company

Shirley 1:08:13
exists. You know, unfortunate. I mean, it's not only for us. I don't think any country can sustain these lockdowns. Yeah, that's just really not sustainable. Like financially, it's not sustainable. And there's a lot of criticism about lockdowns should we be locking down? Shouldn't we is criticism about so we have to now wear masks if you're out in public, exercising anything like that? I'm supposedly supposed to practice social distancing. But that's just up to an individual if you do it or not, we still not allowed to, well, we're not supposed to visit family. So yeah,

Scott Benner 1:08:50
I haven't seen my mother things. I have not seen my mother in like, four months. And I was talking to her last night and she's in her mid 70s. And I started thinking like, you know, at what point are we protecting her body and breaking our mind? You know, like, I got to figure it out.

Shirley 1:09:06
Yeah, I mean, it's very difficult. And I do think for the elderly, it's actually not good for them to be isolated from people. Like it's just not just the elderly, for anybody to sit isolated by yourself, especially if you live alone or something like that. It's not good for you. It's the interaction with humans.

Scott Benner 1:09:26
100% I could use a hug once in a while. So all right, well, surely I know. It's what time is it there by the way?

Shirley 1:09:34
It is almost 20 past six in the evening.

Scott Benner 1:09:38
Wow, that's lovely. Sounds very nice. Well, I I am, I really appreciate your reaching out and doing this and taking the time and adding another perspective, to, you know, to the chorus of episodes. And, you know, I appreciate this very much thank you for, for finding the show and for and for wanting to add to it.

Shirley 1:09:58
Thanks. Thanks for having me as well. Always a

Scott Benner 1:10:00
pleasure. It really was. A huge thank you to one of today's sponsors, g Vogue glucagon, find out more about chivo chi Bo pen at G Vogue glucagon.com forward slash juicebox. you spell that GVOKEGL you see ag o n.com. forward slash juice box. Thanks also to the Contour Next One blood glucose meter. Check it out at Contour Next one.com forward slash juice box. And don't forget that you could bring real advancements to type one diabetes by just going to the T one D exchange at T one d exchange.org. forward slash juicebox. And joining the registry was anyone else really bummed out that truly had never seen a great white shark?

#413 Thyroid Disease Explained

Adi Benito, M.D.

Adi Benito, M.D. explains thyroid disease and its treatment.

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:07
Hello, everyone and welcome to Episode 413 of the Juicebox Podcast. On today's show, I have Dr. Adi Benito, and he's gonna share so much information today about thyroid disease, you're going to just understand it from the back by the time you're done. If you're living with type one diabetes, and don't currently have thyroid disease, I still think this episode has a lot to offer you. Please remember that nothing new here on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan, or becoming bold with insulin. Dr. Benito is board certified in endocrinology, diabetes and metabolism. addict attended medical school in Spain and completed a residency in internal medicine at Pennsylvania hospital at the University of Pennsylvania health system and a fellowship in endocrinology, diabetes and metabolism at the University of Pennsylvania. She has also completed a two year fellowship in integrative medicine at the University of Arizona Center of Excellence in integrative medicine, where she is a guest faculty member, and has developed the curriculum for an integrative endocrinology module, which has been incorporated to the fellowship. This episode of The Juicebox Podcast is sponsored by the Omni pod tubeless insulin pump, you can get yourself a free no obligation demo of the Omni pod today by going to my Omni pod.com Ford slash juice box. And to learn more about the Dexcom g six continuous glucose monitor, go to dexcom.com Ford slash juice box become acquainted with the great work that's done at touched by type one at their website on Facebook, or Instagram touched by type one.org

Adi Benito, M.D. 2:00
My name is Adi Benito, I am an endocrinologist and I in particular practice what are called integrative endocrinology, which is using hormones as well as nutrition, herbs, botanicals and supplements. I studied herbal medicine, as well as integrative medicine. And that's what I practice.

Scott Benner 2:22
All right now, I found you because my daughter was diagnosed with hypothyroidism A number of years ago. And people who listen to the podcast knows she's had other ailments like just joint soreness and things like that. So we have tried to thoughtfully break Arden down into segments and and go through them slowly and try to pick through them because I found that when you try to go with everything at the same time, it gets confusing, right? There's you never know if if the success or failure you're seeing is anecdotal or if you're misunderstanding where it's coming from. So we obviously I mean, the podcast is wrapped around using it. So when we first figured that out Arden's a one C's been five to six for about six years now. sheets, whatever, you know, she don't limit her, her nutrition to get her to that. Which might mean like yesterday, Arden had a pretty big salad for dinner and the day before she had a lawful. So she'd survived a wide variety of foods. But our first run in Well, before we knew you was she got her she started with Synthroid, she got Synthroid, all of her symptoms went away. And Arden symptoms By the way, when when we figured out she had hypothyroidism was she basically couldn't hold her head up anymore. It was just like she was on a dimmer and someone was turning her down slowly and she just didn't have the energy to come back up again. The Synthroid brought her right back. And then she grew significantly, which I'm going to ask you about later if it's common or not. But Arden was at one time the smallest child in her school. And she is now probably one of the tallest girls in high school, which is fascinate. She went from like five when she was five, one, maybe 75 pounds. And she went to over five, seven, like 130. Yeah, so when she started having these joint issues, we thought, Oh, it's because she's growing so quickly. And then she stopped growing. And that didn't end up being it. And, you know, then you kind of go back to your endocrinologist that handles the diabetes, like maybe you know, is the thyroid medication not right. I hear from a lot of people that it's more of a science, it's more of an art than a science and, and none Oh, it's fine. Her labs look good, which was always the answer, right? She's in range, right. And then a person who listens to the show, who I've had come a little friendly with Vicki said to me one day that her thyroid issue was always a mess until she started to think outside of the box and she told me that the way she did that was to Find a doctor who would be more thoughtful and holistic about it. And that idea led us to finding you. So I told people I was gonna ask you to come on the show and I know I sent you the questions and they asked a ton of questions, but I think before we get to them and maybe like you said in your note, possibly a lot of these questions are gonna get answered while you're speaking. Can you can you please just do what you do explain hypothyroidism, hyperthyroidism? hashimotos this whole thing that no one seems to understand. Yeah.

Adi Benito, M.D. 5:35
So, if you think of thyroid, thyroid disorders, the most common are those of thyroid function. So these function the thyroid and that includes both hypo low thyroid and hyper high thyroid. So within dos hypo is more common hypo low thyroid is more common than hyper thyroidism. In the whole world, when we talk about hypothyroidism, the most likely cause is iodine deficiency in the entire world. Now in the US, because we still are considered iodine sufficient, meaning we still have enough iodine in our diets in general, the most likely cause of hypothyroidism is autoimmune thyroid disease. And that is hashimotos thyroiditis. The second most likely cause is actually radiation, both external beam radiation so what would you would have if you had cancer or your neck or former, but also radioactive iodine, which patients with hyperthyroidism actually are treated with many, many times. So within the realm of owning immune thyroid disease, hypothyroidism is one aspect hyper is the other. So it means our disease encompasses both hashimotos thyroiditis, and Graves' disease. hashimotos thyroiditis tends to cause hypothyroidism. Graves disease always causes hyperthyroidism, until later on in the disease, or because of the treatment, you can end up with hypothyroidism. There are some patients who have hashimotos thyroiditis, who will develop hyperthyroidism, and we call that Hashi. toxicosis, toxicosis meaning just too much. So, autoimmune thyroid disease, like any other autoimmune condition is purely genetic, and probably environmental of the genes that cause autoimmune thyroid disease, we've have really advanced tremendously. And if you look at the genes that actually are linked between autoimmune thyroid disease and type one diabetes, there are many common genes. And that's why actually, those two conditions happen in clusters in families to have one member with type one diabetes, and a different member of the family with autoimmune thyroid disease. If you think of the risk of autoimmune thyroid disease in the general population is close to 10%. If you have a relative with Type One Diabetes, that risk is 48%. Much higher, well,

Scott Benner 8:07
that's almost a significantly higher, that's almost a

Adi Benito, M.D. 8:09
s. Yep. And if you yourself have type one diabetes, the risk of having autoimmune thyroid disease is 50%. And if you have autoimmune thyroid disease, the risk of developing clinical disease so either hypo or hyper, is also 50%. So think of for people with type one diabetes, two of them will have autoimmune thyroid disease, one out of the four will develop clinical thyroid disease. Now, autoimmune thyroid disease, usually is characterized by antibodies. So getting these protein that your body makes, usually to defend yourself, but in the case of autoimmunity is sort of like attacking your own body. Right? So antibodies are sort of the hallmark of autoimmune thyroid disease. However, they is up to 20% of people with hashimotos who don't have antibodies. So not having antibodies doesn't mean you don't have autoimmune thyroid disease. But if you have the antibodies is a marker for autoimmune thyroid disease. So finding them is helpful, not finding them not that helpful.

Scott Benner 9:19
That makes your job interesting.

Adi Benito, M.D. 9:21
Right? It does, yeah. Because then you have to think, am I seeing autoimmune thyroid disease that is not showing with antibodies? And sometimes I may use an ultrasound to tell me that or am I seeing nutritional deficiency? So I then deficiency and maybe iron, which is a cofactor, for iodine in the production of thyroid hormone. Yeah.

Scott Benner 9:44
I have to say that, given that I'm beginning to understand why most people can't seem to get to a resolution that is valuable, completely valuable for them, because having worked with you for art and for Kelly, the internet 30 of our interaction in time and and information and they're not being large gaps in between when we spoke I found to be It was exciting actually, because I felt like this was the I felt like my, our interaction with you was sort of like other people's interaction with a podcast in that it wasn't. I'll go to the endo, they'll test my agency, I'll make some adjustments come back in three months notice nothing happened. Try again. Two years later, my a Wednesday, still seven and a half. It was the intensity and the ability to get to you more directly, because you have a an uncommon practice if you're completely private practice, right? So yes, like we paid you in cash, like you don't take insurance. But with that comes the ability to send you an email, which is lovely, because then there's no big gaps, and you can move along kind of quickly. I guess my question to you is, why is what you know, so difficult to find? When the issue is so common?

Adi Benito, M.D. 11:07
It's a good question. I don't really know the answer, to be honest, I mean, I practice I was part of pen for me, I try not pen and then work the pen. And I have to tell you that when I worked up pen, you know, you have we usually with somebody with hypo or hyperthyroidism, we assume that it's autoimmune. We don't tend to test for antibodies. I don't even remember testing people for other autoimmune conditions, which now is part of my routine practice. If I find somebody with autoimmune thyroid disease, even with that type one diabetes, I will be screening those patients for celiac, as well as for something called autoimmune gastritis, which can lead to low iron and low b 12. And many times, it's actually the cause of their symptoms, not the thyroid itself. So you have to think of the person in its entirety. It's not just one aspect, especially when you're thinking about immunity. Because it can affect many parts of you of your body. And if your life, I

Scott Benner 12:01
don't know, how much of the history of this disease that you're aware of, I'm assuming more than me. So I'm gonna ask, how is this becoming more common as time goes on? Or is it just we're noticing it now? No, no.

Adi Benito, M.D. 12:13
So even type one diabetes, we're finding that is, you know, people are calling that an epidemic in the 21st century. And you would think, you know, when we talk about autoimmune conditions, we're talking about genes, but we're talking about environment, there's a complex interaction between genes and the environment. Now, the genes don't change that quickly. You know, in just 100 years, the genes are not going to change that are going to make somebody half more likely to have type one diabetes, and, you know, hundred years ago, so there's something in the environment that we are, we're not, we're not sure what it is, you know, it can tell you that we definitely think of viruses, we think of bacteria as triggering those genes to sort of manifest and cause the conditions. We, for in the case of the thyroid, having too much iodine, we know is a risk factor for developing both autoimmune thyroid disease. And for developing hypothyroidism, maybe you have hashimotos. So just making sure that you don't take any one supplement from the store just because it says iodine, and you think it's good for you. Now, it's a little hard to overdose with, you know, food. So you don't have to worry about whether you're eating too much fish or shrimp or you know, normally, that's not going to happen, it's more with someone. So it's that complex interaction between the environment and the genes are, we're still trying to understand, we've made some advances into the genes, we don't really understand what in the environment is causing people to develop motilium diseases, I would bet that there's a lot of endocrine disrupting chemicals we call them. So these chemicals in the environment that disrupt how hormones work, that probably have a role in this increased prevalence of autoimmune conditions.

Scott Benner 13:49
But it builds you imagine it builds over generations, not just like, my mom used Tupperware, so my daughter has diabetes, like, Yes, okay.

