#1490 Best of Juicebox: Dr. Blevins on GLP Medications Part 1

Dr. Tom Blevins discusses GLP medications. 

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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 0:00
Hello friends and welcome to episode 1212 of the Juicebox Podcast.

Tom Blevins is an endocrinologist that Texas diabetes and Endocrinology in Austin Texas today Tom is going to come on and share his expertise so that we can better understand GLP medications I'm talking about we go V I'm talking about ozempic, zap bound, mon Jarno and more. 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 any changes to your health care plan or becoming bold with insulin. You can find out more about Dr. Blevins at Texas diabetes.com If you are a loved one has type one diabetes and you'd like to be involved in research. All you need to be as a US resident and you can head to T one D exchange.org/juicebox. When you complete their survey you are helping with type one diabetes research. You're also be supporting yourself and this podcast T one D exchange.org/juice box. When you place your first order for ag one with my link you'll get five free travel packs and a free year supply of vitamin D. Drink ag one.com/juice box don't forget to check out the private Facebook group Juicebox Podcast type one diabetes with over 50,000 members. This episode of The Juicebox Podcast is sponsored by Omni pod five Omni pod.com/juice box if you have FUBU the fear of missing out on Omni bod. You don't have to have that any longer. Just go to my link Omni pod.com/juicebox This episode of The Juicebox Podcast is sponsored by the only implantable sensor rated for long term wear up to six months. The ever since CGM ever since cgm.com/juicebox.

Dr. Blevins 2:04
Hello, everyone. My name is Tom Blevins. I'm an endocrinologist at Texas diabetes and Endocrinology in Austin, Texas. I work at a clinic where there are about 12 endocrinologist and we have about 12 to 15 advanced practice providers and we see a large number of people with diabetes, especially type one. And we also see a lot of people with type two diabetes. Of course we treat people with pumps and technology and, and even just regular injections. Happy to be here. Oh,

Scott Benner 2:35
I appreciate that very much. Thank you. How long have you been an endo?

Dr. Blevins 2:39
I've been an endocrinologist since about 1986. I finished training and went to Baylor College of Medicine in Houston and got boarded in internal medicine then Endocrinology and Metabolism ultimately got boarded and lipid ology as well. So I've been in practice for about that long. I think that adds up to be about 38 years.

Scott Benner 2:58
What drew you to it initially? And is that the same thing that you do today. Of

Dr. Blevins 3:03
course, back in the 80s, when I was in training, endocrinology was kind of a different space, a lot of diabetes, a lot of thyroid, I really was fascinated by the conditions. And I saw a big potential to help people. You know, interestingly, I really liked the people I worked with who were endocrinologist and, and that attracted me. Now over time, of course, things have changed a huge amount, which is really fortunate for everyone. And diabeetus has evolved from the days of mph and ultra linty. And all that the huge fingerstick devices, which if you've seen it those made, you're probably too young to have seen those but the old iTunes and the the evolution of technology has been just incredible. And then the evolution of the therapeutic agents as well.

Scott Benner 3:52
And that's why you're here, Tom. So can I call you Tom or would you prefer to be called Dr. Blevins or Thomas? Good Thomas. Good. Okay. So you you mentioned something else though you got boarded in Lippa chronology is that right?

Dr. Blevins 4:06
Lipid ology technology. You know, like lipids, interestingly, you talk to people about cholesterol, and their LDL, the good and the bad and all that and that sounds very basic, but really, there's a huge world underneath that there's a board Believe it or not, it's that's when you study for and there's a society of lipid ology, and I'm a fellow of that group. And there was a lot of work done in Houston and that's where I trained with people like to Debakey was there the the surgeon, and the cardiovascular surgeon, then a guy named Tony Gato came in to be the person that did the lipids to help prevent some of that heart disease that they were treating, then a few other people, very smart people came in and I was fortunate to be able to train alongside them. So lipids, part of Endocrinology, really, that's metabolism.

Scott Benner 4:53
Is there any intersection between that and why you and I are talking today your understanding of lipids? No, no and how you came to, like pay attention to GLP is

Dr. Blevins 5:04
not exactly it's another aspect of metabolism. Yes, and that is what endocrinology is about by specialty the board has actually Endocrinology and Metabolism, then there's not a tight link between glucagon like peptide, one mil. It's a GLP. One meds and lipids are somewhat of a loose link, we could talk about that anytime people lose weight, of course, their lipids get better. And the GOP one meds can can help people do that.

Scott Benner 5:27
I see. So let me tell people a little bit about how I found you. For the people listening to podcast, they probably know that for about the last 13 months, I've been taking a GLP medication strictly for weight loss, I don't have diabetes. And I've lost I think 46 pounds at the moment. Since then I started on we go V I moved on from weego V to zap bound maybe a handful of months ago now. Anyway, I think not this similarly to how most people end up doing things. I was about six or eight months into this. And I thought maybe I should understand better what it is I'm injecting into myself once a week. I mean, it's working fantastically. I feel better, everything about my life seems to be better. But I'd like to learn more about it. And I'm starting to see people with type one speaking openly about the successes they're having. So that led me of course, to where any good research would lead a person to YouTube, where I found you, Tom just doing a sit down talking head describing GLP to people and I just thought you were masterful at it. And I reached out and I'm really grateful that you reach back because I think this is a great topic for people living with diabetes.

Dr. Blevins 6:35
Yeah. Glad to be here. Good. Thank you. Nice to work on the on the weight change. Weight loss.

Scott Benner 6:39
Oh, thank you. I appreciate it. The just about three weeks ago, I went to my Endo, who's the one who manages my weight. She was doing my vitals and she kept like mumbling half under her breath and half of my ear like a kid like a kid. These are great. You know about my BP my blood pressure, like just yeah, just just so much stuff that she's like, wow, this is it's incredible. I look like a completely different person. It's my aches and pains are gone and everything else that you would expect to come with weight loss. But then there's also been other benefits. One being that for my entirety of my adult life, without knowing it, I was running around with an incredibly low ferritin level, I was not absorbing iron, and my digestion was always poor and kind of off. And I guess just the slowing of the digestion. My last Burton was 170. And I'm telling you, I've been in the hospital like in the ER with a nine ferritin where I was like almost passing out. And no matter how I supplemented it, I couldn't cut it to come up without iron infusions. It literally is changing my life in ways I don't even think I know yet. Anyway, I sent off a massive list of questions from listeners to you. And you've kind of boiled it down to what you want to talk about here in our first recording. And I think if you enjoy yourself, we're going to do more. So I'm going to try really hard to make you enjoy yourself. But why don't we start right at the top like GLP one. Of course we go V and ozempic GLP one with a GI P that'd be Manjaro. And zap bound. There's others but these are just the ones that are out in the zeitgeist right now. So let's start real basically with what is a GLP?

Dr. Blevins 8:14
Yeah, GLP one that stands for glucagon like peptide one. And, and the gap that you mentioned, Scott is and let me just recommend everybody stick with the gap abbreviation it's glucose dependent insulinotropic polypeptide. Now, okay, stick with gap and actually stick with GLP. One, if you say GLP, I know what you're talking about. Actually, interestingly, people make these hormones in their body, and they make them in the small intestine, and GLP. One is made in cells called the L cells in the small intestine. And when a person eats, carb stimulates the production of GLP one. And gi P has made in the case cells in the small intestine, and in it to is produced after carb, and maybe protein can stimulate it as well. But those normally do is the GLP. One actually goes to the pancreas and can stimulate insulin production. So that's what they do. Normally, this is natural. This is what your body does all the time. So GLP, one stimulates insulin, it also can affect another cell in the pancreas called the Alpha cell. alpha cells make another hormone called glucagon. And glucagon stimulates glucose release from the liver, and actually GLP one that suppresses the alpha cells, it makes them less glucagon the Alpha cell does, and there's less release of sugar from the liver. And so that's those are two things that GLP one does. Now, I'll tell you, I'm going to skip to tip a minute. Tip stimulates insulin production from the beta cell in the pancreas. That's what it does. That's his main role. And we'll talk more about Then a bit, because there's some other things that GeoIP mimicking medicines can do. Like you mentioned mount Jarrow has GeoIP. And of course mount Jaren is up bound to the same thing GLP one does two more things, though, we talked about the insulin to glucagon all that that's good. But what it also does is slows gastric emptying. Meaning this slows your stomach down when you eat. And it slows the emptying of the carb and everything else into the small intestine. Therefore, the carb can't get in as quickly, that lowers the amount of carb that gets in lowers the sugar after you eat is what it does. And what else happens if your stomach slows down. And Scott, you've experienced this, it makes you get full fast and easily, you don't want to eat as much. And so that's one way by which a GLP one time Ed can lower calorie intake, but also it probably has a direct effect on the hypothalamic area that reduces appetite. And gap can reduce appetite a bit as well. And I'm just gonna go ahead and say GeoIP, and meds, that's the amount jarred can also seems that they increase sensitivity to insulin, which is really interesting. And so these meds, do some really good things. It turns out that people with diabetes, type two, make plenty of this stuff. And as far as we know, people with type one, make these two. But the effect in type two is, is reduced of these two hormones. And so therefore, giving people a medicine that mimics that kind of a hormone can really kind of improve things. Of course, people with type one don't make insulin, so you're not going to get that effect. A person with type one would get the lower glucagon, the gastric emptying effect and the appetite effect. I want to just step right in front and say these medicines are not approved to be used in people with type one diabetes at this point, right? They're approved for type two.

Scott Benner 11:59
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Dr. Blevins 14:41
know, the answer is these. Well, to your second question was a good way to enter back into the first part of the question your first part of the question. That is a concern with slowed emptying and suppressed glucagon. And of course glucagon and people type one your alpha cells do make glucagon and go God can help when you get low, of course, and that's what you get by injection, you know, the glucagon injections. And your your alpha cells make that and they help regulate your sugar. So if your sugar gets low, your cells kick out glucagon. Well, if you suppress glucagon, it could increase your risk of low number one. Number two, what you said is right, if the stomach emptying slow down that could increase your risk of of low also. Now back to the first part of your question. These agents have been studied in people with type one. And I'll just briefly tell you, there were two studies a few years ago, we participated in one of them here, we do quite a bit of clinical research here. One thing I didn't mention when I introduce you should have but we do quite a bit of clinical research. And we were really excited about these studies using it was liraglutide, which you know, as Victoza. And that was being studied people type one and there's large studies. And sure enough, in people with type one diabetes, who were treated with, I'm gonna say Victoza because people know this is Victoza. liraglutide is one of the GLP one meds, it's the one you had to give every day, once a day. Yeah, short duration, you have to give it once a day. And we were very excited about this people's agency did drop, you know, around point 3.4. And, and the body weight dropped five kilos or so that's good. But also and the insulin dose reduced, no surprise, but also those people had more hypoglycemia. And also, there was a little bit of an increase in ketoacidosis diabetes related ketoacidosis. And, you know, that kind of caused everybody to pause. And and these big studies were done, and the drug did not get approved for type one. If you look back into those studies, I will tell you this, just just to let you know, the ketoacidosis episodes occurred for typical reasons, it wasn't they didn't look as mysterious when I looked at the studies. And the hypoglycemia was a bit increased. But I think, you know, it's very possible that could have been mitigated with increased change in doses and things like that. Nonetheless, though, those two studies kind of stopped the whole approval process for type one in its tracks.

Scott Benner 17:21
Do you think it needs to be looked at again?

Dr. Blevins 17:23
I do. I really do. And I'll also tell you that another analysis of this whole area, kind of a pooled analysis of, of a number of studies with GLP, one meds and type one showed, certainly there was more gi side effects, we know that's going to be true. And anybody that takes these medicines are competing nausea, vomiting, diarrhea, constipation. I always tell my patients, you know, with these meds, you could get diarrhea, constipation, nausea, vomiting, and usually gets better I tell people you don't get to choose. One of those might have some of those might happen. But if the this pooled analysis showed no differences in ketoacidosis, severe hypoglycemia between the people treated with the Met or the placebo, so yeah, I think it needs to be studied more. I think, anyone that listens to this should, you know, rattle the cage of somebody and say, Hey, we need to study this again and get this so it's approved. Right? That's my opinion. And you know, we're very cautious about this when people talk why and we'll talk about that more.

Scott Benner 18:27
Yeah, no, I appreciate you being candid. I mean, listen, I think people who listen, no, I am getting, I mean, our endocrinologist is giving my daughter GLP. Actually, she's using Manjaro at the moment, which seems to go Jive better with her. I don't know a better way of saying that. Yeah, the decrease in insulin use is insane. Yep. Yeah, I genuinely believe my daughter will use 16,000 fewer units of insulin in the next calendar year, because she's injecting five milligrams of Manjaro a week. Yeah, it's fascinating. And her her excursions, her glucose excursions are flatter. I don't. And now in fairness, she's also wearing a DIY algorithm she's using Iaps. I don't see any more instances of hypoglycemia. As a matter of fact, without the excursions high we're getting fewer Bolus is to bring her back down, I actually think it might be making less hyperglycemia than before, which isn't to say that she had a lot. I've also told you a story and sent you an episode of 15 year old girl who's gone from 70 units a day down to now, seven units a day of total insulin, a type one, my 47 year old brother went from a seven a one C with type two diabetes down into a five a one C without really even changing how he eats and he lost 35 pounds. I mean, I know there are people who are going to have results that aren't like that or that You know, they have some sort of a reason why they have to stop it. But my gosh, like everything I'm seeing just it screams for us to pay attention to this. Yeah, yeah,

Dr. Blevins 20:09
I agree I do, I do want to emphasize that, since it's not approved for people type one, where I don't want to talk about the information for type two interchangeably, it would be using these medicines and a person with type one diabetes, unless they fit certain weight criteria. And we'll talk about that more in a bit. But is off label meaning it's not approved, right. And, you know, insurance, insurance coverage is highly variable, not guaranteed, in fact, likely won't be covered. And so the doctors, your, your treating prescribing doctor can use a medicine off label if, if that doctor or provider feels like it's appropriate, and some will, and some won't. And everybody wants to be very careful, I'm very cautious, for good reason. And these are some great stories like your brother well, and you know, some people do great with these meds, and some people simply can't take them and they can't tolerate them. And I've had a person in this morning to the office who said, you know, I tried a couple of these. And I simply, she simply could not tolerate, and we can we can adjust the dose sometimes and make it work. And we can use a little bit under even recommended dosing to make it work. But they're not for everybody. Yeah, they really are, are wonderful meds for for many, many people. Right?

Scott Benner 21:25
I do wonder if in the future we won't see at boils down to be micro dosing for people with type one sometimes. Because if you're not looking for the weight loss aspect of it, or the hunger aspect of it, although, you know, when you have type one, a lot of people with type one have trouble regulating their hunger and have digestion issues. It's not uncommon, right? But you know, I want to go back before we go forward, you just said, you know, early on, one of the mechanisms of this is the fullness you feel full, go over again, the part where your brain just doesn't tell you you're hungry, because I have both implications. So yes, I get fuller, faster, right, right. That's slower digestion, that's lovely. You can eat through it, by the way, you have to you have to mindfully stop when you feel it. I can eat through it. I should say, I'm sure some people would vomit, or I've heard those stories, right. Yeah, but the part where your brain, like I have to remind myself to eat, I don't get hungry very often. And if I do get hungry, it's almost always in the last two days of the injection when I think the halflife is waning,

Dr. Blevins 22:32
right? Yeah, you know, there's a lot to learn here. We don't know all the answers. But there does seem to be a central effect of GLP. One agonists we'll call them agonist because that's what these meds are they, they stimulate that GLP, one receptor in various places, there does seem to be an appetite suppressant effect, and GeoIP probably does that too. So those two together work well together when it comes to the appetite part. So appetite could be partly regulated by feedback from the GI tract. That may be and so that could be part of it could still be linked to the to the gastric emptying, issue, or change. But also there's a seems to be a central effect. And when I tell people is, you know, you're taking the appetite, I call it Daymond you're putting into a cave, and you're kind of putting a rock in front of the cave, so won't come back out. Because appetite. Everybody has appetite. And, and I'm sure over time, appetite has been a really good thing to keep people eating. And when there's food eat. And when you're not, you're not getting enough calories eat, you know, but appetite these days, kind of throws people into high calorie intake and high carb high anything intake. And so these meds do seem to have an effect a central effect on appetite. Yeah,

Scott Benner 23:48
that's fascinating. I mean, I think not like most people, I felt impacted by it immediately. And my wife's like, Oh, it's a placebo, but I lost four pounds in the first four days. Yeah, recently, I had to go up in my dose, like I was writing the 7.5 milligram dose as long as I could with the Zep pound. And my doctor, I said, Hey, I put a couple of pounds on but I'm not doing anything differently. And she said, Well, I'm gonna move you to 10. Actually, 10 and 12 is where I see the most weight loss. She goes, I just wanted to see how much you could get out of the 7.5. And all of the little things like I was starting to have more sugar cravings. I was hungrier, all that stuff. I swear to you, I shot the 10. Four or five hours later, I said to my wife, oh, I have that feeling of like when I started the first time in my stomach, my body regulated to it. I've been using it for 13 months. So you know, in a day, I felt better. And now it's been four days since I did that. And I've already lost four pounds. Yeah, and I have not I swear to everybody listening. I haven't changed my activity. I haven't changed my hydration. I haven't eaten any differently. I just I'm losing weight now. Oh, it's absolutely fantastic. And to watch it work on my daughter's blood sugar is is magical. She I couldn't get her she's away at college. And so I, as I was switching her to Manjaro, because she was using ozempic. In fairness, we're getting this through a Canadian pharmacy. So everybody understands how it's happening. I had to ship it to her, and it was late to getting to her. And in five days past her injection day, her blood sugar's got completely wonky, we had to make all kinds of adjustments to her Basal or insulin to carb ratio to her insulin sensitivity factor just to get her through the four days. And then she injected it. And I talked to her last night and I said, Listen to me right now put all of your settings back. And we are going to be looking for lows over the next 36 hours just in case now the algorithms getting ahead of it. But as soon as the medication hit her, her blood sugar's all like flattened out and stabilized. Again, it's, it's really, it's crazy.

Dr. Blevins 25:54
That's really interesting, you said a few things are really important. One is it's not approved, so it's not going to get covered, you're getting it from Canada, which which, of course, I as a prescribing Doc, I can't write scripts, and send them to Canada, they have to be, I can write a script that you could take anywhere you want. But and that's one thing. And the other thing is, it's definitely want to be cautious because the you're right, hypoglycemia is possible, and then you treat it with oral carb, and it may not get absorbed quickly. So you know, the stomach slow down. So you got to be really cautious about that. And if a person has had diabetes for a long time, they might have gastroparesis. And that is slowed down empty, and because of some nerve involvement from the diabeetus, and then they definitely would get doubled to slower in and that would be a person who wouldn't want to take it. So we have to be very, the stories are great. And and the results can be really interesting when you're using it. And off label again, I'll say that repeatedly. Because I want everybody to know that's it as a story right now, with type one and vicious I'd be very careful about it and select people properly and can be careful about the and understand the drug itself may make it a little difficult to treat hypose And could create hypose

Scott Benner 27:08
Yeah, and it's going to be such a case by case situation not that everything about diabetes isn't right. But at the same time, like when this becomes more accepted or covered by insurance or everything, it's going to take some real overseeing by people who understand what's going on, because your transition so important. If somebody wouldn't have told me in the very beginning, hey, it feels like your food stops halfway down your chest for the first couple of weeks, you know, which is how I would describe we go via when I first started taking it. I might have panicked if somebody wouldn't have said to me like do not eat crazy. I don't anyway, but but do not eat crazy, fatty or greasy foods you might throw up, I had help moving into it. I had good direction. It's why I was able to navigate it. Because the truth is there's a lot there to navigate. I you know, people ask like what are your implications, and I had diarrhea in the beginning. But I said to myself, I know that when my body regulates this, I have a good chance of this stopping. So I'm going to try to make it through. Because I want the other side of this because Tom, I thought I was gonna have a heart attack. I'm always carrying all my weight and my stomach. I've classically ready to have heart attack, you know? Yeah, yeah. So anyway, we're gonna go back and forth here. But let's talk about the the half life and the dosing. Right. So I don't I'm sure everybody doesn't know what half life means. But you can explain it to them and tell them why it's important with us. Yeah, thank

Dr. Blevins 28:29
you for asking Half Life is you can look at it two different ways. One is the time it takes when you give a medicine for it when you stop it, the time it takes to reach half the level of the dosing. In other words, look at it as the time that it takes to reach the steady state as you give them medicine. So if the half life is a day, that means that takes about a day for the drug when you give a dose to reach 50% of the metabolized, excreted whatever. And, and so it tells you a lot about the duration of the medicine and the body. And then when you're creating dosing frequency, it tells you how often you have to give the dose I mean, if I gave it a medicine that had a half life of a day, would I want to wait two days to give the next dose? No, because you want to give it every day to maintain the level of the Med and we could go on and on about various meds. But the relevance here is that some of these medicines have very long half lives, meaning they can be dosed infrequently, and some of them have shorter half lives they have to dose more often. And for example ozempic would go v semaglutide. And that rebelliousness is the pill version of that that drug has a half life of a week. So it can be given once a week because it stays around for a long time. The medicine like the mount Jarrah And that's also observed bound. Okay, yeah, as you pointed out earlier, that one has a half life of five days. So it can be given once a week to. And we could go on and on about that Victoza has a half life of about 13 hours. So you really have to give that every day to maintain that level. So the beauty of these new meds that we're talking about the ozempic will go V set bound mount Jarrow, those meds can be given once a week, which is very convenient, really in relative to other meds. And so that that makes a difference.

