#871 Best of Juicebox: Standard Deviation and her Friends

First published on Jun 8, 2020. Dexcom's John Welsh M.D. does a deep dive on Standard Deviation, Coefficient of Variation, A1c, Time in Range and more. 

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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 871 of the Juicebox Podcast

Welcome back to the best of the Juicebox Podcast today we're revisiting episode 343. It originally aired on June 8 2020. And it's with John Welsh, a doctor who goes into a deep dive on standard deviation, coefficient of variation, a one C, and time and range. While you're listening today, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan, or becoming bold with insulin. Are you a US resident who has type one or the caregiver of someone with type one, please go to T one D exchange.org. Forward slash juicebox. Join the registry complete the survey. When you complete that survey. You are helping type one diabetes research to move forward right from your sofa. You also might be helping out yourself and you're supporting the podcast T one D exchange.org. Forward slash juicebox.

This episode of the podcast is sponsored by cozy earth. Now you can get 35% off your entire order at cozy earth.com Just by using the offer code juicebox at checkout, I'm wearing cozy Earth joggers and a sweatshirt right now these joggers are like the best and our sheets are super duper super, super cool. And silky and soft. Also from cozy Earth. Cozy earth.com use the offer code juice box to save 35% The podcast is sponsored today by better help better help is the world's largest therapy service and is 100% online. With better help, you can tap into a network of over 25,000 licensed and experienced therapists who can help you with a wide range of issues. Better help.com forward slash juicebox. To get started, you just answer a few questions about your needs and preferences in therapy. That way BetterHelp can match you with the right therapist from their network. And when you use my link, you'll save 10% On your first month of therapy. You can message your therapist at any time and schedule live sessions when it's convenient for you. Talk to them however you feel comfortable text chat phone or video call. If your therapist isn't the right fit, for any reason at all, you can switch to a new therapist at no additional charge. And the best part for me is that with better help you get the same professionalism and quality you expect from in office therapy. But with a therapist who is custom picked for you, and you're gonna get more scheduling flexibility, and a more affordable price. I myself have just begun using better help. Better help.com forward slash juicebox that's better help h e l p.com. Forward slash juicebox. Save 10% On your first month of therapy. All right, let's talk about John Welsh for a second. John has type one diabetes. He's a physician. And he works at Dexcom. And he's on the show today because I reached out to Dexcom and said, I want to drill down deep. I want to understand granularly the way smart people understand what is standard deviation. And I know that might be like You're like Oh my God. That's what this episode is about. But no, no, listen to me, what we're going to talk about today, standard deviation, we're really going to understand what it is and how they come to those numbers. We're also going to talk about coefficient of variation. Now there's a lot of words you don't know. But by the end of this, you're going to understand. And you're going to understand why it's so important for you living with type one diabetes. After we get all this information into our heads, I started talking to John a little bit about how does he manage what does he call success at the end of the day. And it wasn't as much about the numbers, as you might think. But he really helped me to understand what these words that you know, maybe don't make sense to us right away. Just lay people what they mean, and how they're helping. You know, it used to be all about a one C right? You just tell you tell people like keep your eye one say here, this is what you have to do. But then all of a sudden you start hearing people talk about standard deviation and variability and this is going to help you to understand that even more. I had such a good time talking to John, that it got away from me. I was supposed to talk to him for an hour and like an hour and 20 minutes into it. I was like oh my god, I gotta let you go. He was like four We're minutes away from having to go to another meeting. And I just like, I'm sorry, go, go go. I found this incredibly interesting. I hope you do too. Because I really believe that the concepts that John and I spoke about today are at the core, they're the basis the bedrock of how you should be considering your health with type one diabetes, if you're looking for data to tell you how you're doing. These three things are a huge piece, you'll see. Please remember, while you're listening, that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please Always consult a physician before making any changes to your health care plan. Becoming bold with insulin. I wanted to call this episode, sugar Adam. But anyway, you'll find out why. Here's my finding. And I've been at this for quite some time, being around the diabetes space, I guess. And when the powers that be whoever they be, decide that we should all be aiming for a lower agency, there's a way to disseminate that information they pull together, you know, industry people, and they give them the toxic here's why no one c should be here and not here. And here's what we've learned. And you know, you get that talk. And then those people find different stakeholders and influencers and they spread the word. And before you know it, when it's distilled out to the public, the message is simply, you know, the ADA decided that your agency should be this now. And that's what you're now going to hear your doctors, your doctors talking about. Like it's, you know, like, it's a rule handed down from my PI, though, suddenly, they have a different opinion. And if you don't pay attention, you don't realize that that's just how we get information out to people, right, there's no good way you can't call everybody in the world and say, Hey, by the way, your agency should be a little lower. Now, you do this. But often, while we're spreading that information, it lacks real context. And when this happened recently, I'm gonna guess in the last two years, when all of a sudden, you started hearing your endocrinologist tell you? Listen, it's really much more about variability, your standard deviation, and they started talking like that. There was no context with it again. And then suddenly, everyone's just, you know, they're walking around, like they learned something. And they say, you know, a one sees not as important a standard deviation, and then all the sudden the message becomes a one sees not important, and then it gets, it gets, you know what I mean? Like it gets ruined as people oversimplify things. And so I really want to leave this talk, just backwards and forwards understanding standard deviation. And when I reached out to Dexcom, I said, I need someone who can really do that, and no pressure, but they said it was you. So

John Welsh M.D. 7:50
I guess you know, if you looked around Dexcom, you would say, All right, we need somebody who can tell stories, who can talk in a straight line more or less. And my, just by way of introduction, I My job title is medical and scientific writer. So I love a good story. And I love especially those stories that have to do with numbers and stories that try to convince people that the truth is actually true. And numbers can really buttress a story, you say, hey, look, look what happens if you don't save for retirement. Here's, here's one way you could go if you spend your money in Las Vegas on that gambling table versus spending your money in an IRA or whatever. So the the idea that you can make convincing arguments with numerical data has always been attractive to me and, and that's why I did some residency training, I went to went to medical school, went to graduate school. And after medical school, I did residency training in laboratory medicine. And laboratory medicine is all about measuring things, and saying, Oh, you've got an abnormal value on one of your lab results. And here's why it matters. And here's what you should do to mitigate the risk of, for example, having a really high potassium level. So if you have good data, then you can make persuasive arguments and you can change people's behavior, hopefully, keep them out of trouble. In the case of a higher low potassium, you could save their life, if you get the doctors to intervene. In the case of some really abnormal lab value that might come up in the hospital context. The bigger question about about glucose values and standard deviation. We can get to that but you made the broader point about public health recommendations and man we are just right in the middle of public health recommendations with with the pandemic because there's there's a lot of uncertainty, which is gosh, you know, how can I go to the concert? Can I go to the restaurant? Can I go outside without wearing a mask and that the recommendations that we've been getting from public health authorities have been A little bit discombobulated maybe internally inconsistent and kind of frustrating at times. But I am with you though the idea that we can provide good evidence based recommendations with respect to goals in managing diabetes is, is a big interest of mine. I'm all about all about the numbers.

Scott Benner 10:20
Well, many, many years ago, I came to the conclusion for my daughter, that if I get what I expect is what I started thinking of it as I realized I had Arden's high line set at 200. And I always kept her under 200. So one day, I moved her to 180. And I was like, Oh, I always keep her under one ad. This is really interesting. So I kept pushing it down and pushing it down. And now my daughter's, you know, ranges 65 to 120. And mostly, we keep it in there. And when we don't, it doesn't go that far out. Right, I'm gonna go to 150. That's usually, you know, like, just now, I will use this morning as an example, two slices of toast, an avocado, butter, and an orange. And her blood sugar went to 148. And it's coming back now. And it's not over a longer yet. Beautiful. Right? And so, but her standard deviation will look bigger than someone else's. And I don't know if I'm making up things in my head, or, like, how is it possible that Arden can have a life like that, but her standard deviation could be higher than someone who's a one sees a point or two bigger than hers, and who have swings that are far higher and lasts longer. And so that's the one idea that keeps me focused on I don't understand standard deviation or not. And then when I start talking about it with the people that I that listen to the show, I come to realize that everyone's sort of got that, that confusion. So can we start very over simply. and standard deviation as an idea? Is a mathematical issue. Is that right?

John Welsh M.D. 12:01
Oh, it is it's it's a number that is used to describe a set of numbers. So for the case of folks who are using CGM, you might expect up to 288 numbers every day. And each number represents a glucose concentration. And you can use words to describe that set of numbers or you can use numbers to describe that set of numbers. The the average is a pretty simple number that it's easy to calculate, you would add up those 288 values and then divide by 288. And then you get the mean, in this case, it's the arithmetic mean. There's other flavors, there's the geometric and the harmonic mean. But we'll we'll leave those aside for now. But the arithmetic mean, tells you it's a measure of central tendency, where you might expect the average, if there is such a thing, an average value to fall. The standard deviation is is another number that's used to describe that set of numbers. And it describes the width of that distribution. So it gives you an idea of how surprised should you be when a number shows up, which is pretty far away from the main. So here's I've got a kind of wonderful document came out a couple years ago that looked at glucose concentrations in people without diabetes. And they they came out with normal values. And the normal value here for glucose was pretty close to where is it 99. And express this number 99 is the average and then they give you a plus and minus seven. That plus or minus seven refers to the standard deviation. And the standard deviation. If you imagine a bell curve that you might have seen in school, where the most popular value is right there in the middle, that's the mean value, in this case, 99. The plus or minus seven tells you how steep is the drop off on either side of that mean value. So in this case, the 99 plus or minus seven, if you were to go up to 106. In other words to the mean plus one standard deviation, you would expect to have about I'm sorry, let's go back and say 99 plus or minus 799 minus seven is 9299 plus seven is 106. So anywhere from 92 to 106. The expectation is that you would have two thirds of the values in that pretty narrow range. So if your goal is to have if your goal is to have quite a lot of stability, which in general is a good thing. You want that standard deviation to be low and normal people without diabetes, it is in fact quite low. 99 plus or minus seven is a very tight distribution. Two thirds of the values fall between 92 and 106. Okay, so Whether there's a calculation, we could walk through it if you want,

Scott Benner 15:02
please. Yeah, I was just going to tell you that when we're done. And I can say this because this won't go out until after I'm allowed to, but I'm wearing a Dexcom. Pro. I have been for a couple of days. Ah, so I can see, I'll be able to look while you're talking and figure out what mine is.

John Welsh M.D. 15:20
Oh, good. So are you able to see the real time data or not yet? No, I

Scott Benner 15:25
see it. It's not blinded. I'm looking at it on my phone.

John Welsh M.D. 15:28
Oh, okay. Well, I hope you're, I hope you're within seven points of 99. I hope you're well in the normal range.

Scott Benner 15:34
I certainly hope so too. But I am I, I was really, I have to be honest. As I put it on, I thought, I'm doing this so that I can see how a working pancreas attacks things brings them back what curves look like, I wanted to see all that because I thought it would make it easier for me to speak to people about about using insulin. But at the last second as I was about to do it, I thought am I about to find out I have like type two diabetes or pre diabetic or something like that as like maybe you know, and I just kind of was like, alright, well, if that's if that's the case, it's the case, I'm going to find out. But so far, so?

John Welsh M.D. 16:15
Well, I hope so. And when we do onboarding, we have people come work for Dexcom. And part of the onboarding process is, hey, look at, look at our product and look at what it does. And of course, it's voluntary, but we say all right, if you'd like to wear one of these, just to know what the experience is, like, we can get you set up with one of these. And our expectation is always your glucose values are going to be are going to be let me check boring. And you're going to have a really smooth ride throughout the day. You know, 99 plus or minus seven. But once once in a while we have we have people that come back and they say, you know, John, I learned something really interesting. And what's that? If I have if I have an entire pizza, I can get my sugar up to 180. And I say wow, that's, that's abnormal. And so people learn something, even if they don't have a known diabetes, they can learn something about diet and exercise that you know, I went for a long bike ride yesterday and I crashed I went pretty low. And then I had the the Coca Cola or the sugary drink. And then I saw my sugar zoom back up so you can learn a lot. And that's a general truism that you can learn a lot just by looking. But Scott, I'm pleased that you're wearing one of the CGM sensors and I hope you learned something I really

Scott Benner 17:39
am. I'll tell you already, I had two pieces, smaller pieces of homemade pizza on Sunday. And three and a half hours later, I got a push up from the protein and the fat probably holding the the crust of the pizza in my in my system longer. That was fascinating. And this morning, I had a breakfast that was just a piece of Turkey and toast. People are like oh my god so boring. But, but I smoked a turkey yesterday, it was so good. John, I want to have some sort of breakfast. So I took some turkey and I had a piece of toast this morning. And when I was done, I grabbed a navel orange. And when I ate the orange It tried really hard to push my blood sugar up. You know, not immediately but it was it was drastic, and my body attacked the drastic rise so much so that I was 74 straight down for a second before I leveled right back out at 80 It was amazing. I went from 74 straight down to 80 and stable in a fight in all my shin one five SEC five minute things. So I saw my body go oh, that's a lot of sugar from that orange. And you know, he's already put this bread in here, I guess you know, I don't obviously don't know exactly how my body's thinking but but the idea was I was I was starting to push up a little from the bread not greatly. But then I think when I added the the simple sugar, I just I got a really quick response. So I'm noticing that that every time I press with simple sugar, my body comes back more aggressively than it does with more complex carbs.

John Welsh M.D. 19:03
You know, boy, that's interesting and, and other people have described it to me where they'll, they might have some indiscretion, they'll say I'm gonna have a 24 ounce Mountain Dew and you slam the sugary beverage and you get this wonderful increase in sugar which you can feel in life is wonderful. And then what you described with the orange happens happens in a very dramatic way where they're the insulin kicks in and then the sugar plummets and then all of a sudden you have the the big crash after the sugar high comes the crash and that I think that's a manifestation of instability. And same thing. I'm going to make a quick little analogy to the cruise control on your on your car. What I hoped for when I engage the cruise control on my car is just a smooth ride. And and I don't want the car to be slamming on the throttle and slamming on the brake all the time. You I just want to be going at 65. All the way home. So I am very sympathetic to your experience with with high amplitude glycemic swings. It's it's a common thing, especially in the world of type one diabetes where we're all taking insulin.

Scott Benner 20:17
Yeah, it's it's very interesting. I'll tell you and I'll then I'm gonna let you get back to it. But the other thing that happened that I really didn't expect, but makes total sense, is that for about the first 36 hours, I wore it, every time I looked and saw my blood sugar stable, I had a horrible feeling of guilt. It was, it was really interesting, because my daughter has had type one since she was two, she's 15. Now I have interactions with 10s of 1000s of people who have diabetes, and they all would just, I don't, they would do anything to have that, you know. And it really, it really impacted me for in the beginning, I just was I felt very guilty for my pancreas working. It was a weird feeling. So, but I'm sorry, I shouldn't derail you, because we're talking about something that's, you know, you don't think it's complicated, but trust me, I do. So I shouldn't I shouldn't distract myself. But we were talking again, about about people, you know, who have a functioning pancreas. And you said, you know, let's pick 99 Is that is that that kind of center target? And you can go to 92 or up to 106? And then explain again, what I'm sorry, where were you headed with that?

John Welsh M.D. 21:23
Oh, sure. The value, I'm looking at a big article that came out a couple years ago, they looked at 153 People without without diabetes. And they put glucose monitors on him. And they they collected a bunch of data. And so the question, I guess the first question is, why would you care? Why would anybody bother? The answer is, well, we want to know what normal looks like. So we can decide if if a particular glucose profile is reassuringly normal, or if there's something going sideways on it. The 99 value from earlier is the mean, the standard deviation I gave you earlier is seven. And that tells you something about how wide the distribution is. So one standard deviation on either side of 99 would go from 92 on the low side up to one 106. on the high side, that mean plus or minus one standard deviation, the expectation is that two thirds of the values would fall in that relatively narrow range, two standard deviations 99 plus 14 is 114 113. on the high side, and then 99 minus 14, I guess is 85. Is that right? On the low side, so 85 to 113, the expectation is that you would cover an even higher percentage, I think 96% of the values would would fall in that range. And if you go out even further to plus or minus three standard deviations, the expectation is that almost all the values more than 99% of the values would fall within three standard deviations of that central value the mean. So that's, that's it in a nutshell, the calculation. It's not difficult, it's not trivial, but it's not difficult. I'm not sure if your audience would be interested in walking through it or just looking it up.

Scott Benner 23:19
Right now, John, this is very much meant to be for people who are interested in that. So I have a group of episodes, there's about 20 of them. They're called protests and they are deep dives into specific things about type one. And this is this is one so don't think of this as an interview as much as think of it is, we are really trying to pick this apart so that when someone listens through like, I'll be honest with you. In sixth grade, my guidance counselor told me I could take algebra halfway through algebra, I didn't understand algebra at all. And I thought, oh, my gosh, I'm terrible at math, I dropped out of it. A was a bad decision, because I followed a much simpler math track the rest of my time, which probably wasn't necessary. And just now, as you were talking, I, you know, you set up this scenario, and the standard deviation was plus or minus seven, and you started talking about out one, standard deviation two and three, and it just started to make sense to me. So you're doing a good job. Trust me if I understood what you just said, everyone listening has a chance to understand it as well.

John Welsh M.D. 24:20
Well, you're you're very kind and that's I'm very pleased to think that we're making progress toward the goal, then we can I can introduce the topic again and say the standard deviation is just a number that's used to describe a set of other numbers. The standard deviation, there's a calculation for it, it's a little bit involved, but involves, first of all calculating the mean for a population. The example that we used was the the mean value for people without diabetes, it's 99. You have quite a lot of values. You might have 1000s or 10s of 1000s of values. And this is where it gets a little bit tedious. For every one of those individual values in the set that you want to describe, you have to calculate the difference from the mean. And the difference from the mean is either going to be a negative number, or it's going to be a positive number, depending on whether the the individual value is higher or lower than the mean. You square that. So squaring a negative number, it gives you a positive number, squaring a positive number gives you a positive number. So you're going to get another set of numbers, which is the squared difference from the mean. And if you had 10,000 values in the set, you're going to have 10,000 squared differences from the mean, you have to add them all up, you get a sum of squared differences. And then you divide it by divided by the number of observations in the set minus one. So it's, it's a pretty complicated when you try to describe it verbally. But if you were to look at it on a sheet of paper, you would say, oh, it's, it's a series of steps. Add up all the squared differences from the mean, divided by a large number one less than the number of observations in your sample, and then take the square root. And then once you've taken the square root, bingo, there's your standard deviation. So it's, it's a few steps, but it's something that kids probably learned and then probably forget just as quickly as they learned it in, in middle school or high school algebra class.

Scott Benner 26:26
So how does clarity app like to simplify that all down? What is the clarity app looking at? When it tells me, you know, the, the standard deviation is 35? Can you like, distill it? What is it looking at to make that decision without the without the detail?

John Welsh M.D. 26:44
Oh, absolutely. So the statistics page, for the clarity app gives you some summary statistics. And just a quick little operational note, I wonder if you're able to see my page that I'm trying to share with you on the Zoom meeting? Yep. Oh, good. Okay. So maybe you should ask your question again. So we could rejoin the the post editing narrative?

Scott Benner 27:11
Oh, I just know, I was. What I'm worried. What I'm interested in is, is there's a clarity app, obviously. And it tells me, Oh, your standard deviation, or your daughter standard, if she is 35. Or some people are like, Oh, I'm struggling. And you know, my mind is 65. And I heard from a woman the other day that told me her doctor told her that anything under 100 was okay, which she very smartly was like, I don't think that sounds right. But I want to know, like, what does it look at? To tell me? My standard deviation is 34. Like, taking into account?

John Welsh M.D. 27:47
Oh, sure. Well, that's, I think I can get that one answered pretty quickly. We've got our statistics page. And if your audience wants to look at the Dexcom, clarity, web interface, there's a page all devoted to statistics. Looking right now, at my statistics for Monday, and this is every Monday for the past 30 days. So there's several Monday's in that sample, I've got a total of 1253 readings. And each one of those is estimated glucose value. And then the summary statistics, the minimum 40 Oh, that was scary, the maximum 244. So those are, those are not normal, the mean value 128. That's reassuring, and then the standard deviation 34. So to get that 34, the calculation that I just walked you through, which is look at every one of those 12 153 values, get the difference from the mean. So do the subtraction 128 Minus a particular value. You square each of those differences from the mean, add them all up, and then divide the total by 1252. And once you've done that, you take the square root of it, and it's it's 34. So there's, as I said, it's a little bit of algebra. But it's, again, the usefulness of it. 128 plus or minus 34, tells you that you would expect two thirds of those glucose readings to be within one standard deviation of the mean. So 128 minus 34 is just 90 something and then 128 plus 34 is 162. So you would you would expect most of my sugars to be in that in that range.