Adi Benito, M.D. 13:57
No, no, he actually goes, Yeah, you can see that's, transgenerational, you can see that. So you actually see in there Stephanie studies in the grandmothers, they use these Teflon pans. So this coated pans are the non stick ones, and then their granddaughters developing diabetes and mean, these obesity. So they actually goes through generations. Wow, that's, that's the really difficult piece about this. endocrine disrupting chemicals is not just what you're exposed to is what your grandparents might have been exposed to. And that it transmits to you.

Scott Benner 14:28
Have you tried to make a ridiculous example to make a different point you're like, no,

Unknown Speaker 14:33
that's right. No, no.

Adi Benito, M.D. 14:34
Yeah. You're you're into something.

Scott Benner 14:37
Okay. All right. So but it is it is that is it more prevalent here? Because I guess that makes sense. And if it's more prevalent in the US the auto immune piece of this, it's probably because we're more quote unquote, advanced and things like, like you just said, like a nonstick pan or I mean, should people be throwing their nonstick pans away? Do you own a nonsense? Like, man is my question.

Adi Benito, M.D. 15:01
I don't know. I don't know. I don't know. I don't I actually think people should throw him away. I think, yeah, I think you can use other pans that are nonstick.

Scott Benner 15:11
Yeah. I did that with, um, it's funny like it like 10 or so years ago, I just said to Kelly, I'm like, I'm getting rid of all these nonstick pans. I'm just gonna buy like, just regular, you know, stainless steel? Yeah. And she's like, but I like them because they don't stick and I'm like, I don't care. I'm like, well wash them. It'll be okay. You know, like, it just, and I don't know why I didn't know anything. When I did it. It was really just a feeling like, you know, your daughter gets type one diabetes. All right, well, let me start thinking about how people live before this happened all the time, you know, and try to go backwards a little bit anyway. Alright, so obviously, the people listening to the podcast are into the, you know, in the sweet spot for, for this issue as well. And I'm hard pressed to know, you know, anybody who doesn't have type one diabetes, who doesn't also have another autoimmune issue. It's not always thyroidism but have different different issues with their thyroid. But when people are diagnosed with type one, it's sometimes the very first time they realize that there's autoimmune problems in their family line. It's one of the questions I ask every time I talk to somebody, I'm like, you know, were you the first one? And oh, yeah, I was definitely the first one. Nobody has celiac. Oh, well, my grandmother does have celiac. Oh, like and then you start finding you can see it, you know. But anyway, when it becomes obvious to them that there's an issue, they start becoming more hyper aware of other things, they start paying attention. So what are the kind of telltale signs that people should be looking for if they're thyroids on its way out?

Adi Benito, M.D. 16:47
So what you notice with Arden is pretty common lack of growth. So that's pretty typical, both actually type one or even with that type one diabetes, kids who have thyroid disease will not grow. So that's pretty common. If you have a child with Type One Diabetes, in addition to not growing, they actually may develop more hypoglycemic episodes. hypoglycemia is a big one. And that's really that's a pretty big one for almost any other autoimmune condition with celiac, whether it's Addison's disease, which is the lack of adrenal hormone, thyroid, actually both even hyperthyroidism sometimes can cause hypoglycemia. It can also goes into the ketoacidosis part. But so hypoglycemia, when before you had a child that was well controlled, suddenly, with the same, you know, whatever you're using is causing hypoglycemia and more episodes, that should be a sign that something is not quite right. Either your kid is not absorbing glucose well from their gut, and there's some gut issue like celiac or autoimmune gastritis, or your metabolism has changed and metabolism is affected by thyroid. Wow. Okay.

Scott Benner 17:49
All right. So now, here comes the issue, right? I noticed that I go to the doctor, hey, I was listening to a podcast. These people told me that if this was happening, it might be thyroid. My kids seems to fit the bill. I fit the bill. And I test and then the doctor comes back and says, No, I'm sorry, you're in range. Now, we knew what to do when arm was tested, quote, unquote, in range and had symptoms but we only knew because my poor wife went untreated for I think, seven years, while while honestly while hypothyroidism ravaged my wife. It really it just it just really decimated her. We would go to doctors say Look, she has all the obvious signs of this. They test her and say she's in range. It's not that it was was honestly one day in an office. We were so desperate. I wouldn't say I threatened the doctor. But what I what I said was, will the medicine hurt her if she doesn't have hypothyroidism? And he said no, and I'm like, well, then for God's sakes, give it to her. You know, and I'm not gonna I there's no reason to over exaggerate between four days in a week, turned back into the person I know. It was it was really, really fascinating. But some of the stuff that happened to her she just she's having trouble like still to this day rebounding from, but because of that experience, when the doctor said No Arden's and range, I said, I don't care. Give her Synthroid, and boom, she came right back. But not most people. Most people aren't assholes, like me, I guess is what I'm saying. They're not gonna sit there. And just be like, No, I don't care. Because that's a real problem, that white coat problem, right, like people won't stand up, they won't push back. What do you use? Like if you were a doctor in that position? What argument would get you to think all right, I will say these people and try this.

Adi Benito, M.D. 19:44
So the first one, I will look for some goiter with that person had a goiter enlarged thyroid gland, that to me will be a sign that the body's really trying to do something they can't. Right so you think of a goiter. The theory has become enlarged and there's a reason for that either. You don't have enough iodine. You don't have enough thyroid hormone. Something is going on. If you have a history of autoimmunity, if you have either autoimmune thyroid disease already, you already have antibodies. And I see nothing else, you know, I'm going to be looking. So what I want to make sure when it says somebody who has, as you say, maybe perfectly normal thyroid, and we'll talk about what normal really means. I want to be sure that I'm not missing something else that I could be treated. So whether you're iron deficiency, which I think is very common in women, not just anemia, you don't have to be anemic, to have iron deficiency and iron deficiency causes many symptoms that you see with hypothyroidism. So brain fog, fatigue, muscle fatigue, ability, hair loss, all this happened with low iron, similar to low thyroid so that I'm going to look for definitely my practice. But then if somebody comes to me, and I've looked at everything, and I don't see anything, I just saw a woman recently who was feeling really not well, she was having joint pains. I actually sent it to a rheumatologist thinking it was an autoimmune, rheumatoid condition. And I knew that this woman had hashimotos, she doesn't have antibodies, but she has the look of autoimmune thyroid on her ultrasound of the thyroid. So when she came up in there, with tears in her eyes, saying, you know, she didn't find anything. I said latency without reformer, it's not gonna hurt you. I know how to do that. I'm not going to hurt you. Let's see how this works. lifted your trial, there's nothing wrong. Just like with Kelly with your wife, you know, within a few weeks, she was feeling better. So sometimes you have to bite the bullet and say, you know, have we looked elsewhere? And if we have and we have no one, sir, would it be like you said, Would it be wrong to do auto pharma? Would it be wrong? Again, if you know how to treat with every hormone, there's, there's no wrong, there really isn't?

Scott Benner 21:40
Well, after Arden's big growth spurt, she began to say interesting, I'm kind of telling the story. So people understand how your brain will trick you, she starts having the same symptoms again. But because in my mind, now she's on Synthroid, this must be a new thing. It has nothing to do with a thyroid hormone. I don't know why I still in retrospect, can figure out why it didn't occur to us that she'd put on so much weight that our dose probably wasn't high enough. But there she was, again, struggling to get out of bed, struggling to make it through the day at school, she'd come home and come like, I have so many pictures of Arden asleep at a countertop, like sitting in a bench chair, wow. Weighing forward asleep on a piece of stone, you know, which is you know, just out. And then her blood pressure started to fall. And we went to the doctor. And then the doctor saw the low blood pressure and their mind went right to heart. And now we're spending weeks going to specialists giving Arden tests, maybe she has I forgot one of the things pots maybe or something they had a raising her legs and doing all this stuff. And it took me a couple of weeks. And I finally said to Kelly, I'm like, this is just the thyroid medication. Like why did we not think of this? So I said to the doctor, well, let's test for this first and check on this. Maybe we should get her down to children's. And I'm like, whoa, wait a minute. Why don't we just adjust this? No, no, her labs are okay. And so one day I just said I don't care. And I took a bunch of pills. I didn't know what I was doing. I cut some of them in half. And I started giving her a pill and a half. And in a few days, she was okay. And I called her endocrinologist back before you and I said look, like it or not. This is what I did. She's alright. Now I need a different prescription for. Again, I don't think that's something most people would do. But I don't think you're right. I just have this. And it's the diabetes. I think I've been trained by having a child so young with type one diabetes in another medical area where people don't give you a ton of good actionable advice, right? So it just has come to me and I'm like, Look, I'm not waiting anymore. Like I'm not I just I took everything I knew when I thought I'm not going to hurt her. I'll give her a tiny bit more. She pepped up now it's really important after that to like find out, you know, you got to get labs done, because too much as we you know, throws or the other direction, which is obviously not not gonna work as well. And I'm not saying people should just willy nilly take their medication. This is just what happened here. It was a, you know, it's a good example of my labs look good. So it can't be bad. And this just seems like one of these issues that doesn't play by those rules frequently. What else goes into it say we have our thyroid medications good. Talk about the the supplements and the vitamins that that you like to incorporate as well?

Adi Benito, M.D. 24:35
Yeah, so somebody has an autoimmune thyroid disease. We now have several studies, looking at the use of supplements, minerals, vitamins to help and I'm going to say that none of these have been shown to help prevent thyroid disease. So in other words, if you have antibodies and you're looking for ways to protect yourself from developing thyroid disease, these have not studied haven't been studied and so we don't know that will prevent you from developing thyroid disease. But once you have autoimmune thyroid, and your thyroid levels start to to be a little bit off. Things like Selenium. Selenium has a lot of studies on autoimmune thyroid disease in particular in Hershey motors, but there are also studies on graves disease. Most of the studies on Selenium are positive studies, meaning they have a beneficial effect. They help with the antibodies, they help with the way the thyroid looks on the ultrasound. And they also help with well being. So to me, that's usually something that I will use in people with autoimmune thyroid disease. In the beginning, when the studies were done, the doses that were use of selenium were quite high, but about 200 micrograms, and it's part of the country we're not really deficient in Selenium. So the concern was good Selenium. Because high Selenium can also be linked to type two diabetes, not type one, type two, but also glaucoma. Most Recent studies don't seem to indicate that that's as much of a concern as we initially thought, but it's still you know, one issue I'm not giving somebody too much Selenium. Most Recent studies on Selenium have even used 80 micrograms, which is what you probably find now multiple vitamin with Selenium. That's a pretty nice those for autoimmune thyroid disease. That our study is not using a combination of selenium and something called Myo inositol. inositol is substance if someone's in the beef trifecta B vitamin, but it's in the B family. And it's both a thyroid hormone sensitizer and an insulin sensitizer. So it's been also used in patients with Hashimoto thyroiditis, and the combination of selenium about 80 micrograms with inositol, it really helps people bring the TSH down, it also lowers the antibodies. There, of course, we know about the connection between vitamin D, and thyroid as well as type one diabetes or something with a vitamin D receptor, that there's something that is not completely right. So I'll also use vitamin D to help with this or immunity of the body. And then there's there's a study a couple of studies on something called black cumin seeds, and that is the, the herb or the seed itself is called meet gala, sativa. And black cumin seed, as a seed itself as a powder has been used in people with hashimotos. To help them with their TSH also help with their cholesterol. And as well as weight, it helped people lose weight, when that was used after two months. Those are probably the ones that we have the most data for. And the ones that I will use more commonly, I also talk to people about not having too much iodine as a supplement. But enough iodine because again, I get that it's important for thyroid hormone production. So just enough, not too much.

Scott Benner 27:45
Well, I have to say, I just want to stop you for a second. It's so nice to hear information like this coming from someone with your background and I not that other people saying things like this, you know, aren't writer or well informed. But when we hear supplements, I think people tend to think oh, hippies, quacks you know, like, like that kind of thing. Nobody really thinks about, you know, the medical field paying attention to stuff like this. And you're a, you're a legit Doctor Who has a has a really impressive background, and through some of the institutions, you've been out as well. And so I'm glad you're talking about it, because it really is. I mean, look, I know nothing about nothing, but COVID came, and I went out and found a good source of vitamin D, zinc, and a couple of other basic vitamins, and I was like, I'm taking these, I don't care, you know, like, and I've done really well over the last nine months or so.