Scott Benner 30:34
It's fantastic. And I know I think Novo is working on a pill, a once daily pill I got, it'll probably be 10 years before you see it. But I think that people are people by people. I mean, researchers, pharma companies, they obviously see what's going on at this point. Like, it's the amount of people who use this don't have side effects that don't stop them and are having insane kinds of, you know, transformations, both health and visually. Yeah, it's gonna be a focus. But you know, it brings me to this point that you put on your list here, like what is overweight and obesity. And I really do want to hear from you. Because what you're seeing right now, in the zeitgeist, right? The way people talk about this is you'll either find somebody who says, well, whatever works for you, that's fantastic. Good for you, which is how I think about it, or you'll hear somebody say, well, work harder, eat better. And sometimes for those people, I say, Okay, fair enough, there are plenty of people who are not getting movement and are not eating well. And they, they're overweight. But I can tell you that from my perspective, I was not eating poorly, right? My entire life. This has been my situation, I used to joke with people. If I ate like you did, I'd gained five pounds. I retain water, like a pregnant lady, I would tell people, right? Like, if you and I went out to dinner and had a normal meal, I'd be three pounds five pounds heavier. The next day, I couldn't tell you why I didn't eat differently than you did. And so can we talk about this a little bit like, you know, just weight and obesity? How you think about it in relation to these medications?

Dr. Blevins 32:07
Yes, you know, there's a lot of data that shows that as people gain weight, certain things happen. And if there wasn't some risk to gaining weight, we wouldn't care. You might not like the way it looks. But it has medical consequences. And that's where a lot of the treatment sort of motivations come from. And it turns out that as people gain weight over their usual ideal weight, then you start seeing things like high blood pressure, high cholesterol, type two diabetes, insulin resistance. And you know, it's well known that people with type two diabetes have insulin resistance, some of that's genetic, some of its acquired, like when people gain weight. And so, you know, it's kind of arbitrary, when you set a cut point to say over a certain amount of weight over ideal, it is a problem because sometimes people would gain five or 10 pounds and things go to pot when it comes to metabolic things like I talked about. But a commonly accepted standard for overweight, that could cause medical issues is a BMI of 27. Now BMI, what is BMI? Everybody, I think when you go to your get a checkup, you get your weight, your height, and those two can be put together into a formula. And his body mass index, BMI, his body mass index, it's an index that takes into account height and weight. So a person who's like, you know, 610 ways to 10, that's probably okay. A person who's five, two that has a weight of up to 10. That's way over. So you takes into account height and weight, BMI. We could go on and on about that, but I'll just tell you the currently accepted standard is a 27. Plus on the BMI over 27, is overweight, and that person is at high risk for things like all those things. I've talked about high blood pressure, high cholesterol, type two diabetes, insulin resistance, and over a BMI of 30 is called obese. And there are other cuts that are higher than that too. But those are the two classics. Again, BMI is calculated by height and weight. If you wonder what yours is, you could go to a table online, when you go see your medical person and you can say what's my BMI because the EMRs calculated pretty much automatically these days. That's an adult's. I do want to talk a little bit about pediatrics a little different. There are various standards for defining obesity in pediatrics. The most accepted one here in this country is obesity and pediatrics is a weight that's over the 95th percentile. So you get out of BMI. You could use BMI a little bit but you get out of BMI. In up we're looking at percentiles that is comparing people to other people their age. There's so much dynamic changes that occur in the pediatric population. So they get older, the height changes, weight changes all that. So obesity and pediatrics is defined as a weight. That's over 95/95 percentile of other comparable people they like age matched. And those that that goes from the ages of two to 19.

Scott Benner 35:18
Is there an increase over decades in young people being overweight? Absolutely. Is that in your opinion? Like, I mean, is it a little bit of everything? Is it movement? Is it what's in our food? Is that how we eat? Is it how often we eat is? It's an amalgam of these things.

Dr. Blevins 35:39
Yes. I mean, I could expound on that. But you nailed it. Okay. It's, it's the diet, its nature, for sure. Genetics determined things, determined metabolic rate. And you can see overweight and families. But it's also nurture, it's the environment we live in. And activity changes over time. And, and what you know, everybody knows what's going on. But it were glued to the computer, or to the phone or something like that sitting still a lot. In the old days, that didn't happen. And we could talk on and on. But you're exactly right about that. Scott.

Scott Benner 36:18
So is the clinician, how do you think about it? Meaning? Maybe I should back up and ask this question. How many times in your career have you told somebody to lose weight? And they've actually done it?

Dr. Blevins 36:28
I'll answer that is many, many times, I think people understand the concepts of calories and calories in calories out. And you know, I'll say, exercise is always important. You mentioned exercise earlier, and your own particular experience. And 20% of weight loss is related to exercise, unless somebody's an elite athlete, or a very athletic and exercises all the time most people don't. So exercise is important. And reducing calories is important. But I'll tell you, I think people respond and are successful, many times, the problem is the long term part of it, people are successful frequently for a while, and on average, they tend to gain it back, we're all busy, we're exposed to calories all the time. Activity is challenging, sometimes because of scheduling or, or just understanding about the amount that you need. So I think people really handle this way on their own. And so people can lose weight on their own to keep it off and do really well then understand the medical part of it. But for the most part, it's really challenging. A lot of it has to do with the environment that we live in. My

Scott Benner 37:36
take on that is in a world where I can't impact the environment, right? I can't just it's nice to say like, I love turning on a podcast or TV show, you hear a rich person say get out and move around. I'm like, Well, you have $9 million in the bank. That's great. You know what I mean? Like, I've got to get up and sit back down and make this podcast all day or I don't get to pay my electric bill. And that's how this works. Right? Right. When that's the environment? Do you have any moral qualms with giving people medication just to lose weight?

Dr. Blevins 38:06
The answer is no. That's the answer. But you know, when I have a medicine that I think is safe, and, and effective, and I understand, then I'm much more comfortable prescribing, we've gone through all kinds of medicines over time. And some of them, we still have, I mean, GLP ones are not the only medicines approved for weight loss. Right. And, and some of them, I feel comfortable with others. I don't like the side effects. And I don't like the idea of long term, I have increasingly come to think and No, and I think most people in this area are similar, that any medicine we use is going to need to be long term. Right? And for example, I mean, let's just go look at other like type one diabetes, it's not like you can take the insulin for a while and and get off of it. And and, you know, various medicines, thyroid hormone, it's not like you can take thyroid hormone for a month or two and then get off and everything's okay. It's a it's a continuing need for treatment, then people call it chronic, chronic condition. So I think the weight loss medicine is going to have to be that way too. Because like you pointed, as you pointed out, you get toward the end of the cycle of these very effective meds and the appetite comes back and tries to come out from the appetite demon tries to come back. Yeah. And you just have to keep it where it is. And so I think chronic treatment is is is the way to go. With this type med.

Scott Benner 39:31
I've heard people describe a food noise in their head that goes away. My wife got a got hypothyroidism and it took us seven years to talk a doctor into giving her medication for it. And in that time, she gained a significant amount of weight which she's almost completely all lost on we go vino. And she describes and I'm going to have her on at some point to tell it in her words, but she describes it she would open her eyes in the morning and be thinking about food before she was even conscious and Then, as she was making breakfast, she'd start wondering what she was going to have for lunch. And she said, It's all gone. It just doesn't happen anymore, which makes it much, much easier. And then her you know, then it impacts the insulin, and that your body's using, keeping in mind, she doesn't have diabetes, right. And then the weight starts coming off, and then the metabolic stuff gets better. And that's in there. I think to me, for me personally, the most significant part is the way I ended up describing it as my body works better with the GLP. I don't really care what that means. And I by the way, I am now more active than I was before, because a I lost weight b I have more energy, my joints don't hurt like I am more active now than I was prior, it was easier to get going, it was easy to pick up weights and go, Hey, I'm gonna lift these now. It's a nice say, go ahead and lift some weights and go for a walk, etc. Except every time I tried to do something, I ended up getting a knee surgery or something like that. Because in fairness, my body was too big. And every time I tried to use it, I'm older and it would break. And so if we can all basically agree that there's stuff in the food we shouldn't be eating, and maybe stuff we're spraying on the food that we shouldn't be eating. And we're microwaving and plastic. And there's 90,000 Different kinds of oils, three of them apparently could be her one of them could apparently be an Industrial Lubricant, the way it's graded out, right. And we're eating this stuff all the time. And over time, people don't even understand what good food and bad food is anymore. In many situations, to say to people, I threw you in the cesspool, and I could pull you out, but at you should climb out. I don't understand that. Like I really don't like what is it? You're saying to people, if you're fighting against this idea now, is this ideal? It's not. But until GLP is make food come out of the ground tasted like candy and being good for you like lettuce. I don't know what else we're gonna do. Because this is where we are now. That's my opinion of it. Yeah, it's nice to hear other people wanting to be helpful for those who are are stuck in that. Also, there are plenty of thin people who are not healthy either. So you know, they're eating the same crappy food to their bodies just aren't reacting the same way as mine did, if that makes sense. Yeah, I think

Dr. Blevins 42:13
that makes sense. Yeah, your body, it was built for a certain amount of weight, your chassis, your skeleton was built for a certain amount of weight, your internal metabolics worked better with a certain amount of weight. And when we load the body with more things happen to the metabolics. And they also you pointed out, you pointed out they happen to the structural part to the knees. Cancers are higher in frequency. You know, I don't have a study that tells you when you lose weight, your cancer risk goes down. I would think that's probably true. But nonetheless, we know that overweight is related correlated to all kinds of things cardiovascular answer, all of that. And then losing weight is actually really important for some people losing 40 pounds is was needed. Some people lose 10. And they do a lot better. Yeah,

Scott Benner 42:59
time. Listen, I didn't even go to college. I have no background in medical whatsoever. I'm better off now than I was last year. Yeah, that my common sense tells me right? I've joked with people if I grow horn out of the middle of my head, and it literally says Manjaro up it. I'll go at least I'm not going to die of a heart attack. You'd have to show me some really tough health concerns about using this for me to think about. I'd be better off 40 pounds heavier. Yeah, yeah. So here's the thing like that. We don't talk about enough. Maybe you could do these medications. They started being researched in the 80s. I might is that story about the heal a monster in the Canadian researcher. Is that true? That's

Dr. Blevins 43:38
pretty true. Yeah. Yeah, they were started. The research started many, many years ago. And there was something in the heel of monster spirit that was kind of similar. And the one of the one of the early medicines that you probably remember was by Ada, which is exemplified, we don't really use it much anymore. He had a very short half life and had to get given twice a day. It was effective. It caused lots of side effects. It had peaks and valleys and peaks and valleys because they had to be given so often. And yeah, these are not brand new. You nailed it. I mean, epic has been out since 2017. Yeah, by eight it was approved long before that. And then we had a long acting by Ada kind of thing. I extended it that was by durian, you probably remember and one or two came and went because they just didn't have enough uniqueness to actually be used very much. And then along came Victoza. And we use that quite a bit that eventually got approved as the drug saxenda that the same thing for weight loss. And then you know, started people start observing, Oh, these are good for diabetes, but they also cause weight loss. And most of the drugs before that we use for diabetes, including the insulin would be associated with weight gain. And we'd say, Oh, that's good weight gain because your sugars are better, but nobody that I know Who is listening? And there's no weight gains good. Yeah, yeah, they've been around for a while.

Scott Benner 45:06
Yeah, it's tough because you lose weight when you're diagnosed with type one very frequently because you're, you know, drifting away from life and you don't realize it at first and then you reintroduce the insulin. And then you get back to the caloric intake that is normal for you, which for some people is more calories than they needed. And then they start gaining weight. And then they say, Oh, the the insolence making me gain weight. And I always try to tell people like, generally speaking, it's the calories you're taking in that help you gain weight. Now, the the insolence putting it, you know, is storing it for you. And do you agree with that generally? Or is there more to it than that? I

Dr. Blevins 45:40
agree with that. Okay, everybody, you know, people, everyone's different. And everyone, not everyone, but in general, it's still safe to say it's a good concept. Everyone has a different metabolic rate. And they deal with calories differently, frankly, calorie burn his genetic appetite is partly genetic attitudes about food are acquired. But, you know, we grew up in our families and in certain attitudes about food and amount of food. People are told, eat three meals a day, and you know, have a dessert. Yeah, we live life in real time. And we eat and so the calories, it would be kind of interesting if everybody had a custom calorie for their particular body. And that can be calculated. But But still, the environment we live in is so easy to get calories one on but you know, a handful of us has lots of calories, go look that up. I use, I use the net. And as many people do in Siri, I just say, Hey, Siri, how many calories in a handful of walnuts or something and you know, it's like, wow. And I still remember when I was in training, we were asked to have a dietician sit down with us. And I would go over to the hospital every day, and grab lunch. Lunch was, you know, an event. And, and we got time off to do it. And I was having a chili dog with french fries and a regular drink. And the dietitian calculated calories for that. And I thought, oh, it's gonna be like 450. But it was like 1000. And I will tell you that kind of feedback was a reality check. And I never had a chili dog again, I'll tell you because I just it just floored me. So if you look at what you actually eat everyone, you've done this, you do this, then you'll you'll find some interesting things.

Scott Benner 47:21
I'll tell you that I had an experience last week where I started eating something I hadn't eaten in a while. And I enjoyed it, and I ate it. And then I injected the 10 milligrams up from the 7.5. And I reached for it on the counter one day. And I actually thought to myself, Oh, I don't want this, right. Like the idea of it nauseated me. Yeah. And I was like, but But five days prior without two and a half more milligrams of this medication. I was like, Oh, this is good. I like this. It's it's it really is fascinating.

Dr. Blevins 47:52
changes your attitudes. And you know, something, there's nothing wrong with that. That's good. I mean, people, do you ask the question earlier? Is that really? Okay? And the answer is, you know, if it works, and it's, it's safe, and you tolerate it, go for it, it's what you should be doing

Scott Benner 48:06
is overweight and obesity, an issue in the type one community more so than in the regular community?

Dr. Blevins 48:11
You know, I've had people tell me, oh, overweight, it's not a problem. The type one is type two. And I look at them and go, No, that's not true. I know that because of the people I see in my office, people with type one diabetes have the same struggles with appetite, and maybe sometimes more. So as the people with type two and struggles with weight. If you look at stats, I can say, Is it 2050 or 80% of people with type one who are overweight or obese based on that definition I gave you earlier. And most people probably say 20%, I think most of the people in the medical world right now would say 50 or more. It's not at all mean, but if 50% of people with type one are overweight or obese, and I'll just say this type two diabetes, people with type two, have not cornered the market on overweight or obesity. And they haven't cornered the market on insulin resistance. People with type one can have genetics that are insulin resistant. And when you gain weight, you get more insulin resistant, whether you have type one or type two. Yeah, so it's a real it's a common issue. It's talked about more and more. And yes, we really do need some good studies, with I hope, this kind of medicine, looking at people with type one, and I'm going to tell you more about I can tell you now and there's a study that's going on, but we need more studies that look at this and people with type one, we need to find ways to mitigate risk. And we can do it. When

Scott Benner 49:34
you say we need studies. Where does that have to come from? Is it a pharma company that has to say, hey, I want to sell to these people. So I have to prove it works? Is it researchers like Who are we looking for to jump in and carry this load for us?

Dr. Blevins 49:46
Yeah. You know, it's the pharma companies. And there were these studies early on that there was a lot of optimism and we all assumed it was all going to be approved and it wasn't they have to go to the FDA and have to show the adverse events associated with medicines, and everybody has to come to an agreement, it just didn't happen. So the pharma company typically would have to put together a sizable enough study, which is very expensive, and then show effect, and then show, you know, manageable side effects. To get it through the FDA. Currently, there are some studies going on. In fact, I'll just jump in a minute and tell you about one, there's been reluctance to proceed. Of course, most people with diabetes have type two. And then there's just people who are overweight, who don't have diabetes at all. And then there are people with overweight who have pre diabetes. And that's where the numbers are. And that's where they're going for. A big part of me says, We want to go on something, and you have type one diabetes, go to the JDRF, and say, hey, please lobby for this because they have an organization. And they know how to do that. And they're really good at that. If I went to a company, and I said, I want to put 50 People with type one on this medicine, and that I probably could get funding to do the study. That's not nearly enough people, though, to get it by the FDA. So it really has to be a large study. Question is what about these weekly meds? That that's those two studies I told you about? That had the ketoacidosis and the hyperglycemia. Were in the once a day drug alert. liraglutide Victoza? What about the weekly meds we don't know, we need studies. Now there is a study going on right now. And I'll just jump in and say something about it's called car mod c AR mot that's just the name of the study. And accompany is studying a medicine such as we're talking about, specifically, in people with type one diabetes, who are either overweight or obese. This is a phase two study meaning it's going to turn into hopefully, if things look good, into a bigger study phase three. Now that's the kind of study that needs to be done. And that is ongoing. That's not from Novar. Lilly, it's a different company. And we are involved in that study, here. And in fact, if anyone is in the Austin, Texas region that wants to be with type one diabetes, who could be categorized as overweight or obese, we're looking for people for that study. So these studies, please, I've encourage everyone to volunteer for some of these studies, as you have in the past. Every medicine that's approved for type one, type two, anything, has people who volunteered to study jump on in there and help those things get approved, or at least at least get them study. They may not get approved. You never know.

Scott Benner 52:34
Yeah, Tom, I'll I'll get some information from you afterwards, I could probably funnel some people towards you that would help with that. And also, let's take a moment to chide Lilly and Novo who both in their charters say that they're around to help people with type one diabetes. So here's your opportunity, spend a little money and help them you know, the big problem here is there's not enough people to sell it to afterwards. That's the bigger problem. Yeah, there's not enough type ones. For them to think of it as a splash. But my gosh, like you're looking at really impacting people's lives. Because, listen, I think you can hear through the raindrops when Tom's talking. If he was in charge, if you were the Wizard of Oz, you'd give this to people, right? You do the study, come up with the protocol and give it to people with type one. Is that fair to say?

Dr. Blevins 53:19
And the answer is yes, I would. Yeah, I would be very, very careful. I would talk about all the things we talked about with the little part of my head saying, you know, there was a study that showed increased ketoacidosis. But then another larger kind of analysis said, probably not, it doesn't make a lot of sense to me that it would cause that I can I can come up with mechanisms. When you look at the studies, you come up with your own impressions. Yeah. And it looks like those people might have developed it anyway. But and then hypoglycemia, that one, I get that one I really do understand. And I know how to mitigate. And what you said earlier, you're you're looping your your daughter's loop. And I mean, and and even the automated insulin delivery devices from all of the manufacturers, since hypoglycemia, or since the progression towards it, and they back off the insulin. So with those devices that lots of people with type one are using, would there be an issue at all with Hypo? The answer is I don't know it needs to be studied. We

Scott Benner 54:18
live in a world where generally speaking, people with type one diabetes don't know how to accurately adjust their insulin to begin with. And often they see doctors who are not much more help it so then to say that we will I'll inject something in you that's going to lower your insulin needs. Who's going to adjust the insulin, like the user doesn't know how to do it, the doctor doesn't know how to do it, you know, like it's, that's where the rubber is gonna hit the road right there you have, you're gonna have to tell people look, we're gonna enjoy when Arden gave herself the first injection of ozempic We spent the next three days changing her settings. It was that significant and that real quick, and then after we got them right, it was fine. And that was it. So you know, anyway, Yeah, sorry, can I say about the DK thing? Yes, I bet you could have gathered all those people up and just check them for DK and came up with similar numbers without the GLP. But that's my guess based on nothing other than talking to people for years about diabetes?

Dr. Blevins 55:15
Well, I will say in those studies, there was a group on placebo and the group on treatment and the people on placebo, that is the comparison and a scientific study where you actually have people who aren't on and who are on and the people who weren't on didn't have the ketoacidosis. I can't say that interesting. And why did it cluster in that particular group? It on treatment, it tended to be the higher dose, so maybe the nausea from the higher dose sort of covered nausea from something else going on, like ketoacidosis. And people were kind of misled. It's possible that the lower insulin dose needed, made people more prone to have keto ketosis because they had less insulin going in. I don't know.

Scott Benner 55:59
And they were still eating regularly because they weren't being slowed down from eating. I wonder there's a lot in there. Yeah, there's, like you said, I think further study might prove out that that's not something to be overly concerned about?

Dr. Blevins 56:11
Well, it's something to be very careful, definitely. And what you said, is, is very important about adjusting for the first three days, the studies studies that are the one that we're talking about the karma study that we're doing, yeah, we have a very clear kind of direction as to how to adjust insulin right off the bat to be very cautious. And so we don't know if person is going to go on the real thing or not. And we adjust the insulin in a certain way. And so these studies should look not only and they are this one study, looking at not not only the effect, and the side effects, was also looking at a treatment kind of algorithm approach to reducing the insulin.

Scott Benner 56:55
Yeah. Do you have any patients of yours type one who you've given them a scrip? And they're paying cash?

Dr. Blevins 57:02
And I'll say I do? Yeah, yeah, you know, I'm writing it off, it's off label. And what I tell people is, I tell them about all the side effects, I say it's not approved by the FDA. And if you look at the approvals, many times, it says specifically not approved for type one. And, and I tell them that and give them a prescription of I think is appropriate, we we start low, we always start low, and then we increase the dose as as appropriate. It is off label. And I'm gonna say that so many times, and and I tell them, it could bring out some major gi problems, and you may really not like it, and you may not be able to take it, you may have to discontinue it. And we're really cautious. But I do have people who are overweight with type one, and I will point out and we can talk more about this later, that actually there are instances in which it could be covered in people with type one. And that would be the obesity overweight obesity indication. And and that would be the main one actually. Yeah. So if somebody and then also with what GAVI there is an indication for using if a person is overweight, or obese, and if they have a cardiovascular disease, so someone has a history of SEO, and a heart attack or stents or bypass or whatever. And if they're overweight, then there's a really, really interesting study that showed a reduction in major cardiovascular events. And people given them a govi. It wasn't that people type one. But there were a few people type one of the studies, it turns out, and they still fit that indication. I hope that made sense. Does

Scott Benner 58:41
Do you think we'll see an approval one day or a study one day for PCOS? Have you seen the people talking about that the the mass amount of women in these Facebook groups who are getting pregnant before they're losing weight on GRPs?