Scott Benner 29:41
Take for second example, I know we're going to oversimplify but describe what mean Yes.

John Welsh M.D. 29:51
Oh, sure. I mean, it's also known as the average value. So if you were to look at the NBA players As you say, Wow, NBA players are really tall. You might express that in numbers by saying the average or the mean, height of an NBA player is six feet six inches tall. So it's another word for average, it's a particular kind of average. But we don't need to talk about the other kinds of averages. Mean is usually just the arithmetic mean, you calculate it by adding up all the values, and then dividing that total by the number of values.

Scott Benner 30:31
So what I have here, what I'm looking at in front of me is 12 153 readings. There were 40 that were or is that under a certain number, those 40?

John Welsh M.D. 30:45
Oh, yeah, we're looking at these rows in the in the statistics, the number of readings, 1253 is a bottom, the minimum was 40. The maximum 244. And the mean value 128.

Scott Benner 30:59
Within within those 12 153 readings, there, the high was 244. The low was 40. But on average, this person's blood sugar was 128.

John Welsh M.D. 31:12
That's a that's a nice way to do it. And yeah, we're looking at, we're looking at my readings from the past month or so

Scott Benner 31:17
these are you Oh, my gosh, are you? Do you have type one?

John Welsh M.D. 31:21
I do. I've been living with type one for most of my life for past 45 years. And so far, so good.

Scott Benner 31:28
Show me like an example page. I didn't realize we were looking at your blood sugar. Well,

John Welsh M.D. 31:33
I yeah, you can spy on me. You can you can look at my summary statistics. Here we can we can continue with the summary statistics page. Yeah.

Scott Benner 31:43
And I'm gonna have some questions about it when you're done. But please keep keep going.

John Welsh M.D. 31:47
Oh, sure. And this is an incredibly number, it's a very useful way to get a numerical description of other numbers. And so far, so good. You know, here's, here's a guy, John Walsh, who is this clown anyway, and what is he doing talking about his glucose numbers. So John's, had a, at least one time where he went all the way down to 40. But the main value 128 is reassuring. And then we get down to some other statistics that talk about the median value, the median value is the value above, above which and below which half of the values occurred. So in my case, the median is 122. And that tells you that half of my readings were above 122, and half of my readings were below 122. So that's another measure of central tendency. The end, it's usually expressed alongside the interquartile range. And so you look at the, the value that is 75% of the way to the top, so 75% of the values are below at 25% or above it. And in my case, the the 75th percentile is 153. The 25th percentile is 103. So you can say with, with some confidence that half of my values were between 103 and 153. And those are the 25th and 75th percentiles, and the the interquartile range here has given us 50. And that's just the difference between 153 and 103.

Scott Benner 33:33
So the question here, if if Yeah, if if half of those range between 103 and 153. I'm assuming that the other half are how we arrive at the standard deviation of 34? Like, I'm assuming you need that information to to come back to the standard deviation?

John Welsh M.D. 33:49
Oh, no, no, the standard deviation, the standard deviation relies on all values. And it doesn't, it doesn't care so much about the distribution, it just cares about how far from the mean value the values are. So there's, there's there's another point that I want to make, which is the median value, in my case, 122. The mean value is 128. A lot of times those are very close together. But sometimes they're very far apart. And there's some special circumstances where the mean value is much, much different than the median value. And we can talk about those if you think it's interesting.

Scott Benner 34:32
I wonder what I do want to know is, is how much of sensor like so you know, I've my daughter has been wearing a Dexcom since seven, maybe Dexcom, seven or seven plus back then. And so, obviously, we see things at every generation, improve and improve and improve but I could still say that for Arden in the first number of hours. You know that you put on a new sensor it's not as I don't know, it's not as tight with its understanding of your blood sugars that maybe is on, you know, day two or like, you know, or there's a sweet spot through the middle where it's crazy. Arden uses a Contour Next One blood glucose meter, which is incredibly accurate. And for a large part of our sensor where the meter and the CGM are spot on with each other there within a couple of points. And when you're managing type one, there's a ton of like, good feeling about that, knowing that, you know, she wakes up in the morning, and it says her blood sugar is 96. Now whether or not her blood sugar is really 85, or it's really, you know, I don't know, 104 to me is of no real consequence. It's in that space. And I'm thrilled with that. Then I put it on, and I don't have diabetes. And I wake up and it says my blood sugar's 94. And I think, Oh, my God, I've been fasting all night. And I'm 94 and I do a finger stick. And I'm 85 It's amazing that those seven points to a person without diabetes is, it's a different impact than it is to a person. Right? And so it is seriously like, I wake up in the morning, 94 I'm like, Oh, I guess that's it, I'll just eat lettuce till I die. But you know, like, like, it's just, it feels like that immediately. And, but I take that same information coming from my daughter, I am completely comforted by it, not just comforted by it. But it leads me in my understanding of how to manage her insulin and her health and everything. My question is, is that knowing that the sensor is a little, you know, on the on the edges, it struggles a tiny bit more than it does in the middle? Is there something about my data that I can't look at to micro? Like, do I have like, how much time do I really need before? The inconsistencies in the data? And the consistencies in the data bounce out to where it doesn't matter that it's not all? Perfect? Does that make sense?

John Welsh M.D. 36:53
Oh, that's, yeah, that is a very common question. And I don't have I don't have a good answer, I can tell you how I deal with imprecise measurements in my own life. And, and I've got, I had a wonderful bike ride yesterday, here in San Diego, and I've got a fancy bike that has a built in speedometer, it's based on how many how many times the will completes a revolution. So there's a speed sensor built into the into the wheel. And based on that, you can calculate your speed. And I've got another fancy thing in my phone where you can get your speed based on satellite data from your global positioning satellite system. And and I looked at it and I found myself chugging along the road and and the the speeds, you want to guess if they were exactly the same. No, they weren't. I was going 20 miles an hour. If you look at the wheel sensor, I was going 21 miles an hour, if you look at the GPS coordinate, so measuring your blood sugar and seeing one number and then looking at your CGM and seeing another number. And and it's frustrating, because there's no good way to to know how excited or how concerned to be about discrepancies. There's always going to be discrepancies. It's a rare thing when when the blood sugar tells you you're 105. And then you get that 105 From the CGM. And I don't want to give medical advice over the phone like this. But there is the possibility that you could calibrate your your G six and based on the your confidence in a blood glucose meeting reading, you could say, oh, my GSX is reading a little bit low. I'm going to calibrate it, and then bring it back into better alignment with the with the blood glucose meter. So I know it's frustrating. I wish I had a better. I wish we had better devices for measuring glucose with even more precision.

Scott Benner 38:59
They're amazing. You've had diabetes forever. You know how amazing this stuff is. Just because you work there doesn't mean you can't say that. And it's actually been very interesting for me because of the pro doesn't allow you to calibrate or at least I just had to go with it. And it really sure it was it was it was interesting to live in the space because for my first maybe 18 hours, the glucose monitor was reading about 10 to 12 points higher than what the finger stick was was pretty consistent for those few hours. And I found myself thinking if this was my daughter, and I put a brand new CGM on her that thought she was 110 when she was 91. I'd be like, Oh my god, this is the most amazing thing ever. I love this thing. It's so amazing. Except you know, and I didn't have diabetes and I was like, Is my pancreas not working? You know, like it's very like it's a it was just such a very different thing. But beyond that initial feeling. It really did just cement my idea of how much I love this technology. And and because I can remember managing my daughter's blood sugar without a glucose monitor. And to think that she'd be stable at 110 or 91, ever for hours and hours at a time is insane, but it just never happened. But over these last few days, we've been eating the same meals. And her care is so dialed in, due to a large due in large part to the information that comes back from the Dexcom that her blood sugars and mine are largely matching before and after meals.

John Welsh M.D. 40:35
Congratulations. And that's just That's wonderful news. And, you know, it's, and I'm totally with you, we we can talk about the battle days when when you had to make a make a guest and a lot of times it was not a very good guess based on just a urine dipstick and you could say, oh, I'm spilling sugar into my urine and I need more insulin, and you would have to make a guess. And some of the highs and lows were pretty scary. And, and people you know, sad, sad to say that people are still dying from insulin overdoses, insulin, let me check, it's a poison, and it can kill you. And there's, there's a lot of downside risk to insulin, even though it's a huge blessing, we're coming up on the 100 year anniversary of the commercialization of insulin. So we're all going to celebrate and be thankful for the commercialization of insulin and the fact that we're not dead. But it's, it's a tough disease. And you wouldn't, you wouldn't wish it on anybody because it's really a lifetime burden. But I'm really pleased.

Scott Benner 41:43
I just had a conversation briefly online with a woman this morning, who even with all the technology gets incredibly low every day. So I was turning her on to the podcast as like, this doesn't need to be you're just you're not using your insulin correctly. And it's not that it's not that difficult to figure out how you know, so I turned around, I was like, Listen, I have an idea. Can I hit you with some questions and see if you have answers to them. These are questions that came from listeners. And sure, I'm not asking you now I understand you're a doctor. But I'm not asking you that way. I'm asking you based on this information, this data and how much you've seen it? Do you see? Do you see information in the data that would help people with the things that they're concerned about? So the first one simple? Do you know what a non type one standard deviation usually is? Is there a range where it usually falls?

John Welsh M.D. 42:34
For example, somebody with type two?

Scott Benner 42:36
No, no, no, just someone who doesn't have diabetes at all. Do you know where like, like, where? Oh, yeah.

John Welsh M.D. 42:42
Yeah, so we've got a we've got some data from a big study of 153 people without diabetes. Their standard deviation was was seven,

Scott Benner 42:55
seven. Okay. Okay, is there? Let's see how I want to say this here. So this is a type one question somebody is somebody's asking. If there's a lot of variability within the good range, say like, like 70 to 120, this person's kind of bouncing between 70 and 120. There what they want to know, for their health? And maybe you don't know, but would they be better off sitting at 120 than they would be from going up and down between 70 and 120?

John Welsh M.D. 43:27
Oh, I think so. And there's, this kind of leads into another number that you can get with the, the summary sheet, it's the ambulatory glucose profile is something that Dexcom has. It's, it's not exclusive to Dexcom, but it's called the AGP. The ambulatory glucose profile, what

Scott Benner 43:46
my things John, don't know, you really got to get creative in charge of in medical in general in charge of the stuff that that goes back and touches people. If you look at glucose for I'm sorry.

John Welsh M.D. 44:01
There's, there's a lot of syllables there. And there's a whole industry for you know, if you come up with a new drug, you have to hire a marketing firm to come up with a name for your for your new drug. But there's a digression for you. Anyways, is the numbers. The numbers that are on the top line of the ambulatory glucose profile, the average is there, the time and ranges there. There's another number here, which is the standard deviation, and then the coefficient of variation. And that's a number that I think has has a lot of usefulness because it tells you how big is your standard deviation compared to the mean value. And there's some clinical implications for that as high, high coefficient of variation is dangerous because it puts you at very much increased risk for dangerously low events for for hypoglycemic misadventures. So the the coefficient of very Question again looking at my own data for the past 30 days, my coefficient of variation 31.3. And is that good or bad or indifferent? It's, it's higher than I'd like it. But is it dangerous? And there was a fun article. Fun, I don't know, but useful anyways, the useful article came out a couple years ago, and some folks in France in the UK came out with an article in diabetes care. And they they said, CV coefficient of variation of 36% is the threshold to distinguish between stable and unstable sugars. Because beyond this limit, the frequency of hypoglycemia is significantly increased. And, and if this, my own CV here 31.3%, that's reassuring, it's low, which is good. And it's less than 36%, which tells you that I'm, I could still go low. But the fact that this CV is less than 36% is reassuring. I went to see my endocrinologist and he said, Hey, John, keep up the good work. You're probably not going to die of hypoglycemia before the next time I see you. And I was so alright. Yeah.

Scott Benner 46:15
John, you know, it's interesting that I see with my daughter who is, you know, a woman, a burgeoning woman, is that with our care, the same exact care we use on weeks and days where she's not impacted by hormones? Arden's standard deviation is 24 ish. But oh, my gosh, that's terrific, thank you. But that's not why I'm telling you that what I'm telling you that is because although I appreciate it, why I'm telling you is because that when she is impacted with hormones, the run up to her period, for example, her deviation jumps up to 45. and N are no holes aren't different, her meals don't vary. It just, she needs more insulin. And it sometimes takes a couple of days for you to realize that that's happening. And then once it's happening to remember, it's happening to remember, like, you know, oh, you know, my ratios are telling me this much insulin, but it's four days before I'm gonna get my period. So it needs to be more, it's difficult to recall all that, you know, constantly. But it's fantastic. It's interestingly fantastic to see because if Artem was a boy, I think I would have a son with a with a standard deviation, pretty consistently within 24. Until they hit I'm assuming puberty as well. But you as a, it's just very interesting to look at your 30 day chart here. You're I know we're talking about so you don't mind, but your standard deviations 42. And you're saying it's not where you want it, but it's also not terrible, like people are trying to understand on the outside, what's the number that keeps them healthy? And what's the number where they think, you know, something else is going to happen? It is very simple in people's minds when they think about these numbers, like what am I gonna hit? How do I get to it?

John Welsh M.D. 48:03
Oh, yeah, yeah, and I think if the the more useful number and I think the one that is very convenient to have as a as a goal, and is is the coefficient of variation. And that's just a ratio, it's the standard deviation divided by the mean. And aiming for something less than 36% would be would be a reasonable would be a terrific goal. And if I were still seeing patients, I would say, Here's your, your coefficient of variation is 40%. Let's look more carefully at the trajectories or the, this is called a modal day plot. And I'm sure your audiences has seen this, it lays out the clock time here on the bottom axis, and then the glucose values on the vertical axis. And you can see the median value here and the bold line right in the middle. And then you can see the shading here, the blue shaded area covers 50% of the values and then the area in between the dotted lines covers 90%, or I'm sorry, 80% of the values. So what what I'm looking for what I wouldn't be looking for if I were looking at somebody else's plot is a smooth ride. And sometimes you can identify parts of the day where the ride is pretty bumpy. For example, after lunch, if you're having lunch at your desk and you're not going for a walk and you're having the third slice of pizza, you might see spikes after lunch or dinner. Or you might see plummeting lows after breakfast if you gave yourself too much insulin for breakfast, and fun to go with breakfast. So I'm not the standard deviation. If you're always cruising around a relatively high number like 170 The standard deviation is going to be bigger than if you're always cruising around at a much lower number like 100 And so, um, the number that I think is more reasonable to target as a therapeutic goal is the coefficient of variation.

Scott Benner 50:09
Okay? Under 36.

John Welsh M.D. 50:13
Yeah, that's, that seems to be the magic number. And that's the consensus and, and it's, it should be achievable if you if just pay attention to parts of the day where you might be having a bumpy ride, you can look at your behaviors, look at your response to your behaviors and say, You know what, I think I will, instead of having three slices of pizza, maybe I'll just have one. So CGM can be a wonderful motivator. It can inform people it can motivate and reward good choices. So I'm you can tell I'm a huge fan. I love evangelizing this stuff, but you can learn from, you can really learn a lot from the numbers. And the numbers can tell you, if you pay attention to him, to the numbers themselves, and also to the summary statistics, like the standard deviation, you can learn quite a lot from him.

Scott Benner 51:03
I'm a huge fan, I don't understand that, obviously, nearly as well as you do, but I know what it tells me. So for instance, after Ardennes, my, my poor daughter, one day is going to listen back to this and be like how much did they talk about my period on that podcast, but after so the lead up to her period, there's like three or four days prior to it, she gets, you know, all of a sudden, she needs way more insulin. And then in the first day or two of it, it happens still, but then there's a moment where it levels like whatever happens is done. She's still the periods still happening, but the hormonal impact seems to be going out of her body. So let me give you an example. Because it just happened yesterday for the last 24 hours. Arden's estimated a one, C is five, and our standard deviation is 24. Per average, blood sugar's 98. But if I just go back seven days, through her, you know, through this lead up to this period, estimated a one C 5.8, standard deviation 43, average blood sugar 119. It's an it's just the hormones, it's the lead up to her period. And so it's fascinating and not that you don't know but and then there's another time of the month where it happens again to her for four or five days. But just those just that week, and then that other chunk. So basically what I think is about 789, probably 12 or 13 days of the month, takes what would normally be I think, an SD and like I said in the mid 20s and an A one seat closer to five than six, and it moves her agency more towards like Hurray, once he pretty much sticks at like 5.6 it doesn't move very much. Okay, it's just very, I don't know, like I don't know what I would do before this information like no lie prior to it. I wasn't a different person. And we were not good at this at all. You just diabetes in general her hurry once these were in the eights and I finally got them into the sevens just by having, you know, better tools and insulin pump and a glucose monitor. But I still didn't understand that enough to turn it into real, like success, you know, like, like the idea of knowing when to Bolus and that sort of thing. But I know all that from this data now. And it's sure incredibly beneficial.

John Welsh M.D. 53:27
Absolutely. Well, I'm, I'm with you 100% on that. And I think for my own my own experience was in the bad old days before CGM, I was poking my finger and making a lot of guesses. And it really got me interested in how the body works. And it was a great, great motivator all through college. And that was part of my story when I was applying to medical school and I'm not alone. There's a lot of a lot of physicians who specialize in in Endocrinology and Metabolism who also have type one diabetes. So my own story is, is hey, this is really interesting. I want to learn about it. And I want to go to medical school and what do you know, the medical school here in town said all right. All right. Coming to medical school, and you can learn you can learn quite a lot in medical school about about the disease itself and about how you measure how you measure sugar and measure all the other important things that we care about in metabolism. So it's for me anyway, it was not just a life changing event when I got that diagnosis but it also sort of defined my career path toward a toward becoming a physician and also to to working here at Dexcom

Scott Benner 54:40
Yeah, so that's fascinating and I'm afraid I'm gonna start talking to you and then lose track of what we're supposed to be doing because questions I almost answered ask them and I was like, No, don't do that. What cut when you when you when this data is pulled together, given that there are you know, Blood Sugar legs and meters aren't perfect and nothing's perfect. What? What's built in to deal with the error? Like, how does it come to the number and? And take the the imprecise pneus out of it? Is it like, like looking at yours? For example, your standard deviations? 42? What if if if a Dexcom was absolutely perfect if there was a you know, if it wasn't technology, but it was it was your, you know, I don't know, something organic that could know 100% For sure. What all these measurements are on your glucose all the time? How far off? Do you think that number would be? If you had perfection? Does that make sense?

John Welsh M.D. 55:41
Oh, yeah. Yeah. You're You're hypothesizing that there is some there's no real answer. Yeah, there is. There does exist some true number. And we're always trying to become more more accurate and getting closer to that true number. We are, we're never going to get there. You have to stipulate that we're always going to have some, some wiggle and some imprecision. And that's, I think true. Because nothing on this planet is perfect. And we have to, if we get to heaven, and then everything is perfect in heaven, if we ever make it there.

Scott Benner 56:17
That'd be my first question. When I get there, I'll be like, what was my kids? Really?

John Welsh M.D. 56:24
Yeah, so that's a whole nother line of inquiry. But we're probably certainly within 10%, I think I'm confident that we're within 10%, I'm less confident that we're within 5%, I wouldn't be surprised if we were within 3%. And I would be really astonished. If you told me it was within 1%, I would be astonished. So I've got some confidence, the for the 10% precision. And I've got some optimism that we can usually get within 5% of the true value. Those are just speculative numbers. Because there's no such thing as a perfect value, even if even if you use the gold standard. We could quibble about any reference instrument. And this is one of the things they drilled into us during my residency training in laboratory medicine, which is, is there such a thing as a perfect measurement? No, not until we all die and go to heaven. While we're living on this earth, you have to deal with imprecision and uncertainty. But I think we're pretty good. And just for purposes that we care about managing managing diabetes and living a long happy life, I think we're we're well within the realm of of good enough.

Scott Benner 57:40
And outcomes are good based on what we noticed. Does that mean, from what you just said, if at a 42 standard deviation? Is it possible that your standard deviation is somewhere like 36? Or possibly like, I don't know, 48 or 47? Or is it more likely it's lower? Or more likely, it's higher? If it's Is there a likelihood that it's more one way than the other?