Adi Benito, M.D. 28:43
Yeah, I think, you know, it's always the question. And that's one of the answers when I studied at universities on on my board of medicine fellowship, you know, it's always about risk versus benefit. So to the semedo, we're talking about the thyroid hormone before for organ, you know, or for my patient. What's the risk? What's the benefit? The same thing with supplements? What's the risk? What's the benefit? My concern with specially with botanicals is are you taking other medications? And are they botanicals going to interfere with your medications are they going to interact? That to me is a big concern. I treat herbs like I treat medicine, they are medicine, they should be treated as equal. I you know, I think it's really funny when somebody will say oh, this herb is gonna cause some interaction with your medicine, but it's not really worth it, it's not really going to do anything. My point is like if it's able to cause any interaction is able to come action. So, you know, it's there. I think when I started working more different integrative, integrative practice. There was not a whole lot that I could actually offer patients. I mean, I could often botanicals that have used you know, the herbalist have used for millenia, but there wasn't a lot of there were not a lot of studies that you know, except for Selenium and vitamin D there was not a whole lot that had come out. Now we have studies like a talk on inositol we actually have cited on ashwagandha and on in particular for hybl for Excuse me for Hashimoto for hypothyroidism. ashwagandha seems to work. You know, up to a few years ago, we only have studies on animals. Now we have studies on humans. So I think there's actually more of an interest as well in the in the researchers in trying to understand how this botanicals and supplements do work.

Scott Benner 30:16
Well, I, I'm Emma, what you said just makes a ton of sense to me. I think it's labeling that confuses people, right. So if if a substance is controlled by the government, and therefore it can be, you know, manufactured by a pharmaceutical company, and then sold to you through your insurance, that's a reasonable thing to take. But, you know, this thing over here that, you know, we can't make any money off of that must not be valuable at all. And I just don't think that that's the case. And maybe it is for some things and not for others, I'm sure there are plenty of prescription medications that are not as valuable as people say they are. And vice versa, but that it's being looked at by people who are thoughtful about it, is the part that makes me excited. You know, it's not just somebody yelling, try some dandy lion, you know, they mean, like, yeah, you know, I took it once, and I felt there's a basis for it. Right? Right, there's a real reason to think this thing, like you said, is causing an action, and is that action, something that's valuable for the person taking it. And if it is great, and if it's not, whatever, great, you know, like, I was told, and you know a bit about this, because we've had to talk about it about art. And but over the last two years, I've been struggling with not being able to retain iron in my, in my sister, my ferritin drops really, really low. And I was told this is genetic, you're not going to be able to impact this with with Don't even try, you know, with any kind of supplements. But what I did was I researched, well made vitamins. And I started taking an iron supplement along with an A sorbic acid at the same time. And voila, turns out I can absorb iron. If I take a supplement. Right? I was being told you can't you can't, your body won't do that. And it was true. I was taking the iron and nothing was happening. Add an absorbent acid to it, boom, suddenly, my body can take it up. Why don't even care why it just works. So I now I actually had to be careful. Like, I got my next blood tests back and my heart was so high. I was like, well, it's working too well. And you know, and so I cut it back. But it's an example.

Adi Benito, M.D. 32:22
I mean, invest something. Yep, it is. And I think if you if you understand a bit about how people who have autoimmune thyroid disease, type one diabetes, sometimes both beside risk for these immune gastritis, which is really the lack of stomach acid. And because you don't have stomach acid, you actually don't absorb. So that sort of what you just said, Yes, brings me to think of, you know, people also thinking about that potential complication or another quick system, autoimmune condition that may not allow them to absorb iron or be 12, or, you know, anything else really, right. So it's really important to be aware of that. Apps. It's,

Scott Benner 33:04
I feel like I'm doing better now. Like, I feel like I'm slowly moving into the best health of my life, which is ridiculous, because I'm not in like, I'm not, you know, not working out constantly. I'm not one of those people not like micronutrients and things like that. I'm just living a pretty normal existence. But just prior to this, I had issues. And I had such a blue collar mentality about it, like, and by that I mean, like, put your head down, keep moving forward. Don't stop do this till you die. Like don't give up you know, anything like that hurts. Don't think about it, can't lift your head up. Don't worry, keep going, keep going, you know, and, and now I'm like, you know, I'm not gonna make it much farther like that. Like, it'll be an impressive story for the five people that remember me. But I'd like, you know, I don't want to keep going. Like, yeah, it turns out he had no, yes, we do take that as like, we're badges of honor to you go to the doctor. And they say something like, I don't even know how you're standing. And you're like, that's right. Yeah. I'm standing right person was 13. Scroll my life. Yeah, right, right. But meanwhile, I wasn't standing, I ended up in the emergency room eventually, because I bent over to pick up, my head almost went to the floor along with my hand, I was like, ooh, I just couldn't stay a lot more. And then, speaking of anecdotally, then we start having everybody in the family tested, just to see what's up, you know, and Ardennes ends up being really low too. But then we kind of realize that might be because of heavy bleeding from our periods. So we get our jack back up again with an infusion and she is still drifting down, but she's not falling the way I want. She's not going from up to down. And so I think the assumption is going to be after one more blood test that Arden is going to need to take an iron supplement, as well probably along with an absorbing gas and maybe a couple of times a week, but and I say do this all the time about the podcast itself. And I know you don't listen to the show, but this podcast helps people use insulin. It's really valuable to them. But I only came to the information because of luck. Stay at home dad, my background aligned with being able to kind of figure things out. Most people, this stuff is just coming at them a million miles an hour, they do what they're told when it doesn't work, they go that didn't work, they walk away from it. Most people don't come to an answer. And that's the that's why I wanted to have you on like, I want to teach people how to come to some sort of a resolution when they find that they have a thyroid issue. And most people aren't going to find you. I mean, I I basically had to beg you to see art and you were full. You know what I mean? When when I found you? Yeah, and most people aren't thinking about these things. So where do you think the conversation should go from here? Do you think we should jump into people's questions? Or do you have more you'd like that?

Unknown Speaker 36:01
Yeah. No, you're like I got them, we can do that.

Scott Benner 36:06
The dexcom g six continuous glucose monitor is the tool that I lean on the most for making decisions about my daughter's insulin. We use the information that Dexcom provides. And that's what her blood sugar is. And what direction if any, it's moving in, not just what direction, but how fast in that direction. So I can tell is this an 85 blood sugar that's super stable, where's it falling, or rising, knowing that makes bolusing bazel adjustments and meal times so much easier. You can learn more about the dexcom g six continuous glucose monitor@dexcom.com Ford slash juice box B can't remember that there are links right there in the show notes of your podcast player. And at Juicebox podcast.com. Check out the Dexcom g six today are using pens or syringes. And thinking about trying an insulin pump. My suggestion would be to try the Omni pod tubeless. And on top, it's the only pump without tubing. And it's super simple to wear discreetly if you'd like. The great thing about Omni pod is that you don't have to take my or someone else's word for it. You can actually try Omni pod, we'll send you a free no obligation demo of their insulin pump so that you can wear it around the house or wherever else you are. Although let's be honest, we're all pretty much around the house right now. And see if you like it, you'll be able to put it on. Go about your days. bave Oh yeah, you could bake with it. And you could actually swim with it if you wanted to. Omni pod allows you to continue to get your insulin, even during bathing and swimming. It's the only insulin pump that can say that. So if you're currently on MDI, and you're thinking, yeah, I mean, I'd like a pump, but I don't like that idea of not having my bazel and some all the time. With Omni pod, you absolutely can. And you will. My daughter has been using an omni pod tubeless insulin pump since she was four years old, and she's 16 right now. That means she's been wearing it on the pod every day, for over 12 years, check it out, it's super simple to do, it'll take you five minutes at my Omni pod.com forward slash juice box to get that demo sent directly to you. Last thing if you love watching people do nice stuff. For other people with type one diabetes, you should check out touched by type one.org. They're a great organization, doing wonderful things for people living with type one touched by type one.org. Or check them out on Instagram, or Facebook.

Once again, the people that listen to this podcast were really great, and asked a ton of questions that I think most of them are valuable. Why are thyroid antibodies seen in so many kids with audio immune disorders who don't have thyroid disease, and subsequently, do you expect that those will eventually end up with thyroid disease.

Adi Benito, M.D. 39:22
So antibodies might be the first sign of these autoimmune thyroid disease that again, in only 50% of the cases will lead to thyroid disease, the other 50% and we'll never develop our disease. At the same time, you actually could have antibodies that are positive just because your body has an odor immunity in it. In other words, you think of your immune system sort of like almost like fireworks, and it's almost like throwing little you know, these sort of fireworks in different directions. And one of them could be an antibody for thyroid without you having the disease without you really having autoimmune thyroid disease. So that can happen. I'm going to look at what level of antibody you have. If you're like you know a little bit high, I might not really worry that much, I may keep an eye on it. If you're high, I'm going to say that most likely is true autoimmune thyroid disease, and I'm going to keep a closer eye on you. In general, when people have autoimmune markers, so antibodies for thyroid, and their TSH is a bit off. It's more likely for them to develop therapy sees that if they only have antibodies, but not have an abnormal TSH. So it's worth it's worth keeping an eye on both over time just to make sure that you've detected

Scott Benner 40:37
but if you see those antibodies, you're about a coin flip to end up with thyroid disease.

Adi Benito, M.D. 40:43
Correct? Yeah. Okay. Can it get diabetes? It is in the case of type one diabetes. Okay.

Scott Benner 40:48
And then, how common is it to have happened? What happened to Arden and Kelly, which is they're in range, but they're experiencing symptoms? So I guess the first question is, is that common? As a as what people notice? And can we talk about what in range really means and how to interpret that?

Adi Benito, M.D. 41:07
So both? Good question. So I don't think there are any studies looking at if you're in range, how likely to have you have actually called for a disease? Is it the autoimmunity itself that is affecting you, and if you treat with our hormone, the immune system will actually do better and you feel better? So we don't really know the answer to if you're in range. You know how likely it is that you that you'll find people who need that hormone, or benefit from terraform. We don't have that data. We do definitely know that TSH, which is our main marker for thyroid function, and TSH is a pituitary hormone. So the B two eteri gland, which is our master gland, makes TSH and TSH stimulates the thyroid gland to make thyroid hormones t four and T three, I think of TSH as the thermostat of the house. So think of your third house to set your thermostat in the house is called your therapist and make enough thyroid hormone. The thermostat goes up so TSH goes up. So a high TSH is usually an indicator of thyroid dysfunction. And we use that because of the relationship between thyroid hormones. And TSH, there is this relationship that makes whenever you have a very small change in your thyroid hormone from the thyroid gland is going to make a high a big change in your TC. So it's going to be reflecting a much larger change. So when you look at the reference range for TSH, most labs will give you 0.45 to 4.5. That's your range. That's a reference range and I call the reference normal. If you look at what we think is ideal, probably a 2.5 for TSH is ideal. Alright, so 0.45 to 2.5. So we think it's ideal, if it started to see at TSR is over two or 2.5, that may be an indicator that something is about to happen or could happen or it's likely to happen. You don't know when but it could happen. We definitely are much more strict with that TSH, when a woman is trying to get pregnant, we definitely don't want that Tz to be anywhere above 2.5 sometimes or even above two. So when you kind of reference when you say I'm in range, my question is always Are you really in? Are you optimal for TSH? Are you in range, but not really optimal? Are you 3.5? Are you four? I don't think that's really optimal. I think people have up to four as we may have symptoms. So it's good to keep in mind, Where exactly are you just being normal doesn't mean that you truly are normal. And that would have been almost my first question with both Arden and Kelly, when they were when they were

Scott Benner 43:41
diagnosed. So try to think of it as the reference range, which just means where most people fall when they're tested. And an optimal range, which is more indicative of where your body is going to do.

Adi Benito, M.D. 43:53
Yeah, and if you if you may think give me a bit of the background of how that reference range was, you know, came about you'll you'll see exactly what you're saying. The bad data comes from a big large study in the US where they took a lot of, you know, people in the US and they just asked them, Do you have thyroid disease? Now, okay, you get tested, you have to know you get tested. So they said everybody, and that's what they came up with that range 0.54 or five to 4.5. Then they said, Okay, let's test people who have antibodies, this thyroid antibodies. Alright, let's remove those from now, our range. When they did that the range went from 0.5 to 2.5. That's where their weights comes from. So you don't have antibodies, you have a tier so that it's usually more in range, then you have antibodies because you probably have already developed mild thyroid disease. So the progression of thyroid disease is that you develop first the immunity, you have the antibodies or the look of the thyroid disease, maybe an ultrasound over time, that develops into having a high TSH, maybe still within range, but higher and then over time, that's his case on off rage and that's You usually get diagnosed and treated.

Scott Benner 45:02
You said that it's very important while you're pregnant. Can you give me why that is?

Adi Benito, M.D. 45:08
Yeah. So first for conception so to get pregnant, you need a good TSH, women with higher TSH will usually have. They're not able to make enough progesterone, which is actually what helps, you know, keep the baby or, you know, hold to the baby. But there's also higher risk that higher risk of miscarriage there's a higher risk of complications later in pregnancy when there's preeclampsia or other there are complications in pregnancy. When the teacher says hi, so yeah.