Dr. Blevins 58:54
Yeah, yeah. People with PCO, you know, weight loss can improve fertility and people with PCOS and without, and there are studies that have that are done small studies, there are ongoing studies. Are we going to see an approval? I don't know. I don't see a big study being done. And people PCO at this point, I may not be aware of one that's been done possible, but I think it's really an interesting thought.

Scott Benner 59:21
I think a lot of women suffer with it quietly. Yeah. And it's not looked at and it's

Dr. Blevins 59:26
highly connected to overweight. You said it right. It's highly connected to overweight and insulin resistance. And if you lose weight, the insulin sensitivity improves. Ovulation improves. Really interesting. I

Scott Benner 59:36
am going to share a story that I can't tell you who the person is, but I know them very well. And 20 mid 20s female, not you know, growing up heavy than not heavy, mostly not as an adult through college, and then suddenly in the last year, just gained 60 pounds. They're working out crazy eating as clean as they can gaining weight through the whole Then doctor says you have PCOS. We told her, go back to the doctor, see if they'll give you a week. Ovie something like that. We go, here's that bound doctor gave her we go V. She shot it on Saturday morning, over FaceTime with me because she couldn't bring herself to do it. I had to talk her through it. And she got it in and sent me a text 36 hours later that said, I've lost five pounds. I don't know what that means, or how to measure that. But that's insane. Like is that's not water weight. Do you know what he means? Like, it is probably some of it. But she stopped eating in the past for 36 hours and nothing's happened. And she's eating super clean to begin with. And she's active and everything else. Like, I don't think we have the answer yet. But you can't tell me that there's not something happening here. That's not commensurate to the idea of thyroid stimulating hormone, right? Like you My body's making it but it's not using it correctly. Like, there's gotta be something there making those those GLP receptors light up, that's changing people on a metabolic level like it maybe I'll be wrong one day, but in the moment, this is how I'm thinking about it. Yeah, yeah. Well,

Dr. Blevins 1:01:10
I mean, I'll say 36 hours, five pounds. There's a lot of water there. I think I mean, that or something? Or maybe there was a big blowout, diarrhea, I don't know. But, you know, usually on any diet when a person lowers calories. Typically the first week or two, you lose a lot of water weight for various reasons, part of its decreased salt intake and, and part of it is kind of the ketone formation thing and the less calorie in and all that type. I agree

Scott Benner 1:01:41
with you totally, but she was already doing that. Yeah, there was never a moment whether it was either a Gary has just exploded, and she just that diary, like or whatever it was, that still didn't happen to her when she was eating clean, exercising, and, and etc, and so on. Who knows? Like, I have no idea, I can tell you my daughter's acne is almost completely gone. And she was not overweight to begin with.

Dr. Blevins 1:02:04
Yeah, you know, we have a lot. Well, I will, I will say we have lots to learn. And I will emphasize to the audience, these are anecdotal, please, of course, examples of effect, not that everyone's going to get anything like that. And some people are really not going to tolerate it. And I have some people who simply can't take it as too bad. Can we talk about that people don't have and yet some people don't have as much weight loss as we're talking about either. So life is a bell shaped curve in response to a medicine is to Yeah, and we like to we tend to talk about the real yet exceptional examples. But remember, not everyone gets that that result.

Scott Benner 1:02:42
Talk to me about the not tolerating it when you don't tolerate it, what does that look like?

Dr. Blevins 1:02:46
You know, the main thing is Gi, and it's typically just what we talked about that gastric emptying, change, and maybe even some central effect can induce nausea, vomiting, it tends to get better over time, we always start with the low dose and we titrate or increase the dose very gradually, we if we increase the dose, and then a person gets side effects, we back off. And that's very doable. You have to work with your health care person when it comes to that. And, and so diarrhea, and constipation, the medicines typically slow down the GI tract all the way down, but some people can get diarrhea as well. Commonly, those those effects are tolerable or get better. I had a gentleman in this morning who told me he's taking one of the meds and that at the highest dose, he gets really tight in his abdomen and very uncomfortable. And he's backed it off, backed it off, backed off and I encouraged him to continue to and try to find a happy medium because the GI tract is in the balance here. Some people can't take it and if you look at studies for up to 8% of people on these meds discontinue because of the GI side effects. Now they're those effects can be matched with medicine. I don't like to treat the side effects of one medicine with another but it's sometimes temporary use of like anti nausea pills can help. And you can use medicines or anti diarrheal 's to same concept but that typically are temporary but not always. And so people need to be aware of that. It just happens it's not your fault if that happens. I will say this if you have nausea and maybe Anyway remember that high fat slows the stomach down to so if you add fat plus a GOP one, your chance of nausea it goes right up. So one thing to do is cut the fat back about

Scott Benner 1:04:40
Yeah, no I don't eat high fat to begin with. I don't use any oils almost at all in my life. But I was very careful about that. I also if I don't see myself going to the bathroom I add a little magnesium oxide to my supplementing Yeah, I knew how important it was to keep the process rolling once I started this, like, if I don't see myself going, going every day on this, I hydrate, I take the magnesium like I keep things moving. I know there are some, you know, people love to yell in the media about stuff like this, but have people been injured permanently from it at all that you know of like, I mean, and is that got something to do with who they were before they started? And? Or could it because I think the fear is like randomly you're just not going to be able to like, I don't know, digest food anymore. Like you mean like people get when they hear about it, and you hear them panic about it, they say kind of bombastic things like that, is there a call for concern,

Dr. Blevins 1:05:37
you can ask something, when we talked about half life earlier, I mentioned that, that, you know, the week Half Life means that it takes a week to reach 50%, I'll tell the audience, it typically takes five half lives for a medicine to get totally out of your body. So if a medicine has a long half life, it's gonna take a while for it to get out. So if you have a symptom that you don't like, and you're gonna stop the medicine, it's not like you stop it. And that just goes away with this type of medicine because of the long half life. The symptoms of like the slowed gastric emptying are gonna go on for a while, and maybe they'll go longer than that. But there's really no clear evidence that those go on forever. And some people have underlined gastroparesis, and we don't know. And, and we might bring it out, make it worse. And then after they get off the Med, they may they may get diagnosed. And I may say maybe think Well, I have this now because the answer is I think they probably had it before. And there's still a lot to learn, but there's no clear evidence out of studies that there's there's a permanent impairment. Right. Okay. And, you know, there are other side effects too, we could talk about that. That's, I think the main one that people talk about,

Scott Benner 1:06:48
I would, I would never minimize anybody's experience. But either, yeah, but I want to say this, and I want to leave with that. I've interviewed 1000s of people. And I have access to my Facebook group that has 50,000 active people in it. And so when my daughter at 18 years old, was told by a GI doctor, she had gastro precess, even though her a one C had been in the fives and the low sixes for most of her life. I didn't accept that. And we went and looked at other ideas, and added a digestive enzyme to her process of eating, which made all of her stomach pain go away. I shared that on the podcast. And I have to tell you that the amount of people with type one who I hear back from who just said to me, I thought my stomach was gonna hurt the rest of my life. I thought there was something wrong with me, my body was broken, etc, and so on. Now, I've added this, and it's all gone. It just cleared up. So we don't talk enough about when you get type one diabetes, some people get digestive problems, right. I mean, you know, they used to give Amazon out like it was like candy to type ones. But now if suddenly we don't do that anymore, so we, we ignore the possible digestive implications of having type one diabetes. And then when people talk about stomach issues, they send them right to a GI doc, who just jumps right to you have slow gastric emptying, you have gastroparesis. And I wonder if there's not, it wouldn't be helpful if people were better educated about that and spoke more about that to their patients. Do you find yourself seeing those things? Yeah,

Dr. Blevins 1:08:27
I think it was a really good point. And I think gastroparesis should be diagnosed based on you know, commonly some testing to document what's going on. And I think if anyone goes to their GI doc, please, if you're on a GLP one, tell them about that. Because everyone, you know, we we in the endocrine world, diabetes world, we're, we're all up on it. But not everyone is. And I can't tell you how many people now the GI Doc's I work with are really sharp. And they picked up on this very quickly. But I got some calls early on, from people saying, Hey, I just did an endoscopy on somebody who's on that medicine and they're still fluid in their stomach and they haven't eaten anything since last night. We've learned a lot, we've learned that that can happen. Slow gastric emptying can leave contents there for a while. And you need to be aware of that. If you're a GI doctor, and then this thing about symptoms too. I've had people go through major gi workups. And, and they're told Finally, well, everything's okay. Take these medicines, and it might help. And then they come back to my office, I go, Oh, you're on this medicine that probably cause all those symptoms. And Did y'all talk about that? And the answer is, there's been a lot learned and things have gotten a lot clearer. But But these medicines if you slow the stomach down, what happens? Well, you slow the stomach down, you could get fuller. And, and like my patient said earlier, it felt like his stomach was tight. Yeah, and that's no surprise. You can also have that gastric to juice be kind of pushed up the esophagus because there's more pressure and you could get some a soft vaginas. So it's important to kind of understand the implications of that gastric emptying thing.

Scott Benner 1:10:11
I have to tell you my acid reflux has completely gone away on a GLP. Right? Yeah, good. Is that in common?

Dr. Blevins 1:10:18
All things are possible there. They could get worse. I mean, you said it's got better for you. Yeah. And so the various things can happen. Okay. Most people really don't have any don't have an increase in reflex. Some do. And I can understand how it could get better, too. So there you go. And, and a lot of variability from person to person.

Scott Benner 1:10:39
I think we're coming up on our time. Is that right? We could go a little bit longer the longer Can I ask you about? So two things? So first of all, availability? Are you seeing it get better? I know there was a flood somewhere that slowed it down for a little bit? Like do you think that they just can't keep up with this? Do you think that so many people are using it? What Why are we seeing this? Do you think it'll clear up at some point?

Dr. Blevins 1:10:59
Yeah, availability has been a big deal. And I think part of it is related to some manufacturing difficulties. Part of it, the most of it, I think, is due just as pure demand. I mean, these these medicines are in high demand. And we almost need a pipeline, you know, there's so much that is needed and needs to be distributed. And we've seen those Olympic supply became very challenging, and it's improved a little bit in my experience will go the challenging, and maybe getting better, I keep hearing next month is going to be better. And then the next month comes in, it's not better June next month. And then now now, you know mount Jarrow has had some tight supply zapped bound as well. And of course, we as treatment people, like I want I want my people with diabetes, to have availability to the medicines they need. Right. And I like people losing weight, that's great. And so, you know, people that don't have diabetes, and you lose weight, that's important people with diabetes, big deal. So, you know, there's this this kind of back and forth about, you know, people who really needed aren't getting it really needed, what the definition of that, but that would be, you know, I think most people think those people with diabetes, again, we're talking type two, because remember, these are not approved? Yes. In general, for type one.

Scott Benner 1:12:24
I mean, listen, I, they've got to, they want to make money, right, they've got to figure out a way to get on top of it. I think one of them literally just bought a new place and down south somewhere, or they bought they bought somebody else's building and they're they're manufacturing, they're trying to get set up for it. I don't think it's because they're not trying. To me it lends to the idea of doing studies in other populations, because if it's this popular now, and you're not going to be able to stop taking it. And we have no shortage of people who could use it for diabetes and or weight, or hunger or PCOS or whatever we end up using it for like moving forward, find more people to give it to so you can make excuses to build more buildings and hire more people and produce more. I've heard of people getting it through China, like through China through a Canadian pharmacy into that was happening like that for a while. It's insane.

Dr. Blevins 1:13:13
Your your points well taken? Yeah. I think the demand surprised everyone, the potential the benefit has been embraced. And there's a shortage, which I think will cure in the next few months. Of course, I said that three or four months ago, too.

Scott Benner 1:13:29
Do you think that the demand was surprising is an indication that it works?

Dr. Blevins 1:13:33
I do? Yeah, I do. And I think that, that people understand that people with diabetes, that have the under the indication, benefit, a great deal from it. And that's really a big deal, because lowering the agency reduces risk of complications of diabetes, and helps all the metabolic issues that occur with diabeetus. And we know now that at least a few of these are approved for reducing cardiovascular risk. This studies were done in people with known heart disease, of course, but we know that too, there there are benefits all the way around. And but I think that people who don't have those, the diabeetus. And those risks still want it because weight loss is something people want. And for good reason. I can't blame them at all.

Scott Benner 1:14:19
Can I give you my my big theory? Yes. I think that after a generation of people using GLP medications, and basically learning to eat less and eat better, because they're being chemically kind of directed like that, that we might raise a new generation of people who don't eat poorly. I know that's a big idea. It's a generational idea. But how do your kids end up eating poorly? It's because you eat poorly and you maybe don't even know it. I use this example all the time. My mom who's passed now was told she was pre diabetic a few years ago, and she called me and said Scott i They Say I have prediabetes I'm gonna film to change up my diet completely. So that's great mom. And then I visited her a week later, and I opened up a refrigerator and everything she bought, couldn't have been a worse decision. Because she just didn't know the right things to eat, right. And that's the lady who taught me how to eat, right. And then I taught my kids how to eat except I got lucky, at some point and said to myself, we're doing this wrong, my wife and I were like, we both grew up very blue collar very simply, nobody understood, you know, nutrition at all. And what we consider to be good food was just the stuff we couldn't afford, that we got once in a while is a treat. And that made it good food is really interesting, like how we think about what's actually good for us. So that's my big idea. My big idea is if we take a generation of parents, and write their thinking that they might raise a generation of kids who don't get, I can see in three generations, this completely flipping the other way and forcing Agra to move with it. Because if we're not buying it, they're not going to make it. That's kind of how I feel about it.

Dr. Blevins 1:16:05
I like your idea there. I think starting early, with pretty much anything when it comes to kids is going to have long term consequences. And I think dietary, you know, approaches that early ages that are good, make make things happen. I've actually know some your young children who eat nothing but vegetables and all that all day, it seems. And they really, they do like ice cream and that but they don't. It's a treat, it's not a common, it's not something they expect, but they don't like some of the things that are really what we'd consider it to be high fat. And they're just because their tastebuds are there, they're acclimated to things that are different and, and they're healthy. And I do think you start early, whether it comes to when it comes to food or various things, like Stay away from drugs and cigarettes and all that I think you start early and you teach the kids how to how to go, it

Scott Benner 1:17:00
just becomes kind of second nature. Yeah, I do a Pro Tip series about diabetes with a with a CD or excuse me with a nude, a woman who's got type one diabetes, and is a nutritionist and her children eat fantastically, but So does she. Yeah, and that I think it just is what Liz also, I have to tell you, Tom, if you're willing to do this a few more times, I think you and I are gonna have a Pro Tip series on GLP is together because this is fantastic. I can't thank you enough for spending the time and we still have we didn't even get to the listener questions yet.

Dr. Blevins 1:17:30
So there's a lot to talk about. No, I'd love to. Okay, we'd love to. That's

Scott Benner 1:17:33
great. Kate, listen, do you accept new patients at the practice? Or would it not benefit you for us to share your information like that? I

Dr. Blevins 1:17:41
really don't see new patients. I do supervise a lot of people with advanced practice providers. We have excellent group here, who are really experts on diabeetus. But we have we're a single specialty. We have 12 doctors and three offices here. So though, I don't see any patients. The we as a practice, we see new patients all the time. Okay. In the Austin area, people come from various and we do diabeetus all endocrine so, you know, some listing that would include the practice predominantly

Scott Benner 1:18:14
and no, I Well, for sure. What would tell me the website? Yeah,

Dr. Blevins 1:18:19
it's Texas. diabetes.com. Okay. Yeah,

Scott Benner 1:18:24
I'll put it in the show notes as well. And I'm not kidding you. When you get done. You send me the study information that I can share online. I'll put it in a place where a lot of people say it for you. Okay, I'll

Dr. Blevins 1:18:33
do it. Yeah, we'll do that. Thank you. Yeah, I appreciate that. Oh, my God, let's let's put off the Frezza a little bit, because, first of all, we'll probably want to do more GLP. One first, because there are quite a few things we didn't get to your right. And we need to like the muscle mass change all that stuff. Preparing for surgery, all that very practical, that the impressive thing, American diabetes is late June, and there's going to be I know there's going to be a study presented that will make that discussion more useful. Okay. And I can't talk about the results before them. So anyway, when that's okay,

Scott Benner 1:19:08
can I leave this part in you talking about it? Like that? Yes. Okay. Because what I see here on I'm going to keep recording. You're back with me in two weeks. I think we need that one and one more to get through. GLP. Okay, and, and then do a fourth one on a friends. I think that would be terrific.

Dr. Blevins 1:19:25
That'd be great. Okay, cool. Very good. All right.

Scott Benner 1:19:27
Use that link I gave you and grab a couple more recording dates. I'll do okay. All right, Tom. This has been fantastic. No, you're amazing. Thank you. Bye. It's

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#1489 Fox in the Loop House: Part 6

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Understanding Insulin Sensitivity Factor

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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 0:00
Friends, we're all back together for the next episode of The Juicebox Podcast. Welcome,

guys. Kenny Fox is with us again. You can find Kenny at Fox in the loophouse.com and today he and I are going to talk about the loop algorithm and understanding insulin sensitivity factor. Nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan. Don't forget to save 40% off of your entire order at cozy earth.com All you have to do is use the offer code juice box at checkout. That's Juicebox at checkout to save 40% at cozy earth.com AG, one is offering my listeners a free $76 gift. When you sign up, you'll get a welcome kit, a bottle of d3, k2, and five free travel packs in your first box. So make sure you check out drink AG, one.com/juice, box. To get this offer. Are you an adult living with type one or the caregiver of someone who is and a US resident? If you are, I'd love it if you would go to T 1d, exchange.org/juice box and take the survey. When you complete that survey, your answers are used to move type one diabetes research of all kinds. So if you'd like to help with type one research, but don't have time to go to a doctor or an investigation and you want to do something right there from your sofa, this is the way t 1d exchange.org/juice, box. It should not take you more than about 10 minutes. This episode is sponsored by the tandem Moby system, which is powered by tandems, newest algorithm control iq plus technology. Tandem mobi has a predictive algorithm that helps prevent highs and lows, and is now available for ages two and up. Learn more and get started today at tandem diabetes.com/juice box. The show you're about to listen to is sponsored by the ever since 365 the ever since 365 has exceptional accuracy over one year and is the most accurate CGM in the low range that you can get ever since cgm.com/juicebox, Ken, welcome back. Hey, Scott. What are we going to talk about today? I just, I decided with you, I'm just going to say what are we going to talk about today? And let you

Kenny Fox 2:34
take the wheel. You got it all right. So I think I want to talk about ISF. We covered basal and then meals, and we didn't talk about the carb ratio last time as much. But I think people have a pretty good understanding of I want more insulin for the first few hours of my food, and it can tweak the carb ratio from there. So really, what's left is in terms of main like core settings, we'll talk about ISF, which is insulin sensitivity factor. That one is, I think, one of the more misunderstood variables. I've heard doctors and other folks talk about it in the same way they talk about basal when they don't understand something, when they understand why you're high. A lot of people go to, I don't know, let's just change the basal. Once you get into looping and you can wrap your head around basal changes, it often becomes, well, ISF is even more mysterious. I don't understand this one, so let's change that one. If stuff's not going the way I want, that's a little bit tricky of a situation when you're when you're like that. And so we'll try to demystify that a bit more. Okay. Do you find that same problem when people are not understanding it's easier to see when they first start out, but they start attributing certain problems that from an experienced person don't make sense, but they just start messing with things because they don't under it's the thing they least understand.