John Welsh M.D. 58:05
Oh, yeah, the standard deviation just tells you how, how spread out the distribution is. And the the true standard deviation could be higher or lower? Because all the numbers that the standard deviation depends on could actually be incorrect. So I think, yeah, that's a tough one. Let me let me think about that. Yeah. I'm looking now at this. Looking now at the standard deviation and this famous bell curve, the you know, what the, if I'm understanding your, your question correctly, could the standard deviation be something different?

Scott Benner 58:51
You use me as an example, in my situation, right. Now, if I put on a new CGM, every 10 days, I wear three sensors a month, nine sensors over a three month period, if I look back at my 90 days, my standard deviation, if my if my sensors reading just 10 points higher for the first, I don't know, just say 36 hours of every one of those things. Am I more likely to look higher than I am? Or lower than I am? Because of that? Higher right?

John Welsh M.D. 59:19
Oh, yeah, I think I think you would have a high. It's called a high bias. But your earlier question, could the standard deviation be something other than the calculated result? I? I think the answer is no. If if you give me the numbers from one to five, could the total be something other than 15? And I would say no, the total of the integers from one to five is 15. And if you give me a set of numbers, I can calculate the mean and the standard deviation. So I think the calculation that we've done here, resulting in this standard deviation of four 32 If we did the math correctly, then the standard deviation is 42

Scott Benner 1:00:04
is the I'm sorry, there's the algorithm that's making this decision. Does it scrub anything? Like, you know, like a compression load? Does it see that and go, we're not going to take this into account, does it do any of that kind of stuff?

John Welsh M.D. 1:00:18
Oh, yeah. And that's, I think that's true. That's got to be true for Medtronic, it's got to be true for Abbott, it's got to be true for sensing Onyx. And also for Dexcom, we've got, we've got algorithms, the signal that we are measuring is actually a voltage. It's a, it's so I'm sorry, it's current. So the current is very low. Current, usually measured in amperes. And we're dealing with billions of an ampere, I think, nano ampere, or Pico amperes. So incredibly small currents. And the challenge for the engineers is to take that very small electrical current, and translate that into a number that makes sense and number of milligrams per DL. So that requires some, some engineering talent. And it requires an algorithm. And I think that's part of the secret sauce that we have here at Dexcom. Medtronic, I'm sure they have a algorithm, which is similar, but slightly different. And the same for Abbott. And the same for sensing Onyx. And that's true. Whenever you're measuring something and saying what you're measuring, you know, for the example of your oven, if you're cooking, you're making your cookies, you're measuring temperature, what you're really measuring is the height of the mercury in the thermometer. And the trust is that that's a good representation of your temperature. And then going back to the bicycle speedometer example, what it's really measuring is how fast the wheel is turning in, you're translating that revolutions per minute into a speed. So it's a challenge to take a very small electrical current and turn it into a glucose value. And but that's, that's what we do. And I think that's what all the manufacturers have to do.

Scott Benner 1:02:07
It's amazing. And listen, we're one rabbit hole away from wondering if we live in a simulation. So let me ask a more concrete question. Ready, John? John, in 30 more minutes, we're going to be like, we're probably in the matrix. So just a real quick when Canadians or people who are using other scales, did they multiply their standard deviation by 18? To get their answer? Like, this person gave me an example so that their last standard deviation in Canada was 1.62. They multiply that by 18. To get the number that the way we're talking about it right now.

John Welsh M.D. 1:02:46
They sure would, yeah, so the the units for standard deviation, the standard deviation here in the US as milligrams per deal. outside the US, the standard deviation is millimoles per liter. And the conversion factor is is 18. So the standard deviations would be less by a factor of 18. In places where they use millimoles per liter, the end and that's a good point, thank you for bringing it up. And the point is that what would not change is the coefficient of variation. So if you were to take all my numbers, or if I were lucky enough to be a Canadian, and measuring my sugars and millimoles per liter, I would still have this coefficient of variation of 31.3%. That would not change, because you're dividing milligrams per DL in the numerator, milligrams per DL in the denominator, and those units would would cancel them out coefficient of variation. There's no units for that. It's just a percentage. I'm

Scott Benner 1:03:50
glad you said that, or some person, Saskatchewan was gonna take their coefficient and multiply it by 18. And that's great to know. And thank you for knowing it. By the way, when I asked the question, I appreciate that.

John Welsh M.D. 1:04:04
That's a good one. You know, if you got to, if you were to travel to Japan, you would trade your dollars for yen and you would find yourself 100 times more wealthy. Because you can buy you can buy about 100 yen with $1. But wait, everything's 100 times more expensive so

Scott Benner 1:04:21
well, so let me make sure I'm understanding exactly. So coefficient of variance, or variation we're talking about under 36 Really lessens your possibility of low blood sugar's standard deviation shows us how much stability we have, right like by keeping our variability lower. What is the measuring?

John Welsh M.D. 1:04:45
Oh, in terms of our health Oh, yeah, a one C there's I love a one C I want to strangle it and drown it in a bathtub. i A one C has been with me for a long time. It's about biomarker, it's hemoglobin obviously is the protein that fills up your red cells, it's got the red color, because it's got iron in the middle of it, it's got an iron atom. And it's the same color as rust. The hemoglobin a one C, the a part of it refers to the a chain. There's an a chain and a B chain. The hemoglobin a one refers to the first amino acid in the a chain of hemoglobin. And the C refers to the isoform, if you want to know refers to the isoform, of altered hemoglobin that travels on chromatography. Anyway, that's that's the long answer. The short answer is that hemoglobin a one C is a abnormal form of hemoglobin that has a sugar atom stuck onto it. And having that sugar, I'm sorry, sugar atom, it's a sugar molecule stuck onto it. And it's a nice indicator of how your ambient glucose concentrations have been going over the past two or three months. The downside of having a high a one C is that hemoglobin a one C molecules behave a little bit differently. And they're also markers that things are going haywire in other parts of your body, other proteins in your vasculature in your kidneys, and your liver might be getting decorated with sugar molecules when they really shouldn't be. So having having a very high hemoglobin a one C number tells you that quite a lot of your hemoglobin molecules are traveling around with this kind of gooey sticky sugar molecules stuck onto them. As I mentioned earlier, I it's it's not my favorite biomarker. What's your favorite biomarker, John, there's there's ways that you can fool the hemoglobin a one C test, and we can talk about those. There's some some people have problems with red cell production or red cell destruction that would throw it off. So you can really be misled by an A one C number, it can be too low. And you can say, Ah, you're doing just fine. Your a one C is in the normal range, when it should be much higher. And then on the flip side, you can see in a one C, some people have a one c values that are unexpectedly high compared to what their average glucose values are. So it can it can mislead you in a couple of different ways. I'm a much, much more enthusiastic about just using the average glucose value that you get from a CGM system to assess the adequacy of your glycemic control.

Scott Benner 1:07:50
Is that okay? You know, it's interesting, you made me think of last year I suffered, I had my ferritin was very low. And it's it. You know, at first everyone, the doctors thought I had cancer and we did all these things. And it turns out, I just had low ferritin. And so I got an infusion of of whatever they call it, it's I can't think of it now sit iron and it's a it's a mix, it looks like a rusty bag of water and back up, but during that time, what I was told was we can't trust your Awan see right now, because of your low ferritin. And I was like, huh, dig too deeply into it. But it's something you just said now made me think of it again. And then it made me think about how, you know, measurements, right? And you always get, you could use anything. Here's an example. My daughter has hypothyroidism. But when we first figured it out by her symptoms, the doctor's office looked and said, well, she's low, but she's in range. We don't want to do anything. And we made them give her the hormone, then because we had an experience with my wife who was low in in range, and they would never help her and it really hurt her over time. And so it made me wonder, especially for, you know, women in the menstruation age, is it possible that they have an A one see that looks better than it is if they have lower ferritin just like,

John Welsh M.D. 1:09:14
there you go. There you go. There's that's another of all the ways that a one C could be misleading. That's, that's, that's one of them. And I'm thinking, my own experience, I used to be a really avid blood donor. And I thought, oh, you know, what if I if I were to donate two units of blood, and then wait around for a couple of weeks and then get my a one C measured, that would falsely lower the a one C because as soon as I donate two units of blood, my my bone marrow is going to wake up and say, oh my gosh, John, you did something either stupid or crazy or really altruistic. By donating those two units of blood. We have to ramp up production, and we're going to flood your system with brand new red cells. So after two weeks after donating the blood, I would have a population of red cells, which were relatively young and had not had a chance to get glommed on to by the sugar molecules. And my agency would be falsely low. And I say, Yep, I can sure game the system that way. And that's the same for people who undergo acute blood loss, the A one C would be falsely decreased within a couple of weeks, once the red cell production line kicks into gear. And then people who have shortened red cell lifespans, there's there's some conditions, a lot of syllables, but hemoglobinopathies, if your hemoglobin, if your red cells are, are not up to the task, and if they're prematurely destroyed, you would have a very low a one C, and it would be misleading if you were trying to manage diabetes based on that.

Scott Benner 1:10:55
Okay, so Okay, so you as a person who's had type one for a long time, and is a physician, and I think we didn't really dig into it. But it sounds like you used to help people with type one as well, when you were practicing, is that right?

John Welsh M.D. 1:11:09
Oh, you know, indirectly I specialized in laboratory medicine and also anatomic pathology. So I would, I would look at disease, and I would measure disease and then I and then I went to anyway, so I never directly took care of people who were who needed insulin management.

Scott Benner 1:11:27
But for yourself, then let me just ask yourself that I guess it makes more sense. With your background, and how much time you spent digging around in this data? How do you measure your success? Like which one of these? I know there's going to be a grouping of them here. But but can you tell me what you look at every time you look at your data, just when you want to look and go, oh, I need to do a little more a little less? Like, what what is it your? Where do you focus? And is there any way to put them in descending order?

John Welsh M.D. 1:11:57
Oh, um, well, I am I'm getting old, every if you wait long enough, everybody's gonna get old. I used to worry quite a lot about my agency. And now I I really don't care I what I focus on mostly is the average glucose. And the the example that we're looking at now is 133, which, which is wonderful. And beyond that, I try not to rank myself, I try not to compare myself to my peers. Here at Dexcom. We've got some, some very talented folks with type one who are even more dialed in than I am. If it if it seems like I know what I'm doing, there's people down the hall who are even better. And then there's people in the community who who are need some advice. And that's the mandate, I say, You know what I'm I'm doing fine. But let's, let's see if there's problems that I can address. So I look at my average sugar, I look at the time high and low time and range. And the example that we're looking at 85.9% is pretty good. And then I also look at the the amount of trouble and strife that it causes me and I try to minimize that. I try to settle in on a good routine. That doesn't cause me too much trouble and strife. And finally, after 45 years of I think I've found a good routine for managing my own diabetes. That's

Scott Benner 1:13:23
amazing. That's I think what people need to hear too, it's funny, as you were saying all that I was looking at, at my daughter's nine, like I went to 90 days on her information, because you said average blood sugar. And her average blood sugar has been 115 over the last 90 days within an estimated a once a 5.6. But her standard deviation over that time is like I said, it's it's 45. And is that should I be more concerned about that?

John Welsh M.D. 1:13:54
Well, here's, here's an important question. And it relates to the time that she spends really low and I wonder if there's numbers for either time less than 70 or time less than 54 because because those are those are things that can cause trouble in a hurry. Being being less than 54 is kind of dangerous.

Scott Benner 1:14:14
I have I have her range set as 65 to 120 She's 9% low 54% in range and 37% high but she does not get for the most point we don't go over about 180 ever and under 55 I don't think happens twice a month maybe for long periods of time not like under 55 and falling where people are running around the house you know looking for the will and stuff like that just you know like a dip down that you caught a little too late and and it'll go to 55 and hang and come back up but we don't let her sit under that number. But I look at her standard deviation all the time and I I'm always just like, ah, that's where I need to do better. But like I said, you know, for half of the month, that standard deviation is 24. And then during her, you know, her hormonal times throws throws that number off, like, is that number less scary? Because she's a girl than it would be if she was a boy. I know. That's a weird question. But you don't I mean,

John Welsh M.D. 1:15:25
well, I, I don't know if I'm, I'm gonna take issue with your premise. I, what you told me was, is that number scary? And I? I don't think so. I don't think that's a scary number at all. Just based on the fact that she is so dialed in, and that she has almost continuous awareness of where she is. And she's got good access to to her family and to you and good access to to Kandi if she needs it. So it doesn't sound like she's in harm's way at all. The thing that you know, there's there's some things that are absolutely dangerous. One is one is going low, and finding yourself waking up with a crowd of people trying to resuscitate you is a terrible misadventure. Because you, you went low and you ignore the symptoms. And guess what, you had a seizure, you lost consciousness, you bumped your head. And now the EMTs are out. That's a scary misadventure. So I think if you told me earlier, she's, she's had it for quite a long time,

Scott Benner 1:16:34
she was diagnosed, too, and she's going to be 16 next month. Okay.

John Welsh M.D. 1:16:39
So 14 years, 14 years into it. Hopefully all the autonomic counterregulatory hormones are intact, and I hope they stay that way. So the hypoglycemia awareness, I hope is fully intact, and the counterregulatory hormones that that would kick in to bring her sugar back toward the normal range, I hope are intact. The, the coefficient of variation, you mentioned earlier, the standard deviation for your daughter and remind me of the coefficient of variation.

Scott Benner 1:17:11
Oh, let me get it for you. It does similarly, change with, with what's happening in her I have it at 90 days as 39% in the last 139, in the last week, 36%. But if I go into just the last three days, where like I said, the impact from the hormones is gone. It's 30%.

John Welsh M.D. 1:17:35
Okay, wow. So sometimes, sometimes it gets above that arbitrary number of 36%. So there's some stretches of time where the variability is, is in excess.

Scott Benner 1:17:48
And it's, it's important to note that so my daughter now for over six years has had an A one C between five two and six, two, and we don't restrict her diet in any way. So she'll have pancakes, you know, for breakfast on a Sunday morning. Just as easily as this morning I said she had, you know, an avocado, avocado toast. And so you know, she she's all over the place with what she eats. So we'll have nights where she just has a big salad for dinner, and nothing else. Last night, she had some turkey and small amount of potatoes. But when dessert came out, she wasn't interested. And so she's I call I would call her eating healthy and varied and not excessive. She's not a sweets person, like she's, she'll Trick or treat, but that's the hangout with our friends. And she comes home and doesn't know what to do with the candy. But you don't like that. That's sort of an idea. But, you know, I'm trying to talk through her to everybody so that everybody can kind of get a feeling for how they should feel about this information for themselves personally. Sure, yeah.

John Welsh M.D. 1:18:53
Well, there's, there are some things and we've we spend a lot of time looking at data here we've got some data science, people who built our career on looking at data, there's a couple of comments that might that might be helpful and one is to to look for opportunities to lower the standard deviation lower the coefficient of variation. One is to see if there's any evidence of overtreating highs or lows. And sometimes those really jump out if you look at the, the hourly plot, we call it the modal day plot. Sometimes you'll say, Oh, here's here's something where I know I know where I went sideways on this. I know I had the the big snack after lunch. I shouldn't have oh, there were free doughnuts in the conference room. I should have said no to those doughnuts. So sometimes there's opportunities for looking at your data, not the numbers but just looking at the the image of the 24 hour stretch of daytime you say wow, there's a big spike there. In the early morning hours, maybe I had too much snack before I went to bed. Maybe I have too much my own case, I had a habit of taking too much fast acting insulin to cover breakfast, and I would always go low around nine o'clock in the morning. So being looking at the data, not just as numbers, but as a graph can be very helpful. And it can reveal opportunities for making adjustments. And if if the standard deviation is in, in the high range, if the coefficient of variability is in the high range, then it deserves some some careful consideration about Wow, this is a bumpy ride, are there any particular times of the day that you would like to address with your end might be really amenable to making thoughtful changes?

Scott Benner 1:20:51
Can I ask, given how the numbers are calculated? If? How much is that? What's my question? Are any of the numbers based off of the the range that I've set up? So keeping in mind that my daughter's range is on my phone, it's 65 to 120. On her phone, I think it's 70 to 130. And so on her phone, which is the one that you know, her clarity accounts connected to and everything, if my daughter's blood sugar is quite literally, between 75 and 110 for two thirds of the day, but she has two big meals that spike her to one ad. But she's not more she's not at that one ad for more than an hour and comes back down without getting low. Do those numbers look artificially inflated? If that's how it works for her sometimes?

John Welsh M.D. 1:21:48
The I think your question is, what are the numbers that you see in the clarity report or the clarity, summary. And the time in different ranges? You can, you can set those you can customize the ranges that you want to see for and you can do that in the daytime in the nighttime ranges.

Scott Benner 1:22:08
If I changed her range, this might be a stupid question. But if I pushed my daughter's high number up to 180, would her standard deviation fall?

John Welsh M.D. 1:22:18
Oh, no, it would not know the standard deviation doesn't care whether a number is in the range, the range that you set is pretty arbitrary. You can you can turn that dial up or down. The the range that you set within clarity just tells you when are you going to get beeped. And what are the summary statistics for time and range?

Scott Benner 1:22:40
The data is based off of those ranges. Got it?

John Welsh M.D. 1:22:44
That's right. That's right, the standard deviation coefficient of variation, those numbers are those are not subject to change by just changing the the alerts or the target ranges.

Scott Benner 1:22:57
Okay. And they're based off of what quote unquote normal would be. Is that right?

John Welsh M.D. 1:23:03
Oh, actually, not the the normal range I mentioned earlier than the normal range is no more than 120. And at the moment, I'm just leaning over and checking my sugar right now is it's 109. But for the most part, having having a sugar of 150 would not be concerning. I don't think for any endocrinologist, if you were to cruise around at 150, all day, every day. The endocrinology community would say you're doing a good job, you're a one C is likely close to 7%. And your risk of long term complications is close to baseline is close to what the non diabetic population would have. So that'd be very reassuring. Even if you're having a abnormally high glucose numbers. I got a I got a call once I did some lab tests and for a different occasion, and the nurse called me up and said, John, I've got some very concerning news. Your your glucose is 123. And I thought, well, what's concerning about that? And she said, Well, it's higher than normal. And I said, Well, I have type one diabetes. And and as soon as she heard the fact that I had type one diabetes, she said, Oh, well, you're boring. Have a nice day. Goodbye.

Scott Benner 1:24:24
You mean, my daughter had to give urine one time and I left the room or I dropped off and didn't tell the nurse she had diabetes. And I walked halfway down the hall and ran back because I was worried for the nurse and she was running out of the room at the same time. And I looked at and I went she has type one and she goes Oh, okay. And then she she goes back in the room. Let me re ask my question because I have it in my mind and maybe I might ask another dumb question here. Trust me. It's very boss. I'm ready. So So Arden's blood sugar does sit in the 80s for most of the time, but sure, and and like I said, Sometimes she'll hit one ad on a call couple of meals. What if her blood sugar always sat at 120? And sometimes hit those 180s? Would that make her standard deviation lower?

John Welsh M.D. 1:25:14
I don't think I don't know, I don't think you've given me enough information. To ask that question we could we could do some numerical simulations, which would be interesting, but maybe a quite a digression. I don't think we can tell for sure, just based on what you told me. So it's, it's a big question mark, right now, I'd have to punt and say, I don't know,

Scott Benner 1:25:39
that's fine. I'm trying to I can't wrap my head around my own question, which is frustrating, as you may imagine, and a limitation of my intelligence, but I'm trying to, I'm trying to decide how, you know, so. So you don't, I know, you've heard a couple episodes of the show, John, but you don't listen to the show. And I actually would like to send you a short list of episodes, and let you listen to them and hear what you think of them. But most of the people who listen to this podcast, I would assume having a one C in the fives, or I would think over six and a half, for somebody who's been listening more than three months would be uncommon. And the basic tenant of the podcast is that you don't, you don't stare at a high blood sugar, you get it back down, without causing a low and there's ways to use insulin, you know, with the data that that makes that work. So we, you know, we're pretty heavily talking here about make sure your Basal insulin is right Pre-Bolus Your meals, don't stare at a high blood sugar, you know, don't cause a low bumping nudge with insulin, you know, if you after a meal at a meal time, you know, 45 minutes after you eat. If you're 136, diagonal up, we bump it back down. Again, if you're 85, diagonal down, that turns into 80 that you think this is going to keep going, you don't wait to see a 60 you take in a few carbs, and nudge that that blood sugar back up again, it's like driving between two lines, you know what I mean? Like you don't want to swerve, you just want to kind of try to stay as steady as possible. And we talked about a lot about how to use insulin, temporary Basal rates, both positive and negative, and food in ways that keep those swings from being crazy. And yet, there are people who come back with amazing a onesies who don't get low very often, but have a couple of spikes with larger meals. And these numbers that everyone's telling them, they're super important, you know, standard deviation, they can't seem to get into the space that they want. And then they start thinking about limiting food to make that happen. And I, I think that I think this podcast has a lot of different goals. But one of them is for you to understand insulin enough that you can eat what you want to eat. And I'm not saying that everyone should run out and eat those doughnuts at the conference table. Like, that's not my point. My point isn't, I'm not a person who says, Oh, you have diabetes, you know, don't ever think of you know, don't ever think about your your health, just eat whatever you want, because insulin can take care of it. My point is that if you understand how to use insulin, then you can go off into the world. And with a diet of your choosing, keep your blood sugar's in a more normal range and extend your health. But I'm baffled a little by my daughter's standard deviation. All the other numbers make sense to me. But that one number, I can't wrap my head around.