Scott Benner 45:38
So there's a question here that I think leans into what I said earlier about just soldiering on. And the question is, what are the health implications of poorly managed thyroid disease? And this person says, It would also be great to get an explanation of the different types of hypothyroidism, which, obviously, we've covered already. So what are the implications of just ignoring this?

Adi Benito, M.D. 45:58
Yeah, so I don't think it's good to ignore it. We definitely have no sets of levels of TSH when we think it's actually dangerous to ignore it. So if you're over seven, don't ignore it. And you're young and young, I mean, younger than 65. So younger than 65 to six or seven that increase your risk for stroke and heart disease. As simple as that. So if you are in like I said, before, you know, TSH affects fertility, it affects women cycles, women's probably tend to have cycles that are a bit heavier when the TSH is higher. But definitely Heart Heart is is a big one high TSH usually also affects insulin resistance, the higher TSH the more insulin resistance you are. And that's also been shown now with a TSH again, that is in that reference range, but it's at the high end of the reference range, because again, we know that that's not really an optimal TSH, it's been linked to insulin resistance is being linked to fatty liver, which is quite common in the population as well. Fatty

Scott Benner 47:01
livers.

Adi Benito, M.D. 47:02
Yep, yeah.

Scott Benner 47:04
Okay, so if the TSH is too high, then I could see insulin resistance. And that's especially for this population makes everything more difficult again, there's another question here. That's interesting. Most of it's been answered already. But at the very end, this person says that my daughter has T one D and celiac. I have T one D and hypothyroidism. But the last part of the question is where I want to ask the question that she says, did one cause the other? And I know that one doesn't cause the other. I know that you already said that. That autoimmune disease is kind of, you know, clustered together faster. But it's such a common question for people people have such an anecdotal relationship with what they see, like I got this, and then this happened. So this must have caused that. That's not the case, though, right?

Adi Benito, M.D. 47:52
No, the they have been a concern and having actually some initial research into whether celiac actually could cause autoimmune thyroid disease. And the third was, could people with celiac disease not absorbed Selenium? And then we talked before Selenium modulates thyroid? Could it be that when you have celiac even having a millennium and then Selenium causes autoimmune thyroid? It's never really been explored further money initial sort of question study. I think, you know, it's really interesting, right? It's a celiac, you know, somebody has a question as well on leaky gut. If you think of, you know what leaky gut represents, basically, you think of cells in the gut, the cells are tight to each other, right there next to each other, there is tight junctions between the cells. And when you absorb nutrients in your gut, from the gut into the bloodstream, they don't get absorbed in between the cells, they get absorbed through the cells. Now, imagine that those cells are not tightly together, they're separated. There's a gap between the cells, that's leaky gut, that says your cells have a gap in between them. So things that were not able to come through the cells not coming between the cells, things meaning proteins or other anything that you're you're taking those trigger a reaction in the body that has an inflammatory reaction. And those is where the idea of molecular mimicry comes in. Meaning there are things that can look like other things that your body will react against. So something comes into through the gut, in the body things that is to be something foreign, a toxic, and in the process of doing that is creamy santai to have an attack your thyroid and other organs. That's the idea of molecular mimicry and leaky gut. Could it be that celiac does something like it? We don't know that? Is it a possibility? Sure. It could be we just don't know enough.

Scott Benner 49:43
That's fascinating that the chain of events feels like it's so far away from the thyroid, get, you know, right, but the one thing creates the antibodies, the antibodies, then go do the wrong thing. That's fascinating. Our bodies are amazing and scary.

Adi Benito, M.D. 50:01
Hopefully not,

Scott Benner 50:03
hopefully not right. And so the idea really is, if you're more listening, if you have autoimmune issues, you're not going to stop them most likely. But there is hopefully a way to tame them or to draw them more into into line just to give yourself better outcomes. And not just think, because I think that happens a lot, you know, to people who, you know, for instance, don't listen to the podcast, who have type one diabetes, they do this thing I talk about all the time, I'm always telling people, please don't just say, Oh, that's just diabetes. Oh, my blood sugar just goes to 350 and stays there for a few hours. This is what happens. I have type one diabetes, I'm like, No, that's not what happens. Like, you didn't use the insulin correctly, we can stop that, you know, but it becomes, again, it happens over and over. And it makes them feel like well, this is just part of it. So if you have these thyroid issues, yes, you're going to run into a lack of understanding very likely at your doctor. And there may be more for you to do to, to get through the process. What I'm thinking is we're talking is that I'm gonna bug you for like a checklist for people to take with them, like, like talking points are so good to put along with this. Because that really is my concern. Like, we can educate people as much as we want. But if they hit a firewall at their physician, none of this is gonna matter. You know, understand, they're just gonna understand what's wrong. It's not going to help them fix it.

Adi Benito, M.D. 51:32
Yeah, I so my, my thought process. And this is not just the way I work, but this is actually from guidelines by the European thyroid Association. They talk about how when somebody has this is somebody has a perfectly normal TSH, they're being treated with a requirement to have a perfectly normal TSH, but you don't feel well. So now what right? What do you do with that? So first thing, you have to make sure that your TC is truly in range that you're really in that you know, one to two, maybe up to 2.5, you're really within the optimal range. In spite of that, we do know that patients with thyroid disease, up to 15% of patients who have a perfectly normal TSH will not feel well. And they're still have some especially neurocognitive deficits. So what's next? So first, look for other other things that can actually come along with thyroid that could be causing the symptoms. And the first one I will look for will be iron and B 12. And you could ask your doctors, could this be an iron and a beach deficiency? Could I have anything like that? I know that they're more likely people with thyroid disease, and only me and thyroid could have that. And that's about touch, you can check like you did Scott, your ferritin. And you could also take a b 12. level, that's pretty easy. Then you could ask, could this be that you have another autoimmune condition. And again, cilia can be silent, you may not have any sense of celiac. You know, as a kid, you might not grow up as an adult, you might not have any symptoms. Same with autoimmune gastritis, you may have no symptoms except the lack of absorption of certain minerals and vitamins. So it's always worthwhile asking your doctor, could this be a different autoimmune? I know that I'm at risk for autoimmune conditions, should I be checked for celiac or autoimmune gastritis or something else? And then I will go back if others have been checked, and you have no other autoimmune, your audio is perfectly fine. And I like to talk a bit about iron and a little bit. Then the question is, could you be somebody who in addition to taking legal thyroxin, which is the standard of care for hypothyroidism, should you be treated with my authority t three, is that is that a rule 43. In general guidelines, from many societies do not recommend using t three. However, there is a little spot in one in a test for by the American Association, where they say that an individual case to case basis 43 could be not maybe not encouraged, but could be thought of let's say. So some of the there was perhaps a discussion within the group that wasn't the task force. And some of the people in the test for writing this guidelines really thought that if you're not feeling well, in everything has been looked at, you could consider taking t three. Now. T three is the active hormone in thyroid so your body, our bodies make tea for our thyroid make tea for a little bit of T three, mostly t four and then t four which is again legal fireworks and pills, if you wish sort of the equivalent, t four gets converted to T three in the cells. T three is what gives you your actual energy. So we don't understand exactly why. But that are certainly people with thyroid disease with hypothyroidism who in spite of taken before in spite of having normal levels do not feel well. It's a subset of those people feel better when they take two three Along with T four. So you could then ask the question, am I a candidate for t three? Could this be something that we could explore? Could I add some t three to my T four, could I just take some t three, maybe a little bit less t four, just to make one for the T three, it's always a consideration. If you're somebody who's pregnant, I would, I would not recommend that the baby brain needs t four. And it's a bit, sort of partially impermeable to T three. So if you're pregnant or trying to get pregnant, I would not recommend t three. But if you're somebody who has cardiac arrhythmias, meaning your heart goes into an irregular heartbeat, especially when you go fast, to please not recommend because tip three is going to make those more likely to come back and to happen. But in spite of is when you don't have those is something that you could think of asking your doctor.

Scott Benner 55:45
And for perspective, t three works for my wife, but didn't work for her.

Adi Benito, M.D. 55:49
So that's exactly right. And it's completely an individualized approach. It's not really based on blood test. So I can take somebody's t three level before they give them t three, and they have a perfectly normal t three. So it's a T three levels that's in terms of it needs, it doesn't need it, t three is actually inside yourself. So you really don't get to measure that it's more of a clinical decision. And it's almost like a trial, basically, is what you have to do,

Scott Benner 56:13
as you're explaining it. And I see how detailed it is. And I have to be honest with you, I've had this conversation for years now around my wife around my daughter here today. I still think if you gave me a quiz about t three and T four, and what's making what and what my I think I'd get maybe like 70% of it right. But I do wonder if that's not part of the issue at the physician side. And especially because endocrinology is interesting, right? Like, it's such a blanket, you know, they do so much like how do you be, you know, a thought leader on this one tiny piece of it. I can see that. And for the people listening, it's confusing, you know, TSH, T, three, t four, thyroid goitre, they're like, wow, there's a lot of lingo, there's a lot of like, you know, it can be overwhelming a little bit. And especially in a society, like, let's be honest, we're a light switch society, we want to, we want the pill to go in, we want everything to be done. And that, that, you know, so having to put in the work, I think is incredibly valuable. I'll tell you that. I'm so passionate about this. Because I see the other side of it, like I know, what happens to my wife, and what happens to my daughter, if they're not managed well with this? And it really is, it's a dampening of their life. Like it really it really is it takes significantly away from them. And

Adi Benito, M.D. 57:39
perhaps they Yeah, sorry, the message is to say, Don't give up, you know, if you're not feeling well, you know, fight for what you think, you know, you know how to feel well is if you're not feeling well, nobody's going to be in your body to know if you're feeling well or not. But if you if you don't feel well keep at it. So if it's not one condition, it could be another and if it's not that then, you know, go back and say could be managed differently in the way that I've been treated.

Scott Benner 58:04
Don't give up but look for information in different places. Mm hmm. And, and I will, I will say this, there is a thing that happens when you haven't felt Well, for so long. You do forget a little about what well is because I have to say that when someone gave me an iron infusion, and I could feel its full effects, which takes a little bit of time because your red blood cells have to pick it up and remake cells again, with sufficient iron, it takes a little while. It's then hard to remember how bad you felt so resilient. We are you know what I mean? Like, yes, it's hard to go apples. And like, I know, I was tired. I know, I would run up the steps and be out of breath, which was ridiculous. But that's how bad my low iron was like I if I ascended the stairs, I couldn't talk on the phone at the same time. And you know, but yeah,

Adi Benito, M.D. 58:54
so I want to talk about about about that a little bit. You know, when most people talk about iron, they'll talk about, of your doctors talk about it and talk about red cell count. It's not what you and I are talking about, we're talking about ferritin and ferritin is how your body stores iron. So the average ferritin in us women is 22. Now, I'll tell you, adolescent girls who have levels less than 35 pass out, there's definitely data on that. And we think based on one study that for women, a level of 55 zero is perhaps optimal for energy, if you're looking for hair growth, that's about 70 to 84 ferritin. And again, I'm telling you average women are around 22 that's the average because we menstruate because we you know, children we grow and we miss trade and we'll have kids and all that takes iron.

Scott Benner 59:43
Yeah. Yeah, women's bodies are they get used up by by life in a way that doesn't get replenished all the time. And I don't know if that's some nature plan or anything but I on that You don't have to walk around tired like I had a bunch of kids. It's okay. This is not a great you know, like,

Adi Benito, M.D. 1:00:05
I agree, do something yourself

Scott Benner 1:00:06
help our medicine has improved. You should you should take advantage of it, I changed my life getting an iron infusion. And I think it's

Adi Benito, M.D. 1:00:16
a lot of my patients lives. I've definitely seen a lot of my patients for iron infusions, when I cannot get their iron up, or they're really really low in iron.

Scott Benner 1:00:26
It goes it's not pleasant. As my iron gets lower, I lose my ability to i don't know i'm not measured anymore. Everything either makes me upset or sad. Or like I just it's fascinating to watch how I devolve when it goes down

Adi Benito, M.D. 1:00:43
I I find it really fascinating you think of all the things that lack of iron can do so for women lack of funding is actually more linked to PMS premenstrual syndrome lack of funding is definitely has to do with depression lack of associated with low libido in women you know lack of iron can really cause muscle the muscles not to feel right you know somebody who's running and the starts to get tired like you did you know you're going up the stairs, I'm be short of breath, passing out feeling lightheaded. You know, all those things? I do to look like a buyer. It's really important.