Scott Benner 3:47
I think that you get frustrated and they just start turning knobs, pushing buttons. That's fair. I think they don't know why they're doing what they're doing honestly. And listen, in fairness. There are times when I make adjustments and I'm like, I think this might be it, but I'm not 100% certain. I mean, look, can I look at basal and say, you know, at times where there's no active insulin and no food involved, and can I look and say, Hey, her blood sugar has been sitting at 110 at this time of night, for example, really consistently. I'm gonna, like, tweak the basal here and see what happens. Yes, right? But it's harder to see, like, insulin sensitivity stuff and correction factor like that. I think is harder for people to see. Do you not agree that one? Yeah,

Kenny Fox 4:33
yeah, I agree. Because I think basal we can, I think, relatively quickly, wrap our heads around, especially at night. That's a nice one. Sensitivity is a challenging one, also, because when you first get diagnosed, you're talking about making corrections. So you like, here's your long acting or your basal settings, here's a carb ratio to start with, and then here's this correction factor, or this number you'll use to calculate how much extra insulin to give if you end up higher. Then you should be a few hours after eating, or just a few hours after your last dose. What happens is, we take that idea over to an automated system like loop. One of the things loop is doing is it's making those small adjustments. If you're if it thinks you're going to end up a little higher, a little low. It's doing that every five minutes, so you end up needing to use a number that's much larger than the number you might use when the doctor says, Hey, try this out. You know, you consult that number couple times a day. You're not looking every five minutes. You're looking every couple hours to see if you need to make a correction, potentially, and using that number then. So I think that's a one, one big difference between the idea when you use it or shots or MDI, or even standard pumping, versus using it in a system like loop. You

Scott Benner 5:48
know, when people get put on a regular system where they're doing MDI, and someone says, We think that one unit moves your blood sugar, I don't know, you know, 200 points, so your insulin sensitivity is 200 Sure, they probably try that in the beginning, right? They're probably like, Oh, my kids, got a 300 blood sugar. I want it to be 100 I'll put in a unit, because they said it moves 200 doesn't take you long to figure out that, like, higher blood sugars kind of need more insulin, okay? If that's true, and I want to move 50 points, and I need a quarter of unit, that usually works if I'm, you know, I'm 100 and I'm 150 and I want to be 100 a quarter of a unit kind of moves me that way. But you don't really see the full picture or the full value until you're on an algorithm, and that thing isn't making these big, sweeping decisions like that, like, you know, I'm trying to move a number this, you know, 200 points when it's trying to move a number 10 points, when it's trying to move a number 20 points, and there's a fraction of an amount of that insulin, like, there's where it becomes, I mean, another level tool, because you're never going to, as a person with a syringe or even with a manual pump, say to yourself, I want to move just this much, and it's 15 points, and my pump is not even set up to, like, correct that Number. So I don't think it comes into people's minds that often. Yeah, and

Kenny Fox 7:03
you're probably going to wait and see how things settle before you make a decision to add more or take away right insulin. So yeah, that makes sense. You're just not going to make the decisions that fast. One, because you have a life to live. And two, you do need to let stuff kind of play out. And there's so much very variability that in food or whatever else is going on that doesn't make sense for you to try and do, you know, quarter unit or 10th of a unit, two weeks all the time,

Scott Benner 7:27
even if you were a machine in your mind, and you could make sense of that bigger picture, you can't take insulin away in a manual pump. Well, you can, but now you're setting, like, Temp Basal offs and, you know, but if you're MDI, you're you're done, like, the insulin is in, it's in, right?

Kenny Fox 7:41
Yeah, you're not gonna set a 30 minute half hour, 30 minute Temp Basal off, and then come back and check it again, and then you end up a little high. So you're not gonna play with it that often, like a system would. And I

Scott Benner 7:51
think for those reasons, that's maybe the least considered setting sometimes for people, and it ends up being very important. Yeah, I agree. And once you see it work on an algorithm, you level up your understanding of it too. Why would you settle for changing your CGM every few weeks when you can have 365 days of reliable glucose data? Today's episode is sponsored by the ever since 365 it is the only CGM with a tiny sensor that lasts a full year, sitting comfortably under your skin with no more frequent sensor changes and essentially no compression lows. For one year, you'll get your CGM data in real time on your phone, smart watch, Android or iOS, even an Apple Watch predictive high and low alerts let you know where your glucose is headed before it gets there. So there's no surprises, just confidence, and you can instantly share that data with your healthcare provider or your family. You're going to get one year of reliable data without all those sensor changes. That's the ever since 365 gentle on your skin, strong for your life. One sensor a year that gives you one less thing to worry about, head now to ever sense, cgm.com/juicebox, to get started, let's talk about the tandem Moby insulin pump from today's sponsor tandem diabetes care. Their newest algorithm control, iq plus technology and the new tandem Moby pump offer you unique opportunities to have better control. It's the only system with auto Bolus that helps with missed meals and preventing hyperglycemia, the only system with a dedicated sleep setting, and the only system with off or on body wear options. Tandemobi gives you more discretion, freedom and options for how to manage your diabetes. This is their best algorithm ever, and they'd like you to check it out at tandem diabetes.com/juicebox, when you get to my link, you're going to see integrations with Dexcom sensors and a ton of other information that's going to help you learn about tandems. Tiny pump that. Big on control tandem diabetes.com/juicebox the tandem Moby system is available for people ages two and up who want an automated delivery system to help them sleep better, wake up in range and address high blood sugars with auto Bolus.

Kenny Fox 10:16
In our previous talk, we discussed a lot of variables that I think you made a good connection of. It's really applies to however you manage. If you can start to understand those, we start to remove what I kind of call the fog, and you can really see what the settings need to be, because you're like, Oh, well, I'm high because, oh, I forgot to handle fat and protein to my meal or basal was off last night. So it's probably not going to be so great today, things like that. Maybe your pump site is not working as well as it could. So that's going to be once you remove all of those. Then we can talk about sensitivity. And we talk about sensitivity, the number is, I'll use the word points. I like using the word points as well. How many points is your blood sugar going to move given one unit of insulin? And what you need to remember is you need to consider the entire runtime of that insulin, or the duration of it, which should be about six hours, and loop models that so to do an ISF test, you'd have to get kind of high, have really good basal, have no other fat and protein going on. So it's really got to be quite a few hours since you ate last, and then give half a unit, or a unit, and then wait five, six hours, see how far your blood sugar drops. And then you can, if you did a half a unit, you'd have to, you know, double it to get to the right number. And so it's a really difficult test to do, because who really wants to sit still and have really perfect basal for the, you know, first for a 678, hour duration. You know, it's interesting

Scott Benner 11:42
when you talk about it in context of the algorithm, of any of these algorithms, right? Like it makes so much sense, because you know that that those little machines are tracking all of the different boluses and all of their different outcomes and and making sense of them when you try to imagine doing that manually. I mean, you can maybe keep track of a couple like, you know, like I Bolus at 8am for breakfast, then I Bolus again at 10 o'clock for this, and then I had lunch at one. At one o'clock, I'm five hours after the eight o'clock Bolus. Like no one's in their mind juggling all that anymore and all the implications and the different timelines that the insulin is running on it's why all these systems are just so next level. So I would need a computer right now, if you're looking for that kind of control and that kind of consistency, then, yeah, I mean, you need something smarter than you to track it. That's for sure, smarter than me, for sure. We

Kenny Fox 12:35
talk about points, just in case people aren't tracking we're talking about milligrams per deciliter for those using Imperial numbers and millimoles for those that are not. And it's an easier way to say it, because if you start trying to talk about the ratios here in an audio setting, you're not going to be able to track all this stuff. So I have a video that's been up on YouTube about how ISF affects carb absorption, and we're gonna talk about that here in a second. So you guys can go see that a few more visuals. But the big challenge we have when we talk about using ISF, or figuring out ISF in loop is one, you first have to shed the idea that it's the same number that I'm going to use like I would if I checked my blood sugar every couple of hours and was high and wanted to nudge blood sugar down. And two, it's going to be even bigger. If you think, Well, how much will my blood sugar come down if I dose the unit and waited six hours when I really didn't have any of these other things we've been talking about active that's when it's like, Oh, I'd probably come down quite a bit. The ISF number you'd think of would be a fairly large number, which means you'd move a lot of points given one unit of insulin compared to what you'd use in a situation where you're high, you're usually addressing something like food or some other issue where you do need more insulin. I think a lot of people, at least those that listen to the podcast, get a very intuitive sense, after some practice, that even if they don't know what that variable is, they might need a decent amount of insulin to bring it down, or may want to bring it down sooner than six hours. So what loop is looking at is is a much larger number than what you're used to. When I see people bring over their settings from a previous pump set up, it ends up causing a little bit of problem because the number ends up being too small. And it's not a problem always of too much in terms of a correction, like getting high, and the loop just gives too much insulin. That does happen. But I think a more common situation is it's just a little bit too strong, a little bit too small of a number, and it negatively impacts how loop tracks meals. And that's really like the in my mind, the largest or most significant thing that ISF does during the day. But before we dive into that, it's easier to talk about the easier situation, which is night time, like you talked about identifying basal overnight. At night, you're not running around, you're not eating anything. You might have some some hormone stuff going on overnight, but it's not as significant. So what I like to do is all use ISF overnight, and I'll often make it a little bit stronger, so where I get the system to respond the way. I would, which is you have a little bit too much insulin, enough insulin that after six hours would probably make you a little low, but not so much that once your blood sugar starts trending down, Luke predicts, Oh, this isn't going to go well. We're going to go low, and it starts turning off the basal. And so it's kind of like a like a mild crush and catch situation, like you talked about here.

Scott Benner 15:19
Is it easy to go too far with that, to where it can't catch it.

Kenny Fox 15:23
Yeah, I think it, I don't know. It's super easy. If you move things in steps of 5% 10% at a time, and kind of nudge the numbers down, then I think you end up being in a situation where that's not going to be the problem. One thing to look for is if you see, even if your basal is not perfect, but if you see loop giving Bolus is and then start dropping, and it's not turning the basal off to be able to catch it, it just goes down so fast that even though it turned off the basal, it couldn't catch it. And again, there's no obvious basal problem. Then, yeah, you'll need to back it off a bit. Okay, that said, I think for other systems like Android APS or trio that use the O ref based algorithm that's different from loop. I think it works better, from what I've heard, to use a single sensitivity number across all 24 hours. And I think you could do that with loop too, if you had pretty good basal and we go with a number that works across both day and night. I think you can do that, but I'd like to use slightly lower numbers at night, just in case things go wrong, like Tessa has a basal increase need and she starts kind of drifting up. And I want loop to kind of keep it contained, to keep it from getting up over maybe 121, 30, even if it's like a big change in basal needs. And so I just give loop a little more permission to kind of hammer out that blood sugar, but starts to drift high, but if it starts causing any problems and it can't catch the resulting drop, then definitely back it off. It's definitely the safest thing to do is to leave it as a larger number overnight, rather than smaller. You know,

Scott Benner 16:51
you talk about pretty frequently the idea of giving loop the autonomy to make a more aggressive move if it needs to. But I think that could be confusing to people. So like, if they're wearing a regular pump, and their basal, empirically, is one unit an hour, we just know that it is, you know, for the conversation, if they make it 1.25 an hour, they're going to get low pretty quickly in a couple of hours. If you tell loop, you know, if you're saying to yourself, I think my basal is one an hour, but you tell loop it's 1.25 Are you saying that loop is going to push, push, push until it sees a low and then take it away and then next time not push is hard because you've given it like a wider decision tree to use right like, as far as the amount of basal goes. But it doesn't necessarily mean it's going to use all of it.

Kenny Fox 17:36
Basal is tricky. Basal, unfortunately, with the way loop is built. Right now, if the basal is off, if you went with a one and a quarter instead of a one heat at an hour, at some point, you're very likely to go low, because loop is assuming that the insulin on board that it sees of, let's say zero, is going to keep you flat. But if your insulin, if your basal is too high, you're going to just start drifting down and loops like, Well, no, you should be straight, and you keep dropping. It's like, No, you should be straight and you keep and you keep dropping. And then if you look like you're going to drop below the glucose safety limit, then it starts to turn the basal off, and you start to get negative insulin on board. But it's still always like, Well, you said basal was one and a quarter, and we now have negative insulin on board. You're going to go up. And so as soon as you do start coming up, when you treat the low, then it comes back. You end up hit. You end up getting over treated. Yeah, so basal is a tricky one. That's not as safe a one to overstate, there's some work being done right now about trying to adjust how the negative insulin on board affects the prediction so loop doesn't think you're gonna come shooting up and then hammering you with us quite as much insulin and send you back low. But yeah, there's not a lot of forgiveness in the system, as it's designed today, around basal. This is why I like to turn down the sensitivity, because it only comes into play if your blood sugar, you know, is higher than the defined range. Basically, if you're high, if you're low, or you're in range of where you told the system you want to be, then the there's no correction or sensitivity nudges that need to happen so it stays out of the way, so it's a little safer in that sense, that you can hover around your range, and it's not going to just all of a sudden shoot you down low, okay, but if you start creeping up a little bit, it can nudge a little bit with sensitivity number. I just

Scott Benner 19:13
want to make sure people understood that, so you can't just tell that. You know, I know my basal is one, but here take more in case you want to use it a different way. It's not going to work that way. It's going to push you too low. Going to push you too low. Correct with sensitivity, though, if you say a unit moves you 100 points, and you then come back and tell them, like, hey, you know what? Instead, like, let's say a unit moves you a different amount, so that you have a little more autonomy in here. So if you wanted it to have more autonomy, and you were one unit moves you 100 points. Would you want to make it one unit makes you 90 or moves you 110 to make it more aggressive?

Kenny Fox 19:48
More aggressive would be 90, the smaller number. And the nice thing is, loop has other pieces to its prediction, one of them being momentum. So if you're if it does. Does get you with an amount of insulin for the 90 and you start dropping, loop does presume, oh, well, you're moving down. You'll probably keep moving down a little bit. So that tends to push the prediction down a little bit lower, faster. So it's not going to just give the 90 dose and then wait for it to settle. If you start moving down right away, it's going to try to pull back. So that's why it's a little bit safer to do. But more aggressive is definitely a smaller number that you'd pick.

Scott Benner 20:25
Okay, I just listen. I want to be clear. I know that I just wanted to say it out loud so that people could hear it right. Because I get the idea of like, oh, I want to give it a little more, a couple more bullets in its bag if it wants to pull it out and start and start shooting. It doesn't work there. Now this might be, I don't want to get too far off the course here, but if your insulin to carb ratio is, you know, one unit covers 10, you know, you change it to one unit covers nine because you want to be a little more aggressive, that's still a thing that the loop could probably adjust within. Is that fair? Yeah,

Kenny Fox 20:56
we talked about meals before. And so if your blood sugar starts to, let's say nine. One to nine is too much, and you'd have drifting a little lower. There's still kind of speed and momentum pieces that we'll talk about more detail later. But moving here, where loop would be like, Oh, you're running a little lower. We should probably turn the basal off, and then you still have the the time window, the absorption time we talked about, that loop will expect that food. But if the nine is too much compared to the 10, you might run a little lower, but there's a chance that you might not go low, and that loop will maybe give you a little bit too much insulin here and there, but still maybe catch it. And then when that time window runs out, it's like, okay, well, we're done looking for those carbs. So it can cause a problem, but it's less likely I think, okay, I appreciate you

Scott Benner 21:39
going over that with me. Go ahead, please go back to the course you were on when I took you off course.

Kenny Fox 21:44
The sensitivity stuff's good. The other thing to remember about, about the sensitivity is that when actually, when loop doses, let's say automatic Bolus, when it gives the insulin that it thinks you need at nights. And use the example, it's only going to give a fraction of that. So if we're using a one to 100 and you end up drifting up and it wants to give you, let's say the recommendation is as much as a half a unit. It's only going to give a fraction of that. So the default setting would be, like 40% so less than half of that half unit, so like little less than a quarter unit, is what it would give. And then the next time, it will only give 40% of what's left of that recommendation. And if your blood sugar starts to curve and starts or start to come down, that recommendation will kind of disappear or will drop significantly at any given point, loops not really giving all of the whole one to 100 or one to 90 sort of sensitivity calculation, which is good, and this is also a good time to mention that there is a algorithm experiment, piece of loop, like an extra little algorithm, modification you can use that will change how that dosing occurs. It will either do 40% which is the standard automatic Bolus, or this one called glucose based partial application, which we referenced before, but it gives a smaller percentage of that recommendation when your blood sugar is closer to your defined range versus and then as you go higher, it'll give a higher percentage of that recommendation. So even though you're dialing down the sensitivity, it's never really going to give all of the insulin right away. So that's the other reason why you can say, well, if I turn it down a little bit lower than maybe it should if you were to do a full six hour test or something, there's a lot of play in there, because the system is not going to deliver in its confidence, not going to deliver everything. So it has time for your blood sugar to start to level out or start going down, and then take appropriate action. So it's something to remember. We're talking about sensitivity, and why I think it's kind of forgiving, especially at night. Yeah, to dial it down. Okay, thank you. Daytime is the trickiest part, and honestly, probably the more important one. What's interesting that I learned a couple years ago from some people smarter than me is that, if you take the sensitivity and you divide that by your carb ratio, and we'll talk about all the units, it gets a little crazy. You end up with, instead of a nice sensitivities of points per unit and carbs is grams per unit, per unit per gram. I forget which one, but if you divide the sensitivity by carb ratio, you end up getting a points per gram, which basically says, if you have one gram of carbohydrate, how many points is that expected to raise your blood sugar? And so now operates off this assumption that a certain amount of carb is going to raise your blood sugar a certain amount. So if you ever go into loop and you enter 10 grams, and then you see the prediction says you're going to go up to a certain number, let's say 500 that's the assumption, if you don't give any insulin. And I always wondered, how did it come up with that number? Well, it's using your sensitivity divided by your carb ratio. And so with that expectation, when your blood sugar does go up after you enter a meal and start eating, as your blood sugar goes up, loop says, Hey, that rise equates to this many carbs. Now. Says, Okay, let's say it's five carbs. It's going to subtract five carbs from the active carbs, from the carb entries we discussed last time. And so that's how it's one other main piece, how it's subtracting the active carbs, or the carbs being absorbed, as the other term loop uses. It's tracking the meal progress based on how much your blood sugar goes up, is one of those major components. So if you have your sensitivity set to too small of a number, this affects your points per gram. The short version is, without trying to talk about all the units, because you really got to see it on the page, is that when your sensitivity is too small, loop sees a lot more carbs when it goes up. And the picture I like to give is a small child might have a sensitivity of 200 or more, and you give them one Skittle, and their blood sugar pops up maybe 15 points for that Skittle, you grab a middle schooler or high schooler, some bigger person, give them a Skittle and their blood sugar is long gonna pop up a couple points. They just don't go up as high for each gram you give them, or we discussed before. You know, you used to have to save Tessa from a low with just a couple grams, and now it takes quite a bit more if she's going low with any substance. I think that's an important concept to wrap your head around, that the less sensitive you are to insulin, the smaller that sensitivity, the less sensitive you are to carbs as well. There used to

Scott Benner 26:18
be times where I'd be like, just drink a quarter of this juice box. That's all, yeah, take three sips. That'll fix it. Now I'm like, just here. Just drink it. Drink the whole thing, yeah, just drink this, and then we'll see what happens. And we've talked about it already, I think, but just over, like, go over it again, mostly that's body mass, or it's also the amount of insulin you think. Do you think some people are just making more insulin as they're younger or more newly diagnosed, and then that goes away over time too. Like, what are all the variables that you think impact

Kenny Fox 26:47
that? Yeah, that's a good question. I think, I think it's all of those things. I think when Tessa was younger, she probably still had some beta cell function. There's even times, I think recently, it's been a while since I've seen this, but I thought I would try to get an ISF test in while Tessa was sleeping. I just give her some of her like, honey. I give her at night, while she's sleeping, she'd never wake up and her shoot her blood sugar up, and then I could give her some insulin and kind of see how far she comes down, you know, maybe, like, three in the morning or something. And I've seen it where I give her the 345, grams of honey, and she pops up and pops right back down. Like, well, obviously there's some body function here that's taking care of this, because it wasn't loop and it wasn't me, so I think that plays into it, and why, I think it's also difficult to get these tests in. But I'm sure body mass is a big one, right? It's there tends to be a relationship between body mass and how much insulin you generally use and how much basal you often use. I think those are two big pieces, and then there's always, like diet plays into it too. How much you're know you can modify your insulin sensitivity with reducing fat in your diet, as a recent study that was coming out, so reducing the your fat intake will improve or increase your insulin sensitivity. So I think there's a lot of factors that are really hard to nail down, but I think body mass as a good placeholder, at least in my mind, from a little child to a big child or an

Scott Benner 28:04
adult just changes. Oh, there's too much to think about. Again. That's all there is.

Kenny Fox 28:09
There's a lot to think about. So the main thing that I want to use, that I encourage people to try to use the daytime ISF for one, let's just acknowledge that it's really hard to test for, and it's a pain in the butt. So what I like to do is I use the sensitivity during the day. I make one rate that covers the daytime, or at least the hours that you could be entering and eating carbs, and then use that number to help you get to the absorption you want. So we talked about using the ice cream all the absorption stuff in the last episode. So I think most people, especially listen to the podcast, will have a good sense for how much their carb ratio should be. Generally, like, if you're not getting enough in the beginning of your meal, you end up a little high with proper pre bossing. And so you they people tend to adjust that down. I think people end up with a fairly aggressive carb ratio if they're listeners of the podcast. And most people that come to me are in that boat too. And so once you feel like the beginning of the meal is good, but then you're noticing that either the carbs are absorbing too slow, meaning loop gets to the very end of the time window for your food, and it still didn't see nearly enough carbs, or the opposite, you get to the end of the time window, and loop saw way too many carbs being absorbed for that meal, that's going to be a sensitivity problem. So I like to find a sensitivity number that helps us get to where most of the list of cars on that carb screen are absorbing pretty well, all within their expected time frames, not too long, not too short. And just change that one number and dial it in. So if we're happy with how much in summer getting the beginning of a meal, and you adjust the sensitivity to get to a spot where loop says, Yep, that meal is over at the right time. Most of the time, you're not going to get it all perfect, but you're going to get it done pretty well. I think that's a guiding principle that's helped me and helped others when I talk about how to use sensitivity, because you can talk about, you know, how much is it correct and how much is it fixing things? Yes, I think if you get the meals mostly finishing right, and you do a pretty good job of counting the meals and the fat and the protein, that's like the major variable we have to deal with in the day. So if we can just nail that, and I think everything else kind of falls into place. And you know thing, you might go a little higher, a little lower here and there for some other reason, but meals are going to look good, and loop is going to do what you want it to do the vast majority of the time. Yeah,

Scott Benner 30:23
do you think you could go back and do this manually? Oh, like just being on MDI. You mean, I put tests on a manual pump. How much of this do you think you could mimic per success?