John Welsh M.D. 1:28:28
Yeah, and and you mentioned, you mentioned the hormonal changes that come by every month and and sometimes the good control becomes more of a challenge, obviously. And the coefficient of variability goes up. And and then unfortunately, the having a high coefficient of variation gives you a higher risk of symptomatic or potentially dangerous lows. But but so it's it's especially important to have that awareness of misadventures on the low side, especially during that time of the month where the swings are, especially high amplitude. The but the goal is, as you said, I think the goal is to spend most of your time out of harm's way. And to live a long happy life where your retinas your retinas last your whole life and your kidneys are going to last your whole life and you're going to die with all 10 of your toes where they belong at the end of your feet. So it sounds like she's well on the way and especially the education that you've been giving her and the insights that she's been getting from from CGM. Sounds like they've been tremendously helpful.

Scott Benner 1:29:40
I appreciate John I just did something that I'm so I feel badly about that because you're sharing sharing your screen. I can't see my screen. And I just realized that I've had you on for an hour and 20 minutes I'm so sorry. I didn't even I didn't really enjoying this and I didn't I didn't recognize about the passage of time. I hope I haven't kept you from something here. not just being polite to me.

John Welsh M.D. 1:30:01
Oh, well, let me You know, I think I had something that I did have something else on the calendar and I hope I'm not. I mean, check my little outlook here. You can see my calendar, there's something coming up at noon, so maybe we ought to

Scott Benner 1:30:15
go is what I was gonna say, yeah, 100% I, I just looked at my phone to look at something about art and to save you. And I was like, Oh my gosh, they're gonna crucify me. I've been I've had you wait too long. Listen, this was incredibly interesting. And I can't really thank you enough for doing it. Because, you know, it's not something everyone jumped up to do when I say can I get somebody who really understand standard deviation talk was a long line of people with their hand up, you know, so I really, I genuinely appreciate this. And I have to tell you, it's gonna go right out tomorrow. I don't usually put stuff out this quickly. But if this fits right into my schedule, so you'll be able to hear yourself and be horrified by your own voice in probably 12 hours or so.

John Welsh M.D. 1:30:57
Well, that's great. So you can I hope you cut out the obscenities and the screaming and and the lawnmowers. And

Scott Benner 1:31:03
all that horrible stuff you did will be cut out now people will just hear you say that and wonder what it is that we

John Welsh M.D. 1:31:10
Scott, what a pleasure, I enjoyed speaking with you, thank you for thanks for reaching out, and I'm a dew point. Dexcom is great. I'm just surrounded by really smart people who love who are really bought into the mission. It's a good company, it's a good product, it's a good mission. And I it's nice hearing about your own experience and your daughter as well. I hope you have a long happy life with with this thing that nobody wants. But we're doing the best we can with type one diabetes, you're very

Scott Benner 1:31:39
nice, John, but to think that you're not going to get drunk back on this podcast at some point is, is not reasonable. I'm gonna get you back here at some point, we'll find out more about you and your diabetes one day. I really appreciate this. I'm going to be incredibly humble all day long after talking to you just so you know.

John Welsh M.D. 1:31:56
I realized you've got to You're the God of podcasts, though. You can go have some podcast swagger, and brag about having a wonderful podcast.

Scott Benner 1:32:03
I'll have to lean on that since I couldn't get out of algebra in sixth grade. So thank you very much.

John Welsh M.D. 1:32:08
Okay, cheers Have a good rest of the afternoon. You too.

Scott Benner 1:32:13
I know that was a denser episode than you're accustomed to on this podcast. But I just thought that having someone like John walk through these ideas was important. I took a ton from it. I'm going to listen back to this a couple of times, because I am I'm not as smart as I need to be sometimes about some of this stuff. But John made it understandable and complete. I was really thrilled to have him on I'm going to have him back someday and just talk about him and his diabetes and try to learn his story. I wish you could have heard the conversation I had with my Booker when I was like, hey, I need somebody from DAX calm to talk about standard deviation, like, really deep dive. Is there somebody over there that can do that? And she was like, I'll find out. And boom, John Walsh comes out of nowhere. Really lovely. Man. I want to thank you for listening. I mean, especially if you're still here, an hour and a half into this, you are a major geek about diabetes data. And I love you for it. Thanks so much to on the pod touched by type one, the Contour Next One blood glucose meter, and Dexcom for sponsoring this episode of The Juicebox Podcast. Please again, go to juicebox podcast.com. For those links, or look right into the show notes of your podcast player. You can clicky clicky on him right there. One way or the other. If you use my links, you'll let the sponsors know that you came from the Juicebox Podcast and I will of course really appreciate that. Hope you're all well, especially in these times. I'm thinking of all of you, and I'll see you soon.

I hope you enjoyed this episode of Best of data. Data. Duda data. People love diabetes data. This is a all time favorite episode of the people. Would you like to save 35% on this sweatshirt that I'm wearing here? Are these silky joggers? Am I rubbing my legs while I'm saying it? I'm not gonna tell you because it sounds creepy, but they're super soft, cozy earth.com Save 35% at checkout with the offer code juice box. And of course you can get 10% off your first month of therapy@betterhelp.com forward slash juice box just by going through that link. It's all you have to do. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. If you enjoy this conversation and you're not in my private Facebook group, it's absolutely free and I think you would love it Juicebox Podcast type one diabetes on Facebook private group 35,000 Plus members. That's over 35,000 members, tons of conversations, opinions, perspectives, and great conversation absolutely free. Go check it out.

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#870 The Alaska Principal

Molly has type 1 child with  diabetes and she is a school principal.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - iHeart Radio -  Radio Public, Amazon Alexa or wherever they get audio.

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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 808. And welcome to episode 870 of the Juicebox Podcast what happened to my voice there when we

Molly is the mother of a child with type one diabetes, and she's also the principal of a school. So we have this very cool kind of hybrid conversation around like 504 plans, but also being a parent, but also they live in Alaska. So, I mean, that's different, right? You're gonna love it. Just listen, you know what I do? Settle in. You're ready, you feel it? Alright. While you're listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan, or becoming bold with insulin. Yeah, they're great. I just went into the Frosted Flakes rhythm there for some reason. Sorry about that. If you are a US resident who has type one diabetes, or is the caregiver of someone with type one, please go to T one D exchange.org. Forward slash juicebox and complete their survey. You're going to be helping research by doing that. It's HIPAA compliant. Anonymous, it'll take you 10 minutes, T one D exchange.org. Forward slash juicebox. Don't forget cozy earth.com. Use juice box at checkout to save 35% This episode of The Juicebox Podcast is sponsored by us med now us med is where Arden gets her Omni pods or Dexcom and a lot of her diabetes supplies us med.com forward slash juicebox head there right now to get your free benefits check. Or you can get that benefits check at 888-721-1514. Let us med bring your diabetes supplies the way they bring ours. If you've been thinking about talking to somebody and are considering online therapy, check out better help@betterhelp.com forward slash juicebox Juicebox Podcast listeners get 10% off of their first month of therapy at my link. Better help.com forward slash juice box. That's better help h e l p.com. Ford slash juice box.

Molly 2:34
My name is Molly, and I live in Alaska. And I have two kids. My daughter is 19. And my son is almost 16. And he's my type one. And I have been a teacher and I'm now a school administrator and elementary school principal.

Scott Benner 2:53
Wow. Born and raised in Alaska moved there.

Molly 2:57
moved here when I was 19.

Scott Benner 3:01
When you were 19 on your own or with your family.

Molly 3:06
Following a boyfriend

Scott Benner 3:09
I was I always wait for following a boyfriend or escaping a crazy parent. Yep, wasn't sure which are both who knows, you know?

Molly 3:18
Pretty common story. I came up here for a summer job and then stayed.

Scott Benner 3:22
So the original plan was just to hang out for the summer work to pay for your life and then head back. Yep. What kept you there?

Molly 3:31
Oh, it's just an amazing place to live. Really?

Scott Benner 3:34
That's excellent. I do know people who also said they were going to Alaska for a little while and they never came back. So yeah, I assume they have been killed by a polar bear. But I don't know a lot about geography or nature. So yes,

Molly 3:49
well, I knew there would be I knew you would talk about bears or moose. I was going to tell you as lakes how to hitch up my dog team but

Scott Benner 3:56
there's no way you don't have a husky.

Molly 3:59
I do have a dog and she is a I like to call her a reject sled dog. She is an Alaskan Husky breed, which is what they use for running the Iditarod. But she didn't make the cut. She's lazy.

Scott Benner 4:14
Molly, do you think that when I say my silly things, and then they come true that it's funny or scary because I can never tell which

Molly 4:24
it's funny. Okay,

Scott Benner 4:25
because you have a husky and I have a husky but I don't live

Molly 4:29
in an igloo. Well, you Sam, who knows

Scott Benner 4:31
what you'll lie about today? There's no way I don't know when you get embarrassed, like, oh God, we do eat raw salmon right from the river. How does he know that?

Molly 4:41
We do eat a lot of salmon.

Scott Benner 4:45
But not with your hands like Smeagol Am I correct about that?

Molly 4:48
Correct? Correct. Way to cook it.

Scott Benner 4:52
Would you eat it? On a bagel? Maybe it was a LOX? Yes, I would say well then I was pretty much right. Okay. So you have I'm sorry to children. You said 1916. Yeah. 16 year olds, the type one boy or girl, boy diagnosed how long ago? Almost two years ago. Okay. Was that a surprise?

Molly 5:15
Yep, yep, for sure. No history of type one and either of our families. No major auto immune things. There's maybe some mild allergies on my side. And he had, he's had allergies since he was small. But nothing. Nothing major.

Scott Benner 5:38
He's allergic to ice.

Molly 5:42
When he was when he was a baby, he was allergic to cow's milk. So I used to joke because he used to, I used to buy a really fancy cheese for my then what like to and three year old because he couldn't have cow's milk cheese. So he had goat's milk, cheese and sheep's milk cheese. But he kind of grew out of that. And he has hay fever now seasonal allergies. But that's it. That's about

Scott Benner 6:10
it. Hey, the boy that you fall into Alaska, the kids that are no, no. Okay. Is that? Is that kids still in Alaska? No, okay. Well, he left and you stayed. Can we not talk about diabetes and just talk about the year that you lived in Alaska with that guy, please.

Molly 6:32
That's a really long story. We don't have time for that.

Scott Benner 6:36
So far, that's what I find myself caring about. But you seem like a reasonable person. I'm gonna move in the correct direction now. But I want to hear about what I assume was, I mean, drinking and debauchery and then cheating. And then somebody got caught. And

Molly 6:52
oh, it's less, it's less dramatic than you're thinking.

Scott Benner 6:56
Trying to turn it into an after school special. That's all. Anyway, well, I'm glad that you stayed and, and made a whole life for yourself. You became an educator, obviously, did you go to college in Alaska?

Molly 7:11
I did. I was working seasonally up here for a while and then decided to go back to school and get my teaching degree. And so I did go back up here and eventually got my credential up here and started working.

Scott Benner 7:26
And so how long did you teach before you became became the man? Because you're the principal now?

Molly 7:34
I am. Yeah, I taught for six. I think about 12 or 13 years in the classroom.

Scott Benner 7:44
Okay. How old are you? Can I ask? I am 48. Do you not know or did you not want to say? No, I have to

Molly 7:53
think about it a little bit. Because, you know, you forget I understand.

Scott Benner 8:00
Okay, so it's been 29 years since you follow that stupid boy to Alaska. It looks like you met another boy. Probably stupid but nicer and you like him, and made a couple of kids with him. became a teacher taught for a while. moved into the administration side. How long? How long have you been in that side of it?

Molly 8:21
This is my fourth year.

Scott Benner 8:22
Okay, so pretty free recently, then. Yep. Yep. Okay, what made you wait a minute? Can I ask a question that's not attached before we move on? In my head? Yeah. How does the sun work in Alaska?

Molly 8:38
Well, it's summertime right now. And it's July. So we have a lot of daylight. And I think the sun is setting. Gosh, I would have to look it up. But you know, if I go to bed at midnight, it's still light out, it's maybe getting dusky. And when I get up, it's bright, bright day. So where I am, we have I think, at the height of summer, we have over 18 hours of daylight. And then in the winter, it's darker. And it's not dark all the time it gets it gets fully light in the middle of the day. But I would say in the middle of winter that you know, the darkest time in December, it's maybe starting to get light between nine and 10. And then it's starting to get dark, like between three and four in the afternoon.

Scott Benner 9:30
So just from nine or 10 in the morning till three or four in the afternoon during the wintertime. Yeah, okay. All right. Sorry. I just, I have a note here that says ask about the sun. And I know I'm gonna start asking you about diabetes and stuff. And the whole time you're talking I'd be thinking, I wonder how the sun works. And now that I know I feel I feel better about it. And I never knew if that was a television thing you understand I'm saying,

Molly 9:51
right. Yeah. Or it's real. The Land of the Midnight Sun is is the real deal.

Scott Benner 9:57
How would you get a name if it wasn't real then that's that's Okay, so there's no autoimmune in the family, some light stuff around allergies. So how does the how does the diabetes present for your son,

Molly 10:16
um, just pretty typical symptoms, although the thing that threw us is he never said he was thirsty all the time. He said his mouth was dry. And he just kept saying, my mouth is so dry, I can't figure out why my mouth is dry. I assume he was probably going to the bathroom a lot. Although he wasn't always drinking a ton, he would just swish water in his mouth and then spit it out. Because his mouth was dry. And just tired, you know, lethargy. I, he had started taking allergy medication, because his seasonal allergies had been getting worse. And so when we were trying to figure out what was wrong, I looked at his box of it's just the over the counter allergy meds, and the side effects were dry mouth and lethargy. And so I thought for sure, oh, it's the allergy meds, and we'll stop taking those and he'll be fine. So of course, that didn't work out. He just kept declining. So eventually, and it was during COVID. So this was July of 2020. Okay. So, you know, not so easy just to go to the doctor, but we had finally decided, okay, yeah, we need to take him in. So first step is to go get a COVID test. So we took him to the urgent care to get a COVID test. At that point, they were just coming out to the car to do the test. So they did that. They asked him questions, you know about how he was feeling. And basically said, Okay, we'll call you with the results. We think you should just go home. But if he gets worse, I think they were suspecting appendicitis, maybe they said, if you know, if he's if his stomach pain gets worse, go to the ER. My husband had taken him to that appointment, and I was supposed to meet him there. And then and take our son home. I got there and I looked at at our son, his name is Jack and I looked at him, I said, Oh, I'm not taking them home. There's no way he's like He had declined even more. So can we live about 45 minutes from doctors and hospitals. So I wasn't willing to take him home. So we were able to get him inside the clinic for another for another look. And then he was you know, at that point, he was vomiting. I mean, he was in DK for sure. And as soon as the doctor asked to smell his breath, I knew exactly and like, oh my gosh, it's diabetes, you know, I have a little bit of just kind of basic first aid training and stuff. And my husband is he's also a teacher, but he's also an EMT. And so we kind of knew the basics, but it just until she said, Let me smell your breath. It didn't really click

Scott Benner 13:09
is the fire chief, also the mayor? Sorry, I know, I held it. You couldn't wait for the doctor to come in on the wagon train. So I don't know how I'm supposed to hold it all in.

Molly 13:23
This isn't. This isn't a major city we're in. We're in the biggest city and Alaska says,

Scott Benner 13:27
you know, I'm just kidding. I like it when Canadians are like, I live in a city and I'm like, do you and then it's Toronto or something like that? Oh, my God. Whoa, okay. But, but okay, so but still 4045 minute drive. And you're saying that in the time? From what you saw him last just that day till when you saw him at the doctor's office, there was a noticeable change.

Molly 13:50
Yeah, you know, he just had that look, I just it he just didn't look right. I just said no, he needs to be seen. Do they keep

Scott Benner 13:59
you in the hospital? Or how did it work with COVID?

Molly 14:02
Yep, he was admitted. You know, they told me to drive to the ER. So we did. And we were in the hospital, I think maybe two and a half days. So that because he was in the pediatric unit, they allowed both parents. But there were some restrictions. I think, like we couldn't come and go during the day, we could leave once and come back, but you couldn't come and go and so we took turns spending the night but then we were both there for the diabetes education piece so we could figure out what's going on. Okay.

Scott Benner 14:44
How did he handle the news?

Molly 14:47
He handled it really well. He and I think it's because apparently he's he's pretty mellow. He's pretty even keel kind of person. But also he had A friend all growing up that had type one. And he had a pretty close, there were maybe four or five of them in this in this friend group, and she was always one. And so I think it was, it didn't seem too abnormal are weird to him. It was like, Oh, she's got, like, I have what she has.

Scott Benner 15:21
Okay. Yeah, somebody who's living well, and he sees all the time and seems

Molly 15:26
right. And she seems very normal and functional. And she does whatever she wants, and it doesn't limit her at all.

Scott Benner 15:33
And that hasn't changed over time.

Molly 15:37
No, no, but he also, I mean, it's interesting, because he's a teenage boy. So he doesn't talk much. And that's kind of how he is anyway, you know, lots of one word answers, hates talking about diabetes doesn't, doesn't even want to acknowledge really, that that's a part of his life, or that that's a big part of his life. Kind of reminded me when you were when you had art and on how she just, you know, kind of blows it off. Like, whatever. Yeah. He has that attitude.

Scott Benner 16:10
And would you say he's 16? Now?

Molly 16:13
Yeah, he'll be 16. In a couple of weeks,

Scott Benner 16:15
you might have four more hugs, you can get the next two. Right. Oh, yeah. That's where I see you.

Molly 16:24
I realized that.

Scott Benner 16:26
Can mommy get no, okay. I'll just keep paying for the house.

Molly 16:31
The least favorite thing that I say to him is, well, I heard on my podcast, or the the juicebox guy says this, that he wants zero information about diabetes from me, and most of my information comes from you. So he really dislikes you without ever having heard you.

Scott Benner 16:52
Oh, I can appreciate that. Also, there's a kid in this house with diabetes, it doesn't want to hear from the juice box guy either. So it's a pretty common thing for for that to be perfectly. And if you can use me to deflect I actually think that's a good idea. as I as I heard you saying and I thought oh, people should use me like the doctors use the nurses. You don't even they're like, Oh, the nurse is gonna come in now and give you a shot. I'll wait out in the hall. So you'd like me when this is over? Like I could be the nurse with a needle and you could just be the person who's like, I'm sorry, this has to happen. But the guy said, right. Yeah, well,

Molly 17:24
I do stay. I don't say you know, I think you should try this. I always say, you know, all my podcast guy says that you should do this.

Scott Benner 17:33
You know, I always used to take that as, as people saying that I knew, but now I'm thinking everyone's just hiding behind me. So they don't have to deal with their kids. All

Molly 17:43
right, because we know what I mean, especially as an educator. I know that. Kids don't want to hear anything from their parents. Their parents don't know anything. Yeah. So as a teacher, I can tell kids things and they'll listen. And if their parents told them the same thing they wouldn't. So

Scott Benner 17:59
do you think they actually listen to other people or they just don't have the nerve to yell at other people?