Scott Benner 1:01:16
No kidding. I'm a huge fan of paying attention. A question is, can hypothyroidism hashimotos hide symptoms of a slow or late onset of Type One Diabetes like Lada if type one has started making hashimotos anybody's but it's not symptomatic, is it just a waiting game at that point.

Adi Benito, M.D. 1:01:37
So definitely type one diabetes and hashimotos are linked through these same genes. Again, hashimotos. If you don't have if you're not hypothyroid, I don't think hashimotos by itself is going to affect your glucose metabolism. But having hypothyroidism literally can affect your glucose metabolism, you know, just think of if you think of hypo as being low, just think of a low metabolism. So you're going to AppStore things more slowly, you're gonna not be able to clear medications as fast from your body. So all that is going to play a role into how your sugars are gonna get affected. Basically, Lada is actually photos a risk factor for hashimotos. They don't seem to have the same genes, it's more of our risk factors a little bit different than actually even when it's close to type one, it's not exactly type one, the genes those seem to be the same. And again, we talked before the wedding gave me Yes, a 50% chance of developing thyroid disease. If you are type one, you have type one diabetes.

Scott Benner 1:02:47
So this next question is interesting, because I think we covered some of it, but not the whole thing. The question is my son's bloodwork shows he has the markers. So the endo has put him on a low dose of thyroid. Is this a protocol because he has no symptoms? So we've talked about if you're, if your ranges, quote unquote, good, but you have symptoms, yes, you need it. But what about if you don't have symptoms, but you have the markers? Right?

Adi Benito, M.D. 1:03:10
So maybe that's it. And again, I would like to go back and take a look at that TSH was a TSH at the high end of normal. Does that person habitually avoider, enlarged thyroid gland, that actually is an indication to treat even without symptoms? If somebody has antibodies, and they have an enlarged thyroid gland, there's an indication to treat even without symptoms. And that's at that point working on the body is really trying to push to work too hard.

Scott Benner 1:03:35
What do you recommend? Like once people get their medications set up? What's the maintenance for it? Because this person asks, Is it good enough to just test my T TSH every year? Or should I be doing other things?

Adi Benito, M.D. 1:03:47
Right? So guidelines are that you check once a year, I'm a little bit more OCD. And I'll check people twice a year, I still see them in my office once a year, you know when we can meet in person, but I'll take them twice a year and I have a very low threshold, I do tell them if you feel different. And I just say that different than what you normally feel and it doesn't go away, just have have a low threshold, check your levels. I also tell them if you're taking a new medication or a new supplement, I want you to tell me what you're going to be to get for that I know there are certain medications that can actually interfere with it either the absorption or the metabolism of thyroid hormone. So that we can even a birth control pill can actually affect you know how much sorry hormone you need. So there are things that that we know can have an interruption or have an effect on sorry, so I want to know about them so that we can, you know, be more you know, proactive about them.

Scott Benner 1:04:36
Yeah. Well, I think that one of the most amazing things about working with you is is that there's no there's only enough pausing to see what works. So if it's get a blood test, find out where we are, add the medication way to appropriate on time, but usually just about 30 days, blood test again, keep moving like that is such a valuable perspective on it. And yeah,

Adi Benito, M.D. 1:04:58
if you know that level three Roxane, which is what sort of care is, takes about six weeks to take any effect? That's all you're gonna you know, that's that's all you have to wait if you're changing your dose or something it's introduced just six weeks doesn't take that long.

Scott Benner 1:05:12
Yeah, no. And actually, interestingly enough, COVID making people's connections more instantaneous, right, not having to wait for as long for an appointment, right? Being able to get in and out of conversations, I actually think there's a couple of things that are going to come from all this. That's good. And I think this is one of them. Doctors, seeing people like this, I think is going to speed people up to resolutions, because it gives them the access at the at the intervals that I think are more necessary. So I definitely found that. Yeah. This one's interesting. Do people tell you not to eat soy sauce? If

Adi Benito, M.D. 1:05:50
you have? Oh, that's a good question Is it so you so few things on so one is if you take that requirement, if you take legal thyroxin, whether generic or Brandon would talk about that as well dinner, you can brand, you should not take your federal government at the same time as taking soy, soy, it does affect the absorption of thyroid hormone. So not at the same time. If you're already taking a reformer, you can take you can have your miso soup, or your tofu or, you know, at a different time, that's perfectly fine. There have been many studies on soy and thyroid, the initial concern was actually babies who were fed soy milk, you know, when they were infants, I guess. And soy actually is even having of iodine is actually going to affect thyroid function. So but if you have enough iodine, soy will not cause any problem with the thyroid. There has been only one study where they use quite a bit of soy. So there were people having soy for breakfast, lunch and dinner. Those people had an under a mildly underactive thyroid, they became much more than thereafter after eating a lot of soy. And again, it was so breakfast, lunch and dinner. It was a lot of soy, right? So if you're somebody has a mild dysfunction in your thyroid, you're trying to avoid taking foreign form. And you really want to try to do this naturally for yourself. Don't overdo it on soy is what I would say.

Scott Benner 1:07:12
Okay, that's interesting. So like, I can't wait, I don't want to, well, let's talk about the medication for a second because you just alluded to something that we found. Synthroid works fine for my wife, that generic, Synthroid doesn't touch her at all, for some reason. We've bounced through multiple medications for art and just looking to see if she had an interaction with one of them, which she didn't end up having. But she now takes Harrison which is, I think, has no fit even. I don't think Synthroid has that many fillers, but cireson has none of them nothing. Yeah. So, you know, do you see that first of all between generic and non generic?

Adi Benito, M.D. 1:07:50
Right, so generic, it's legal thyroxin. And the concern with generics, if I write a prescription for generic just for, I guess, right, legal thyroxin, the pharmacies will give you what they have in stock, which means that the first time you feel these generic A, then the next one could be generic B and the next generic seat, each one of the generics gets absorbed differently. So from going from A to B to C, your levels are going to change just because you're sorted differently. Same is true of brands, if you go and see him for the first month and then the voxel the second time in a unit for the third month, that's also going to change. So if we write brand like Synthroid, let's say, the pharmacy will honor that and they always give you a Synthroid. Now I have a way sometimes somebody has a hard time paying for medication for brand, right? legal thyroxin by x. And my x will be let's say mainland, which I like it because it's gluten free and lactose free. So what I tell my patients is gonna just like you know, be an advocate, right, so thyroid hormone pills, tablets are color coded and shaped coded. The color tells you the dose, every single 50 microgram pill is white, every single 100 is yellow 112 is pink 137 years Brown, you know, they all have a color that's a dose doesn't matter what the brand is, doesn't matter what the generic is, the color tells you the dose. Now that shape tells you who makes it. So synthesizer which round the voxel is almost like a thyroid shape, some like a butterfly type thing. You know, so if you go to the pharmacy, and now you pick your pills, and last month, they were white and round, and now they are purple and oval. They give you a different dose, and a different manufacturer. And that's how you know and if your doctor didn't tell you that we're changing it, you better call back your pharmacist and your doctor and tell them they give me something that I was not supposed to be taking.

Scott Benner 1:09:40
That is rock solid real life advice. I did not realize so maybe Kelly's issue back then when she was using generic wasn't so much that generic wouldn't work for it was the cheapest be getting something different every time there was no consistency.

Adi Benito, M.D. 1:09:54
Right. And some dinners will have gluten or lactose which many patients with Hashimoto said So if not celiac fully, they might be intolerant. There's more likelihood of being intolerant to gluten and to lactose when you have Hashimoto somewhat, you don't have hashimotos.

Scott Benner 1:10:08
So there's a question here that I feel like has been answered. But the second part of it, again, is valuable to still bring up. It sounds like this person has a doctor who tells them that you should try to get off of all medications, which obviously, if you need this hormone, you need it. Right. But it does beg the question. If you're, are there safe ways to titrate? up? titrate? down? Are there other ways to take medication that they this medication that you can't like? Can I just pop them in? Or do like how does that work, like if you're moving up at a dose or switching from one to the other,

Adi Benito, M.D. 1:10:43
right, so usually, when we need to change somebody, those because our three levels are not, right, they're not optimal. Usually, we go one level up and one level is about 12.5 micrograms up, and that most of you Your, your thyroid medications have those levels, most normal, Sabrina and you have 75, you have 88, you have 100, you have 112 125 137 150. So you're totally gone in 12.5 13 microgram increments, 50 to 75, there's no nothing in between 15 to 25, you know, going down, there's nothing in between. So there are a couple of them have nothing in between by usually one level up is 2.5 micrograms. And that's usually how we go up unless somebody started that was really, really off. And you have to go up quite a bit. Fabric hormone level thyroxin is long acting. Meaning if you miss one pill one day, take to the next day, that's perfectly fine. It's not a problem to go away for the weekend, you forgot your pills, when you come back, make up what you missed. So make up your Saturday, or Sunday, that's not a problem. Let's say somebody is has been given thyroid hormone, and they want to see whether because I thought it was wear off. And they want to see if they actually needed and can they come off it. So if you have been taking thyroid hormone, and you suddenly stop it, your thyroid levels are going to rebound, you're actually going to have a high TSH, and that's just a normal physiologic effect. Even if you don't need it, your body's going to do that. So it's going to bump up your TSH. So instead of getting off abruptly, what I have people do is actually have them take one pill less per week. So one day, a week, they miss their pill, the lunar for about two months, I'll test them and see what the TSH is their standard range. I'd say okay, take one pill away again, another missing two pills per week. Two months later, we'll do the same thing. So very slow process, but it really works. And he tells me what's the dose you need if you need it? Or can you actually be without it. So and that's particularly true, because sometimes when you have a high TSH, it doesn't always mean you have a thyroid disease, high TSH could happen because you are sick, could be 30 days, not the chronic that is hashimotos, but sub acute. So something that really is caused by a virus that causes your TSH to go high for a couple of months, and then your tissues will go back to normal. But if somebody gets given fabrik at that point, then do you still need it two months later? Or could you actually come off it?

Scott Benner 1:13:05
Can we talk about that for a second? Because I think you believe that happened to Arden this year, right? Yes. Right. So she gets some sort of a virus. She fights it off. But then she starts having real impactful thyroid, like issues. And as we tracked them, medication wasn't the answer. Not that time was the answer. Right. Yeah. So is that what people call a thyroid storm?

Adi Benito, M.D. 1:13:32
Oh, no. So Pepperidge Farm is what happens when you have graves disease, and suddenly your thyroid releases a lot of the fabric hormone that you've had in storage that happens on graves that is not treated, which is why graves disease should always be treated. You know, we talked before about when you treat when you're hypothyroidism graves disease in my mind should always be treated because fairy storms are they can really, you can end up dead without restore. So to prevent that, so that's different. That's sorry, data's, which is what we call this will be a subacute thyroiditis mean, it's subacute means that it lasts for a short time. They're usually painless, meaning you don't have any pain in your thyroid. A virus happens about two months prior, a cold, flu, something usually some cold like virus about two months before and then suddenly your body starts to release, a lot of thermal has been stored. So you just have a lot of releasing your personal making more favourably just releasing what's has been stored in your body just a lot of it and once that makes it person hyperthyroid because the thyroid gland has only about two months storage of thyroid hormone, once that power has released everything that's in storage, now the thyroid goes hypo thyroid and then nobody sort of kicks in and regulates itself and you normally usually go back to normal sometimes people actually end up a bit hypothyroid after that happens, so it's usually hyper hypo normal. So that's a typical pattern that's

Scott Benner 1:15:02
interested in that. Can that not happen to people who don't have thyroid disease? Does that not? Yes,

Adi Benito, M.D. 1:15:07
yeah. If

Scott Benner 1:15:08
I don't have thyroid disease, I would never see any of this happen.

Adi Benito, M.D. 1:15:11
No, actually sorry. You can still have a beautiful holiday season. Yeah,

Scott Benner 1:15:15
it could happen. Still. It could happen. It's fascinating, too, because like you said, it's months of one direction and then swing back the other way, and then a leveling eventually.

Adi Benito, M.D. 1:15:24
And I don't know why. But I've seen a lot of those cases this year. I have to say, I don't usually see as many cases I've had. Many, many, many of my patients have actually had that happen to them this year when it became hypothyroid. And then we would have two more months. I mean, we get adjusted, they're fairly close, and they wouldn't be as hyperthyroid then we'll have to readjust back. Because they weren't getting hypothyroid. It's been interesting, huh? Yeah.

Scott Benner 1:15:48
Are you in firing? COVID? Or no,

Adi Benito, M.D. 1:15:51
no. And those people that say what testing that many of them did not have? COVID. So is it stress that we know can affect thyroid, the distress affect the immune system? And then effect was another virus that was happened at the same time as COVID? I really don't have an answer.