Kenny Fox 30:33
I think a fair amount of it, because you've covered most of the core components with Jenny talking about fat and protein. And if you can take care of pretty good carb ratio and expecting the fat and protein and dosing for it, I think you're going to get very similar results to what loop will do with decent settings. I think the biggest thing that loop makes a big difference is protecting against lows. Like you mentioned before, you're not gonna sit there and turn off the basal all the time, right? The other one, someone mentioned to me that was working with they came from the tandem pump, and we did the had the same problem when we were using the tandem you could only extend meals in the tandem pump like they have one extension running. You can do the same with any any pump. You can't extend another Bolus on top of a currently running extension. And that's kind of the for me, kind of the magic with loop, with the way Tessa eats sometimes, is she'll have decent amount of fat and protein for multiple meals in a row and so but they're overlapping each other. You want the insulin to extend and handle that fat and protein over a fairly long period of time, but then she ends up eating again, and the fat and protein impacts not done. Release the dosing for it's not done. And so what loop and other systems like this help with is you can just say, enter a long meal, a pizza icon, you know, the long meal, and then enter another long meal. She gets seconds, enter another long meal, and loop sort of handles that extension in response to blood sugar. And if you get this ISF stuff working well, then, you know, four hours after she's eaten, it's going to, know, a pretty good amount of insulin to give for the fat and protein without giving too much. And that's, I think, what takes a lot of the burden off or managing food with a system like this, is that you don't have to worry about, are we extending? Is this to the extension still going? And do we need to cancel that extension and add more insulin in to cover the last extension, and then also extend into this food. So I think that that really helps a lot with how Tessa eats, just that she makes she doesn't eat frequently, or meals are overlapping with each other with respect to the fat and protein window of time that the impact is there. And so it's just it helps a lot for tracking meals that way or lack of tracking. I don't have to do the tracking. We just enter it and move on so we could do it. But I don't know how well Tessa could do it on her own, whereas, right now, she just enters it and she moves on with her day, and it's usually pretty fine. What about you? What about you guys? You know, our needs a lot different, right? She spreads out her meals, sometimes fairly frequently. Yeah.

Scott Benner 33:00
Kenny. I mean, could I go back and do it again with the same success if you give me a child young enough that doesn't have opinions and, you know, doesn't fight back, you know, when you say, do something right, I could easily do it and probably have better outcomes, but I think I'd be exhausted again. I think

Kenny Fox 33:19
I was thinking the same thing, you lose sleep. I think the sleep I think the sleep part is a part I didn't think about till just now is, yeah, that part is the initial magic sauce for most people, right at any automation system, is it can go to sleep and it morning turns out better than it would have if I had just gone to sleep with a regular

Scott Benner 33:35
just 1,000,000% like the the process seems to be is, you know, you have a diagnosis, or, you know, whatever, you've been at it for a while, and you just aren't having a ton of success. Somebody slaps you on one of these algorithms. And then eventually you're like, oh, it's not perfect, but I'll tell you overnight, I'm sleeping again. And then you kind of like, come back to life a little bit. You can start paying attention a little to what's happening. I do think that if you took it all away, the first thing that would happen is my sleep would get dinged. You know, I am almost 20 years older than I was when she was diagnosed. I would find myself making those concessions in the middle of the night. I'd be like, Oh, it's only 170 I gotta get some sleep. I think you'd slip back into that pretty quickly. Then I think that starts to impact the daytime again. And before you know it, you're starting the day with a high blood sugar, not enough insulin, everything starts shooting up, and you're off to the races, and you can't figure out what the hell is going on. And then you struggle all day with it, which makes you exhausted, which then puts you overnight again, into a bad situation. Try to keep up with it the best you can. If I didn't have to sleep, if I wasn't older, I know more now, like if you put me just in charge of somebody's blood sugar, I think I could manage it with an inch of its life, but I don't know how long I could do that before I dropped over dad. I just think that there are so many people out there who are not using this automation or not using it effectively, and you have no idea how much your life would change if you if you had it. And it was and it was working well for you. I really

Kenny Fox 35:02
like how you talked about that with the last episode of your caregiver series. That was great. You guys really hit that pretty good is the lack of sleep is significant burden on caregivers, especially. But you know, just as much with the people with diabetes, once they're in charge of their own blood sugar,

Scott Benner 35:19
it just runs you down. There's no way to get ahead. After a while, you think, no, it's okay. I'll figure it out. But, man, I don't know. Like, you know you're not a machine. You just can't stay ahead of it forever. So right, yeah,

Kenny Fox 35:31
I think the last thing I'd like to drill home with people is this is the most hard to grasp and see, because it's not as visually obvious a lot of times. And so my sequence of going through to figure out what might be wrong, we use the iob overnight, especially as our guide to say is basal right or basal wrong. We make basal adjustments based on we see inappropriate negative insulin on board, or those other data points we talked about in the first episode. Then if they're running high, then before you make any changes, check the pod site, make sure it's working. And then we lean on food. Are we counting things? Well, are we not forgetting to enter food? Are we adding fat and protein, all that food stuff called Food accuracy? And then if we're doing a pretty good job of counting, then, then you got to mess with the car ratio. You're going to get better results. If you're running high or running low. Once basal is good, yeah, to just make sure you get enough insulin with your food. And then, as a last resort, like if you mess with all that stuff and you tinker with it, or you just don't think any of those things need to change, because everything else looks good. Then you start playing with the sensitivity. You look at the arboration of the carb List screen and how absorption is going on, and you tinker with the ISF. But it's something that I find with a with a kid that I don't have to mess with very often, Tessa or any child, really, when you're starting younger, their sensitivity is only going to go to a smaller number. It's only going to drop as they get bigger. So that's one thing, is that if you can get a pretty good number eye sensitivity number during the day that works, then chances are you don't really have a question of whether or not it needs to go up or down. Most of the time. You're just going to say it just needs to go down if it needs to change at all, because they're just going to keep growing and getting bigger. So it is make it easier until your kids done growing, you know, early 20s or something, and then they then maybe can go up and down a little bit more. But with kids, it's pretty simple. It's only going to go down, and I really only mess with it a couple times a year when all the other stuff's not helping. So don't let the ISF confuse you and wear you down and keep playing with it all the time. Like pick a season where you have your basal dialed in and meals are looking pretty good those first few hours. You're happy with your carb ratio and you're counting. And then play with it and get it dialed in, and then you don't, don't mess with it too often. Couple times a year, revisit it and move it down a little bit. I don't want it to drain anyone's brain too much. People spend a lot of time thinking about the stuff they don't yet understand, which I appreciate. There's a lot of people that come talk to me, but I think you can just let it go a little bit and make some other adjustments, and you'll probably be

Scott Benner 38:04
okay. I'm adept at turning the knobs and making things work out, but if you listen to the voice in my head while I was doing it, you wouldn't hear this, like, quiet confidence of like, Oh, I see this number and this outcome. So I know I'm gonna make this that I've learned over time. Her blood sugar has been too high lately. I think I need a little more insulin sensitivity power. Here. I'm going to take it from where it is and make it a little more aggressive. Yeah, I don't think it's the basal. I know we Bolus well for the food, so I'm going to try this here. But you, if you're a person who isn't sure if their carb ratio is right, doesn't understand the impacts of food, basal is off by a little bit, imagine if your insulin to carb ratio is one to 10, but you have it set to one to 15, and your basal is a unit an hour, but you have it set at point eight, five, and your insulin sensitivity is like, who knows? By then, the basal is off, the carb ratio is off. All your meals are moving you around in ways that you know you can't know. Forget being on an algorithm for a second, you're going to get out of whack. And then how would you even figure out the insulin sensitivity? Like, in my mind, the basal has to be right, no matter. I think basal is always first, right. So always, yeah, your basal is first, right? Excellent, great. You eat foods that aren't high in fat, that you're really good at bolusing for that. You really know the carb counts for you count the carbs. You look at the insulin, you say, you reverse engineer. You say, Look, I know this meal for sure has 50 carbs in it and whatever, like, you know, two units always covers this. So great. So your insulin to carb ratio is one unit for 25 carbs. But that doesn't mean that the next meal you're gonna have is gonna hit the same way as that meal, but it's a great starting spot. The thing again, like Kenny keeps mentioning it, because I don't think people appreciate it enough. But if you don't understand the impacts of fat in your food and how it's pushing blood sugars up or holding blood sugars up, you really are at a loss for figuring this whole thing out. I. Know, as crazy as it sounds, but I think the one thing that throws more people off than anything else is the fat in their food.

Kenny Fox 40:05
Oh yeah, for sure. Like someone I've been working with for the full eight weeks of my session with them, and they were near the end, and their 11 year old was munching on a bunch of nuts, like fattier nuts and cashews or something like that. And they're like, yeah, she didn't really enter those a whole lot, or just the carbs for them, and then they should just ended up high, like, couple hours later. Like, do you think it was the nuts? It's like, yeah, that's like, the only reasonable explanation here, that you just kind of drifted up high and then ended up a little bit higher at dinner time. So it's just one of those things that I think happens the most frequently. Yeah, is the easiest thing to under count. And I think if you get that right, the sensitivity, if it's just in the ballpark of where it needs to be to help loops. Be to help loop see the meal, then you'll be much better off those those things are, are the basics. The basal has to be right, and if it's not, then you know, you can't really go tweaking other knobs too much until you get that dialed in with confidence, which when we covered in the first episode, I think it's one of the key things when people are working with me is I really try to hammer in on that, using the iob and getting the basal pretty right, and having confidence that it's that it's right, and then you can mess with other stuff. That way, you kind of have an order that you go through for this stuff. And I really like your idea of using predictable meals. I've had a lot of situations in the last few weeks where a nice, predictable meal turned out to not do what it normally does, and that told me that either the site was bad or some big setting needed to change that I just didn't like usually carb ratio. Just didn't know. Tesla wasn't feeling well. She said she was feeling fine, but she needed a lot more instant for her food that day. Yeah, and you just, you had to catch it. So predictable, meals are a great way to just calibrate off of I don't know where else you're

Scott Benner 41:39
supposed to start, because this idea of fasting, for a really long time, I don't know who you tell me the kid you're gonna say, Look, tomorrow morning, we're getting up, we're not eating. We're gonna get your basal worked out, like I say, figure out basal overnight. Get it close, adapt it for the morning. Once your basal is good, look harder at your carb ratios over predictable meals. Excellent. We got that. Now let's look at a blood sugar that's went up the foods out of our system, but, you know, it never came back down from 180 great time to check your insulin sensitivity. Go ahead and throw a unit in and or a half unit and see where, where do you land? And don't wait like, an hour or two, like, really, just, you know, wait a few hours, like, where does it land? It's not going to be perfect, you know, if the unit moves you 50 points, and it's about at, you know, you went from 180 to 130 and it's just resting in there. You know, there's a great place to start, to start with, yeah, and if you're on an algorithm, and you're close enough, like you said, then the algorithm there will kind of make up the difference for you, because it'll push a little bit more when it needs to push. I mean, how long do you think Kenny with the service you provide? How long do you think people have to work with you before you before you can get them in a place like that? Yeah, what

Kenny Fox 42:44
I've seen this year with the groups that I've gone through, it's been about week six or so of pretty dense conversation for the first three, four weeks, training and stuff, and then some messaging in between. But after about six weeks, they kind of get how to do the basal they've they're have a good understanding of the carb ratio and even have a good guess when it's sensitivity. If they move through that list by week eight, they're pretty solid. Those last couple weeks are just kind of letting them practice. And we go over some other topics that like. We'll cover some other pieces around the algorithm just to improve their understanding. But it's the core of it is probably about six weeks. And I emphasize that the program is training. It's like educational. It's going to be videos that you can watch, but then we're going to do like group calls. It's going to be a group coaching. You're not going to be left to just watch a video. You're going to have access to someone to ask questions and to if anyone else wants to share, you can see their data. I know people really appreciate me showing Tess data so they can kind of understand, like, it's not all sunshine and rainbows all the time, and how and when I would make changes, and just, you know, real life stuff that comes up. And so, yeah, it's about six to eight weeks. The whole program right now, I'm planning on running it for a full eight weeks. But it's, it's really start to kind of get it after about six you have time to practice. Have something go wrong, have an illness show up, have a pod site go bad, those kinds of things. There are a few people that made it the whole time and just didn't have anything significant that needed to change. And so right after we were done, and they called me and we worked through it, but a lot of it's just practice, and most people have setting changes, even just a small basal change, sometimes every couple days, sometimes multiple times a week. Sometimes you wait a week or two before you have to change anything. I think that's really important for people to see, and if they just don't need a change, it takes a little longer to practice all the stuff that you're learning. Tell people how to find you box in the loop house, com, you can sign up to get my email newsletter, so you'll know when classes open up, they're only going to open up a couple times a year. So you can jump in. You want to do some one on one instead of going through with the group. You can also find that information on my website, Fox and loop house, calm, awesome.

Scott Benner 44:55
I told somebody today, I'm like, Oh, I can't talk. I'm I'm recording. And they said, with who and I. Said Kenny. And the response I got back was more Fox in the loop house. I was like, yes, but that's just funny. I can't believe I tagged you with that. I'm so sorry. Like that I tagged you with that moniker, but, uh, I'm glad people know you that way. It's awesome. Hey, I'm gonna roll with it. It's fine, excellent. Is there anything we missed that we should have talked about here that we didn't? No, that's good. Awesome. All right, thank you, man,

today's episode of The Juicebox Podcast was sponsored by the new tandem Moby system and control iq plus technology. Learn more and get started today at tandem diabetes.com/juice box. Check it out. The podcast episode that you just enjoyed was sponsored by ever since CGM. They make the ever since 365 that thing lasts a whole year. One insertion every year. Come on. You probably feel like I'm messing with you, but I'm not. Ever since cgm.com/juice, box. Okay, well, here we are at the end of the episode. You're still with me. Thank you. I really do appreciate that. What else could you do for me? Uh, why don't you tell a friend about the show or leave a five star review? Maybe you could make sure you're following or subscribed in your podcast app, go to YouTube and follow me or Instagram. Tik, Tok. Oh gosh, here's one. Make sure you're following the podcast in the private Facebook group, as well as the public Facebook page you don't want to miss. Please do not know about the private group. You have to join the private group as of this recording, it has 51,000 members in it. They're active, talking about diabetes, whatever you need to know. There's a conversation happening in there right now, and I'm there all the time. Tag me. I'll say, Hi. Are you starting to see patterns? But you can't quite make sense of them. You're like, Oh, if I Bolus here, this happens. But I don't know what to do. Should I put in a little less, a little more, if you're starting to have those thoughts, if you're starting to think this isn't going the way the doctor said it would. I think I see something here, but I can't be sure. Once you're having those thoughts, you're ready for the diabetes Pro Tip series from the Juicebox Podcast. It begins at Episode 1000 you can also find it at Juicebox podcast.com up in the menu, and you can find a list in the private Facebook group. Just check right under the featured tab at the top, it'll show you lists of a ton of stuff, including the Pro Tip series, which runs from episode 1000 to 1025 Hey, what's up, everybody? If you've noticed that the podcast sounds better. And you're thinking like, how does that happen? What you're hearing is Rob at wrong way, recording doing his magic to these files. So if you want him to do his magic to you, wrong way, recording.com, you got a podcast. You want somebody to edit it. You want rob you.

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#1488 The Cat Has Fleas

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27-year-old nurse Cassidy battles T1D, Crohn’s, hypothyroidism, and anxiety while offering a unique perspective on the hospital system.

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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 0:00
Welcome back, friends. You are listening to the Juicebox Podcast.

Cady is a nurse who has type one diabetes, Crohn's hypothyroidism, anxiety and an interesting take on the hospital system. We're going to talk about that and much more on today's episode. Nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan. I know this is going to sound crazy, but blue circle health is a non profit that's offering a totally free, virtual type one diabetes clinical care, education and support program for adults 18 and up. You heard me right, free. No strings attached, just free. Currently, if you live in Florida, Maine Vermont, New Hampshire, Ohio, Delaware, Missouri, Alabama, Mississippi, Iowa or Louisiana, you're eligible for blue circle health right now, but they are adding states quickly in 2025 so make sure to follow them at Blue circle health on social media and make yourself familiar with blue circle health.org. Blue circle health is free. It is without cost. There are no strings attached. I am not hiding anything from you. Blue circle, health.org, you know why they had to buy an ad. No one believes it's free. This episode of the juice box podcast is sponsored by us Med, US med.com/juice, box, or call 888-721-1514, get your supplies the same way we do from us. Med, this episode of The Juicebox Podcast is sponsored by the Omnipod five. Learn more and get started today at omnipod.com/juice box. Check it out.

Cassidy 1:55
Hi. My name is Cassidy. I am 27 years old. I currently work as a registered nurse in pediatrics at a major Midwest hospital, and I'm a type one diabetic, and I have been for 15 years. Last month, those are kind of my major points. You

Scott Benner 2:16
were diagnosed when you're 12. Yes, okay, 27th the best age. You think you don't know this, but, yeah, it is okay. Yeah, what were you gonna say? What about it?

Cassidy 2:29
This year has been a little rough, but it's been good, but it's been like a roller coaster of, like, good news, bad news, good news. You know, we'll

Scott Benner 2:37
find out about that, yeah, but I'll give you my thoughts, and you'll tell me why I'm wrong. It sounds good. The best conversations are when I say something and then people are going, I don't know, man, I don't know about Yeah. So my theory on like 27 is this, you're not married, right? I just got engaged last month. I hear the joy in your voice still, so I know you're not married, correct, right? Yeah, there's still time. Oh, yeah, I can tell you don't have kids. I know you're not married, but you're not 24 and, like, confused and trying to figure everything out, and you're not 35 and have a mortgage and are like, right, yeah. And I've had the same argument with somebody, like, 17 times. There's still, like,

Cassidy 3:16
some optimism there. You can hear, Oh, yeah, no, you

Scott Benner 3:19
have, there's a lilt in your voice. It's lovely and so and you know enough words, but not all of them yet. So life's not completely boring, like you still hear things that you're like, Oh, I didn't know that. Yeah, exactly, yeah. This is it right here. This is your golden age. You won't recognize it until it's too late. And you look back and you think, Oh, damn. What about 28 How do you feel about 28 you still have time right in here.

Cassidy 3:45
Okay, okay, okay. When does it end? When you're 30, it ends

Scott Benner 3:49
as things pile on top of you, yeah, and then it turns into something else, like so you still haven't like you haven't had an argument yet with your fiance's Mom, where neither of you actually said what you meant, but you're both trying to get something you want at the wedding. And like, you haven't, like, I don't know, like, you know what I mean. Like, you haven't woken up in the morning and been like, Oh, there he is again.

Cassidy 4:16
You didn't go home. Okay? You haven't

Scott Benner 4:19
woken up yet and had him look at you and go, Oh, okay. See it on his face where he's like, Oh, I can't leave. And you're thinking, like, oh, I can't leave either. And then you buy a cat, but the cat gets, like, some like disorder, and there's like, a chunk of your Yeah, right. So weird that

Cassidy 4:39
you say that, because, literally, like a month ago, my fiance's friend, they adopted a cat, or rather, they found a cat behind like a dumpster, and it had fleas. And my fiance went over to his house, didn't know the cat had fleas, came home. Guess whose cat? Has fleas. Now, the

Scott Benner 5:01
cat has fleas is the name of your episode, by the way. Cassidy, oh, that's incredible, unless you say something awesome between now and the end, I'm not kidding, right? Like the cat has fleas is going to take you a month, and you're basing the cat, oh, yeah, right. And

Cassidy 5:19
there's a month. Oh, three months. Yeah,

Scott Benner 5:21
you're gonna have to replace a sofa at some point. And then, like, and it'll be fun, like, there'll be these small memories in it where you and your fiance, uh, you know, bathing the flea cat, and you're laughing. Like, how did this happen? Except you don't realize that the energy you use to bathe the flea cat is the energy you were gonna use to have sex, right? And then you Yeah, and then things drift into different, like, directions, and, you know, then someone gets sick. Doesn't even have to be you. It could be a person in your life. It beats you up a little bit. You're gonna have a friend who gets into a bad relationship. You're gonna end up spending six months helping her. Like, your car is gonna, like, not work, and the dealership is going to screw you and like, and then just one day, you wake up and you go to stand up, and all that weights just like, on you somehow, and you That's it. This is the time. So it's really looking up from here. Is what you're telling me. I'm telling you, no, you're missing the point. The point is, enjoy, yeah, now is then. Do you understand what I'm saying? Yes, I understand what you're saying. All right, get in there. Do something fun. Have you ever wanted a trip somewhere you kind of can't afford it, a little go, like that kind of stuff, yeah? But please be saving money for the future at the same time,

Cassidy 6:38
also that in this economy.

Scott Benner 6:41
Let me ask you a question. Any chance you'll be able to afford a house, you're a nurse, like you have a real job, you get paid, right? Like

Cassidy 6:48
I do have a real job now. So nice. I mean, yes, I think what we're going to be able to buy is going to be like not our

Scott Benner 6:56
dream. Gonna come with its own fleas. It's probably gonna come

Cassidy 7:00
with its own, please, but we already know how to treat it. So, I mean, we have back on for us, right? I mean, I think this is the first time in my life where I felt like, oh, okay, like I'm not completely just like scraping by, where it's like, truly living like paycheck to paycheck. Yeah, because when I was in nursing school, I was working as, like a PCA, so I was a nurse's aide, and they don't get paid a lot. And I was also working part time, and then in full time school, and I was in an accelerated bachelor's program, so I did my full BSN in 18 months. During that time, I had, like, no money at all. And then before that, I was a barista for four years. So

Scott Benner 7:43
you made people coffees for four years? Yeah, I'm sorry. Okay, it

Cassidy 7:49
was honestly, if it paid the bills. I love it. It's so fun to make coffee, I think. But also, I worked at a cafe in Seattle for a little bit, and so it was like, literally, like, the quintessential, like, exactly what the experience that everyone dreams of, right? Like, as a barista, anyway, not everyone dreams. Obviously, you don't dream.