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pushback

Molly 22:11
I think it's I think it's a little about

Scott Benner 22:12
both. Yeah, Molly, you just got all serious. Molly's a principal with your answer there. Stop messing around, you're like I have a real thought on this. Hold on a second. Do you? And that is why you wanted to come on the show. Right? Because of your background education. What you see with 504 plans and and what you

Molly 22:29
Yeah, I just I saw a lot of people asking questions about five of fours. You know, I'm not a 504 expert, but I definitely have that school perspective as, as a classroom teacher, I had students with type one, before I knew anything about it before my son was diagnosed. So I, I have that perspective. And then now as a principal, and as the one at my school who is responsible for writing 504 plans and, you know, working with my son's school to write his plan. Just wanted to you know, I think like most people say when they talk to you, like we've learned a lot from from you, and from the podcast, it's really helped. And if there's a way that I can help, or give somebody some information that might smooth their path. And I want to do that, I appreciate

Scott Benner 23:17
that. And we'll we'll see what you know. So I'm just moving the last 504 plan I've ever made over to this computer, so I can pull it up while we're talking. Because I haven't looked at these or thought about them in a while. It's funny, something that I thought was so important, at one point, became a throwaway document as art and got older when we really just didn't need it anymore. And it was just right thing we kept going because that's what you do sort of want to do.

Molly 23:48
And I feel the same way. I mean, I, you know, was very involved in in creating Jack's fi before when he first went back to school. And now I you know, when he when they call for the annual review, I have to remind myself what we put in there. And yeah, and a lot more relaxed about it now.

Scott Benner 24:08
So do you have them? Do you use a template when you make them? Or do you let the people I asked because the first time I brought in my 504 plan. They were like, This is not what we do. And I was like, Well, I've already done this. So we're all good. And they said no, no, we'll take your document and put it into our document. I was like, okay, like this is a formatting thing is what I thought at the time. And they took like my, I don't know, three or four page, like thankfully typed out documents, probably actually two and a half pages when you take out headers and etc. And they turned it into like four bullet points. And they handed it to me and I said, This is it. And she was going into kindergarten at the time and they was like yeah, this is it. This is This is enough. We have other kids here they said with diabetes. And I said if you try to keep my daughter alive with these four bullet points, she He's not going to make it a month here. And then I said, I really think we should go over mine. And that was the first time I pushed back and got them to I got them to sit down with my document to see that just because it had words in it didn't mean that it was trying to trick them or put them in a bad position or anything like that. Right? Yeah, but

Molly 25:21
I don't I think he, I think every district probably has their own format. So yeah, we have a template that we use. It's, you know, specific to our district. But, you know, the 504 the rules and laws and policies that that govern fiber fours and IPs are our national laws. So we're all conforming to the same thing. But how we do it, I'm sure varies district by district. So I am by no means a 504 expert, but I, I have some familiarity with how we do it in my district. And it is, you know, it is just taking those ideas that that you bring as a parent, and fitting it into our format, and making sure it looks right. And then you know, I'm fortunate that I'm in a big district and I have people that can review those documents for me to make sure that they're just as they need to be and legally compliant. And

Scott Benner 26:19
I know that Ardennes at one point Ardens 504 plan became the, like the one that people in town used. And then I think I noticed that the school was not happy with me because it was okay if it was for one person, but then all of a sudden, people were coming and be like, we're gonna use this fiber for plant. And they couldn't argue with it, because we were using it. And that became an issue. And then of course, it went on the internet eventually. So I think people probably all over the country use it at this point,

Molly 26:45
right. And that's how it works with all 504 plans and all disabilities that, you know, if if your child is dyslexic, then you know, there's 1000s of those floating around on the internet that you can find an advocate for but you know, it's a legal document, and we're required to provide everything that's in there. And so from the school side, you know, that's why we are a little more conservative, or we're gonna question your two and a half page document and and say is do we need to have everything in here. And, and part of the trick, I think, too, is that in this probably varies district to district and state to state. But, you know, we have a medical document, the diabetes care plan in our district that outlines medically what happens. And then the 504 is really, you know, just making sure that students can access their education equally with other students. And in to me, those are two different documents. But part of that is because my son was in high school when we were doing this and he was already fully independent. One of the nice, nice things about him being diagnosed older is that he's, he was fully independent from the beginning. You know, we had to learn how to give him shots and were in the hospital, but he always did all his own shots. And now he's on a pump. And he, you know, he he's completely independent. Yeah,

Scott Benner 28:14
yeah, I am. I want to ask you something. I feel like you can't answer. But because if you can't, you're fine. But is there ever I always felt like there were things in our 504 plan. They were like, yeah, yeah, yeah, we'll do that. And then they just never did. And it was little stuff like, you know, I was like, I want the bus driver trained. And for years, they'd be like, oh, yeah, yeah. And then one year, it actually happened. And I noticed the year that it actually happened looked a lot different than the years they told me it was happening. But I think to your point, the school looks and says, We can't get this accomplished. Even like the guy that drives the bus works for a third party company. I think that was the holdup. I think it took them years to talk to the bus company into allowing one of their employees to come to the school for a training session. And is that the kind of like, is that most of the time? What the What the? I guess the trip ups are? Is that you? You don't have the ability or the staff or?

Molly 29:17
Yep, yeah, we don't have the ability or the staff or the money. You know, I'll say I originally went into my son's five before asking for the bus driver to be I don't I don't even think I use the word train. Like I just wanted the bus driver to be aware. You know, like if if he came across Jack passed out on the bus that maybe he you know, have an idea of why and and he my son has a his best ride is almost an hour both ways. So you know, there's there's a good chance something could happen on the bus. And they told me no and I didn't push back on that. And I do know it's because exactly what you're saying. They have The school district doesn't have any control over that driver. They don't train the driver, they don't employ the driver. You know, right now we have school bus driver shortages. We're lucky to have a driver. And it just I think, I think that they couldn't imagine a system where they could uphold that.

Scott Benner 30:21
Yeah. So then once you say yes to it, now you're bound to it. Right. So,

Molly 30:27
and bound to it in the in the, in the sense that just like you said, are there some years where not everything in the five before is happening? I would say that certainly could happen. And that's when parents need to advocate.

Scott Benner 30:41
Yeah, right. And how do you do that best? So when you? You know, listen, sometimes you're in a situation where people just aren't being helpful. Sometimes the parents are unreasonable, but but in a, in an apples to apples situation where, you know, everybody's doing their best, and it's not working out? How do you handle that? Like, what's the best way to approach you, I guess,

Molly 31:03
calmly without freaking out. I mean, for everything, I mean, it just general basic life rules, right, realize that everybody's trying to do their best and, and try and bring everybody together. I think that's, that's a big one. And, you know, I think it's interesting, you know, and you talk about an acknowledge, like Juicebox Podcast listeners are, you know, they're their top tier people, I think, you know, they, they understand and are really engaged in, in their own care or their kids care. And I always find it interesting that it's widely acknowledged that there are some uneducated endocrinologists, right and, and you kind of have to advocate for yourself with your Endo, and find the right person. But then I hear people when it comes to school, like they expect the school nurse to be the be all end all and know everything about type one. And they're a school nurse, you know, they had probably, I don't know, a week of diabetes training when they were in school, which could have been 2030 years ago, you know, and they're managing, I've got 350 kids at my school, and, you know, not to mention COVID, but even before COVID, there's, there are a lot of medical needs in the school. And so to expect your school nurse to, to be able to manage or to know everything that is going on in the type one space, like, like we as parents do. And there's really involved parents, and it's just totally unrealistic. So approaching, you know, an issue or your advocacy advocacy with, with that in mind that, that we're trying to do our best. And we've, we've got a lot of things on our plate. And, you know, your child is one student in our school with significant needs that we need to meet, but that, that we're trying our best, and we don't know what you know, and we don't know why you're asking us to do what we do. You know, I'm really anxious now, for I haven't had, as principal, I haven't had a type one student in my building, yet. I had one. When we were in COVID. During COVID, we were not in person. And so but I'm excited now to be able to say to a parent, like, No, I get it. Yeah, I know what you want. And let's work together and make this happen. You're making me

Scott Benner 33:41
think that like there's, you know, people have a job description. And the what you might want from them might not be their job description. So you might trip into an administrator or a nurse who's willing to go the extra mile or comfortable going the extra mile. And the you may meet some who aren't, for whatever reason, maybe they just don't have the bandwidth. Or maybe they don't, maybe they're like doing you a favor. And maybe they're like, Look, you don't want me involved in this. I'm the wrong person for this, I can do the job, but I can't do this extra stuff, or I don't have the time, or I just don't want to and it's not my job description, like whoever you run into. I think the only chance you have is to start having more private personal conversations with them and just hoping that you can come to some sort of like a human agreement, I guess, and see if you can't get them to be in love. I've always been kind of amazed at the number of people who would not be willing to be a glucagon advocate, for example. Hmm, lots and lots of teachers were like, No, I won't do that. I won't do that.

Molly 34:44
Yeah, and I will say as a as a teacher, when I had type one students in my class and we were going on a field trip and I taught fifth grade. Mostly, I think that I had two type one students that I can Think of, and we'd go on a field trip. And I think maybe one time the nurse went with us, but then another time, she didn't. And so I carried the glucagon. And I remember going through the training. And it was super overwhelming. I mean, a field trip is a super chaotic day for a teacher, and you've got, you know, 25 kids, and they're all amped up. And, and you have a variety of needs between those kids. And then you have a student who you're being told, you know, could die if you don't give them this, and you have to mix this and put it, it's super overwhelming. And there are definitely teachers that said, No, I'm not comfortable with that. And, and I get it, I understand why they would say that. It's, it's overwhelming, and you just don't know enough. And you have so many details in your head. You know, I wish I knew what numbers to be looking for. I remember like that day of the field trip. But if you asked me a week later, like what the normal range should be, or what numbers I'm looking for, I wouldn't have known. And this was before Dexcom, you know, so we weren't getting tons of data. They were supposed to do a fingerprint, and then tell me what their number was. And I had to have a little cheat sheet. And again, yeah, like a week later, I wouldn't have known

Scott Benner 36:15
Yeah, no, I understand. I mean, I do understand, I also understand when people are in that position, usually for the first time or so their kids are more newly diagnosed, they're already freaking out, they sort of don't know, either. I think that's an important piece, too, is that when you're a new parent, you're going off of the information that was given to you, which, you know, we talked about in the podcast, a lot might not have been rock solid to begin with. And now you're trying to make sense of spotty information, and then pass it on to somebody else who's probably like, either, like, I don't understand what you're saying, because I don't know anything about diabetes, or you're saying some stuff I don't think is right. And you think Well, no, it's gotta be right, I got it from the doctor. You know, but how many people come on the podcast and say, my doctor never told me to Pre-Bolus my doctor never told me fat would make my blood sugar stay high because of slow digestion, like, you know, hear all the things people have never said. Or, you know, even said to people incorrectly, so you can see where the game of telephone could get messed up pretty easily.

Molly 37:15
Oh, definitely. And that's it. I mean, even all the more reason to come in, calmly, and with, you know, with the attitude of, let's work together to figure this out. And let's build this relationship so that it can turn into something where, you know, I'm comfortable calling you and asking you to change this or do this. And, and same thing, on my end, I'm comfortable calling you and saying, Hey, we had this happen today. How should we fix this? And when people come come to me with that attitude, then it's just so much easier for me to work with people and help them get what they want. Versus the parents that come in and say, you know, you violated my 504. And I'm going to sue you and my lawyer is gonna be contacting you later today. Yeah, you know, it's like, when people do that, and I, and I understand why, and you're totally right. At the beginning, when you're first diagnosed, it's super overwhelming, and you want the best for your kid, and then that's where you're at. But when some when a parent calls me that way, then I have to react differently, right? Well, I have to be, you know, takes me probably five times as long to compose the email because I have to double check every word and I have to have somebody else read it. And I probably have to call the district office and, and double check to make sure. Versus if you just call me and say, Hey, this is going on. What do you think I can have a casual conversation, we can probably problem solve something right there.

Scott Benner 38:41
Aside of diabetes, aside of diabetes, even I've had a number of conversations with teachers over the year where I started to go, Listen, I'm not trying to cause a problem. I know your job is hard. You know, I know it's tough to, you know, some of the parents in this town are difficult. Like, that's not my goal here. I don't I'm not trying to be right. I'm just trying to make things okay for my kid. And can we work on this together? Because I think the first time I have a little nutty, you're gonna remember that. And then forever and ever, that I'm the guy that came in there and, like, seemed unhinged, and you're always gonna remember that about me. So I tried.

Molly 39:21
Unfortunately, that's yeah, I try and give everybody the benefit of the doubt. But yeah, you do remember that?

Scott Benner 39:28
Yeah, here's the lady that threw the papers across the floor. I just gonna stand here and smile and try to get through this. You just you lose your I don't know. I think you lose the ability to have a human interaction at that point. And you've now turned it into something like you said, like you have been an aggressor in the past or on reasonable and now you have to start running things past lawyers and you know, talking very carefully and it's just, I don't know, I you know, one time I think we were setting up I think it was back when Dexcom was first around. And we were setting up art and being able to have her Dexcom receiver on her desk during state mandated testing. And we were making, making our way through it. And it was going, okay. And the superintendent called my house to talk it over. And I promise you, Molly, I don't remember the context at all. But within 10 minutes, he and I were screaming and cursing at each other. And we knew each other, like, he's a person who lived in town, you know what I mean, and by the way, a lovely man. And, and we yelled at each other, like, we were about to have a bar fight. And then we stopped. And he went, I'm sorry. And I said, Me, too. I apologize. And then we just kept going. And later I said to my wife, I know this might not be the right thing to say, but I was like, only two guys could do something like that. We were just like, I mean, Bali, I swear to God, he was he was cursing at me more than I was cursing.

Molly 41:05
Well, I will say that brings up an interesting point, like with state testing. And and you asked about the template that we use, I will say that the verbiage that we use that we typically use in five oh fours, and the verbiage that comes with state testing guidelines, has not kept pace with diabetes technology. And so there's a real disconnect there. And as an educator, whether it's a teacher, or a principal or a building test coordinator, I can lose my license if I violate a state testing guideline. And so I can see where that you know, a dispute or a disagreement over an electronic device and the testing environment.

Scott Benner 41:48
And we were breaking totally go through the roof. We were totally breaking new ground, I was pressing the state, like the state was like, we can't do this. And I was like, oh, no, you can and we're gonna figure it out together. And you know, when it was all over, the then principal of the school, she moved on, but she pulled me aside afterwards, she said, You know, I really have to thank you for going through this, because now it's so much easier for us to do this with all the other kids. She's like, well, you needed one person to just make an issue of it point out a way that it could be handled. And she said the biggest piece ended up being the education part, meaning meaning me reasonably explaining to the person from the state why this was necessary. Exactly, you know, and they probably didn't,

Molly 42:37
that's where people just don't know. And, you know, the 504 coordinator is, sometimes it's a principle, sometimes it's a school counselor, we have no medical background. And so just coming in with that calm attitude, and be able being able to explain, you know, why you why you want something in the 504, I had to explain to the counselor at my son's High School about, you know, I wanted something about being able to test, I can't remember the exact wording we use, but basically, like if he's showing up for a high stakes test, and he's super high, I want him to be able to take that at a different time, because that affects him cognitively. And they didn't know that, you know, they didn't really know that there were the or the extent of the cognitive impairments of higher low blood sugar, right. And, you know, my son's a really bright kid, and he's, he's going to do well on this test. And I don't want his diabetes to impact that in any way. So taking the time to explain that to the counselor like, no, here's why I'm not just saying like, he woke up and he has a bad day. So he gets a do over. Like his medical condition could be impairing his ability to show his best effort on this assessment, one of

Scott Benner 43:59
the problems is that there are people who would use it to gain advantage. And so that there are Yeah, there are any having to defend against that, then. Yep,

Molly 44:08
yep, there are. And I will say that the one thing to do, of course, you know, most people, I think, at this point in their final fours, if their kids are on, you know, Dexcom or whatever, have the phone as an accommodation. And I will say that, I would bet that 95% of kids at some point in school, misuse their phone, and my son has done it, I know he's done it, where he pulls out his phone, you know, to, quote check his number, and then he's distracted like kids don't have the ability to not get sucked into their device. And, and that's where I think parents sometimes have a hard time understanding. You know, every every parent thinks that their kid is always You know, perfect angel in school or most parents?

Scott Benner 45:04
Their kids are little apples, right?

Molly 45:06
Well, thanks. They do things that you wouldn't expect, like your perfect diabetic Angel actually does scroll through their phone at times. You know what, they're not just checking their number. And I have gotten to Jack's teachers and said, Okay, here's the deal. If he's checking his number, he pulls out his phone, he looks at it, and he puts it away. There is no scrolling in the Dexcom app. If he's scrolling. He's, he's not using it for what it needs to be used for. And you can tell him to put it away. And, you know, I've told him that, for me, the phone is a privilege, like, yes, it makes it a lot easier to check. You don't have to pull your pump out. You know, he's on a tandem. You know, he could, he doesn't have to have his phone there. He could look at his pump to read his Dexcom. Right. So I'm allowing him the convenience of having his phone, but he has to try and manage that. Yeah. And not be a pain in the butt first teacher.

Scott Benner 46:06
If you're gonna stick all your text make sure nobody sees. That's right. That's what I was gonna I was gonna roll through Arden's 504 with you a little bit. So we haven't broken down into little, by the way, I have to just tell you first the word accommodations was misspelled on this document, not not typed by me. And I will tell you that I don't think I live in a in a dingy place, you know, where you expect the schools to not be on par. But I have never been emailed. So many misspellings, and writings that don't make sense as I have while my children are in school. Oh, I'm sorry to hear that. The amount of times that you get like you learn to not even look at the first email, because the second email was going to apologize for what they didn't do in the first email first certain. And it was just, I don't know, it didn't fill you with a ton of hope. In case you're wondering. Anyway, with that memory in my head, I pulled this document up. And in two seconds, I thought, yeah, I really think there's two M's and accommodations. And so anyway, so we had it broken down into personal right, it was sort of like all the staff will be trained. The nurse has to designate a person, it actually says the nurse shall designate in constitution with a board of education employees of the school district who volunteer to administer glucagon. So there's a there's a passage there, they eventually would find people. The teachers are trained to recognize type one, emergency indicators, and look during large group portions of the day, including recess assemblies, etc. It describes that Arden is going to be carrying a bag or a purse, and it tells what's in it, it tells you what to do in the event of a hypoglycemic event. And it actually walks through, like give her a juice, then do this, if she's not compliant. And drinking the juice, you're allowed to do this or be more forceful with this. It actually says in here, this goes back aways it says district personnel have a parent's permission to restrain Arden, if she becomes combative during the application of a glucose gel. And we put that in there so that they wouldn't feel like out. She flipped around twice. We'll wait for 911 like we were trying to think through everything that might happen. And of course, none of this ever happened. But if Arden becomes unconscious before, after the juice, the nurse will you know, and then in steps do the glucagon here's how call 911 Call the parents, you know, etc. Like it all kind of broke down that way. We added later in time to the glucose testing and insulin dosing section that Arden cellphone is considered a medical device. That is such a big one now. Yeah, you know, it's permitted to be with her at all times. Her proximity to her phone is crucial. Because some teachers in high school, remember the thing where they just used like, they'd hang a shoe tree up. Yeah. And maybe like everybody put your phone in there and go sit down. You know, Arden had to make her wait for that, to be honest. We're going to a concert, a comedy concert in a couple of days. And we had to call the venue yesterday and say, Listen, you know, it says that you're going to take our phones and lock them in bags. You can't do that. Like you know how bow but you don't start with you can't do that you start with here's our situation, is there a workaround for this? And they say, oh, yeah, sure, do this, you know, but I found it's very um it's, um, it's always interested in May, right? Like, you're working for somebody right now, Molly, right. If I come in and I start questioning the rules, I'm not questioning you. But it is hard not to feel that way if you're you so So a lot of times employees will start defending the institution as if the institution is themselves, which is why you call the comedy venue and say, Hey, here's something we have going on, can you please tell me what to do about it, not start telling them what to do, because they're like, it's not your job. It's easy to get kind of like, I guess the bras go up against people.

Molly 50:20
Anyway. Yeah. And I think, you know, I was just listening, you just put up an episode with a teacher, mom. And she was talking about that, that I think, as parents, you know, we get used to having to fight for things. You know, I think of insurance companies, I would say, if I didn't have to work, maybe I would just spend my time fighting with insurance companies and trying to make a change there. Because that's, to me, the most frustrating piece of the whole diabetes spaces is health insurance, but we're just kind of programmed that we're gonna have to fight for our kids and fight for what they need. And every little thing, like, you just want to go to a concert, or you just want to go to do this. But you're gonna have to make the phone call and explain the situation and, and we're just kind of programmed to do that. It's just, it's just the way you go about doing it. And again, when you're calling the venue, you know, that person answering the phone doesn't know about type one, they don't they have no idea that your phone is your, you know, your link to your glucose monitor.