Scott Benner 1:16:04
No kidding. Yeah. Because we did check Arden for COVID to during this whole process, and she's never had it. So, Mike. Really? Wow. You talked about leaky gut earlier. And this person's asking, does healing leaky gut help thyroid symptoms? Which I think the question the answer, there's pretty clearly Yes. But how do you go about that? And what kind of a doctor do you see? And how do you even know that's happening?

Adi Benito, M.D. 1:16:28
Yeah, so I would say still not into the, you know, completely accepted by more of the Western medicine, if you wish. So probably a functional medicine provider is the one that will test for leaky gut. There are some blood tests that can help that are sometimes stool tests that will do it. But it's not a routine that you can go to a labcorp request and you know, at a hospital and get tested for I think,

Scott Benner 1:16:54
let me jump in for a second. I think what I learned by watching you help the girls was that doctors in a Western situation, they look for results, numbers that tell them for sure this is a thing. What I watched you do was test a bunch of different stuff, and then use your knowledge to infer a little bit from it. Yeah. Is that fair?

Unknown Speaker 1:17:17
It is Yeah,

Scott Benner 1:17:18
yeah. Yeah. So you're looking

Adi Benito, M.D. 1:17:20
at and sometimes I will not treat I will not buy, I will not make the testing for the leaky gut. But I will say, you know, could this be leaky gut and in the way I think of leaky gut sometimes that if you start to have reactions to almost anything that you're, you're either eating or taken. That to me suggests pretty strongly leaky gut, because it means that things are just coming into your body, your body's reacting against it, why would anybody do that? It shouldn't do that normal, right? There are, you know, stress can trigger leaky gut infections can trigger leaky gut. So if you have any of those a history of having had significant stress in your life, or just a recent gut infections, and I'm going to be more suspicious of leaky gut, there's, you know, people will use even bone broth that can be very much mentorship from leaky gut that there are some some of the the protests in the in the bone broth actually help with leaky gut. glutamine is one of the big ones for leaky gut. Interestingly, there's one herb that is used for leaky gut co it's not right now. It's a it's a, it's a semi so called an alkaloid that come from plant is called berberine. berberine, comes from goldenseal and tennies, coptis and rest, blocking minima, the other one, but anyway, berberine is, is this chemical that has been shown to help leaky gut, but it also has stayed actually, for hashimotos. The data actually is not in, in clinic call so that they were not doing the study to see whether your symptoms got better the status itself, so suddenly self study, so like what we call, you know, petri dish if you were studied, but it's interesting that that same compound helps but hashimotos only keyguard. And, you know, the question is, could this be because you're helping the guy you're helping them to hashimotos unclear, but it's a, you know, is definitely a question that is worth exploring. In the future.

Scott Benner 1:19:06
Well, okay, I feel like we've done a lot. Did we miss anything? That you're like thinking, Oh, how did we not talk about this one thing?

Adi Benito, M.D. 1:19:15
All right. So I'm going to go back a little bit to the generic versus brand versus terrorism. I just want to make a mention on that. So when we talk about generics and how, as long as it's going to seem generic, that may not be so much of an issue as long as you're okay with all the fillers and the colors. Again, white doesn't give you a color. So usually whites are easy. terrorists and sort of the newest, legal thyroxin on the market. And Harrison is beautiful, lukasik capsule, and it means that by being a capsule doesn't mean it's like acid to be absorbed. So it also has the fewest ingredients. It has gelatine and water. So sometimes your kid would tell it and then you could take 2% terrorism is usually not covered by insurance companies unless You failed legal thyroxin or if you have gut issues that don't allow you to make enough stomach acid. So my patients with celiac disease, I put them on Terra sent my patients with autoimmune gastritis. When they don't have enough stomach acid, I put them on terrorism's. Even if you're taking one of those personal pump inhibitors, my personal pride looks like one of those does actually block your stomach acid. Terrorism, this is the way to go. Otherwise, your your absorption is too erratic. I'm going to say that I have even patients who if I can get to rescind approve, they'll feel a ton better and terrorism that they felt only will thyroxin perhaps because of the absorption difference, perhaps because I don't have as many fillers. Okay.

Scott Benner 1:20:40
And what about just the taking of the medication? Because it's me, we talked about a lot of like, down deep idea saying this is a really basic one. But I see people ask all the time, does it need to be the same time of day should absolutely be without food? How long before? If so, all that stuff.

Adi Benito, M.D. 1:20:57
Okay, so the ideal is I do take them around the same time every day around, so morning, afternoon or evening. Ideally, the thought is that you take it about 30 minutes before breakfast. And that's because if you have food with it is going to decrease the absorption a little bit. There's a recent study where they looked at whether you took your thyroid hormone, half an hour before breakfast, an hour before your main meal, or three hours after dinner. Most of those were very similar, the best time was had something before breakfast, then three hours after dinner, and then the one hour before your meal. You know, when I trained, my mentor would say to the patients who were taking thyroid hormone, do whatever you do, get a rhythm will adjust your thyroid hormone, meaning if you take your legal fabrics and your Synthroid with breakfast, what you might mean is that I might need to give you a bit of a higher dose to compensate for your fabric, my being sort of bound to that what you're eating. If you're eating about the same thing, every breakfast, your levels will get you know will even out. If you're eating different things, it might be a difference. So what I usually tell my patients that don't have it with something that has a lot of fiber, if you have a high fiber breakfast, you have a smoothie with a fiber supplement, that's really going to bind your thyroid hormone. Don't do that. Right. So if you're having that type of breakfast, definitely do it half hour before your breakfast. Again, if you miss one pill take to the next day. The things that really are no no, for thyroid hormone, when you take it is any minerals, you cannot take karma with magnesium, or with iron or calcium, they're going to bind your thyroid hormone, they're not going to let it get absorbed. Those have to be separated about three hours, even chromium. Some people take chromium, or you know, it's between type two diabetes, or insulin resistance. So those have to be three hours away from your thyroid hormone so that you have enough time to let the thyroid hormone be absorbed and then put the minerals in the in the gut.

Scott Benner 1:23:02
Can I have it in the morning with my vitamins like or is it just those things you just mentioned? I shouldn't mix them with I get to have it

Adi Benito, M.D. 1:23:09
exactly. Yeah, vitamin B, vitamin B 12, four D, they're gone. You know, I always have people look at the bottle mission, there's nothing else in that. There's no D with calcium, or there's not a b 12 with a prebiotic that is fiber base, you know, something like that? Just take a look at the bottom make sure there's nothing else What about birth control pills, you can take them at the same time. So the effect of the birth control pill on thyroids, not really, because they bind in the stomach, it's actually a binding issue by with the protein. So our bodies make these, what we call thyroid binding globin these are proteins that help you carry the thyroid hormone throughout the blood into itself. So when you take a birth control pill or women take a birth control pill, the thyroid binding globulin goes up. So now you have more of these proteins binding to the thyroid hormone. So let's say that your body is taking a certain amount of fabric hormone, you're gonna if you take a birth control pill, you have no more of those binding proteins, you have less free hormone available to you. Which is why if you were not taking a birth control pill and suddenly you go and control pill, you might need a higher dose of your fabric. Because with the same amount now you're binding more you have less free.

Scott Benner 1:24:21
This is probably a good time to tell you that Oh, Arden might need a blood test in a month then.

Unknown Speaker 1:24:24
Yeah.

Scott Benner 1:24:26
That's what I always tell people they might not affected. But just to make sure give it four to six weeks, take your salary levels, you can even increase mobility because So the one thing that Arden also has, by the way, we joke about it all the time on the podcast, so don't feel weird about this. I know it's kind of a strange intersection because you're helping Arden too. But we always joke that the whole world knows about Arden's soulcycle. But so Arden gets her period too frequently. It'll sometimes come twice in a month or it'll last a long time so long that it feels like the next time It came as twice in a month. So we did just start on Monday with the first day of her cycle of low Lester in the very, very low dose of control pill. And we're treating it the same way as everything else. We're gonna try it and see if it brings or any kind of relief. And if it does great, and if it doesn't, she'll Stop faking it. But yeah,

Adi Benito, M.D. 1:25:18
Lisa will help her iron in it as often or as or as much she will, you know, her iron will stay up a little bit more than, you know, just always been, you know, consumed.

Scott Benner 1:25:28
Right? So, again, we're just we're taking a very small pieces at a time even,

Unknown Speaker 1:25:33
you know, you've

Scott Benner 1:25:34
suggested ardency rheumatologists, which we're, I meant to get back to you actually, it's odd, but it's not as easy as you would think for a younger person.

Unknown Speaker 1:25:42
Like, you know, I'm

Scott Benner 1:25:44
having trouble finding a doctor that wants to help somebody under 18. It's very, very interesting. And, you know, for things like like, this morning, Arden woke up, she's in the middle of her period, she's like, my ankle hurts, my knee hurts, like, you know, can, you just might, but it's not both of her. It's not both of her legs. It's one of them, you know, so you just, it's, I'll tell you, I have to tell you like a side of all the great information that you shared with everybody today that I really want to thank you for the part that nobody can make you ready for? Is that horrible feeling? Like you're not finding the answer? And that every day you're thinking about this stuff? And that not finding the answer is leaving somebody at one or multiple different deficits in their life. And I try really hard because, you know, she's my daughter. I don't know if I would try this hard for myself. I have to be honest. I don't know. I don't know. Yeah, I've got a few more years with her. And it's my goal to set her on the best path possible for when I'm assuming she leaves here, never talk and

Adi Benito, M.D. 1:26:46
just think that with Arlen, you know, because we know that he had this iron deficiency. If she's having her cycles, he's gonna drop iron once she's having her cycle. And that actually, by itself can actually cause her to have some pain. Usually it's more muscle than joint. But I wouldn't put it past that, that it could be an iron deficiency,

Scott Benner 1:27:03
why actually have come to the conclusion now that I've seen my body pick the iron up with the absorbing gas, and I'm going to start her on maybe just once a week, and then twice, and then we'll check her again and see, you know, where she gets to? Because I think there is a way with the supplements, the holder in that range, like, in my mind, tell me if I'm wrong. I'm shooting for that, like 70 range where you said hair growth?

Adi Benito, M.D. 1:27:26
I would? I would and I think I think every single woman who's having cycles should take some iron. Yeah, I really think so. I mean, unless you have an iron issue in your own body, that your body sort of makes too much iron. Right? If you had that been done, but most people don't have that issue. So you're a woman and you're having cycles, you know, have iron. Yes. You know, iron can get absorbed easily every other day. You don't have to take it every day. It also allows your guts not to get so constipated with it if you wish. And yeah, you should vitamin C or something acidic. Something with vitamin C will help you to absorb Valium better.

Scott Benner 1:28:00
Well, I can't thank you enough for doing this. I I have to tell you that the idea of you being on is the most excited. I've seen the people online. And I knew how good you are. So I've been super excited to do it. I've been very worried that I was going to screw this up. But I feel like I did. All right. So

Adi Benito, M.D. 1:28:18
well, everything is great. We answered people's questions. You know, happy to come back if people have more questions or something we didn't touch upon. And somebody had asked about nutritional deficiencies. We'll talk a bit a little bit about that. You know how Yeah, definitely iodine can be you know, it's still the US, is it done sufficient. But also you're vegan and you have no dairy, you could be even deficient. And if you do that you could also be iron deficient in iodine and iron are both really important for thyroid production.

Scott Benner 1:28:48
You know, I was gonna ask you, if you could pick a style of eating, and you have thyroid disease? Is there one that lends best to it?