Scott Benner 8:12
I thought everyone dreams to be a barista. In Seattle, that's crazy.

Cassidy 8:16
If you were gonna be a barista, where would you want to be a barista? I

Scott Benner 8:20
mean, I don't know, in my dreams, you all go tell five other people about the podcast. So, okay, fair enough. Yeah, I don't know. My dreams are different than yours. I don't know. Like serving people coffee makes it makes me feel like I wouldn't enjoy that. I

Cassidy 8:36
think so. I mean, you know, you get it's, it's, it's like any other customer service job that I love. What was fun about it just the like, learning about different coffee learning how to make like latte art and like suggest different things to people. Also, it's different than working at like a restaurant, because when people walk into a restaurant, they're like, hungry and maybe hangry and so, but when people come to get coffee, they're like, Oh, this is the best part of my day.

Scott Benner 9:03
Yeah. I can't, you know, cocaine anymore, so I'm gonna do this, like, that thing, yeah, yes, yeah. Also, your generation is like, were you broke growing up? Or was your family comfortable? My daughter is 20 years old. I can't even believe it. She was diagnosed with type one diabetes when she was two, and she put her first insulin pump on when she was four. That insulin pump was an Omnipod, and it's been an Omnipod every day since then. That's 16 straight years of wearing Omnipod. It's been a friend to us, and I believe it could be a friend to you, omnipod.com/juicebox whether you get the Omnipod dash or the automation that's available with the Omnipod five, you are going to enjoy tubeless insulin pumping. You're going to be able to jump into a shower or a pool or a bathtub without taking off your pump. That's right, you will not have to disconnect to bathe with an Omnipod. You also won't have to disconnect to play a sport. Or were to do anything where a regular tube pump has to come off. Arden has been wearing an Omnipod for 16 years. She knows other people that wear different pumps, and she has never once asked the question, should I be trying a different pump? Never once omnipod.com/juicebox get a pump that you'll be happy with forever. I used to hate ordering my daughter's diabetes supplies. I never had a good experience, and it was frustrating. But it hasn't been that way for a while, actually, for about three years now, because that's how long we've been using us Med, usmed.com/juicebox, or call 888-721-1514, us, med is the number one distributor for FreeStyle Libre systems nationwide. They are the number one specialty distributor for Omnipod, the number one fastest growing tandem distributor nationwide, the number one rated distributor in Dexcom customer satisfaction surveys, they have served over 1 million people with diabetes since 1996 and they always provide 90 days worth of supplies and fast and free shipping us med carries everything from insulin pumps and diabetes testing supplies To the latest CGMS like the libre three and Dexcom g7 they accept Medicare nationwide and over 800 private insurers find out why us med has an A plus rating with a better business bureau at US med.com/juice box, or just call them at 888-721-1514, get started right now, and you'll be getting your supplies the same way we do. I think

Cassidy 11:47
it depends on who you ask, because if you ask my fiance, he would say that I grew up somewhat comfortable, but my dad had three jobs at one point growing up, so I mean, I wouldn't call that exactly comfortable,

Scott Benner 11:59
but you weren't worried about money personally as a child growing up, right? No,

Cassidy 12:03
no. So I think that's what the argument was like. We didn't have an argument, but we talked about it a little bit, and he was like, Yeah, but you never were like, oh, where's my next meal going to come from? Or, oh, you know, and that's true. I never, never was aware of our financial situation. And I feel like that's the difference,

Scott Benner 12:21
yeah, my point is, that's how you end up being able to be, like, interested in, like, Frappuccino art. You're not thinking like, I have to quickly get out of here and make a bunch of money or I'm gonna die. Oh, yeah,

Cassidy 12:33
Scott, I was a theater major for about a year and a half. So you tell me if I was aware of finances, literally at all. So

Scott Benner 12:43
we'll change the name of this episode too. Cassidy was comfortably Caucasian. Okay, actually, yeah,

Cassidy 12:50
that's great. Let's do that. That's a good one.

Scott Benner 12:53
And I'm not coming down on you for it. I'm just saying, like, no, it's just Yeah, it's true. I just when you were like, Oh, I find this interesting. I thought, I don't know how she had time to find that interesting, like, because there were things I found interesting, but the energy I used to work in my uncle sheet metal shop was used up on that, so I couldn't, like, get an image, sure, yeah, okay, all right, hippie, I got you. I know what's going on. I know.

Cassidy 13:16
I know my fiance would love you. He'd be like Steve.

Scott Benner 13:22
So at what point do you decide to be a nurse? I was only

Cassidy 13:26
a theater major for a year and a half. It was less about like, financial stability and more about like, it took something that I loved so much and turned it into like, this is what it's going to look like when it's a job. And I was just like, I don't think I want to do this. And I'd always been interested in nursing, like it was kind of like a thought that I'd had, but I was so focused on acting, it was never like a top priority or voice. And so I left the school that I was at and went into pre nursing. So I did, like, all of the prerequisite classes that you have to do. And I just talked to probably three different people who are in nursing, who talked me completely out of nursing. And they were like, nursing is the worst career ever. I'm so miserable, I'm so tired, like, I don't get paid anything. Like, people are awful, blah, blah and like, so at the age of I was 20 or 21 I like, really let that dictate what I decided to do. So I was early enough in the degree that I could switch to a social work degree. So I did that, and then I graduated in 2020 met my fiance. We moved to Seattle for his job, and I was like, looking at entry level social work jobs. I went to an interview. They offered me a job, and I just was like, This is not what I want to do at all. And to do what I want to do, I have to get my masters. But I was looking at jobs like with people who are masters prepared, and they were paying them like, $25 an hour. Oh, my goodness. I. And I was like, Okay, well, obviously, financially, this is not a great decision, because your MSW is like, $100,000 so it's, like, it was just not, I was like, okay, the stream is dead. I don't want to do

Scott Benner 15:11
this. That's where my Oh, my goodness came from. Not that $25 an hour is not a, you know, reasonable amount of money, but it's, I'm talking about, like, after I paid for a master's and an undergrad, yeah, yeah,

Cassidy 15:21
yeah. I feel like social work is an incredibly difficult job for a lot of reasons, but it's just like, I think that they see a lot of red tape, like they're like, I see how to help this person, but there's like, seven obstacles in the way, you know, and so I think that would be frustrating, but so I kind of fell back into researching nursing. I did, like, a ton of research. I talked to a few nurses, and then I was like, I that's what I want to do. I really want to be a nurse. And I found a program. Well, actually, my fiance's dad lives in the Midwest, and he was like, if you guys move out here, you can live in my basement while you go to school. So we did that, and then I was able to, like, save a little money, and then I worked part time, and then just, like, commuted to school.

Scott Benner 16:07
So like, Silence of the Lambs, you lived in someone's basement in the

Cassidy 16:12
Midwest. Was it like it wasn't quite as dungeon? Well, it's a little it isn't as bad as it sounds. It

Scott Benner 16:22
rubs the lotion on nothing like that happened. Nothing, nothing,

Cassidy 16:26
nothing like that happened. Yeah, so and then, yeah, I went through 18 grueling months of nursing school.

Scott Benner 16:36
You hammered away like you got it done fast, huh? Yeah, it

Cassidy 16:39
was. It was definitely like, I think that a lot of people that go through nursing school know that it's not necessarily like the difficulty of the content, but it's more the amount of things that you have to learn in a short amount of time, right? Yeah, and I work at an adult hospital for about a year as a PCA or nurses aide. I thought I was going to work with adults, and then I had my pediatric clinical rotation. There's a floor at the hospital that I work at that's like, the diabetes floor. I like, talked to one of the clinical leaders there, and she was like, Well, I really would like you to work here. So that's where I work now, as a nurse. Oh, awesome. The floor that I'm on is, like, if it is the diabetes floor, but also we're like the organ transplant floor. We get a lot of, like, liver and kidney transplants, and then kids that have had transplants, and then kids that are pre transplant. Like almost every auto immune disease you can think of, we see on our floor too. So okay, yeah, cool. Let's find

Scott Benner 17:37
out about this. So yeah, you were diagnosed when you were 12 with type one? Was that your first autoimmune issue? Or No? No.

Cassidy 17:44
So I was diagnosed with hypothyroidism when I was two days old. So I don't know if it was autoimmune or if it was like congenital hypothyroidism, but I've been told both by different providers, so I don't know if that's truly auto immune. I gotta

Scott Benner 17:59
jump in. Somebody just said this to me in the last couple of days while I was recording, like, How was that possible? No one ever said that to me before. And now, in the span of like, seven or 10 days, two people have said, basically, I was born with hypothyroidism. Yeah, uh huh, yeah. I was two days old. Is your little thyroid underdeveloped? Still today? No, no, I don't think so. There's was. That's why I asked, okay, okay, well, I mean, have you had it scanned? You know, I

Cassidy 18:24
haven't had it scanned, but they've, like, palpated it and said it feels normal. Maybe that's not super reliable, though I

Scott Benner 18:30
love that, the way that we had to make up a word so it doesn't sound like your thyroid is being molested by a clinician. We palpated it is that what you

Cassidy 18:39
did? That's a nursing term.

Scott Benner 18:43
Okay, so you've been taking Synthroid your whole life. No, no. So

Cassidy 18:46
here's the interesting thing, the physician that diagnosed my hypothyroid was like, okay, so it's very important that she takes this medication for like the first couple of years of her life. I think I only took Synthroid for like, two years, and then they re checked my levels and determined that I didn't need it anymore. Do I know if that's like, actually what you're supposed to do? No, it sounds wrong to me, but I don't I digress. I feel like because then they I kept telling my mom, like, before diabetes, I'm so tired, I'm so tired, like I'm cold, and I was like, gaining weight, and they would check my thyroid, and I don't know what my TSH was, but I'm sure it was high. And they were like, Nah, she's fine. I didn't get back on Synthroid until I after my diabetes diagnosis. Then they checked my TSH again, and they were like, Oh yeah, you need to be on Synthroid. And we were like, oh,

Scott Benner 19:41
okay, you're a person who lived through this and has a nursing background. Can you, I'm asking, wrap your head around a person coming into a doctor's office with hypothyroid symptoms, having had the story you had at birth, and then someone saying you it's. Definitely not that

Cassidy 20:01
it's crazy. Yeah, I don't know, because I've thought about that too. Like, because I hear people talk like patients talk about it too, right? Like, you know, oh, we've had these symptoms for a long time, and it kind of and we'll talk about this later too, because the same thing happened to me this past year. But I just think, I don't know. I feel like hypothyroidism is not that rare, so I guess that this theory doesn't really track. But, like, I feel with diseases that are quote, unquote more rare, they're just like, Oh, we're gonna, like, make sure that it's not the more common ones first, and we're gonna make you wait, or we'll see if it goes away, or we'll try. You know what? I mean, Cassidy,

Scott Benner 20:34
I'm trying to get you to tell me if everybody is a dummy. I mean, you work with a lot of people, right? Like, so is it just law of numbers? Like, is it just that if I put 100 people together, a certain number of them are just not going to be good at it. What am I dealing with here? I don't know. I plead the fifth. I don't know. Should we make this anonymous? You want me to blur out your name? Can I ask you again?

Cassidy 20:59
No, I don't want it to be anonymous. Okay, I just think healthcare is really messy, and it's coordinating so many different things all together at once, and it's just like, I've just seen miscomm minutes, like miscommunication happens in my everyday life. As hard as you try, it's just like, it's just there's too much going on, you know, like patient care is so multi faceted and complex and nuanced. And it's just like, I think you just have to know as a patient that you have to advocate for yourself. Because I don't think that it's that providers, nurses like, don't care or don't want to take the time, at least in my experience, like, I haven't really ever felt that personally, but I think it's just like, truly, if you feel genuinely something is wrong, you just have to be very honest with your doctor and be like, listen, like, I understand that you want to take the conservative approach to whatever you're addressing, but like, something is really wrong.

Scott Benner 21:53
You know, you're asking people then to understand the foibles of the system, and they don't. I know, yeah, and they don't. I'm going to say this here, because I'd like this to be recorded somewhere. Today is December 18, 2024 I'm saying this to all healthcare providers. You all got to pull your together, or you're going to get replaced by a chat bot in the next five years.

Cassidy 22:13
Oh, oh yeah, it's already, it's already happening, yeah. Like, I feel like we're already, we already have, I guess it's not like a chat bot, but it's like, it's gonna be, it's gonna be, no, I and it's like, I just had this conversation with my dad the other day. I was like, Well, I think we'll be replaced by AI. He was like, nurses, no. And I was like, definitely. I was like, Yeah, eventually, for sure, like, if not completely, then partially, you know.

Scott Benner 22:38
But if I sat just at a prompt right now and said, 11 year old girl complains of tiredness, always cold. Whatever you just said was put on Synthroid at two days old and then taken off of it. What do you think's wrong? The chat bot would come back and say that the kid has hypothyroidism.

Cassidy 22:59
Yeah, I think it's more like, also, I think providers just can't always, like, agree on certain parameters for tests.

Scott Benner 23:07
Oh, I know. I guarantee your TSH came back at like, four, and they were like, No, this is fine, right?

Cassidy 23:13
That's what I mean. I think it's just like, I don't know. I think it's interesting, and it's also devastating, because you're right, like, they don't understand the system. They might not understand what's going on with them. So if a doctor says, like, you're fine, then they go, okay, you know, and and they they move on.

Scott Benner 23:29
Translate that over to diabetes, right? Someone's diagnosed with type one diabetes, they get poor direction. They don't understand how insulin works, you know? They come back to a doctor six months later with an A, 1c, and the eights. And the doctor says, Hey, how's this? Why is this like this? And the person goes, I don't know. And the doctor writes down, non compliant, like, how come the doctor doesn't write down, doesn't seem to understand how insulin works. Didn't understand the, you know, the my question, right? And the reason is, the doctor didn't understand the question either, or if they did, they would have explained insulin to the person. The person will understand it. And their A, 1c, understand it and their a 1c, wouldn't be nine. I'm telling you that the problem is people, yeah, I'm sorry, because you seem like, I bet you're a good nurse.

Cassidy 24:11
Oh, thank you. Yeah, I try. I think I I do understand too. Like, as a person with multiple autoimmune diseases, like I'll sit and talk with patients for if I have time to, you know, just like about my own experience navigating healthcare, and like how it can be really challenging and frustrating, and if you have something that the vast, you know, like, I think that most providers are educated very thoroughly on things that are super, super common that we see, you know, every day in The hospital, right? But like, things that you don't see every single day, it's just like, it's, I don't know, and I don't really even know what the answer is. Or, like, how we fix these issues with people that have diseases that have a little more nuance to them, because it's like, it's hard to understand, like, the intricacies of all of the diseases, yeah. But. We can't just be like, well, we don't understand, so we're just gonna do what we can and then send them

Scott Benner 25:05
home. My expectation is, is that your healthcare system, one day will give you like, I don't know how it'll work, but you'll log into an account where you will log your complaints, like, everything, like, you'll like, you'll keep a diary of your health. Then the system will be able to point out what might be important to look into. That's my expectation about how it should happen. So, yeah, I don't know

Cassidy 25:29
what. And then people can bring it up, I guess.

Scott Benner 25:31
And nurses and doctors will be more like the guardian of that information. They'll look at the information and say, that seems correct to me, will move forward. That's the only thing that makes sense to me. I've been doing this podcast for a long time, and I mean, it's fun sometimes to, you know, or interesting, or whatever word you want to use, to have this conversation and be like, horrified that they took you off Synthroid, then you got like, you know, hypothyroid symptoms, and nobody did anything, and you're like, some little girl dragging her ass through life, yeah, yeah. But at the same time, like you don't have to have this conversation over and over again to realize that this is just how it is, right? And it's not because someone's not trying, it's not because the health care system, it's just because when you involve this many people into this situation, this is the outcome you get. That's all, yep,

Cassidy 26:18
right? And it's just, that's what I mean. It's just like, when it's so multifaceted, and there's so many different people involved, it just, it just gets messy, and it's hard to like, that's why I don't have a good like answer. I'm like, I don't know how to I like, see the problems. I literally see them, like, at my job, right? I'm like, Oh, yep, this is how this happened, you know? And it's like, but do I have, I don't have a clue of how we're supposed to fix it, and I think that's how other people feel too. They're like, yeah, we see the problems. I think the only thing it's like, it's good for me to see it, though, as a nurse, because then I can do what I can to try and advocate for my patients better, because I know what has happened, even in the past, or what has happened to other people. Being aware of it makes you a better provider, and I've seen doctors do that too, like, where they're like, oh yeah, this is what happens all the time. So I want to make sure that this doesn't happen to the people that I'm carrying. There's no

Scott Benner 27:08
actual fix what you know like when you're 10 years from now, when you find yourself Cassidy at a PTA meeting, okay, and then whatever horrible thing is happening to you, and you're in one of those situations, and you recognize that this PTA meeting is going to go just like the last one, as we'll go the next one, because Margaret over there is cheating on her husband with the soccer coach, and that lady's been drunk since noon, and that guy is full of anger and anxiety, and this person is On a power trip and blah and like, you realize that every time you go into that situation, it's not going to be the same people, but you're going to have a lot of different variables like that in the room. They're always going to exist. And you can step back as a reasonable person and say, Well, I know how to fix this situation, but the next step is to make her not a drunk, make her not a cheater, make him not a lunatic like and you can't actually do that. So the PTA meeting always goes the way the PTA meeting goes, and there's always a mom in town having sex with somebody who works at the school. You're never going to get away from 10 out of 10. Yeah, yeah. Always gonna be happening.

Cassidy 28:21
I will say too. I think this is why, like, your podcast is so important and meaningful, because there's something and the Facebook group too. There's something really cool about having another person, multiple other perspectives outside of healthcare, for people that have a lived experience and really understand diabetes. And I mean, I just think it's really awesome. So I feel like, I definitely like mention it to patients. I don't know if I'm supposed to do that, but I'm like, This is not medical advice. But like, if you if you want community, if you want something, you know that's like, real other parents who are walking through this, like, this is great, and I would recommend, like, looking into it, well, I appreciate that.

Scott Benner 29:02
I'm glad that it strikes you that way, and I appreciate you sharing it, and my opinion is that you're supposed to be sharing it. So yeah, I'm sure the hospital was like, Wait, what's happening? She's telling people about a podcast. No, no.

Cassidy 29:14
I think honestly, I asked one of our diabetes educators about it, and she was like, Oh yeah, I tell them that all the time. They said, Oh, okay, well, then

Scott Benner 29:23
awesome. I'm gonna continue to do that. Yeah. How did you get pulled onto that floor? Do you think that you were just bright, clear minded, doing a good job? And she thought, I need more people like that up here. Honestly,

Cassidy 29:34
my clinical instructor really liked me, and then she introduced me to this clinical instructor that worked on the floor that I work on now. And I was like, Yeah, I'm definitely interested in working with kids with diabetes. I think that'd be really cool. And that was really it, I mean. And then, so then I switched, I don't think I said this, but I quit my job working with adults at the adult hospital, and then I started working as a PCA at the hospital I'm at now. So, yeah. I don't even know if it was so much like, what I did or said or I don't know, I just probably was like, I'm really excited to be a nurse, and I have diabetes, and I'd love to work with other people with diabetes. And she was like, perfect.

Scott Benner 30:10
This one doesn't even know yet, we'll just get her up here and we'll just drain the life out of her up here. Perfect. Yes. What's the the lifespan of a nurse? How long do they usually last?

Cassidy 30:21
Oh gosh, what a question. They say that we're at a nursing shortage. I don't know if you've heard this or read this anywhere, but we're not in a nursing shortage. We're in a shortage of people who are tired. They're very tired of working at the hospital and working bedside nursing. So I think that in the past, like lifespan of a nurse, bedside nurse, working in the hospital. I don't know 2025,

Scott Benner 30:44
years, really, but now, yes, I don't

Cassidy 30:47
even know. I feel like it's, it's hard to find people that work on the same floor at a hospital for more than, like, five years. What

Scott Benner 30:54
do you think happens? Do you think the job is harder? Do you think that people just have a more kind of, like, Go get 'em attitude, like, I'm just not gonna sit here forever. I wanna move up. What do you think's gonna happen to you?