Scott Benner 51:23
It sounds insane. If you don't know what it sounds like, is you want to keep your phone so you can record this concert for an excuse to why to do it. Ya know, it's the whole thing is communication. I don't like Mali, I don't want to give it away. But most of life is communication. So yeah. You know, it's funny, we have one in here, really interesting. And it's something we figured out a couple of years in, that they'll do their best in conjunction with the Transportation Director to make the bus route beneficial to Arden. And that was a thing where she used to get picked up first in the morning, and then in the afternoon was dropped off last. So it was always maximizing the amount of time she was on the bus. So one time we explained to him like, listen, here's what could happen. I think if you minimize the time she's on the bus, everybody be happier. And they came back a couple of days later, they said, Hey, we were able to rework the bus route. And now Arden gets picked up. Like she was like picked up three from last before getting to the school and dropped off. Again, three from you know, she was the third drop off. And it wasn't fun for anybody. And I don't think the person who had to rework the route was thrilled. But they figured it out. And you know, and it ended up being I thought beneficial to everybody. And I did point out how it would benefit them as well. Which is a is a big point of all this because when we went to texting, the school didn't really like that idea at first. And the way I sold it to them was like, Look, if I'm texting with her, and she and I are making decisions together, I really think there's no legal, like, legally, we made the decision. Like, it kind of gets you off the hook. And at that idea they lit up about. Yeah, and I kind of like since it didn't happen to you. I want you to if you're comfortable to talk a little bit about how exciting that must have been for them when I said, Look, you know, let's get you off the hook here on these insulin decisions. Do you think they were thrilled when they heard that?

Molly 53:25
Oh, sure. I mean, I mean, we have people threatening to sue us every day. So so I'd be lying if I said that wasn't a consideration. Yeah. So yeah, definitely. No, no. And I totally agree. I mean, and that's again, where the education, taking the time to explain how you're managing and how this is going to make it easier for the school. Not to mention less liability, but just easier. Because your indirect communication. Yeah, you need to explain how that works. I felt like 504 for Arden is interesting because it's it's definitely more on the medical side than then I would have in my school or in our district. I think just because we do have that diabetes care plan as a separate piece, so. So like my son's 504 In high school has a lot less medical and more about what he's able to do in the classroom. My big thing was, I don't want them leaving the classroom. Right. You know, there's a lot of content. I know you had mentioned one time about, you're worried about Arden's math, and then it was just that she was going to the nurse every day at that time. Yeah. And and that's a big thing. We talked about, you know, engagement in the classroom and, and that's, that's key. And so if you're leaving the room every hour, or even if it's just a couple times a day, that's that's missed instruction. And so for me, I want for my own child and for my students in my school I want every student in the classroom all the time. Yeah. If that means the nurse comes down or if, you know if kids on the Dexcom and the nurse can follow. I just I just want kids in classrooms.

Scott Benner 55:14
No, I mean, it was it happened in second grade. And it's so impacted her. It stayed with her for years, it took her years to rebound from that, from basically not being at the math, the math direction part of the day, every day, she'd she'd see a couple of minutes of it, then miss the middle chunk, and then come back when it was time to do the work. And she was significantly behind, like to the point I've said it on here before where she thought she thought she was just not adept at all. And I mean, there were times where we were like, well, at least we won't have to pay for college. You know, like because she's she seemed really dopey you know about that. And, and it turned out she just wasn't getting the direction. Yeah, you know that people underestimate

Molly 55:57
the impact of missed time. Yeah, because there was a missed instruction. We have, you know, the kids that come 15 minutes late every day, like while you add that up, they're missing days upon days of of instruction. And yeah, they're not reading well, because we do phonics first thing, and they're missing that, you know, and that's exactly the impact. Yeah,

Scott Benner 56:19
no, it's exactly what ended up happening. And she rebounded from it. Luckily, I guess. But it was hard for and nobody knew what happened, right? Like, no, like, we weren't there. Like how would I know they do the exact same thing at the exact same time every day? Like I didn't, it stands to reason now that you say it, but at the time, they were in second grade, like in my mind, they're just like, they're just like little ferrets running around in a cage. And every once in a while, you get them to look at you and you say letters at them. And then they run around again, like I didn't know what they were doing, you know. But But I think that's a big deal. Like not missing class time. But I was going to tell you like your 504 plan is is a pretty complete document. We used to do an IEP, I think they call them IEPs. individualized, something plan. Yeah. Education Plan. Yeah. And we just at one point, I was like, can we just leave this on this document, and they were like, sure, and we just sort of left it there. Because then there's a breakdown of how to handle snacks and meals for Arden. And it's little stuff like Arden gets to finish her lunch. You know, she eats at the same time every day, if there's an unforeseen change in the schedule, you tell us as soon as possible. Like that kind of stuff, you know, she has unfettered access to the bathroom, you know, stuff about environment around her like, you know that she's going to have to have access to her bag, you know, to her CGM. At that time to her on the pod controller, glucose, food etc. We double down on the cell phone, it's mentioned twice in there so that it can't be lost. And then testing which you brought up. You know, we we started to put a plan into place when she was younger, where when a test would start, she would write her blood sugar on the top corner of the test. And if the test came back differently than you would expect for Arden's you know understanding of the material, you could point to that and say hey, your blood sugar was pretty high can we do it again? And the truth is it never really came to fruition because it soon after we put it in I guess soon after we put it in index calm became really like a viable part of how we managed her blood sugar's just didn't get that high that frequently. And so it became but I still think it's a great idea for people just getting I

Molly 58:39
think, I think that a 504 Just in general in an IEP. It's just like the insurance policy for parents, right. I want it to have everything in there just in case and and hopefully you never have to deal with with something like that. You know, I hope that my son never shows up for a test and he's high and we have to think about should he should he redo it or, or any of that. But if it happens, I want something in that document that says we have the right to do this at a different time.

Scott Benner 59:11
Yeah, right. We can we can just call do over and do it again. She had during her art it took her SATs in a room privately with a teacher that she knew. And there was a time where I texted so the way we had it set up actually I can read it to you that I can tell you that it says allow for medical induced breaks if art needs to check her blood sugar per that and then that's all we asked for. And then the state testing coordinator added that art and cell phone may be on and present in the testing site but must be in the Proctor's possession. So the way we handle that was art and would give the phone to the teacher and say, Look, if there's a problem, my dad's watching, he'll text this phone, you can answer the text and then like decide what to do next. So we did that that way. That worked fine. It says they all the tests, excuse me, the state also added during a medically induced break art and may be given her testing materials too. So Arden has to give her testing materials to the proctor to hold. Then she can text about her blood sugar information to a parent. The proctor will look over our shoulder as she texts to ensure only medical information is being shared. Yeah, and the state also added if Arden needs to share medical information via her cell phone either due to an incoming text prompting her to do so not feeling well, or monitoring alerts, she must close her test booklet and answer sheet move away from the desk and retrieve her cell phone from the proctor again, the proctor will watch over our shoulder. So clearly what the state is worried about is cheating or taking pictures of the test. Yes, that's what they're worried about. Right? Because there are people who sell like they get a whole picture. So those tests and you sell them? Oh, yeah. Right. Because that's the business. Yeah, it's great because your kids not gonna get to college and then still be the same dummy that couldn't do well on the you know what I mean? Like, what's the point? Exactly, I got into a better school. Now, I don't understand what's happening here. So anyway, I mean, unless I could lead could Photoshop me in like a rowboat right or something like that, then I could just get any college I want. But, but um, this worked really well. And if I'm being honest and Arden's out of school. Now, I don't want to out anybody. If you asked Arden, if anybody ever looked over her shoulder while she was texting about our blood sugar? She would tell you, they probably did it, because it's a very human thing once you're in the room and the door is closed.

Molly 1:01:32
Right? Yeah. Right. But again, it's it's in place, and all those safeguards are in place. And so everybody can feel good about it and sign off on the plan and know that the integrity of the test is secure, and that she's going to be safe. Yeah, yeah, that's interesting. I have some similar statements in my son's 504 for testing, but he, you know, kind of goes along with, he just doesn't really want to make diabetes, a topic at all, he doesn't, he doesn't want to be in that separate room. He wants to be in the same room with everybody else. So I had to work with the counselor to say what, you know, what can we provide in the same room? Yeah. So we know, the big one is usually just food and drink, like I just want him to have, you know, he doesn't. Like I said, he doesn't need his phone. But that's partly because he's on a tandem pump. And so he can look at the pump. Yeah. And I had, but I had to clarify with them that the pump is not an electronic device, because you know, the rules say no electronic devices. The pump is a medical device that has electronics. And if he's looking at it, it looks like this. And this is what he's going to do. There's no, you know, it's not connected to the internet. He can't take a picture with it. But we had to go through all of that to make sure that they were going to feel comfortable having him in, you know, the general ed setting, right? Because it was important to him. He doesn't he doesn't want to feel like he has to go to this special room.

Scott Benner 1:03:04
Arden went back and forth on that show, there were times where she's like, I just want to stay in my room. And we've done that. And there are times where she's like, Hey, they set me up with a proctor. And I was like, Oh, they're not supposed to do that. And she's like, I don't care. And that was it. Just like, I'll never forget the time it happened. She's like, you know, she texted me. She goes, I just took a test with a proctor. I thought that wasn't supposed to happen. I said, it's not. I said, Do you want me to fix it? She goes, No, you know, it was nice. And I said, Okay, that's nice and quiet. Nobody was talking, I got in and I got out. Plus, like little things like, you know, once you finish this part of the tasks, you're supposed to wait till the next time to start. And and the teacher would inevitably go, Hey, listen, if you want to start now it's good with me. Can we get out of here? And I'd be like, Yeah, sure. Let's go. And so you know, again, it's funny, isn't it? We write it down so that you said it earlier, so everybody can feel comfortable. But then we all just coach whatever the hell we want to do anyway. Yeah.

Molly 1:04:00
Well, and it's important for me to know, like, even though Jack wants to downplay his diabetes right now, I just want him to understand that he will have to advocate for himself, you know, and you do it before the fact you know, you don't do it. When you get your test scores back and you bombed it because you were, you know, high the whole time or whatever. You make sure that that people understand the situation beforehand, on the off chance that that you might need to call called out into play. We've always

Scott Benner 1:04:32
been very careful not to use diabetes as an excuse, or to even have the appearance of using it as an excuse. And we did a really I'll tell you, we were really just like boyscout honest about it the entire time. Like the last I think the last two weeks of Arden senior year, she had she just I don't know pretty she got behind on something. She was up late working on something and she says to me in the morning, can you just call and say my blood sugar's low. And I said, she goes just one time. I don't want to go in. And I was like, Yeah, all right, whatever. So, and she was only late like she was late. And it was one of the I don't know if people like get this. But in Arden's senior year, the last couple of weeks, they were just, I don't even understand you guys sometimes what? Maybe it doesn't happen at your school. But what passes for instruction. Sometimes she's like, well, we're just sitting in the common area, because that was the weirdest thing I've brought up on the podcast recently. But the weirdest thing that changed from when I was in school to when she was in school, if your teacher calls out sick, you just don't have class that day.

Molly 1:05:42
Yeah, I heard you say that, that. That doesn't happen in our district. But I can only imagine that it's because there's a shortage of subs. I mean, I had a lot of days during COVID That I could, there was no sub available, right? But I'm Elementary School. I can't tell kids to just go to the comments and entertain themselves

Scott Benner 1:06:02
make talks because I think that's what happened. No,

Molly 1:06:06
I have to provide an adult, they might not be getting the instruction. They'd be getting in there with their regular teacher, but you know, they are supervised and they're doing something.

Scott Benner 1:06:17
Well, I'm sure there was an adult with them, but I'm making air quotes. She just like she'd come home. She'd be like, hey, check out these pictures. And I'm like, what was there a dance party? She goes, Hey, this was during, you know, English, the guy didn't show up. And there's 40 kids there. And they're just like voguing and like, I don't know what they're doing. You don't even like, Okay, I was like, well, good luck in life. Yeah, I hope you understand English. Anyway, did you? I'm so sorry. Because we're like talking for an hour already. And I has this gone any way that you considered? Or did we not cover things that you wanted to talk about? I

Molly 1:06:56
want to make sure I know, I think it's, it's gone? Fine. I, like I said, I just I hope I can provide something that's useful for people and dealing with their schools. And yeah, I hope I've done that.

Scott Benner 1:07:10
So come to them. So come ahead of time. Right. Be don't yell. seems like an obvious so I'm very Reasonable. Reasonable can even be angry, just reasonably angry, please. Sure.

Molly 1:07:24
I mean, I think one thing I've learned as a principal is that, you know, I get I get complaints all the time, you know, people have issues with what's going on. And, and usually, it has not a lot to do with, with what people are actually complaining about, you know, usually it's, it's something else that you're frustrated about, or, but but we're dealing with people's kids and, you know, people send us their very best product. You know, nobody's purposely not trying to do the best for their kids, including us on the school side, you know, we are, we are trying to do the best for your child and and every other student in the school. And, you know, with diabetes, I think as parents, we can sometimes put our blinders up. And because there are life and death situations. And

Scott Benner 1:08:15
where you say, Well, is there a time though, when you go, Look, I don't care about reasonable, I don't care what you have the ability to do? Like there are some things like this has to happen. And those things, they do end up happening, right?

Molly 1:08:27
Yes, yes, I think for the most part, you know, I think the part where maybe, maybe you and I would disagree is the extent of the tight control that we can have now, because of the technology. You know, at what point is that still reasonable that that your that your child has, has the same control every minute of the school day that they would have if they were at home with you every minute, right?

Scott Benner 1:09:03
Well, that's why the texting, I think texting is the unsung hero of diabetes, kids. And you know, because you can take other steps out, you can remove people who don't really know what they're doing to begin with, or don't have the time, you know, even if they didn't know. And I think that direct communication also allows insulin to be used more effectively to because you're not saying not waiting for a beep and then walking into a room and then waiting in line behind three kids with bruised knees and don't eat meat and then find right bolusing for your meal or whatever. Right Yeah, I but I see both sides like I really do like I I love that you're presenting your side of it. And I also think that it is not unreasonable for a person to want their kid to be healthy or for a newer diagnosed family who really doesn't know what they're doing to just be like, frazzled, get right and everything and everything seems out of control. Roll. It's interesting, though, isn't it that I guess there's not enough kids? I guess, thankfully, in places where people just know where there's a system where they're like, Oh, no diabetes, sure that happens here all the time, or even with the state like that. You don't you don't have to explain to the state, this is an insulin pump. It's not a you know, it's not a handheld, you know, gaming system. Like, your son can't be the first person to take an SAP and, you know, in Alaska with an insulin pump on, right, like how right

Molly 1:10:28
I just think it's just changing so fast. And everybody's different, right? I mean, I don't feel I mean, I guess I have been teaching a while. But, you know, when I had students in my classroom, the technology was totally different. Right? You know, and then and even now, it's changing fast. And it depends on what system you're using, you know, if you're, you know, tandems different than Omnipod are different than emanate MDI, en, and what you need is going to be different based on that. So it's so individualized and how people manage and and how parents manage versus how much kids manage and at what age there's just so many variables that it's it's unreasonable I think for for school officials who aren't medical professionals to have any idea about what what you want as a parent, or how best to manage your child because it's all individual.

Scott Benner 1:11:23
Molly over under, let's set the number at 10. How many day drinking parents have you had to deal with in your career? Over Under 10?

Molly 1:11:33
Over Under 10 individuals over 10?

Scott Benner 1:11:38
Oh, definitely. I'm here to give Billy his lunch. It's a bottle of vodka Do you want to do? Was there another bag in the car? Did you want to get the other bag? I just I don't know.

Molly 1:11:52
We we see lots of things in school, I would say the one thing that maybe parents don't realize in elementary school is is how much their their little kids talk. And you know, everybody, you know, if you're six, whatever happens in your house, you think that happens in everybody's house. And so you just talk about it as if it's, you know, a typical everyday thing. So,

Scott Benner 1:12:17
you know, all the dirt like the infidelity and the town and like everything, it comes to the kids, right?

Molly 1:12:22
They I mean, they just tell you, in the same way that your child might say I had Cheerios for breakfast, somebody else's child may say something, you know?

Scott Benner 1:12:33
My, my neighbor comes over on Wednesday nights and my dad goes to their house. Really? That happens. Okay.

Molly 1:12:41
So let's just say whatever whatever happens.

Scott Benner 1:12:45
I feel like you have a book. I feel like every teacher has a book in them of just things that they've seen or heard. Oh, I'm

Molly 1:12:51
sure they could. There weren't, you know, last potentialities.

Scott Benner 1:12:56
They rattled each other these kids to in there just the openness. Like you learn about the other kids through kids, the way you learn about like home stuff, is it? Oh, yeah.

Molly 1:13:06
Well, and I always tell, you know, if I'm dealing with discipline issues, and I have to call a parent, I can't name you know, other students that were involved. But I usually just tell them, I said, just ask your child what happened? They'll they'll give you lots more details than I can I have to tell you, they'll tell you exactly who said what, I have a

Scott Benner 1:13:27
completely different in the age of the internet feeling for what teachers must go through. When more recently I saw an educator educators like physical appearance attacked on a public Facebook page by a parent who had just, I guess, been frustrated, and decided that, you know, they were gonna vent like a five year old online, and then started attacking the guy personally. And I was like, what is happening? Like,

Molly 1:13:56
yeah, that would be my other piece of advice is come talk to your school first before you post things online.

Scott Benner 1:14:04
You don't think go into your the Facebook page is the way to take care of it. I've seen so many reasonable things worked out that way though.

Molly 1:14:11
Right? I know it always it always de escalates.

Scott Benner 1:14:15
Fine, absolutely fine. My wife says to me the other day, it doesn't matter what side of the perspective is on she goes. There's the woman in town explaining January 6 to everybody in the Facebook group for the town right now. And I was like, What's that now? And and she's like, Yeah, she's she's explaining all of her theories and things she knows for sure. And blah, blah. And I was like, and this person if you met them, like, like, and you bumped into them, you think like this normal person. And by the way, I didn't say I don't mean that her opinions were abnormal. I mean, the idea that she felt compelled to like, go on Facebook and explain it to everybody, right my mind. And then when something happens at this or, and someone else agrees that Oh, this one isn't good or this one is like that, then it just turns into a free for all. Yes, fascinating. Anyway, I don't know. It lowers my expectations for adults when I see that stuff. It's really, it really does. And if you're listening right now, you've done some of that. Stop yourself. I mean, honestly,

Molly 1:15:23
just I mean, like you said, it's just communication, just talk, talk to the people

Scott Benner 1:15:27
directly step away, step away. It's okay. Just just go take a break somewhere before you start bad mouthing a guy who makes $45,000 on the internet for what he looks like, just like, how about he's trying to get an amen. And you don't know his life. But anyway, Molly, this was terrific. I appreciate you doing this very much. Well, thanks for having me. Yeah, of course. And we didn't make fun of Alaska at all. Almost.

Molly 1:15:50
I know. There weren't I thought for sure. Yeah. You know,

Scott Benner 1:15:53
Yeah, but you're not more on there. You bring a you bring a different like you have an East Coast feeling to you.

Molly 1:15:58
Oh, an East Coast. Wow. I grew up on the West Coast. You really interesting. I don't know if that's a compliment.

Scott Benner 1:16:04
I feel like you're like a no bullshit person, Molly.

Molly 1:16:07
Oh, well, I would. Yeah, I would maybe describe myself that way. Okay.

Scott Benner 1:16:11
Yeah, that's just what I mean. Like, I don't think there's a lot of room for shenanigans with you. Anyway, you probably have to go kill a beaver for dinner. So I'm gonna let you go. I know you don't live in a place where there are other people. Your kid is on that bus for an hour.

Molly 1:16:30
Yeah, we are. One of the we're kind of in a 45 minutes from the major city. So is that

Scott Benner 1:16:39
city where Santa lives like what are we?

Molly 1:16:43
Well, Anchorage is the largest city in Alaska. We are 45 minutes outside of Anchorage. So for a long time, the school in my town is a K through eight school. So my son had a like two minute commute to school and it was the school that I worked at. So that was super convenient. But the High School is in Anchorage. Alright, so for high school, he hasn't when your long bus ride when

Scott Benner 1:17:09
you grow up in Anchorage? What, what is it? Like if you want to stay local? What do you expect to do for work? Is just anything like Yeah,

Molly 1:17:19
I mean, I think anything you would do in a typical city, we have an anchorage. I mean, we have a lot of, I mean, in addition, I guess the Alaska specific things would be maybe, you know, resource development oil industry. There's a there's a lot of jobs in that sector.