Adi Benito, M.D. 1:28:57
You know, it's interesting people have actually look abroad. There's a lot of talk about paleo, as well as autoimmune paleo. Not many studies, there's actually one study was done many years ago using palya for people who have high TSH, and the teachers got better. Now, I don't know those people actually have thyroid disease, or they will just inflamed because inflammation can also cause a high TSH. So how do you know if you take away a lot of your pastas and your processed foods, you're gonna lower the inflammation. To me, it makes sense that you decide for yourself what I will call an anti inflammatory diet. So one when you have lots of vegetables, lots of different colors of the rainbow, mostly because that in addition to being anti inflammatory, and each color giving you a different anti inflammatory compound, they also help you make good gut flora and have good gut flora is less like you have leaky gut. In addition to the rest of us, you can use you know healthy protein, whatever that protein is for you. But there is Fish, maybe a little bit chicken, maybe your grass fed beef. And then nuts, seats, healthy oils, avocados, things that are very rich in this polyunsaturated fats. So the healthy fats if you wish, that's also beneficial for us. So it then you figure out what works for you. I think we're all different. And we all have a best way of eating, you know, I don't think burgers and chips and you know, pasta, our way of eating. And so you never eat those, but I don't think it's healthy. Yeah,

Scott Benner 1:30:32
I've been I've just started doing a series where people come on and talk about different ways they've been we've had a person come on talk about carnivore plant based, I just interviewed a flexitarian the other day, which, you know, so I'm trying to, as the podcast has grown, it's grown beyond my expectation. So when I was first doing it, I was like, Look, I'll show people how to use insulin. So they can have lower, like more stable, a one season less variability. And then my, I feel like my responsibility has grown, because I always start with the idea. Like, I'm a very, I guess this makes me a capitalist in some way. But But, but the way I think about it is, is there's probably a better way for people to do things. But I don't have the power to influence that. So at its core, I want them to know how to use insulin. So if they decide to eat a cupcake, they can use insulin, if they want to be a vegan, they know how to use their insulin, if they want to eat a carnivore diet, they understand that protein breaks down and gets picked up as glucose and they'll need insulin for that. And so as it's been growing, I was like, wow, I I start feeling that responsibility of like, now I've told them they can do this. Now I should, you know, illuminate other ideas. So, and thyroids been one for a while, the way thyroid is talked about is kind of criminal. It seriously is like the the lack of understanding that most people or physicians have. It breaks my heart. So I'm thrilled you did this. I want to ask one last question before I let you go, and I will end up I will take you up on it and have you back someday for a follow up. But how do I find the you where I live? Do you know what I mean? Like I know it's easy to say like, Well, no, but but that's not that easy, isn't it?

Unknown Speaker 1:32:19
No, no.

Adi Benito, M.D. 1:32:23
You know, and I don't, you know, I don't think that you need to find somebody who will tell you about Selenium or vitamin D or you know, vitamin it's really quite common, but or inositol or ashwagandha. It's not really what you I think the most important part of your journey is it's not really the supplements, I think it's having somebody who will listen, and who you like you said, even with your thyroid levels, not looking off, that will be willing to explore, and we're willing to look outside the box, and we'll take the journey with you. I think that's what we all want is to have somebody who's our partner, who is not just somebody who has knowledge, but who also is willing to partner with us and trying to figure out what's what's going on. I think I'm looking for somebody who's more compassionate, and is going to be word of mouth is going to be between the people either within the podcast or outside of the podcast, just knowing what doctors both listen to, and sit down with you for an extra five minutes even just to to get to know you and to get to know what is not right. And how can they help you.

Scott Benner 1:33:21
That's to tell you I watching you work, I have this tiny bit of connection with how the podcast makes me feel because I know right now that I could gather up 10 people who are having no success with their blood sugars, and I can fix it. Like I know how I know how to like, I know how to explain it to them. I know how to put them on the right path. I know how to get them going in the right way. But I only have so much time. And so I use the podcast to try to reach more people and it's you know, I think that somebody who has such good has so much good knowledge the way you do, you must run into that too. Just the idea of like you could talk to people all day, but really At what point do you have a life as well? And and how do you help more people?

Adi Benito, M.D. 1:34:01
You know, people with type one diabetes are really the masters of their own condition of their own, you know, bccp wish. And really many times you will type one diabetes, no word on their doctors. No, my mind and anybody. I think that's very clear.

Scott Benner 1:34:15
Well, I definitely believe that it's easier to ask for forgiveness than permission. That's for sure. And I tell people all the time like I'm like what what are you waiting for? You need more basal insulin, and like Well, I'm gonna wait to see what the doctor says I was like you're looking at it right there. You don't have enough Faisal Islam. You know, you don't ask the doctor before your boss at a meal, but they want to but they want to it's you have so I think that's a great thing to end on. Because I felt like you said something really important that there are doctors out there that may not have your level of understanding. But if you can be a partner in the situation and hopefully something in here leads you to ask the right questions, and to be a little more direct. I think you'll find that most physicians want you to be better. They're not like you know, unless you get one of those old crotchety guys is like this is how I've been Do it forever and you just leave me alone. You know, like, but but if you say to somebody, look, I'd like to test my blood more frequently, every four to six weeks, I want to get an idea of what's really happening here. I don't think anyone's gonna say no, you know, you just have to have the nerve to, to ask and and when people say no, I'm a proponent of why, if somebody says no to me, ask them why because sometimes they don't know why they're saying no, other than that's just how we do it and you've asked something outside of our norm, but that doesn't mean you can't. Anyway, that's the that's what you get. If you listen, I really, really appreciate this. Thank you so much.

Adi Benito, M.D. 1:35:37
It was my pleasure.

Scott Benner 1:35:42
I want to first thank Dr. Benito because she has a thriving practice that's full. She's not looking for new patients. She's not selling a book. She's not out doing anything trying to drum up attention for herself. She was just very willing to spend the last hour and a half sharing what she knows about thyroid with you. I just can't thank her enough. I also want to thank Omni pod Dexcom and touched by type one for being longtime sponsors of the show. Check out that Dexcom G six@dexcom.com Ford slash juice box. Get your free no obligation demo of the Omni pod tubeless insulin pump at my Omni pod.com Ford slash juice box and of course touched by type one. Is it touched by type one org. They're also on Facebook and Instagram.

#412 Turkey Tutorial

Bold With Thanksgiving

Thanksgiving Pep Talk

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:09
Hello, everyone, and welcome to Episode 412 of the Juicebox Podcast. Think of today as a pep talk for Thanksgiving. Today we're just going to talk about how Arden's going to manage on Thanksgiving Day, which, if I'm being honest, really is about how we manage every other day, just that people seem to get very nervous around these holiday situations. And I understand why there's probably more grazing and snacking. There's also a lot of variables and what you're eating. We'll break it all down. Talk about how I'm going to attack it. See if you can find some good ideas in here for yourself. Please remember while you're listening that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making changes to your health care plan. Becoming bold with insulin, or stuffing your turkey and that's not some weird euphemism. actually think when you stuff the turkey. You can like mess it up and cause a problem is it trickin gnosis botulism botulism that sounds like something to do with a can. Alright, so before we get to everything else, let's just figure out what undercooked poultry does to

hold on

Scott Benner 1:26
cooking you're stuffing in the turkey they're calling that a mistake to avoid I can tell you personally, I used to put my stuffing in the turkey but it slows the cooking time way down. It doesn't allow an even heat to go through the bird and I don't do it anymore. I prepare my stuffing I actually make it by hand I bake the bread I tear it up days in advance let it become stale almost and then combine it with a whole bunch of different stuff not the point I make my own stuff I make the stuffing and I put it in a pan and bake it because I found what I put it the stuffing in the bird took too long to cook and I wasn't getting a cook through the way I wanted so now I'm drying the outside of the turkey to cook the internal portion what Hold on a second. On cooked I know we'll get to the rest of it. Just give me a second turkey causes Wow. Raw and undercooked meat and poultry can make you sick. Most raw poultry contains wow can't be low backer can't be low backer needs a better name. It also may contain salmonella, Clostridium perfringens and other bacteria. raw meat may contain salmonella, e. e stands for you in this situation. How long does it take to get I'm falling down a rabbit hole here? How long does it take to get food poisoning from Turkey? 12 to 72 hours to symptoms usually lasts around four to seven days about cook your turkey. You know, poultry has to be cooked to 165 degrees, right? Hold on Turkey. Done. 100%. Right. Yes, 165 degrees. A whole Turkey is safe when cooked to a minimum internal temperature of 165 degrees Fahrenheit as measured with a food thermometer. Check the internal temperature in the innermost part of the thigh and wing and the thickest part of the breast. Alright, there's our little turkey tutorial. Oh, I just found the name of the episode by mistake turkey tutorial. That'll be fun. All right, I'll do that. Let's talk about some other stuff. Everyone freaks out around holidays. Oh my god, we're gonna be snacking all day. There's food in the house. There's bowls of food on the cabinet. There's grazing. I hear you. Maybe this COVID Thanksgiving might not be exactly the same as most But still, it's here, right? You're gonna get up have a breakfast, there's gonna be a big launch or a big dinner. grazing in between pie. I'm assuming cookies. gluttonous extravaganza. Here's how I think about a meal with insulin. First, I wonder how long does it take for the insulin to start working? How long till it effects the blood sugar? And how long will it last in the body? It's my first thing. How does the insulin work in order? First thing to consider. Second thing? What is ardan? eating carbs? How many? Yeah, that's easy, right? You count the carbs. Everybody's like no, no, it's not easy, Scott. Because stuffing it's pretty easy. You don't I'm saying pan full of stuffing ish is probably a piece of bread and a half something you gotta you got to wing it a little bit. Just I didn't mean to wing it because of the turkey. You got to just kind of like roll with it. You got to look and guess be kind of aggressive. But still, the most important thing here is Pre-Bolus. Getting your insulin in and working so that it can time itself up with the impact of the food. So what we're talking about here is timing. So the insulin kind of comes online at the same time that the food comes online meaning while the food is pulling up on your blood sugar, you want the insulin to be pulling down you want them to get involved in a tug of war that no one wins. That's how you keep a stable line. You know, when you see people's lines are super stable on their graphs, but they have food. And then they're like, Yeah, but you can't find the bagel. You know, people do that. Hold on. Sorry, I've been sick. How do you not see the bagel on the line is because that as the food impact is trying to push the blood sugar up, the action of the insulin is trying to pull it down. And so it just creates this stability. No side is winning the fight. So you have to Pre-Bolus your food, you can't let the carbs get ahead of the insulin. To understand Pre-Bolus thing better, you can check out Episode 217 diabetes pro tip Pre-Bolus. Now the next thing to consider is the impact that the food or the drink you're having, is going to have on the system.

It's not as easy as saying this is 10 carbs, because 10 carbs of Hawaiian Punch will impact your blood sugar differently than 10 carbs of macadamia nuts. I don't know how many carbs are in macadamia nuts. But imagine you've eaten 10 carbs of them. The punch will hit you quickly and harsh, right your blood sugar will shoot straight up while the macadamia nuts which by the way, I've checked on and one cup of whole or halved macadamia nuts have 19 carbs. So if you have a half a cup of macadamia nuts, which is probably what like a handful, you've got 10 carbs, but they're not going to hit with the same exuberance that a simple sugar like a juice would. So keep that in mind for a second, you have 10 carbs worth of impact on your system. If it's something liquid, like the juice, or something sugary, it's gonna happen very quickly. So you need the insulin to be working. When the Hawaiian Punch goes on, I have no idea why I picked one punch. I've never drank one punch in my life. Nor do I know anybody that drinks it. But that's not the point. The point is, you may need a longer Pre-Bolus so that you can match the action of the insulin up to the impact of the Hawaiian Punch. Now for something like the nuts, you might be able to Bolus with the carbs, wait a couple minutes and start eating. Because as the insulin slowly comes online, and begins to work, the nuts are slowly coming online and trying to push your blood sugar up. Now the key around these bigger days, I think is understanding there's going to be a mix of foods a mix of impacts. Pumpkin Pie is sugar, and milk, right there's like, like milk in it, I think so there's some fat, but then you have the flour from the pie. So you have two different impacts, you have the sugary filling impact. And the carby flour impact. Same with a cherry pie, apple pie, sugary and carb at the same time. It's not dissimilar to Chinese food, where you'll get the slower carbon pack of rice, but the quicker sugary impact of some of the sauces. So imagine that for pumpkin pies and example, you'll need enough of a Pre-Bolus that you'll head off the sugary spike. But you still need enough insulin over the timeline that the pie is going to impact your system to keep down any slow risers. So there's two things in there, a more fast acting carb and a more slow acting carb. If you're pumping, you may use an extended Bolus, a bolus that would put in a portion upfront and drag the rest of it out over time. I'm also a big fan of manipulating basal insulin top line idea being that if your bazel is set to keep your basic body function stable, and now all of a sudden, you're adding a whole lot of carbs over many, many hours. It's reasonable to think that the basal insulin you're using on a normal day might not work as well, on a carb heavier day. To learn more about Temp Basal increases and decreases go to Episode 218, also part of the diabetes pro tip series for Temp Basal. While we're at it, you're going to want to look at Episode 263. It's about how fat and protein impacts your blood sugar. Two things that you don't think of as being impactful on your blood sugar, but they are fat slows down digestion. Slower digestion lengthens the time that the carbohydrates impact your system and protein. As your body breaks it down. Your body turns protein into anybody. glucose and glucose is anybody. Sugar and sugar makes your blood sugar go up. So all those proteins people like those are free carbs. Those are free carbs, huh? Are they diabetes pro tip Episode 263, fat and protein. Some people who aren't MDI multiple daily injections who are in injecting their basal insulin and not manipulating it with their pump. Find on days like Thanksgiving, but a little extra bazel might be the way to go. The idea being your basal insulin, again is only supposed to keep you stable at a number and stable. So if you're super stable all day without food and your blood sugar's 200, my opinion your base was not strong enough. But if you're super stable all day at 95, without food bazel is probably right on. But what if you put in a tiny bit extra,