Cassidy 31:07
I think it's a combination of things. I think some people go into nursing and don't know what the job is, or they have higher expectations for what their their work life is gonna look like. And a lot of people graduate nursing school at like, 22 or 23 it's an immense amount of responsibility at, I think, at that age. So like, the people that I work with that are like, fresh out of nursing school, and they're just like, killing it. I'm just like, Man, I could never have done this. I was like, I was making lattes. I don't know about you, but, and I think it's that people don't know. I think it's that people have higher expectations for the job. It's a hard job, it's long hours. You're exhausted. And it doesn't sound like, I don't know, when I started working 12 hour shifts, I was like, oh, like, that's fine. Like, I've worked an eight hour shift, like, you know, what's four more hours? But it's like the amount of stuff that happens in four hours in the hospital is actually bonkers. Like, I tried to write down my busiest day, like, I had a really crazy day a couple weeks ago. It was like, I'd get a call, and then I would have to go and and then I went into a room. Oh, you're a patient, you know, their potassium is high. Okay, now I have to call the doctor, okay. Oh, now your your blood sugar is 40. Oh, okay. Well, I gotta go take care of that and re check it and do it. And it was like that, literally for probably eight hours of the day, and it was just non stop. And so it's like, if you think about like your busiest day at work, like a standard person's busiest day at work, nursing is like that almost every day you go there. So I think people just get burnt out and they're tired, and they're like, Oh, this is not what I imagined nursing would be. And then also, like, nursing has just changed a lot. Like, I've talked to nurses who are more seasoned and have worked for like, 10 years or whatever, and they retire, and they're like, Yeah, nursing didn't used to be like this. I'm done like, and I don't know, I can't say, like, exactly what the differences are. I think it's just technology is advanced, and so we're, we're getting better at treating people, and so I think we just have more. I don't know it's just, it's, it's a conglomeration of, like so many things, but it definitely is harder and rougher than it used to be like to work in the hospital, than it was, maybe even pre COVID, honestly, really, because people have said too that COVID changed everything. And I don't even know what that means exactly. They're like, Oh, yeah, I was different before COVID. And I'm like, Well, what do you mean? Like, how? And they're like, I don't know. It's just different. And that's the response I get from everyone. And I'm like, How can no one tell me? Like, what's different about it? Like, so I don't know. I also think a lot of nurses left after COVID or during COVID, because they were just so

Scott Benner 33:39
is it possible that, beyond that, the world is different, that nursing isn't different? How would they know? Do you know what I mean, like, how would they know that nursing magically got different, right, right? And but not be able to, like, quantify it. You know what I mean? Like, does it feel different to you? Does like the world feel different to me? Does the world of nursing feel different to you. I guess I can't really, like speak

Cassidy 34:03
to that, because I so I started working in a hospital in 2022, so, like, I was already post COVID, but I just know that, like, people were pushed beyond their limits in COVID, really unsafe working conditions, no. PPE, no. Like, everything changed every day. It was like, I feel like it was, I can only imagine that it was, like, an average day of nursing, but like, 10 times worse, because you were dealing with something that no one understood, and that was changing literally by the hour, sometimes, like protocol and, you know, and then people were getting really sick really fast, and I don't know, I just think, like, I can't imagine what that was like, like, I just really can't so

Scott Benner 34:41
then, is it possible that COVID added a layer to the job that didn't feel like it existed prior? And so now suddenly, a bunch of people who came into imagine if you became a professional football player under today's rules, and then. In six months or a year into your job being a professional football player, they added bats with spikes in it for tackling, right, right? Like, you'd be, like, I don't know, my football just got harder, right? That you could say, Why? Because, like, before, why before they couldn't tackle me with a bat with a spike, and, like, now they can. So I don't want to do this anymore. Do you think that it just leveled up? I think it probably just leveled up. I do also, I've heard this argument before. I've heard people argue that a lot of people got into health care at a time where it was like, like, not war time, for example, like, almost like joining the military during peace, and then all of a sudden someone's like, No, we need you to go across the country and actually shoot at people. And you're like, Oh, I thought I was just gonna be down here giving a hand and out band aids and hugs like that kind

Cassidy 35:47
of thing, right? So I think that there, and this is like, total, like, full respect to people that maybe didn't expect nursing to look the way that it does, because I don't think that we do a very good job. Like, well, somewhat, I think in nursing school, we don't really do the best job of, like, showing what the job really looks like. I think when you go to, like, your clinical rotations, you're there for not a full shift. You have one patient, you like, can't do all the things for them, like, you know, there's certain things they won't let students do and whatever. And it's like some I had my my friend who didn't work in a hospital prior, was like, I think working in the hospital would be boring. And I was like, Huh? And she was like, Well, yeah. Like, look, we're just, like, sitting around. I was like, Yeah, but, like, imagine this. But like, add four more patients, and then add the doctors calling you, pharmacy calling you, PT calling you. Every call light is for the nurse, you know. And she was like, oh, yeah, I guess I hadn't thought about that. But like, I just think that, like, nursing school doesn't always paint the best picture. And so then it's like, you're shell shocked when you get into your job and you're like, Oh, I had no idea this is what it was going to be. So yeah, I think anyone who wants to go into nursing I highly, highly recommend that you work in a hospital first, because it gives you, not only, like, it makes you more comfortable working with patients, because it's a very different role than anything else in your life. Going up to someone and being like, okay, like, I'm gonna, I don't know you very well, but I'm gonna take your vitals and I'm gonna talk to you and I'm gonna, oh, now we're gonna go, I'm gonna draw your blood and, like, I'm gonna be taking care of you for 12 hours. Is like, kind of nerve wracking, especially when they're sick and they have, like, tubes, lines and all that stuff. So and you get a better idea of what the hospital work is like. Like, when I was working as a PCA with adults, I would walk eight miles a day. Couldn't even tell you, like, why? Like, where I where I went, you know, but I was just running around doing

Scott Benner 37:39
this. So what's the real answer here? When I hear people say there's a nursing shortage, do they mean like, every nurse should have six patients in a 10 hour cycle, or something like that, and if you're helping more than a certain amount of patients, then that's how you get stretched too thin. I

Cassidy 37:56
think it's, yeah, I think it's a lot of things. I think it's the nursing shortage comes from people leaving bedside nursing. We have plenty of nurses, like registered nurses, in the country to supply the hospitals, but working conditions and like, every hospital is different. Like, some hospitals, working conditions are so terrible they can't keep nurses there. And that's just like, you know, that's just kind of the way it is. Yeah. Like, there are some hospitals that are completely staffed by travel nurses who are getting paid double the amount that they normally would, but they're having to work in these conditions that are maybe not so safe, or maybe they're just, like, I don't know, at the, like, the patient ratio, like the, you know, maybe they give them seven patients instead of four, which is really what they should be giving people as, like, four patients. Okay, yeah, I wasn't sure

Scott Benner 38:41
what the number I was getting. Number I was guessing, but okay, yeah, that travel nursing thing still is confusing. Like, why don't they just overpay the people who work there? That's

Cassidy 38:50
a wonderful question. Scott, I don't know. My dad and I have had this conversation. He's like, these hospitals are gonna have to start paying the nurses more. And I was like, I mean, yeah, I guess. But like, I feel like, wouldn't we start seeing that now? Like, I travel nursing has been really, I mean, it started being, like, super popular during COVID. Obviously,

Scott Benner 39:08
I know a travel nurse loves her life, yeah, it's in Hawaii right now,

Cassidy 39:13
yeah? Well, and you get the benefit of, like, going on a vacation, if you want, right?

Scott Benner 39:17
Like, it's been to a lot of cool places, yeah, so I don't know.

Cassidy 39:21
I think it's interesting, though, because then the hospital has to pay whatever company they're traveling with. Wouldn't you rather just pay your I don't know what I know. I don't listen.

Scott Benner 39:30
I don't know anything about anything. But if you dug into it and found out that the large conglomeration that owns the hospital also owns the travel nurse company, and that they're just passing money back and forth to each other, I wouldn't be

Cassidy 39:42
okay. Maybe you're onto something. Because maybe that's maybe that's true. I don't know, right?

Scott Benner 39:47
I mean, I don't listen. I want to be clear. I have no idea. I don't either. I just work there. I know people who own construction companies that use a certain kind of construction material. So then. Go and start like a shell company that sells the construction material to this construction company. So they buy the material at one rate, sell it to themselves, basically at an inflated rate, and then make too much money on the material. Then take a loss on the job, on the construction side, write it off on their blah blah. So there's, like, trust me, there's, I'm not smart enough to figure this out, but there are people who are, and I'm going to assume that things are set up that way, so that we're just trying to hold on to our Money Longer. I don't know. Maybe I'm wrong. Maybe it's just a boubard system and like, I have no idea, but I'm just saying, if that was what it was, I wouldn't be crazy. It wouldn't, wouldn't shock me. Yeah, yeah. Let's go backwards a little bit, because we've been talking for a while about this. Do you have any other autoimmune besides type one and Hashimotos, or do you have Hashimotos? Or do you not know that? I

Cassidy 40:53
don't know. It depends on who you ask. I'm asking you. I've had a provider tell me that I have Hashimotos. I've had a provider tell me that I have congenital hypothyroidism. I don't know. I just know that I take centroid

Scott Benner 41:05
the way it's treated. It's not it is going to be the same. So,

Cassidy 41:09
right, yeah, what else do you have in April of this year, I was diagnosed with Crohn's disease. I mentioned earlier. It's been, like, kind of a rough go, because I was, like, graduating nursing school, and then I got this auto immune disease, and then I started my first nursing job, and then I got engaged. Job, and then I got engaged, and then it's just been, like, kind of

Scott Benner 41:25
a whirlwind. But what a shitty surprise. You should have said, what? Yeah, literally. How does that? How does that? How does that get diagnosed? Like, how does it come on to you? Like, I mean, is it a thing you've always had you just realized? Or did it?

Cassidy 41:37
I've, like, done quite a bit of, like, research on people's experience. Like, I read something that was like, Oh yeah, it takes the people, like, on average, five years to get diagnosed. And I was like, Whoa, that's insane. That's so long. I started having symptoms in January. So it wasn't like that long for me, I guess I don't know. It was longer than I would have liked. I was, like, was finishing my last semester of nursing school, so I was incredibly stressed out. And I do have anxiety. And I had stopped taking my anxiety medication like many months prior. And so I thought that, like, the symptoms that I were experiencing or was experiencing were anxiety related. And so I would kind of lead with that. Like, I I went to the doctor in January, and I was like, here's what's happening. Like, but I have anxiety, so, like, maybe that's what it is. And so, of course, they were like, Oh, yeah. Like, that definitely makes sense. I'm sure you have anxiety. Like, let's put you back on your your medication. And so I went back on. I was just taking Zoloft, so I went back on Zoloft. And if you know anything about SSRIs, like, one of the top side effects, they're gi related, like, nausea, diarrhea, abdominal pain, that kind of thing. I was still having these symptoms, but they were getting worse. I went back to the doctor, and again, I, like, led with but I have anxiety too. And, like, I don't know if this is, like, maybe I'm overreacting, you know. So like, three different times. I was told by three different doctors that, like, this was anxiety. I had one doctor ask me if I had a history of ulcerative colitis or Crohn's. And I said, No, but I have diabetes, type one diabetes. And he was like, Okay. And he was like, I really don't think that's what this is. And I was like, Okay. So then I finished, like, finish the, like, didactic portion of nursing school. And I had, like, a little bit of a waiting period before I started my job, and so I was just, like, just experiencing an immense amount of anxiety because I was getting more symptoms, and the symptoms were getting worse. So now I was having weight loss, fevers, night sweats, sores in my mouth. I like thought I had cancer, because the symptoms for inflammatory bowel disease and colon cancer are really like, almost exactly the same. Okay, I went to a, like, a GI doctor, and at this point, I had been to the doctor three times for this. And so, like, and my my family knows that I have, I have, my anxiety is very health related. My fiance was like, Cass, like, I really think that this is your medication. This is anxiety. Like, you're really stressed out. Like, I think, I don't think you need to go to the doctor again. And I was like, I really feel like there's something wrong. So I went to this GI doctor, and he was so nice to me and so kind. And he was like, I really think that this is the medication, but if your symptoms don't get better in three weeks, I want you to come back. I waited for three weeks. The whole time I'm thinking, I'm dying, right? Like, I'm like, I have colon cancer. I'm dying, like, and no one's doing anything about it. I scheduled an appointment with him. I went back to him, and I was like, Could this just be the medication? And he was like, No, this is not the medication. He was like, this is something else. So they did, like, inflammatory test. It's called the calprotectin, and your normal level should be, depends on where you go. But less than 50, and mine was 800 he had me come in, like, emergently. It was like three days later for a scope, he diagnosed me with ulcerative colitis. At first, he. Like, it looks really mild, but it's definitely, you definitely have something going on. And then he was like, I want to start you on prednisone. And I was like, freshly off, like, verse Ed and fentanyl. And I was like, I can't, my blood sugars are going to be so high. I was like, I can't take prednisone. And he was like, Okay, we'll, like, put you on a different steroid. So he put me on budesonide, which is, like another, like, more mild steroid, and it worked. It helped a lot for like, the first two or three weeks, and I had my, like, graduation ceremony during this time. Like, I was, like, relieved, but also I had just been given this diagnosis that, like, I knew basically nothing about. I just felt really angry because I was like, How can I have diabetes? And this, like, I went to an IBD specialist next, and she walked in the room and she was talking to me, and she's like, okay, yeah, like, tell me a little bit about what you've been experiencing. And she was like, Okay, well, I'm looking at your scope results. And this is not ulcerative colitis, this is Crohn's. I was just like, so overwhelmed, because I had kind of come to this, like, I was like, Okay, I have ulcerative colitis, like, I'm accepting it. And then she was like, actually, no, you have Crohn's, which is, like, a similar disease, but also totally different. We have to put you on a biologic medication. And so I'm like, sobbing. I'm like, I don't want to take a biologic medication. I was like, I'm terrified of them. And she was like, I understand. And she's like, trying to talk me down a little bit. Can I

Scott Benner 46:25
ask a question, where do you Where does the medical like anxiety come from? Do you know? No, when did it start? It

Cassidy 46:31
started before I had diabetes got I think it got worse when I was diagnosed with diabetes, because then in my my child brain, I was like, oh, so I can get diagnosed with things, you know. And I even experienced, after my Crohn's diagnosis, I also experienced, like a heightened, you know, what's next, what's next, what's next? I'm gonna have something else. Because, look at me, I have three things wrong with me, and I'm only 27 you know, is your

Scott Benner 46:55
father anxious? Not at all. Your mom, literally, yes, yes, your mom have any other autoimmune stuff, not

Cassidy 47:04
diagnosed. I think she might have, like, the ankle izing ankylosing spondylitis, yeah, because she has back issues. And they initially told her that she might have that, but then she was like, oh, because I brought it up to her, and I was like, do you have that? Because you need to be taking medication for that. And she was like, oh, no, they told me, I don't. But then in the back of my brain, I'm like, You should go see a rheumatologist, because I feel like, maybe you have that.

Scott Benner 47:29
I'm looking at your last name. You're like, European descendants, right? I've

Cassidy 47:34
heard an avian,

Scott Benner 47:37
yeah, right, German, Scandinavian, something like that. Okay, I was just that, like, I was gonna say pure I didn't mean that. Or your mom and dad both from the same it really didn't mean it like that, but your mom and dad from the same damn guy.

Cassidy 47:54
Yes, my my mom is German, so,

Scott Benner 47:57
I mean, I've heard a lot of, like, a lot of auto immune coming out of that part of the world, like with those kind of with those descendants, like, that's not uncommon for my experience. Oh okay. And anxiety, I genuinely think, is probably auto immune as well. So, oh yeah,

Cassidy 48:15
yeah, I could see that, right? I think seeing if your parent has anxiety that's not managed, and you see how they respond to things, you are going to learn that that's the way that you respond to things, especially

Scott Benner 48:26
if you're wired that way already, too, you know, right? And

Cassidy 48:30
like my I remember telling my dad, and my sister is a clinical psychologist, so I've talked to her about this too. I told my dad like, you know, I see these parents in the hospital and their kids are going through, like, really rough, you know, terrifying, like, scary things, and they're so calm. And I was like, I just thought that they would be freaking out, like, and he was like, Yeah, but, like, that's because that's what your mom does. And I was like, oh, right, okay, so that wasn't normal. Like, you're

Scott Benner 48:59
freaking out the way your mom freaked out when you got diabetes or whatever else, right? Yeah. And the reason your mom let your doctor push you off that thyroid medication so easy is because I think she prefers out of sight, out of mind or No, it's okay. They told me. It's not that, my God, it's like, you've met her. Yeah, I know it's good. Yeah, don't worry.

Cassidy 49:16
She's very, yeah, she's very, Everything's fine. Everything's fine, everything's fine. I just need to live 40

Scott Benner 49:21
more years and we'll die any and we'll die anyway. Don't worry about it. Uh huh, yep. So you're following in footsteps, or followed in footsteps already. And so do you really think you have Crohn's, or do you think you're wound up tighter than a top? Oh, I have Crohn's. Okay? All right. Well, that's good. I mean, at least it's real, like, you know what I mean? Like, you're not just, like, having, like, a, like, a psychological implication, psychosomatic, yeah, on your stomach.

Cassidy 49:46
Yeah, they so the way that they diagnose Crohn's, I don't know if you know much about it, so I don't mean to, like, speak to you like you don't know anything, but I don't know you explain it to me. Basically, they do a colonoscopy. Well, first they do like, an inflammatory marker test, which they did. And it was positive. So they knew that one of two things was going on, either I had colon cancer or I had inflammatory bowel disease. And so then they do a colonoscopy, and based on like, the like, obviously, they put a camera in, and they can see, like, the inside of your colon, and when you have Crohn's or you see there's like, visible redness and sores in your colon, and then they can take so then they take biopsies, like all over to see under the microscope which one you have. And some people have indeterminate colitis, they don't know which one it is. For me, I'm actually very thankful I know, because it's just like, nice to have more information. But mine, there was, like, there's a certain, I think it's like granulomas or something. There's like, a very specific cell that is only present if you have Crohn's. And I had that, so they knew immediately. But the IBD specialist that I went to, we didn't even have the biopsy results yet. She just was like, she told me, she's like, I've been doing this for 20 years, like, this is Crohn's, and she knew, and she was right. If you have like anxiety induced, like GI distress, or IBS, or whatever, you won't have any inflammation present. IBS doesn't cause elevated inflammation. And then also your colon will look normal, like endoscopically. So,

Scott Benner 51:14
so what do you do for it? Because they wanted to give you the biologic, and you didn't want that.

Cassidy 51:18
I was terrified to take biologic. I think the reason I was terrified to take the biologic is because, you know those commercials where Side effects may include cancer, blah, blah, blah, blah, blah, and it's like all these terrible things, more often than not, that's a biologic drug. Basically, it's like acts on different inflammatory markers in your body. So like, the one that I'm on, I can't remember which one it is. It's very like, it doesn't really matter. Basically, my immune system is overactive and it's attacking my GI tract, so the biologic just brings your immune system back down to where it should be. Okay, some people have to have, like, more aggressive therapy, where they go on multiple drugs, or they go on, like, a biologic that's more immunosuppressive. That's what I'm on now. How long have you been on it? How long have I been on it, since the end of May? Is

Scott Benner 52:07
it helping? Yes, yeah. Is it helping with anything else?

Cassidy 52:12
Do you mean, like other physical I'm saying if you're if

Scott Benner 52:15
your immune system is overactive, are you noticing other things that are not impacted by overactive immune systems, I feel

Cassidy 52:22
a lot less tired. Okay, before I was diagnosed, I, like, could barely walk up the stairs. Having active inflammation in your body like that is just exhausting. Yeah, again, all the symptoms. I was like, I'm dying. Like, I was like, this is the end. I guess, aside from, like, having like, a high blood sugar, diabetes doesn't really give me like, I don't have a lot of fatigue. That's my experience. I don't know if other people feel like they're, you know, they feel more tired than the average person. And maybe we do, and we just don't know like, because we just live with it, rheumatoid arthritis, lupus, any of those other autoimmune diseases that cause like, widespread inflammation, that's one of the biggest symptoms. Is fatigue, yeah?

Scott Benner 53:03
But I mean, so you're seeing a lessening of that, a significant lessening, oh, yeah,

Cassidy 53:08
okay, that, and then just other than a near absence of symptoms at all, like, not really anything else. So

Scott Benner 53:16
you're like, the poopy stuff is better? Yes. I don't want to be too technical, but no,

Cassidy 53:24
no, yeah, too technical, Crohn's and Ulcerative Colitis. Like, I think people think, and this is, like, understandable, that people think that it's just like, Oh, you just, like, have, like, you just have diarrhea all the time, and that's all it is. It's pain, it's the fatigue, it's fevers, it's like, it's a widespread disease, and it, like, affects so many different things. That affects your appetite, it affects how you absorb nutrients. Or it can, you know, like we, we have kids that come in and their hemoglobin is super low, or their iron is super low, their B, their vitamin B 12, is low, their vitamin D is super low, like, lower than the average person. I mean, I know everyone,

Scott Benner 54:00
you're not absorbing those things that you should be. You just

Cassidy 54:03
don't absorb it. And it just depends too. Like, if you have Crohn's, it can be in your colon, it can be in your small intestine, it can be in your stomach, it can be like, all over. And it just depends on, like, where your body has attacked you. That can kind of change the symptoms too. I've read some stories of people who have Crohn's, and they were, like, I had symptoms for like, three years, like, every doctor told me that, oh, you're just anxious, or, Oh, you have IBS, or whatever, if their disease is in their small intestine, you can't see that on a colonoscopy, and you can't see that on an endoscopy. You literally have to get like, a pill cam study done, because even if you get like a CT scan, sometimes it doesn't show on the CT scan for I'm sure, like, for those people, it's incredibly frustrating, because they're like, I know something's wrong. It just takes them so long to get like, approval to to really look done.

Scott Benner 54:52
Yeah, I'm dying to know, is your anxiety any better? Yes, yeah.