Scott Benner 1:17:36
I just imagined canning or bartender like I don't have everything. It's that stupid TV shows. The only thing I've ever seen a fan of Lascaux. What does that?

Molly 1:17:46
Right? Yeah, I don't think well, there's all sorts of TV shows about Alaska. Now. We got the crabbing ones and the Alaska State Troopers and the survival.

Scott Benner 1:17:57
I met Northern Exposure.

Molly 1:17:59
Right. Yeah. Well, that's that's probably more realistic for a small town. I don't think that I think that show was you know, not for a big place like where you live but not Anchorage. Anchorage is a city like any other city and we have

Scott Benner 1:18:12
tell everybody a professional football team you have and the baseball and the hockey.

Molly 1:18:18
Well, we don't have any of them. I mean, we do have hockey, but a lot of people

Scott Benner 1:18:23
that's walking Molly You can't count on people have to go from place to place on ice skates. A

Molly 1:18:30
lot of people go to Seattle or things that you know, other places for their professional sports for $20.

Scott Benner 1:18:36
I couldn't point to Atlanta to Anchorage right now. Like, if you just show me like, in fairness, I probably couldn't point to where I live either. But I have no idea where you're at. I mean, I know Alaska is like that like little like nubby thing at the top next to Canada.

Molly 1:18:53
Well, it's just you know, floating down. It's by Hawaii in that little box. Okay, I thought the west coast

Scott Benner 1:18:58
and you can see Russia from Alaska. I've heard Yes, yes. Yes. Yeah. So that's what I know. It's all true. Yeah, exactly. Well, thank you very much. I do appreciate it. Hold on one second. Okay.

A huge thank you to Molly for coming on the show and sharing what she knows with us. I also want to thank us Med and remind you that you can get your free benefits check at us med.com forward slash juice box are by calling 888-721-1514 And of course our newest sponsor, better help better help.com forward slash juice box use that link to get 10% off your first month of therapy. I want to thank you so much for listening. remind you to check out the private Facebook group Juicebox Podcast type one diabetes with over 35,000 members in it. That's pretty budget I hope you have a good day I'll be back very soon with another episode of The Juicebox Podcast

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#869 Type 2 Diabetes Pro Tip: Medical Team

A series for people with pre and Type 2 diabetes.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - iHeart Radio -  Radio Public, Amazon Alexa or wherever they get audio.

+ Click for EPISODE TRANSCRIPT

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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.

• 00:04:38 Regular check-ups are important.
• 00:07:03 Testing is important for diagnosis.
• 00:14:01 Lack of education for type 2 diabetes.
• 00:23:22 Take control of your health.
• 00:25:02 Knowing the consequences of diabetes.
• 00:34:48 Take charge of your health.
• 00:35:12 Take control of your diabetes.
• 00:40:16 Advocate for yourself in diabetes.
• 00:49:50 Take control of your health.
• 00:50:25 Blood sugar monitoring and therapy.

Scott Benner 0:00
Hello friends, and welcome to episode 869 of the Juicebox Podcast

Welcome back everyone. This is the third episode in our type two diabetes Pro Tip series. And today Jenny Smith and I will be discussing your medical team. While you're listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan, or becoming bold with insulin. And don't forget, this is episode three. Episode Two was type two diabetes pro tip guilt and shame. And Episode One was type two diabetes Pro Tip series intro so we're up to three doing well, actually next week, fueling plan, the week after that tech. And the week after that is testing. Like what you'll ask your doctor to test for. It's coming together very nicely. I hope you're enjoying it. still much more to come. Don't forget, if you are a listener of the show, everything you buy it cozy eartha.com is 35% off when you use the offer code juice box at checkout. So if you're looking for some sheets or joggers, I actually really love the joggers. My sheets are great too. But jogger sir. Excellent cozy earth.com 35% off at checkout with the offer code juicebox. This episode of The Juicebox Podcast is sponsored by Dexcom, makers of the Dexcom G six and Dexcom G seven continuous glucose monitoring systems. Doesn't matter what kind of diabetes you have. Dexcom is the way to go. dexcom.com forward slash Juicebox Podcast is also brought to you by the contour next gen blood glucose meter, you need a great blood glucose meter, you might as well get one that's actually accurate and easy to use contour next one.com forward slash juicebox. There are links in the show notes and links at juicebox podcast.com. To these and all the sponsors. When you click on my legs, you're supporting the show and helping to keep it free and plentiful. Hey, Jenny, how are you?

Jennifer Smith, CDE 2:31
I'm great. How are you? Scott?

Scott Benner 2:32
I'm doing well. Thank you. Yay. So right before we recorded, you and I kind of went over what the next step was here, right? We've already recorded like an introduction to the series, we talked about guilt and shame. And then we said, do we talk about technology and medications and insulin next? Or do we talk about what might happen when you get to the doctor's office next, like what's the path that the story should take in the series? And we came down to? We're going to talk about medical care first. Yes. All right. So there's some stuff here from people, and we can definitely go over it. But I think I want to talk to you first about this. So I am a person who has type two diabetes, I'm listening to this, I've decided I'm going to do something I'm going to do. I mean, what I'm trying to think of what the average person is going to do, they're going to call their general practitioner and asked to get a physical probably

Jennifer Smith, CDE 3:28
correct, typically, or if they've got if they've had enough types of symptoms kind of building up that they're concerned about. They would call with a specific concern, right, not just to get a physical but like, I think something's going on. I feel like this. I don't like how I'm feeling. I'm tired all the time, et cetera. I think I really need to come in and many adults get into the habit of not even going for a yearly physical. Right? Because I'm healthy, I feel fine. And I get a cold once a year and everything is totally fine. And I'm up to date on everything. So what do I need to see my general practitioner for? Yeah, then you start feeling nasty, and many adults with a busy life. They put off that I'm not feeling quite right. And they put it off. And they put it off, because there are many things as an adult that we're trying to manage day to day and overall. And so you end up not taking care of yourself for a longer period of time that is probably appropriate.

Scott Benner 4:39
And you're sliding, you're sliding so slowly down that hill, in many instances, you don't recognize how far you've kind of gone, correct. Yeah,

Jennifer Smith, CDE 4:47
I mean, I think you know, as a preventative, quite honestly, if anybody takes anything away, it really should be. Even if you don't have diabetes, go to your general medicine. Medical Provider once a year, get your base labs done, get them done, get them evaluated, have a discussion, family history, all of those kinds of things. They should be being reviewed. Yeah. Because if you can catch a change in glucose levels, as we're talking about diabetes, if you can catch that earlier, I mean, what is it? I think the statistic is one in three Americans, right now has pre

Scott Benner 5:27
diabetes. How is that defined?

Jennifer Smith, CDE 5:31
So pre diabetes is, if we're looking at glucose levels, you're looking at fasting levels that are above 100, but not in the realm of diabetes. And if we're looking at a one C, which again, is a parameter that, I think it should just be added, with this yearly visit, every single year, you should just have an A one C thrown in there, kind of like they throw in cholesterol and you know, your complete panel, just throw the a one C in, if we can catch and have somebody know, well, goodness, this level has gone up, it's not where it used to be. pre diabetes is defined as the a one C 5.7, upwards to 6.4. And anything above 6.4 is diagnostic of of diabetes. So you've got this, this window of ability to navigate management. Again, the problem being that many adults have put off a lot of their own health care. Unless something really doesn't feel right. And sometimes that's you're well beyond prediabetes at that point,

Scott Benner 6:38
what are some things that I can see in my home? That I don't need to go to a doctor for? Like, I'm trying to like? Do you get tired after meals? Like what are indicators that your blood sugar is high, like physical indicators for people, not type ones, right? Like, is there anything I can like say to myself, geez, maybe this is an indicator for me? Or do I need to do the testing, even just to know.

Jennifer Smith, CDE 7:03
So pre diabetes, the unfortunate thing is that there are not really signs or symptoms, honestly, it really would involve testing. I think those who, who may be concerned already have had some testing done, everything looks like where it should be. But if you really want to keep up with it, get a simple glucose meter from your pharmacy, and just do your own random testing. And this would go because we know that type two has a genetic component to it. This would go for those who especially have a strong family history of type two, or maybe have some metabolic things that they already know about, that could potentially predispose them to diabetes.

Scott Benner 7:48
So what blood sugar Am I looking for? When do I test?

Jennifer Smith, CDE 7:52
Yeah, so fasting blood sugar should really be again, under 100, under 95, and somewhere under 95 to 100. Right? That's a fasting level. And that would be without diabetes, which is the reason that in diabetes, we focus on that, like, Oh, my fasting was at today, that's perfect. That's right where I want to be. And then you know, in terms of of diagnostic, then we not only often look at an E one C level, but also lab work that kind of goes along with that, right? So blood sugar levels in the aftermath of meals, if you're doing any of your own testing really, in they shouldn't be rising above that 140 mark, honestly, they should be kind of coming right back down on their own. So those are some of the things that you could be looking at, again, if you are someone who is trying to pay attention, and stop it before it gets to a diagnosis of type two diabetes.

Scott Benner 8:56
All right, well, okay, so now I'm motivated, and I'm gonna go to my doctor. Now, here's some feedback from people in the in the, in the group, but standard of care for type two globally is terrible. It goes like this Metformin, long acting insulin, eat better finger wagging. That's it, you know. So I know a number of people have type two diabetes. So I'm sort of calling off my knowledge from my private conversations with them. I'm going to make an amalgam of these people and talk about it, right. They go in, they don't know, they have a problem. We've already gone into this, right? There's no real symptoms, they find out they have this issue. And then what happens next is scattered and they leave more confused and scared now on top of being confused right before they were like, I'm fine. Then they get in there and they're like, oh, it's not fine. I have pre diabetes. I think I'm gonna get type two diabetes, or I have type two diabetes and They get a meter and no direction. And they get told to eat better and come back in six months, and we'll see if this gets better. That's about it. Right?

Jennifer Smith, CDE 10:10
That is, that's the best in a nutshell. 100%, correct? Absolutely. I mean, it is. Because consider going to the doctor, even if it's just a random once a year, right? And you think I'm feeling fine. I don't think there's anything going on here, right? And diagnostic for type two, not just pre diabetes is fasting levels above 126, which, in diabetes, were like, Man, my blood sugar's 120. You know? I'll take that. Take her, you know, I mean, some people are like, Oh, 120, I gotta like, go take a walk, I have to get that back down, or, you know, whatever your targets are. But in type two diagnosis, or diabetes diagnosis, it's fasting above 125 126. and above, right? So when we're looking at going to that doctor, maybe you did have some fasting levels done, maybe there wasn't an emergency in it, but there was a fasting level done. That should be an instant discussion that the doctor brings up, hey, your levels are here. I mean, many times they focus on the lipid panel, or like your cholesterol panel, right? Oh, look at this, and they want to add these medications in and whatever. But the other ones are very important. And glucose, I think is I want to say that it's missed. But I think it's, it's too coded over. And it's not explained well. So the doctor who spies it, and says, Well, gosh, you're fasting is here, let's have you come in again, and do another fasting level, or, Hey, this level means that you could have type two diabetes. And in order to best evaluate, let's get an E, one C done. This is what the a one C means this is what it will show us. And so you can see all of the steps of discussion that should be given to the person, just from one test result, you can't necessarily prove however, something like an A one C would be very, very beneficial. Because that's as we all know, a good overall of how your glucose has been managed by your body for a bit of time already, not just this one point of time fasting level.

Scott Benner 12:29
So So what's going to happen, right is that people are going to be told, eat better, that's it's going to be very simplified, they're gonna say you got to eat better. Meanwhile, you might go from actually eating perfectly well, to not knowing what the hell that means, like, you could run that gamut anywhere. But what I see when I speak to people, is that they go home, and they do eat better. And then they come back to the doctor, and nothing's changed most of the times. And then you get that like, hands up in the air feeling or you are you get put in a position where you're a person who really doesn't eat well. And now in your mind, you're picturing three little crowns of broccoli, and a quarter of a chicken breast with a little pepper, like sprinkled over it, you're like, Wait, that's how I like you don't mean, and then I talk to people who do that, they get that and then it doesn't matter. Because, you know, like, that's not the whole answer. Right?

Jennifer Smith, CDE 13:26
And what does what does? What does better in any sense mean? Betty better is nondescript, right? Yeah. It doesn't give you any good avenue to follow to improve in one way or another. So eat better? Well, gosh, Doc, do you know how I'm eating already. I'm already trying to do this, and this and this. And I might have one Friday, every other weekend, that I do something with my buddies, or, you know, I go out with my girlfriends or whatever. But in general, I do think that I'm doing pretty well. I think that what ends up happening in adult diagnosis is that you are given this information. It's very lacking in

Scott Benner 14:14
their education and their basic assumptions.

Jennifer Smith, CDE 14:17
They're based on assumptions that you can say that the doctor can tell you go eat better and go get active. The doctor thinks that as an adult, you you know what that means, right? That you can take that and you can run with that information. But as you know, those with type one really know, we need more information. So someone with type two who has lived a lifetime thus far into whatever age of diagnosis as an adult, you've gotten to, you're looking at a significant amount of change, and not having anyone point you to where to start. That's very frustrating. And so you might leave you know In terms of what, what can you ask, right? When you are at your doctor's office, and they say, Well, you know what your your levels are looking like this. And it looks like you have type two diabetes. Okay, Doc, what does that mean? Point me to some resources, right? Am I going to need some medicine? These are all questions that unfortunately you as the person, you have to start asking. Yeah, and a lot of people don't yeah,

Scott Benner 15:25
this is the time where you think yourself like, why am I listening to a conversation about type two diabetes with a guy who's the father of a type one, and a lady who's a type one and and you know, well, first of all, JD is also a nutritionist. But that's, you're listening to us because we know how to advocate for ourselves. And because that, that's where that's where the big differences between type one and type two become important type one diabetes, you get it, you're dead in three days, if you don't take care of yourself, right? So you have to figure it out. And then like it or not, most people don't get decent direction with type one diabetes, either. So you go home, and you're like, This is on me, like, I gotta, I gotta, I have to figure this out. I have to read about it, I have to find somebody who knows it's you get into a mad panic to figure it out, you know,

Jennifer Smith, CDE 16:15
either that or the person with type one, especially as a caregiver, or as an even as an adult diagnosis a type one a lot of people are, they beat down their doctors door? Yeah, they say, this is not working, you will call me back, you will respond to this. What can I do different? Where can I get more information? They are, again, I think advocate advocating in a way that means they're requiring someone to respond to their questions. Unfortunate with type two is, again, the way that somebody is sent out the door with a diagnosis. It's almost as if you're just given this little bit of information. But it's okay. If you if you just take what I gave you and you eat better, right? Don't worry about it. There's no definition to when to come back. Where to seek out additional help. What does your medication even do? I'm telling you to take this and do this this many times a week? What does that even mean? How am I gonna feel from this? So these are, these are all the questions that I think from an angle of type two diagnosis, you have to take it on yourself, and you have to go back to your medical team. And you have to say, Steve told me to do this. And I started with these base things like you said, I've cut down in my my eating or I've portioned better, or I've started to take a walk three times a week when I have some time. And how do I measure that this is doing anything, doctor? How do I know that this is making a difference? Right?

Scott Benner 17:51
That's what I was saying earlier, it's one of the biggest problems is that when you're when you have type one, you'll know you're not doing well in a few days when you slip into a coma and you're in DKA, right? But type twos don't have that happening in that moment. So you might go along just the way you like, you have to really think about this before you go to the doctor and did the blood tests. You thought you were okay. How would you like to know what your blood sugar is, without poking a hole in your finger, you can with the Dexcom G six continuous glucose monitoring system, which is available@dexcom.com forward slash juicebox. Not only this Dexcom offers zero finger sticks. But you can get your glucose readings right on your smart device that's your iPhone or your Android don't have a phone. That's okay. You can use Dex comms receiver on any of these devices, you're able to set up customizable alerts and alarms, setting your optimal range so that you'll get notified when your glucose levels go too high or too low. End, you can share this data with up to 10 followers. Imagine what that could look like your child could be at school, and their data could be available to you, your spouse, their aunt, the school nurse, anyone who you choose. My daughter has been wearing a Dexcom for ever, and it helps us in multiple ways. Around meals, we're able to see if our boluses are well timed and well measured. If they aren't, we can tell by how her blood sugar reacts and then go back the next time and make an adjustment. Without the Dexcom CGM were sort of flying blind, but not just at meals. Also during activity and sleep. The Dexcom offers us an unprecedented level of comfort and security, being able to see my daughter's blood sugars in real time and not just the number but the speed and direction is an absolute game changer if you're using insulin dexcom.com forward slash juice box head over there today to see if you're eligible for a free 10 day trial. file of the Dexcom G six. The Dexcom is at the center of how we have been able to keep our daughter's a one C, between five two and six two. for over seven years, we've been able to minimize variability and keep her blood sugar's in a stable range because of the information that we can see with the Dexcom. These are our results and yours may vary, but using Dex coms feedback has helped my daughter without any food restrictions, live a more normal and healthy life dexcom.com forward slash juice box. And guess what in about three weeks Arden's gonna start using the Dexcom G seven. So I'll be able to report back about that just as soon as we have some information. Okay, so you've got your CGM, you're all set with your Dexcom. But you still need a blood glucose meter, right, you're gonna have to check your finger. Sometimes, the one that doctor gives, you might not even be accurate. But you can know you can trust in your soul, that the contour next gen blood glucose meter is one of the most accurate meters you can find contour next one.com forward slash juicebox. couple of cool things about the contour meters. One of them is that they may be cheaper in cash than they are through your insurance that goes to the test strips as well. And those test strips have Second Chance testing, meaning if you kind of touch some of the blood, but don't get enough that you don't ruin the strip, or the accuracy of the test. By going back and getting more blood you got a second chance those strips that meter all the meters, check it out, go to my link contour next.com forward slash juice box. Click on Buy Now it's orange and blue. And it will take you to a number of places online links of that so number of places online where you can pick up the contour meters, places like Walgreens CVS Meijer, target right and more, you'll see it there at contour next.com forward slash juice box, get an accurate meter

then you get the blood tests you find out you're not. But then when you go back home again, things sort of go back to like the way they were correct. And as you get farther away from that doctor's appointment, you start feeling calm, okay? And then so you don't know that things are either getting worse or not getting better until the next time you think to call the doctor to make an appointment to get more bloodwork, which no one wants to do. It can come six months or a year sometimes. Yeah, and then you find out I'm either no better off or things are sliding further. And an exercise. Listen, it's obvious, you know, we all need exercise like like, right, like, that's fine. But people have lives. And they some people just don't exercise very much. Some people don't have the money to buy decent food. And some people don't know what any of this means. So you didn't know before you get to the doctor, you find out you're in a situation you still don't know anything different. The guy just said, eat better exercise, come back and see me sometime. Get yourself a meter, you have to dig in and figure out what this means. Like you have to decide like, am I gonna be the one that takes care of this? Or am I gonna sit around and pretend this isn't going to get worse, right? And I'm here to tell you it is going to get worse.

Jennifer Smith, CDE 23:35
Because there are a lot of if you kind of set it the right way. It's like you you've given this, you've gotten all this information, but on your end, now it's up to you, unfortunately, it's up to you to go and look for more like what does this mean? And there are there are a lot of good resources for type two diabetes management. I mean, the internet is endless, right? It is an endless wealth of of information where you get the information from could be great or not so great. But there there's a lot of good information but if you don't even know what you're supposed to be looking for, again, it's it's a sense of confusion and frustration. And you know, I think we talked about it before like this sense of, oh gosh, I've I've now I have this to take care of Clearly I've not done anything right It's like a It's a self blame and you feel bad about it and you're not you're not maybe you've got a family to take care of and now you've got also this thing to take care of for yourself and it's another load on the pack of stuff that you have to manage.