it would be holding your blood sugar down a little farther. But if you're planning on grazing all day, and eating that may again be necessary. All we're talking about is manipulating the insulin to put it where you need it. My goals during the day are really simple. Yours should be to, I'm trying to maintain the steadiest blood sugar, so as I possibly can, and I want to avoid spikes and significant lows. After food, I don't want hardens blood sugar to go over 140. And in a perfect situation, I'd like Arden's blood sugar not to go below 70. But you know, it hits 65 for a second. Not the worst thing in the world. My opinion, I follow a few rules around this. First one is, it is far easier to stop a low or falling blood sugar than it is to return a high blood sugar to a safe range. Right? So stop a fall with a little juice, get it leveled out, start over again, or have a 300 blood sugar that you're fighting with all day. Which scenario would you rather be in? For me? I'd always rather be on the other side. But don't get me wrong. I'm not trying to make a low blood sugar. I'm saying that they're easier to fix without a rebound. How do you stop a high blood sugar from happening if you've messed up the bolus? Well, I'd look into bumping and nudging a little bit. That's going to be an episode 225 diabetes pro tip, bump and nudge. Basically, the idea is this I think of type one management as driving, there's lines on either side of the lane, and I'm trying not to leave the lines. That's why I have my daughter's dexcom CGM set at a high alarm of 120. A low alarm of 70. If she should drift under 70, we bump it back up with a little bit of juice. The idea being the less you use in carbs, the less likely you are to overcorrect up. So I'd like to know sooner so that I can kind of bump it back up. Same thing with a high blood sugar getting over 120 nudge it back down again. Again, the idea being the amount of insulin that it takes to turn on 120 that's rising into a 90 that stable is far less insulin than it would take to turn a 200 into a 90. And you know, once you start getting up 151 8200, you start using more and more insulin, which eventually causes a low later. And then should you miss address the low now you're on the roller coaster and you're up and down. So I like keeping what feels like tighter tolerances, so that you can just make small adjustments to stay in your lane. Over time, that turns into better bolusing better correcting, you just get better at it in general, before you know it, you don't really leave the 70 or 120 or whatever range you set. That's been my finding. If you're interested in learning more about the dexcom g six continuous glucose monitor, go to dexcom.com Ford slash juice box. There are links right there in the show notes of your podcast player. And that Juicebox podcast.com. Now I think it's important to remember to Bolus for what you're eating. But all of that infers that your settings are good to begin with. And for many of you, this might end up being your Achilles heel. What do I mean? Well, many people I find have bazel insulin that is not well dialed in. So either your blood sugar's are always on the higher side. And you're making these very aggressive bonuses at meals because you don't realize it but when your bazel is off, well then your meal boss is off to Here's what I mean real quickly. Let's say that your basal insulin should be one unit per hour, but you have it at a half unit per hour. That means that every two hours of the day, you're missing out on a unit of insulin. So if you're at a half, and you're really a one, you're 12 units deficient over a 24 hour period. So you're trying to make that insulin up somewhere, you're very likely mixing it up with your meal insulin. So if you're not using enough bazel you probably think you need more for your meals than you actually do. Meaning if you had more bazel which would hold your blood sugar lower and more stable. You would need less insulin mealtime and vice versa. If you're a Basil's too heavy. You're probably one of those people who's like oh, I barely use any insulin at meals because you have so much basal insulin going throughout the day. You're basically feeding the bazel to stop you from getting low Does that make sense. And if that does make sense to you, but you'd like to learn more, check out Episode 237, diabetes, pro tip, setting basal insulin. So back to my original thought here, you need to put insulin in for the food you're eating. If you eat something at 9am, and then 10am 11:30am, and then again at 11:45am, these things all need to be covered by insulin.

Now, if your settings are right, then put what you put in at 9am is for that food, what you put in a 10 is for the next food, etc, and so on. But if you're too aggressive with your meal, insulin, meaning your settings are way off, maybe what you put in at 9am, and 10am was too much for that. So you're thinking, Oh, but the thing is, you know, 1130, that's free.

Unknown Speaker 15:44
Yeah, it may be,

Scott Benner 15:46
but it'd be better to just get your bonuses down better. So that you can continue to Bolus for the things that you eat, that becomes very important on days like today, while grazings in line. Because what happens is you start thinking, Oh, I have enough insulin for that, then you don't, then you're 100 blood sugar turns into 150. Like, it'll come back down. And then it doesn't, you have the bolus for what you're eating. My opinion is to stay aggressive with the foods that you're eating, keep after them with insulin, and if you do cause a low later, well, Lucky you. It's the most food horrific day of the year, there's something to eat. Again, I'd rather be on the lower side than the higher side. And you might be thinking, Scott, that's stalking, my doctor told me never to stack insulin. To that, I would say it's only stalking, if you don't need it. If you do need it, that's called bolusing. If things do go wrong, please do not throw yourself into a tizzy. Don't start yelling about diabetes being unfair, and you always knew this was gonna happen and falling into the drama. Because the drama stops you from learning the lessons. Because everything that happened is right there in front of you. You can see I bolused here, then this happened, I wanted that to happen next time, I should boast a little more or a little less or a little sooner or a little later. You don't want to give up the lessons. They're hard fought right. And you don't want to keep having to have them over and over again just to learn them. So get rid of the drama. Try to figure it out. You can do it. You can absolutely do it. Make your best guesses about carbs. Keep in mind that potatoes are going to hit a little more substantially. Then I don't know green beans, right green beans, thought cars. Um, I think green beans, carbs. I don't really eat green beans. Hold on a second. Yeah, green beans have carbs. A couple of green beans has seven carbs. I don't really count carbs. Actually, I just sort of guesstimate the plate. And you probably can too. If you have enough. If you have enough, you know time in the simulator and you really been able to figure it out. He just sort of looked down you go. I'll tell you right now here's how I do a plate I go potatoes. 30 piece of bread 20. Turkey. Yeah. 10. Beans, 10. We got here cranberry sauce, I don't know, a little bit of it five. I just roll like that was it Bang, bang, bang, bang, bang, insulin goes in good Pre-Bolus get a good fight set up between the food and the carbs. And then correct on the backside. If you have to. You may have to correct with insulin. And you may have to correct with food. I'm not sure. But sitting around and waiting and crossing your fingers. It's not a good plan. I would much rather punch first. That's sort of how I think about bolusing. Because when it this is a sports metaphor. So I'm sorry if you don't get it right off the bat. But you need to dictate the pace. Right? You come out swinging Anyway, you want to think about it. You act first. So that the next thing that happens is because of you because at least that you can measure. Right when you cover your face. And you're kind of hiding and you're just hoping not to get knocked out. You don't know what's happening to you. You don't know why your blood sugar is doing what it's doing. But at least you can say, You know what? I had an Eclair. I thought it was 35 carbs. My blood sugar went to 200 and later I had to correct with another unit. So next time I'm gonna get that unit into the original Bolus. I'm gonna say I guess that he Claire, maybe it is 35 carbs, but it punches like it's 45 carbs, or whatever. You know, your numbers may vary, but the idea is there. I learn from that and move on and the next time I have an Eclair I do a better Bolus job. That's it. Get out be aggressive. Don't be scared. Do your best test if especially if you don't have a Dexcom CGM test use your meter my daughter loves the Contour Next One meter and you can learn more about it at Contour Next one.com forward slash juicebox. But that's how we roll Arden pumps. I should have said that up front Arden has an omni pod. She's had not a pod since she was For, and she is 16. Now, as a matter of fact, if you'd like to learn more about Omni pod, you go to my on the pod.com Ford slash juice box and on the pod would be delighted to send you a free, no obligation demo pump, you can actually try it in your home, see if you like it. But that's beside the point, I digress. You have to do what you have to do. Whether you're on MDI, and you're going to be a little more aggressive with bazel for Thanksgiving, or you're on a pump. And you think yourself Yeah, this is the second day of my Omni pod, but my site starting to get a little funky. So I'm gonna change my insulin pump the night before Thanksgiving, so I have a nice fresh infusion going on Thanksgiving Day, those are the kind of little things you can do to prepare. From there,

don't get behind, because when you start chasing blood sugars, it takes a special kind of ninja level to crush a high, bring it down and get it stable again. So as corny as it sounds, you'll never get high. If you don't get high. Make sure your base was right. Learn your Pre-Bolus times understand the differences in different glycemic loads and glycemic indexes of foods. ie how hard and how fast they hit you and go for it. Test when you need to test. Be ready. But don't let it ruin your day. I'm saying you can have a good day too. And if you're catching this one the day before Thanksgiving, you're like, well, this would have been helpful last month, the podcast is always here for you will get it go let's get together for Christmas dinner. Right? doable. It's very, very, very, very doable. perspective. My daughter is a one season between five two and six two for almost seven years. She has no diet restrictions. Her blood sugar's are very stable. Her time and range is excellent. She has the consistency that you want. And the only thing I know how to do is use insulin. Everything else is extra. There's a ton of variables Don't get me wrong, a lot more than what we spoke about here today. As a matter of fact, in Episode 231 diabetes, proto variables, we talked about a lot of them. We talked about a ton of stuff, how exercise impacts things, and there's no doubt that it will take time for you to understand all the variables in a way that's actionable in the moment. But it is incredibly doable. So if this is your first time hearing the podcast, I hope you jump into those pro tip episodes and see what you can figure out they're all available at diabetes pro tip comm or right here in your podcast player. And if you're a longtime listener, you're just looking for that pep talk for Thanksgiving, go get at it, you can do it. Oh, you know what I should say? If you're gonna have time around family and friends who don't understand diabetes, and you wish they understood it better. Episode 371 explains Type One Diabetes to an outsider. Maybe then mom will understand why you're a little agitated. Because all the different pies are coming and nobody told you how many carbs are in them and etc, etc. All right. I really enjoyed this. I hope you have the happiest of Thanksgivings. I know you can do this. And if you need help, check out the private Facebook page for listeners to the podcast Juicebox Podcast type one diabetes. There are over 7000 people in there talking about management. If you have a quick question I can't think of a better place to ask. I want to thank the sponsors even though there were really sponsors On this episode, but I slipped them in you know I'm saying the Omni pod tubeless insulin pump you can get a free no obligation demo of the Omni pod sent directly to your home by going to my Omni pod.com Ford slash juice box. You can learn more about the dexcom g six continuous glucose monitor@dexcom.com forward slash juice box. You can also get yourself a Contour Next One blood glucose meter which is the easiest to use and most accurate blood glucose meter that I've ever used for my daughter. Contour Next one.com forward slash juice box. Add your voice the Type One Diabetes Research with the T one D exchange T one d exchange.org forward slash juicebox. That's for us residents only.

You know I cook every year Thanksgiving. The one thing I can't figure out is how to make gravy myself. I am bad at it. And it has something to do with the drippings and flour. There's whisking involved, but I just can't do it. I don't know what your plan is. This year. I'm gonna actually smoke a turkey a smaller one and a pellet grill and make a smaller one in the oven bacon tubers. I'm trying to cook two burns with two ovens that didn't work. trying something new but didn't want to mess up and have to be like Oh great. This sucks. So I'm gonna double up on the birds this year and see which one flies that was a terrible joke. mashed potatoes, I'm great at maybe some yams, beans, vegetables, cauliflower, making some fresh bread. Like I said earlier, I make this stuffing myself. Order for my grandma. Hope you have a great day too. No matter what your tradition is. I think you can do this. I swear you can. Let me just leave you with this. If you told me I could, in two sentences explain diabetes on Thanksgiving to you, I'd say get ahead and stay ahead. And then if you didn't cut me off right away, I'd say you have to get your basal rates, right, you need to learn how to Pre-Bolus and please understand the different impacts of different foods. That's really the basis of this. That's enough to get you through tomorrow. And those pro tip episodes, they'll teach you the rest. Thank you so much for listening. Have a Happy Thanksgiving. There's a lot more coming on the show between now and the end of the year. actually have a doctor coming on next week who is so well versed in treating thyroid issues I just recorded with her today. It's a it's an absolute joy, the treat you're gonna love. And you know what I'm asked to say here, all the sponsors are back in 2021. And I'd like to thank them Dexcom Omni pod Contour Next One touched by type one, g vo type O pen. T one D exchange. Their support allows the podcast to get produced the way it does. I'm sitting in front of a microphone the day before Thanksgiving recording this for you. Because this is my job. And I get to have this amazing job because you guys support the show. And your support leads to add support and add support pays my bills and then I get to sit here and do this. So it's a circle of life kind of a situation for everyone except the turkey.