Cassidy 54:56
I also went, I'm on a different SSR. I'm on, like. Pronoun, yeah,

Scott Benner 55:00
I know. But I was wondering about on the biologic, did it touch it? Oh, on

Cassidy 55:04
the biologic. I think that's really hard. Because, like, obviously, when my symptoms got better and I was feeling better, and I knew what was going on, my anxiety was a lot better, because I

Scott Benner 55:13
was like, okay, yeah, see, there's no way for you to measure that, I guess, yeah, there's

Cassidy 55:16
not really a way. I'd be curious, though. I wonder if there are any studies done on that, like, you know, people who are on whatever medication, like, if their mental health is better, the only studies that I've ever seen about that is just like, people with Crohn's are more likely to have anxiety and depression. But they say that about diabetes too. And I feel like any chronic illness, they're like, you're more likely. That

Scott Benner 55:38
makes sense, but I think that's probably just the thing they say too. Like, you know, you have a chronic illness, you're more likely to both. But I'm, I'm trying to say, like, if you have inflammation, and inflammation is impacting you in different ways, yeah, and one of those ways is anxiety, then depression comes along with anxiety, etc, and so on. Like, you know, like, yeah, that all makes sense to me. So, yeah,

Cassidy 55:58
no, absolutely. One of the worst parts about getting this diagnosis was I was like, frantically looking for other people that had diabetes and Crohn's, and I just, like, couldn't find

Scott Benner 56:11
anyone. What anybody was willing to speak up maybe, or that knew,

Cassidy 56:15
I mean, or that knew, yeah, but it's just like, there's one person that I found that I follow on Tik Tok, and I, like, message them immediately when I, like, found out, and we had like, a long back and forth, which was really nice. Yeah. I just don't think those two things, like, coincide very often. Or, like you said, maybe they just aren't diagnosed or what, but I know that type ones, especially on the like Facebook page, like, people have a lot of like, GI issues or, like, it's common,

Scott Benner 56:40
yeah, there's that overlap too, with, like, a lot of people just experience poor digestion after type one as well, which is, yeah, maybe not the same thing, not maybe not the same but wouldn't be the same thing as what we're talking about. But there's overlaps there too. Yeah, it's very frustrating to me, because life is already what life is. And then, like, some people get anxious, like, What the hell, ridiculous. They weed. Didn't help. You tried? I imagine

Cassidy 57:04
I can't smoke weed. I'm a nurse. I'm

Scott Benner 57:08
sorry. I didn't understand. Did you try it? No, okay, no. Nurses can't smoke weed. No. You get drug tested. Really? Where do you what state are you in? Ohio, okay. I mean, in some states, how do they handle that? Like, I always wonder about cops too. Like, if you make weed legal, then can a cop smoke weed?

Cassidy 57:28
No, because even if I were to get a job in Seattle or Colorado, I don't think that healthcare professionals can. I think that they are, because it's on the national level, it's still illegal if they make it legal nationally, then it would be like, you know, because obviously, like, they can't, they don't test you to see if you drink alcohol every day, you know?

Scott Benner 57:49
Yeah, no, I'm assuming you tried that. That didn't work. Yeah,

Cassidy 57:52
yeah, I did try that. That made things worse, actually, yeah, I

Scott Benner 57:56
was gonna say that. That doesn't help, but in 1976 that's definitely what you would have tried, you're like, I feel nervous, is how you would have put it by was just having this conversation with somebody last night, awesome that like, if you go back a number of years, no one's ever like, if you go back 20. I don't know how long it is, but in my lifetime, I never heard a person describe themselves as anxious in my life.

Cassidy 58:17
Yeah, I was diagnosed with anxiety when I was eight, I had certainly never heard the word really used, like, oh, I have anxiety. And I was like, I'm the only one in the whole world that has anxiety, because, you know, and then now, of course, like, everyone is like, I have anxiety. Let me ask you

Scott Benner 58:34
a question, because this conversation I found interesting, and I'm going to end here with this on you, because I want to hear, like, your thoughts about this? Yeah, I'm not saying that people weren't anxious 20 years ago. What I'm saying is, like, you didn't hear anybody, like, running around going, like, I'm anxious, but what you heard was Bill throws things when he gets pissed. Or, like, you know what I mean, like, that one's always crying. Or, like, you know what I mean, like, that kind of stuff. Like, they didn't have like, a word for it. Like, so yeah, and people just pushed through. Now, I'm assuming a lot of them push through with alcohol and drugs, you know, in other ways that they tried to cope. But do you think this is my question that came out of this conversation last night. Do you think it's valuable to be told you have anxiety, or do you think that it's leading when you tell people what's wrong with them all the time? Like, do you know what I mean? Like, instead of just saying like, you know, in high pressure situations, I wouldn't go to Cassidy instead of like that. And then you just being a person who we don't like turn to in high pressure situations, and you don't think of yourself as good in high pressure situations. I'm making up things. But like, instead of like, you walking around going, I have a thing. There's something wrong with me. Is it better? My question is to just think I'm not good in high pressure situations, or is it better to think I'm an anxious person? I have anxiety. Sure, that's my question.

Cassidy 59:49
I think it depends on the person, because I've had some therapists say, like, do you like, identify as a person who has anxiety. I know you have anxiety, but do you not want me to like, say. Like, because of your anxiety, because you because I think for some people, it's kind of empowering in a way. And they're like, okay with it being like, you know, a descriptor of, like, part of who they are. And then some people feel like, oh, it, it makes me more anxious. It the label kind of reinforces the idea that there is something like, going on in my brain that I, like, can't control. I just wonder if we over diagnose anxiety and depression, because anxiety is a normal human emotion. Everyone experiences anxiety. You know, when someone says, Oh, gee, like, I have, I have bad anxiety before I take a test, it's like, okay, well, that's normal, right, right? You just have to manage it. It doesn't mean that you have anxiety disorder, because anxiety disorder is where you are in fight or flight all day, you know. Or you're having panic attacks at random times, and you don't know why. Or, yeah,

Scott Benner 1:00:48
I'm thinking if we stormed the beaches of Normandy in 2024 somebody would have told me that all those guys on the boat had anxiety, but I'm going to assume that what they had was a knowledge that the boat was going to open in there was going to be a lot of shooting. I think it's weird that everybody Yeah, but a lot of people are running around telling you about their diagnosis, about things all the time, almost like, it's like, see, I'm special. I got a thing. I don't know if that's right or not, like, it just feels weird to me. It feels weird to me to meet a person who is 1,000,000% to my eye, completely normal, and to have them tell me I'm autistic, yeah, where I'm in the middle of the most boring thing in the world, and somebody says I can't focus on this if my ADHD won't let me. And I'm like, ADHD, this is just boring. Do you know how many people come on this podcast and tell me before we start recording? Listen, I gotta tell you, ahead of time, I'm gonna be all over the place. I've got ADD, I've got 80 I don't know what they say, and I can't keep a straight thought. I'm gonna be all over the place. I talk to them, there's not one sign of that. And I'm like, Why does everyone think there's something I'm using the word want to be something wrong with them. But like, why are they looking for what's wrong with them? Like, when there's so many things that are right with them? Like, just, you know what I'm saying. I don't know. I agree.

Cassidy 1:02:04
Yeah, you know, as a person who, like, I have anxiety disorder, for sure because, and the reason I know that is because, like, even before I had any symptoms of Crohn's or whatever, I would just be like, Huh, I'm having a panic attack for no reason. I feel really unsafe right now. Why? I don't know it when it's disrupting your life, that's when it's like, I feel like that's when the diagnosis comes at least, that's for me. If anxiety

Scott Benner 1:02:28
is inflammation related, for example, or something like that, then sure, yes, that's happening to you, and I don't want to ignore that. That's happening to you. I'm not, I'm certainly not saying that. And are there more autoimmune issues in the world? Is it possible that there are just more people with anxiety and ADHD, which probably is also inflammation related, or something like, You know what I mean? Like, is that possible? Yes. But in the real world, if it's not stopping you from living your life, I just find it strange that everybody's running around all the time telling me what's wrong with them. Like, I don't know. Like, am I just old?

Cassidy 1:03:01
No, I don't. I agree. I think it's, I think it's fascinating, because, like, and I've talked to my sister about this too, and she agrees that, like, we're seeing it more often, but she has also argued that, like, the criteria has changed, and so it's, like, more inclusive, like, in terms of, like, the diagnosis, like, you know, we can, we can diagnose more people with autism because, like, the spectrum has, like, not grown, but like, I don't know, the diagnostic criteria has changed a little bit. Yeah, when you say, like, you can't, someone tells you, like, oh, I have autism. And you like, can't tell. It's just, it's interesting. But then it's like, it makes me wonder, like, what made them seek out testing? Like, I wonder if it was like, Oh, I feel like I

Scott Benner 1:03:42
Is there a problem and they wanted to get tested, or is it just the world telling them that, oh, I fit into a category. Now I should go find out if I'm really in that category. I just feel like, 20 years from now, we're gonna look at the tight end from the from the New York Giants, and go, he's a giant. He's a real giant. We decided that in the category of giantism, like he instead of just going, there's a big guy. Listen, I'm not making judgments. What I'm saying is, I don't know if there's a value in doing this, like segmenting people down to the last little thing that's wrong with them, or if it's a weird like navel gazing thing that's not needed all the time, that's what I can't figure out. That's all. I don't care. By the way, you'd call yourself whatever you want. I'm already right. Like,

Cassidy 1:04:27
at the end of the day, if you have you know. And also, like, I try to, like, I definitely meet patients. And I'm like, that kid has anxiety, and it's not on their problem list. And I'm like, That is a kid that, like, really could benefit from therapy and or medication, like, you know, just because they're panicking. And I'm like, Oh my gosh, it's like, looking in the mirror like you, you poor thing, you know. But then there are kids that, like, have a laundry list of mental health diagnoses, and I go and talk to them, and maybe it's just because their medications working really well or whatever. But I'm like, I don't. Know, it's interesting,

Scott Benner 1:05:01
is that person harmed by walking around always thinking there's something wrong with me, there's something wrong with me when they're dealing perfectly fine, dude. He means, like, Can my back hurt? Do I need to be a person with back pain? And is there a difference in there? Like, is that problematic for some, also for some people? Like, I think if you listen to this podcast, you know, I think therapy is great. Like, I think it's a fantastic idea. But yeah, if you asked me if I thought there are some people who get into therapy and stay in it way too long, and it ends up being more of a deterrent in their life than a value, I would say, Yeah, that happens to people too, even

Cassidy 1:05:36
people who, like, the last therapist that I saw was like, I don't want to see you for five months. He was like, we're gonna talk for two months or two or three months, and then we're gonna be done. Because, and he's been doing this a long time, and he was like, there is so much research that suggests that if you hit the whatever problem you're having really hard for a short period of time, it's way more effective. But also, I think some people just, like, want a therapist to vent to, maybe listen if

Scott Benner 1:06:04
you need a part, you want to pay a guy to complain to. That's fine with me, right? Yeah, you know, like, you see, like, like, sometimes super famous people are very germ phobic, and it makes me feel like they just have too much time to think about something. That's how that that occurs to me. Like the guy that works in the sewer. You don't hear him talking about germs, right? By the way, he lives the same life as everyone else, right? I've heard Jason Bateman talk about I've heard Donald Trump talk about it. I've heard like they're germ folks. And like, is it a situation where if you had to get your ass up in the morning and go to work and dig a hole, you wouldn't have time to worry about this? And can that happen in other things, is my question. Like, can you get so focused on something that you turn yourself into the thing you're concerned you might be? I don't know. Yeah, I think

Cassidy 1:06:48
so. But I also do think, like, there are people who genuinely are like, I can't leave my house because I am so scared of XYZ. Oh,

Scott Benner 1:06:58
sure. Like, are there people who are like, agoraphobic, or, like, other, yeah, 1,000,000% but it can't possibly be all of us, can it?

Cassidy 1:07:05
No, I don't think it's all. I agree with you. I think it's a combination of a lot of things. It's just like, but yeah, I definitely think that. I think some people benefit from the label, and I think some people it hinders them a little bit, because then they're like, Oh, well, you know, I don't know. I don't know. I can't wait for

Scott Benner 1:07:20
people to yell at me online for wondering out loud. But

Cassidy 1:07:24
just for the record, we prove of therapy we believe that, you know, I don't know the diagnosis is real. But also, yeah,

Scott Benner 1:07:32
you're not gonna once hear me tell you, like, no, that's not true. You tell me, that's how you are. I believe you like, you know what I mean? Like, I have no trouble there. I'm saying bigger picture. Like, just bigger picture. You're the only one thinking that, though a lot of people I know I'm not, don't worry. Here's what happens to me. Cassidy, I say something, and everyone yells at me about it, and a year later, everyone agrees about it. Scott's just slightly ahead of the curve. That's all like, by the way, I did it this year with this year's Scott gets screwed for caring about you. Was about GLP medications. Yes, we'll find out what 2025 Scott gets screwed for caring about you ends up being. So what you're saying is, you're the real hipster. Actually, I'm a little ahead of the curve on something, yes, not on everything. Is that? What that means? Yeah, I'm gonna grow a mustache and wax it up into a point right now. I think you should. I don't think I could actually, but, my God, listen, I do want to i I'm not covering my ass, but let me cover my ass for a second. You really have an issue or a problem or a concern or whatever, like I'm not sitting here telling you you don't. I'm sitting here telling you that I have met people who have told me they're autistic, who, 20 years ago, would have just been a really smart person that I met, they, by the way, they have a house and a car and a payment and a family, and they're living completely fine. And from the outside, I cannot see any indication that they are struggling in any way, shape or form. And yet, it seems like when they get into a crowd of people, they are drawn to tell me they have autism. Yeah. Okay. Like, I all right. I mean, you say you do you do? Like, I ain't gonna argue with you. I'm like, but what are we doing right now? Like, I have allergies. Sometimes I don't run around telling people all the time I have allergies. Like, I don't know why. Why did you need to tell me that? Do you know what I'm saying? Yeah, I don't know if I'm making any sense.

Cassidy 1:09:17
No, I Yeah. I hear what you're saying. And I think it'd be interesting to I'm gonna ask my sister about that, because,

Scott Benner 1:09:22
by the way, beat Cassidy's mom a little bit. Like, just get up and be like, don't worry. We got this. We'll make it.

Cassidy 1:09:29
You were good. Everything's good, everything's fine. God love her. She's great, but she's very anxious.

Scott Benner 1:09:33
We blended wrong. We went from your mom, who would like, be like, That's not cancer, I'll be fine, and then drop dead. That's too much, right? All the way over to I have ADHD, so if we have a conversation, I get off track. It's like, no what? Like, you're pre telling me that you're going to get off track. Like, that's and then I wonder

Cassidy 1:09:52
if it comes from, like, a place of, I think for a long time I was very embarrassed about my anxiety, so I, like, didn't I didn't tell people I. Anxiety, and even now, like, I don't really talk about it unless it's, like, relevant for you to know. Like, I was at work one day and I was like, I'm having a panic attack. And I was like, with my friend, and she's like, Oh, are you okay? I was like, No, but I will be and like, just give me, like, 15 minutes, you know? And it's like, I don't personally, like, love to be like,

Scott Benner 1:10:15
Well, yeah, no, Cassidy, if the gunner on my helicopter is having a panic attack, I'd like to know about it exactly. That's awesome, right, right? I don't know. Like, it's a big idea. I'm not doing a great job of I'm just rambling a little bit, but I just know I get

Cassidy 1:10:29
what you're saying, and I think too, like, it's a, it's a question of whether, because I think I don't know, I can't speak for my sister, I guess. But like, I think she probably would say, like, we just have opened up the criteria more, and we're diagnosing people more accurately or more appropriately. That's why there's like more people with it. But I think it's both, I really do. I think it's that and I think it's also just like people. I think people are getting over diagnosed too. I think

Scott Benner 1:10:53
it's always in the middle. What do I know? I don't know. I don't know. I think everything's always in the middle, like because we see Sal too much. Your mom's generation ignored everything, and now the next generation is paying attention to everything. And then there those people's kids are going to be like, my mom's a lunatic, and then they're going to go back the other way, and it's going to like, see and saw and go back and forth, like, I get we

Cassidy 1:11:15
just got to find a happy

Scott Benner 1:11:15
medium. Yeah, I don't know. Yeah, the cat has Crohn's. The cat has Crohn's, is all the cat has

Cassidy 1:11:21
Crohn's. Aw, I really hope not. That would be really terrible. I just want to say this too before I like, forget to say it. The reason I wanted to come on the podcast is because I felt like I was the only person who had type one diabetes and Crohn's. And so if there are other people out there who have both, or their child has both, or whatever, I like, just wanted to be like, Hi, I'm here, and you're not the only person out there. Because it really was like, that was the hardest part. Was being like, oh my gosh, because I see, I work with kids that have Crohn's. I work with kids that have diabetes, I work with kids who have ulcerative colitis. I'm like, but I'm the only one that has both, you know.

Scott Benner 1:11:58
But that's definitely not true. It's not,

Cassidy 1:12:00
but I just think it's isolating. It feels isolating when you're like, it's not that common to have both, and you're like, oh gosh, like, completely alone out here. Oh, I should have mentioned this, because this is connected to diabetes. When I was first having symptoms in January, I had crazy, crazy insulin sensitivity. I would give, like, my carb ratio was like, one to 10, and I would give for 100 carbs, three units of insulin, and I would drop low, wow. And I talked to two different doctors and my endocrinologist about it, and they were just like, oh, no, that's weird. And that was it, which is fair, because it's like, what else are you supposed to say? Like, huh? Well, I had one doctor ask me if I was pregnant, and I said no. And she was like, okay, she's like, hot. That's really weird. I just wonder if, like, your insulin sensitivity changed. I'm like, but this much, it's like, a crazy amount, like, I was, sometimes I was eating and not giving insulin at all, because I was like, I'm just going to drop low. Why would I give insulin? And I don't have confirmation of this, but I genuinely think I wasn't absorbing any carbs, or I wasn't absorbing them as well, because when I would drop low, I also had to drink like, 60 or 70 carbs of juice to get my blood sugar back up. Yeah, and it was, it was terrifying, because I was like, I'm 60, okay, oh, now I'm 50. Oh, why am I still 50? It's been an hour like this was before the symptoms even got really that bad. That was probably the first symptom I had. Actually, I know that people after like, post stomach bug will sometimes have a little bit of that, like increased insulin sensitivity. So that's why I think it just makes sense that, like I was just having inflammation and so

Scott Benner 1:13:41
and now that inflammation is gone and that that impact is gone as well. Yep, that's completely gone. Well, listen, I'm thrilled for you. I'm glad that your anxiety didn't stop you from trying the biologic, because it sounds like it's really helping you. You know, I'm very happy for you. Did they tell you, is there an amount of time that it works for? Like, sometimes you hear people having to switch biologics. Sometimes. Is that a thing? You're on the on the lookout

Cassidy 1:14:03
for nice? Yeah, I so. Was that

Scott Benner 1:14:07
nice? We were like, oh, Scott understands you.

Cassidy 1:14:09
Because you understand there's a lot of people that, I think there's a lot of people that like, are like, Oh yeah, you just taken that, and you're good. Biologics have about a 50% efficacy rate, which is not great. So it depends. Some people, it works for two months and then it's done. Some people, it works for 10 years. I think that that's the hardest part, is that, like with diabetes, there's some predictability, or, I would argue, like there can be a lot of predictability, if you like, have your everything set you know correctly, as it should be, like for your basal and stuff. But with Crohn's, there's and you see, there's not, like, a lot of predictability as to how your body will handle it. Like therapy that you try if you'll respond to, like, one therapy over another, they it's really like a crap shoot. Like they just will, like, start you on a med and see if it works, and then if it doesn't, then they move on to the next one. That was also a stressful thing for me to think about, too, because. It was, like, with diabetes, I was like, okay, insulin will lower my blood sugar, like, 100% it, it will, you know, and this is, like, it might, it might work, I don't know. Yeah, just keep trying things until something hopefully works for you, you know. And that was, I was like, Oh, I don't like that. That's terrifying.

Scott Benner 1:15:16
Well, it's working, though it's awesome that it's working for you, yeah, thank you. I love that. You also don't know the name of it. That was, that was my favorite part of this. You're like, oh, it's

Cassidy 1:15:24
called Stelara. The one I'm on is Solara. They have all of the biologic names are crazy. They sound like furniture from Ikea, like, they really do, if you, like, look up some of them, like, I don't know, there's like, Sky Rizzy and Remicade and humera. There's like, so many now,

Scott Benner 1:15:41
maybe the they just heard you were from a Scandinavian background, and they wanted to make

Cassidy 1:15:45
you comfortable. Yep, they were like, Here you go. Here's here's your IKEA. Med, awesome.

Scott Benner 1:15:50
All right. Well, I really appreciate you doing this with me. Can you hold on one second? Yeah, thank you. This is great.

Us. Med, sponsored this episode of the juice box podcast. Check them out at us. Med.com/juice, box or by calling 888-721-1514, get your free benefits. Check and get started today with us. Med, earlier you heard me talking about blue circle health, the free virtual type one diabetes care, education and support program for adults. And I know it sounds too good to be true, but I swear it's free. Thanks to funding from a big T 1d philanthropy group, blue circle health doesn't bill your insurance or charge you a cent. In other words, it's free. They can help you with things like carb counting, insurance navigation, diabetes technology, insulin adjustments, peer support, Prescription Assistance and much more. So if you're tired of waiting nine months to get in with your endo or your educator, you can get an appointment with their team within one to two weeks. This program is showing what T 1d care can and should look like currently if you live in Florida, Maine Vermont, New Hampshire, Ohio, Delaware, Missouri, Alabama, Mississippi, Iowa or Louisiana, if you live in one of those states, go to blue circle health.org to sign up today. The link is in the show notes, and please help me to spread the word blue circle health had to buy an ad, because people don't believe that it's free, but it is. They're trying to give you free care if you live in Florida, Maine, Vermont, Ohio, Delaware, Alabama and Missouri. It's ready to go right now. And like I said, they're adding states so quickly in 2025 that you want to follow them on social media, blue circle health, and you can also keep checking blue circle health.org to see when your free care is available to you. A huge thanks to Omnipod, not just my longest sponsor, but my first one. Omnipod.com/juice box. If you love the podcast and you love tubeless insulin pumps, this link is for you. Omnipod.com/juice box. Hey, thanks for listening all the way to the end. I really appreciate your loyalty and listenership. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording, wrong way recording.com. You.

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