Scott Benner 24:48
Shame on you the shame and guilt pile on and it just and I think here is the place to say like I've done this in the type one series and in the in the pot To cast and I just think it belongs here to, I don't think people know why it matters that they have diabetes, I think they know that diabetes is bad. And then they relate it to people being overweight, and then they relate it to something they saw happen to their grandparents, right, like nobody really understands, there is a certain amount of glucose that should be in your blood. And when there's too much, it begins to rub. inside of your body, everywhere, blood glows, the tiniest little veins and your eyes, arteries everywhere, everywhere, there's a course glucose on there, and it's rubbing. So just think of yourself as being sandblasted from the inside out, like there's a certain amount of glucose that your body can deal with. And there's a certain amount not. So when you hear somebody say, Oh, my grandfather lost his leg to diabetes, you don't really know what that means. You know, when you hear somebody say, I had a heart attack, or he had typed he had diabetes, and he had a heart attack, he had a stroke, he doesn't see anymore, he can't feel his fingertips, all these things that you hear, it just means that the glucose inside of your blood, which was too much for it was rubbing, rubbing, rubbing, and it causes and I liked the way you describe it better causes little, like utopia we talked about at one time were kind of like, like, what's

Jennifer Smith, CDE 26:17
like little abrasions inside, right, and so your body then has to, to patch them, right? It has to heal that your body is a really good self healing machine. So it sees all of these scratches, if you will. And it wants to put a bandaid on it. And the problem with that is if you don't take steps in your life to improve the glucose levels, your body will continue to get deterioration in the vessels on the nerve cells and everything. And your body will continue to patch and patch and patch. And so, you know, I know people can't see me like my hands getting closer. But if you imagine a vessel as it's sort of narrowing, the reason that heart disease is a big part or could be a complication with diabetes is that the more vessel level damage that there is, the more narrow the vessels get from all of the healing and the patches that the body has tried to help. And so now your blood pressure goes up. And now cholesterol levels go up and all of these pieces. It's like a snowball effect, right? Yeah, yeah, I

Scott Benner 27:29
mean, I just try to imagine a three inch pipe and has a hole in it, you slap some putty in it, and then it starts leaking, again, you slap and more putty in the 20th time you slap them putty, nothing can go through the pipe anymore, you high blood pressure, right bloods moving through that pipe, you're restricting it, you're increasing the pressure, the blood in your system, high blood pressure, this is just, here's the thing. diabetes untreated, and a type one is going to, it's going to get your way before these things can happen. But in type twos, this is this is where you're on your way to it just it just is and you're not going to it's not going to stop on its own. So you have to step up and do something and when you run into a doctor who's given you, but now, bullshit, that isn't going to help you, and they just are running you back out of the office again, you can't just go well, that's what the doctor said. So I guess that's okay. Because the doctor won't be there. When an artery in your heart gets blocked. Or when your vision is that doctor won't know though you'll get a different doctor, then we'll say something to you, like, oh, did the last guy not telling you about this, which is not going to help you. It'll be fun. It'll be easy to be mad at somebody and to blame somebody. But if you really want out of this, you got to do what you need to do. And that's why in future episodes, we're going to talk about technology and medications and insulin. Because from my perspective, when I think about me, if you told me right now, I had pre diabetes, and I went and did the things that I was supposed to do. And I came back and nothing had changed. I would immediately go to getting help. Because yeah, so I can turn the ship around on my own. I don't want it to take on water. Like that's how that's how I would think of it I would go immediately to keep me as healthy as you possibly can. And slow deterioration as much as possible.

Jennifer Smith, CDE 29:27
Right. Yeah. And there are and that's why I think the word advocate right becomes really important any, any time you go to your doctor's office, even if it is just for your once a year checkup. You have to be rented ready to advocate for you. Hey, Doc, I've noticed this or I seem to have this Well, the doctor then in terms of what you've brought in, she'd say, Well, gosh, it sounds like you see the eye doctor right? I'm not seeing quite as well or my night vision is go Okay, let's go get that checked out. Right. But if you don't bring those As pieces up to your doctor, then the doctor can't provide back any further suggestion. And so with type two diabetes, advocating by saying, Well, gosh, you've told me to do these things in this first visit, what does it mean to have high blood sugar? The doctor should be able to answer that for you. Right? And on a very base level and what Hey, Doc, what should my blood sugar be? You said that it's high in this lab result that you have in front of you? Where should it be? What am I aiming for? So these are questions that you may not know to ask. So hopefully, you know, hearing this, you you may know better. And or you can help somebody, you can teach somebody else,

Scott Benner 30:44
I want you to be ready with questions and know the answers to the questions already. Otherwise, you'll accept anything that's told to you, and I'm telling you, you are going to get advice that sounds like I don't know, like, Hey, Doc, I have this cello here. I don't know how to play it. But I want to play Bach, what should I do? And the doctor is gonna say something like, oh, you should sit down, take the bow and play Bach and skip a lot of the stuff in the middle. And so you're gonna get a lot of, it just sucks. Like, I don't know another way to say it. And if doctors are listening, I'm sorry. Like, I know, you think like, oh, there's a lot of Doctor hating going on in here. Well guess what do a better job. You know, like, I think the problem is, is that for a lot of doctors, not all of them, they're going to see you with your type two diabetes coming. And they're just going to do the same thing everybody else does. They're just people. And they're just going to assume that you didn't live right. And this is basically something you've done to yourself. But that listening, it doesn't matter. That may or may not be true. None of that matters now, because here we are,

Jennifer Smith, CDE 31:48
right. And we need to take care of this now. And so from that level, you know, the doctors job, if there are doctors listening, certainly the doctors job at that primary care level is to be somewhat of an advocate in sending you out to the right person then, right, they should say, I don't know how to tell you how to check your blood sugar. Okay, but I want you to do it. So here are the education programs, or here is the diabetes educator, or here is the dietician that I'm going to send you to, for some baseline information. Yeah, they should have those as references and resources to provide to anybody, whether they ask for additional education or not, that should be on their prescription pad of, I've prescribed this medicine, I've prescribed this glucose meter, you also need to go and get information because I can't give it all to you. And I think even on a level of admitting that, I think many, many people hearing a diagnosis from a doctor would appreciate that that doctor says, I don't know much more about this, I have a baseline amount of information to provide you. These are the people that are going to help you navigate this in your life. Yeah,

Scott Benner 33:07
yeah, you have to find other people who already have succeeded. It's no different than anything else in the world, you have to look ahead of yourself and say, who's on this path, doing a good job? Like, I gotta go find out what they're doing. Because, you know, maybe they're, maybe their situations not going to be exactly the same as mine. But there'll be a lot for me to learn. And then I'll go find someone else who's having success and learn from them. Yeah, you can't learn from people who don't know, and you can't learn from people who are failing at it. Like you need to find someone who's doing and I know, failing and succeeding are bad words and healthcare and everything. But this is what we're talking about here. Like, like, you don't have forever. We all know that. Right? Jenny? Like doesn't go on forever. Yeah, unfortunately, once you're 60 your knee hurts anyway. Like, get in the game. You know what I mean? Like, this is this is the part here. Also, you have to realize that if you find a doctor, who is gung ho, and is like, no, no, we're going to stop this thing in its tracks. Here's this and this and this. Now, the here's the next thing, they don't tell you, that pill might make me nauseous. It might have me in the bathroom forever, that that doesn't make you feel good about taking the pill. And so you're even if you run into somebody who who knows what they're doing and knows how to help you, you still have to understand what's about to happen next. And is that supposed to happen? Is it supposed to happen to this degree should we be changing the the amounts the frequency, etc. You I know this sucks and people with type one who hear this will just know that this is part of their life, but this is a thing now. It's a thing you're in charge of. And and you you need to understand it and you need to stay on top of it. And you need to be the captain like piloting the ship. Like there's just you can't let anybody else do this for you. Because they're not going to be there. It is where you start seeing overlap in the conversation. And if you have type two diabetes or prediabetes, you don't know this. But Jenny and I are sitting here looking at each other. This is where the overlaps with type one start coming in. Like you have to, you need to go out get the information you need to be paying attention to the outcomes of what you do, you need to be thinking about what can be adjusted here is the time of you skipping through life is it's kind of over now that you're in charge of something important, you know,

Jennifer Smith, CDE 35:30
right. So and that's, that's hard for, as I said much earlier, from a lifestyle angle. This is a lot of adjustment. And when you're already as an adult, especially when you're already on a routine of doing things a certain way, and it gets you through your week, and you make it to the weekend. And then you've got other things that you have to do. You have to learn how to work this in. And unfortunately, it's not a well learn how to work it in in a couple of weeks, when I've got time, kind of like straightening up your office three weeks from now, when you've got time. That's not how this works. And I'm not I mean, it's not funny, but it makes me laugh a little bit, because honestly, it's, it's like a here and now you have to start making a shift and a change. And I think that's why the very simplified information the doctor gives you is like, we'll just walk out of this office and just change up a bunch of things. But it's downplayed to the degree that it's not really something to worry about too much. Yeah,

Scott Benner 36:31
they leave you feeling like it's not that big of a deal, right. And then and from the perspective of other people I've spoken to, then it goes on for a while. And one day, the doctor looks up and thinks that guy's been coming in here for two years, nothing's getting any better than they look up at you and yell at you. And they're like, you're gonna die. You're like, Wait, what the hell? Like, what, like, you gave me a meter, you told me to eat more chicken, like, now I'm dying. You know, like, it's just it's

Jennifer Smith, CDE 36:56
are the addition of so many more medications, like you said, you know, you've come in, you've come in routinely, you know, for the past two or three years. And while the doctor might now be looking at some baselines of numbers, while those numbers aren't improving, okay, well, as we all know, a one C again, is it's an average, it doesn't show day to day what's happening. So unless you've got finger stick data, or unless you can advocate and coverage is okay for you to get a continuous glucose monitor. All of these pieces could show the doctor that while he or she has been adding more medication that hasn't been helping, so there's got to be something else to provide, rather than just loading you up with more medicine.

Scott Benner 37:45
I'm gonna tell you right now, I the the insurance system works the way it works. And people's money is what it is. But you make me the king of the world. If you're not regular. If your body doesn't regulate your blood sugar, well, you get a glucose monitor a continuous glucose monitor, you're wearing a Libra or a Dexcom or something like that, if you put me in charge, because it just teaches you so much faster. I see how this food impacts I see what this medication did I see what my exercise? Did I see what my better sleep does like it all. It's right there for you. So yes, yeah, if you will argue

Jennifer Smith, CDE 38:20
Exactly. If you've got a good insurance, absolutely argue from the start, and it's snowing again. Do you know enough to argue, this is why I think this information is so important so that if you are more newly diagnosed or you're not, and you didn't know what to argue for, you're thinking, Well, why didn't anybody tell me about this? Yeah, gosh, I could have a lot more, you know, beneficial information. But I didn't know to even ask for.

Scott Benner 38:48
And now it occurs to me to say, a continuous glucose monitor is a device that you wear, and it's measuring, this is boring for you, but it's going to measure the glucose in your interstitial fluid and on a receiver or your cell phone, it's going to show you constantly where your blood sugar is the number if it's moving up, if it's moving down, how fast it's moving up, or how fast it's moving down. And then eventually these you know, these plot points give you a graph that show you the last three hours last 12 hours last 24 hours. And there's so much to learn from that. So while we're sitting here telling you learn about your diabetes, the easiest way to do that is to wear a glucose monitor. If you told me today I had pre diabetes, I don't think the doctor would get it out of his mouth before I said, I need a Dexcom right now give it to me. Right so

Jennifer Smith, CDE 39:37
and there are there are some platforms to that even there. They're like the weight loss types of platforms now that are using some of the continuous glucose monitors, just from an overall health like visibility. They they're not even specific to diabetes. They're just Hig get a continuous glucose monitor and use it with our weight management system. So you can see how the effect Have all of these things in your life? What what's happening,

Scott Benner 40:03
I'm recording soon with a person who uses the talks to people about how to use a glucose monitor just to see the impacts of the food on their life, not people who have diabetes, but for other health reasons. And it's just I'm telling you, you have to I know the word advocate seems boring, but you, you really just have to fight for yourself. You just you have to, like, I'm gonna kind of end with this, then I'll let Jenny say what whatever she wants to end with here. But my daughter is walking around now 18 years old. She is 16 years past the day she was diagnosed with type one diabetes, her a onesie has consistently been between five two and I used to say six, two, but now she's in college by herself. So between five, two and six, five, she lives every day. She's not afraid of her diabetes. She's using her insulin when she's supposed to she manages her food and her activity and her illnesses. And I am telling you that she is in that position right now because of two things. She's in that position right now, because of how seriously I took it when she was diagnosed. And because of how seriously she took it as she got older. It's all about I don't know, like, it's like, it's probably like trying to hold a tornado in your hands if you're a giant, right. But you can try, right? Like, it's not easy. But it gets easier. It's not, in the beginning, it is not something that will make sense to you. But you can make sense of it. And then it's not something fun. Like nobody, nobody listening, you know, was like, Oh, I know how my life's gonna go, I'll be great at T ball. And then I'll go to school and I'll meet a girl, then I'll go to college, we'll buy a house, we'll have kids probably get a dog, I'm gonna get a car, the car, I always wanted my whole life, those kids will have kids, it's going to be amazing. I'll go to Florida. Like, I know, that's what you thought was gonna happen, or some version of that, you know, people are probably like, this guy's idea of life is very boring, like so. But, but But okay, but like, you had some path that you thought you were gonna go on. And now suddenly, in the middle of it, somebody's like, No, you have diabetes. These other things still can happen. They can happen exactly the same way, except now there is an amount of your, of your bandwidth every day that's gonna go towards this. So you're gonna have to, you're gonna have to give it to it, or you don't end up in Florida at the end. Right, you know?

Jennifer Smith, CDE 42:27
And, you know, I think you bring in it's sort of like a, it's a behind the scenes to what you're saying, honestly, because I've said before, nobody would want to live in the land of Jenny. Suffer, Jenny. Because there, there are so many things that in everything you just said, all of these shifts and changes, unfortunately, from a light their lifestyle perspective shift. And from, from what we know about type two diabetes, there are many lifestyle things that we could be cleaning up in terms of potential prevention. Does that mean 100%? Prevention? No, it does not. But there are a lot of lifestyle things that you will end up learning you need to shift or change that are not well described by the doctor. But had we started with them earlier in life.

Scott Benner 43:26
You might be here now or maybe it would have happened later or less severe. Like, I think there's there's this thing, we're always going to be talking around that we don't want to blame people for further help. Oh, yeah. And we certainly don't want to, but you should know that somewhere everywhere. There's a person who stands six feet tall, super handsome, nice and lean, very athletic, blah, blah, blah, and has type two diabetes. Yes, right. And that same body style has type one diabetes. And somewhere there's a person who needs to lose 150 pounds, who has type two diabetes, there's also doesn't, right? And there's also somewhere a guy who needs to lose 150 pounds, who's never gonna get diabetes in his entire life. Like, the problem is, is that our brain shift to building a person in our head visually, that we think looks like didn't take care of themselves. And that is not a factor here. Like, but, but for the person it is a factor for it is a factor. It is a factor. Everybody like you can be you can be wildly overweight and healthy, you can be wildly in shape and have

Jennifer Smith, CDE 44:34
medical problems. Absolutely.

Scott Benner 44:36
Trying. The point is, is that the rhyme or reason to all that is bullshit, except to the person who it isn't. So if you're a person who eats poorly, and you know is you know, I don't know just eating food, you probably shouldn't be eating and you're carrying extra weight and you have type two diabetes. Well then here are the things that we can fix right now. And my

Jennifer Smith, CDE 44:57
you have to take the variables you have the ability to control. Yes.

Scott Benner 45:01
Yeah. And you also have to get rid of the. I don't know what like the pompous thing of like, well, I'm in such great shape. I can't have died. Well, yes, she can. So, right. Yeah, metabolic metabolic, right. Like, it's just, it's one of those. Yes. So I think that I think that I want people to, because I always come down on the side of when we start talking like this. It's like, I don't want to blame anybody, mostly because I don't think it gets us anywhere. Like, you know, like, we're in the point. Now, I obviously, this is a podcast, you listen to a podcast, you can easily turn on another podcast that would say to you, like, you haven't problems with your health, you know, whatever. They say, like who rose the boat, you get out there run 19 Miles eat a piece of chicken the size of a Bic lighter. That's your day? Yeah, you can do it. Like, I don't think that's reasonable for most people. Like I just don't you know what I mean? So, so here we are, we're in the situation, just because I'm not the person who's gonna run up the beach every morning at 4am Doesn't mean I deserve to die. Right? Right. Like I get a life too. So here's the ways to get to that. You don't need to be perfect to be healthy, and you don't need to be perfect to deserve things. And I think that, I don't know, like, I've just I've had some conversations with people specifically who have type two diabetes, and it feels like, it can feel like they're like, Well, I did this. And now this is what I get. And I just don't think that's the case. And I don't think it needs to be. So we're going to try to get you through that in this series. Yes. Cool. All right. I'm sorry, Jenny. Somehow, it was upbeat and a bummer at the same time. sad things and a happy voice. And it was confusing

Jennifer Smith, CDE 46:41
to me. I got something it was confusing.

Scott Benner 46:45
I just they think about people in my life who were in the situation. And there are some of them who are not doing anything about it. And I don't think it's because they can't, or because they don't want to, I think it's because it's confusing, and no one's helping them.

Jennifer Smith, CDE 47:00
Right. It's a lack of information. And it's a lack of, it's a lack of knowing where the right information is, or even where to start looking. Honestly. And so, again, from the standpoint of your medical practitioner, advocate and ask for more information, because I guarantee you, while doctors are educators in a in a sense, they are not an educator, they are not there to sit for 45 minutes, and teach you things. It's not their job, either. That's not their job, and but their job is to provide you with information about where to get the right stuff to navigate with. And so they should have references and resources, again, diabetes education classes, especially for type two diabetes, there are a series and a number of education like ours that you can have within a year's time based on insurance coverage. So those are things you may have to ask for them. But don't be shy. Don't be shy about asking for them say, Hey, Doc, great. I think you've given me some information. Now I know what I have. I know why I've had, you know, some blurry vision. I know why I've had to go to the bathroom a lot more. You know, I'm more thirsty than I ever used to be or whatever it might be. But now, I don't know what to do about that. So can you send me to somebody who can teach me you have to ask

Scott Benner 48:27
you're in the game. You're in the game. Now I know. It. I know. It used to be. I broke my arm. I went to the doctor, he put a cast on it. I came back in six weeks, he took the cast off of it. The doctor did the thing. I didn't feel good. I went to the doctor, I cut my hand I had a cold. There's a lot of resolution in those relationships, right? Yeah, a thing happens. You meet the person, the person resolves it for you. It's over. This is not that. No, so this is different. You're you're you're, you're a real adult now. And you're sick, you know, something. And it's and it's on you. And you know, it's funny. I'm getting ready to see a new doctor. And I've been building a list in my head and I literally just went back to when I was young and I started writing down everything that's ever happened to me. I'm like, I don't know how much of this I'm going to tell them or not. But I looked and I thought How the hell am I standing up? Like, like, my shoulder, my knee my this my that like, and I look back and I think like, this is where that song came from. Something something I never promised you a rose garden. mean, like, my expectation was my shoulder wasn't gonna stop working during my lifetime. But here we are. Yeah. And so it'll either hurt and it won't work or I will figure out the best path to get it fixed. But I'm not just going to show up and tell somebody and they're going to wave their magic Doctor wand over my head and it's all gonna be over so you have diabetes, take care of it. That's what I got. Now. I'm frustrated. I'll talk to you later.

Jennifer Smith, CDE 49:54
Okay, sounds good. Thanks. Got it

Scott Benner 50:04
First I want to thank Jenny for coming on the show and sharing all of her knowledge with us. Jenny works at integrated diabetes.com You can check her out on their website. I also I also, I also want to thank Dexcom, makers of the Dexcom G six and G seven continuous glucose monitoring systems dexcom.com forward slash juice box, find out what your blood sugar's doing, how fast it's doing it, and what direction it's going in. And of course, you need you want you desire an accurate blood glucose meter, contour next.com forward slash juicebox. Check it out, please, they're fantastic

if you have type one diabetes, please go to T one D exchange.org. Forward slash juicebox. You have to be a US resident have type one or be the caregiver of someone with type one to take their survey. But that survey helps move type one diabetes research forward. So please go check it out. Don't forget if you're listening to the podcast 35% off your entire order at cozy earth.com When you use the offer code juice box at checkout. And BetterHelp is a sponsor of the podcast and they're offering my listeners 10% off their first month of therapy. It's a great deal. I hope you can check it out. Better help.com forward slash juicebox. Now better help is the world's largest therapy service that is 100%. Online. They have over 25,000 licensed and experienced therapists, they can help you with a wide range of issues. All you have to do to get started is hit my link. answer a few questions about your needs and preferences in therapy. And that way better help will be able to match you with the right therapist from their network. Better help.com forward slash juicebox you're gonna get the same professionalism and quality as you expect from in office therapy. And if for any reason your therapist isn't right for you, you can switch to a new one at no additional charge. Do therapy on your terms, text chat, phone video call and you can even message your therapist at any time and then schedule a live session when it's more convenient. So if you're looking for someone to talk to check out better help. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

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