#1635 This Just In

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Andrea, 59, newly diagnosed with LADA, shares her late-onset journey, family ties to autoimmunity, and finding community after isolation.

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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 back to another episode of The Juicebox podcast.

Andrea 0:12
Hi Scott. My name is Andrea, and I am 59 years old, and I was diagnosed with LADA. I call it just auto immune diabetes, but usually for people who don't know about diabetes, I say type one.

Scott Benner 0:30
I am here to tell you about juice cruise, 2026 we will be departing from Miami on June 21 2026 for a seven night trip, going to the Caribbean, that's right, we're going to leave Miami and then stop at Coco k in the Bahamas. After that, it's on to St Kitts, St Thomas and a beautiful cruise through the Virgin Islands. The first juice Cruise was awesome. The second one's going to be bigger, better and bolder. This is your opportunity to relax while making lifelong friends who have type one diabetes, expand your community and your knowledge on juice cruise 2026 learn more right now at Juicebox podcast.com/juice. Cruise. At that link, you'll also find photographs from the first cruise. 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. This episode of The Juicebox podcast is sponsored by the contour next gen blood glucose meter. Learn more and get started today at contour next.com/juicebox com slash Juicebox. This episode of The Juicebox podcast is sponsored by the twist a ID system powered by tide pool that features the twist loop algorithm, which you can target to a glucose level as low as 87 Learn more at twist.com/juicebox that's twist with two eyes.com/juicebox. Get precision insulin delivery with a target range that you choose at twist.com/juicebox. That's t, w, i, i s, t.com/juicebox. This episode of The Juicebox podcast is sponsored by Medtronic diabetes and their mini med 780 G system designed to help ease the burden of diabetes management, imagine fewer worries about Miss boluses or miscalculated carbs thanks to meal detection technology and automatic correction doses. Learn more and get started today at Medtronic diabetes.com/juicebox

Andrea 2:41
Hi, Scott. My name is Andrea, and I am 59 years old, and I was diagnosed with LADA. I call it just auto immune diabetes, but usually for people who don't know about diabetes, I say type one, three years ago, three years ago and change. So this is all new to me.

Scott Benner 3:05
Yeah, you're 56 when you're diagnosed 59 now,

Andrea 3:08
yes, correct. I got it pretty much right before my 56th birthday. Happy birthday to me, happens more than

Scott Benner 3:15
you think. Question is, Do you have children? Yes or no?

Andrea 3:22
Yes, I've got two grown children, okay, and lovely,

Scott Benner 3:26
a mom, a dad, aunts, uncles, extended family. Do any of these people have type one diabetes? Nobody.

Andrea 3:34
In fact, I have never, since diagnosis, I have yet to meet a person who has type one out in the wild. I met people on, you know, Facebook groups and and stuff like that, but I have not yet met another human being with this even though I live in a very populous city, I worked with a woman a long, long time ago who has type one, or had type one, that was all new to me then, and and I still haven't met anybody else, yeah,

Scott Benner 3:59
but since you're diagnosed, you haven't met anybody, right? Yeah, right? Of that large group of people, your children, your extended family. Does anyone have celiac hypothyroidism? Do they have, I don't know, Crohn's disease? Do they have anything that relates to inflammation at all? Yes.

Andrea 4:20
And, well, it's funny, like looking at the tree, you know, the family tree, Nobody that I know. I mean, my dad had type two diabetes. He danced around type two for a long time. Nobody I know had that had anything like that. But one of my daughters has Crohn's, and the other one. It turns out that when I found out that I had type one, I also found out that I have antibodies against the thyroid, so Hashimotos and my my other daughter has that as well, even though we're both asymptomatic with that.

Scott Benner 4:58
Okay, so you have. Have the antibodies, but you don't have symptoms. You're not, let's see, right? You don't have trouble getting rested. You don't feel tired, your hair doesn't fall out. You know, a problem with your fingernails. Periods aren't none of that happens to you. No. So they, at least not that I've noticed, yeah, yeah. So they only checked because you got Lada type one.

Andrea 5:21
Yeah, yeah. I'm guessing. I can't remember them having checked before. Yeah, it never came up as anything abnormal before. What made them check your kids, my daughter, the oldest one, she there's like this whole push to try to find people you know, before they develop any symptoms of diabetes, you know, to see if it can be, you know, sort of stopped. And so, yeah, there's sort of a push to test your children and other family members to see if anybody has auto antibodies to, I guess, beta cells and all the other stuff. Gad 65 but also, because I had Hashimotos, they tested her for that too. And turns out she had that too.

Scott Benner 5:58
She's also asymptomatic. Doesn't have any sense. Yeah, she is. Did you get found by like, trial net, or screen it, like you mean it, or one of those things for

Andrea 6:09
trial net, that's the one I found. But, but I told my daughter, just go to the when next time you get a check up, go to the doctor and tell them that I was diagnosed and to please check you. Yeah. So she did what

Scott Benner 6:21
else, like any other autoimmune stuff that you've seen throughout your life, vitiligo, anything at

Andrea 6:26
all? Yes, I was just about to say vitiligo. My daughter, who has the Hashimotos, also has a little bit of vitiligo, you know, just a little bit, just a touch. And my sister has that also, you know, both my mom and my sister had thyroid issues. I don't know if it was ever the Hashimotos. My sister had thyroid cancer, and my mom had to take thyroid medicine, medicine for hypothyroidism at some point later in life. But I don't know if it was Hashimotos or not.

Scott Benner 6:53
Well, I'm gonna guess that maybe it is interesting. Okay, now we have a little bit of a background. Now you're, I mean, more than chugging along 56 years old. Had you had any major health issues through your life?

Andrea 7:04
No, no. And, you know, it's funny, because I always considered myself pretty healthy. And, you know, you sort of pat yourself on the back, and you're like, Hey, look at me. I must be doing something, right. I've never, you know, never had any kind of health issues. But a friend of mine called it the sniper alley of the 50s. And I don't know how old you are, you know, in the 50s, like all sorts of weird things started happening to random people, like a sniper alley. You don't know who's going to be hit. People get MS, people get cancer. And this sort of, you know, came to me, and I was just like, wow, you know. And so going from patting myself on the back for, you know, doing such a great job at keeping myself in good health. I was like, wow, what did I do wrong? Oh, and then I thought, well, you know, it wasn't anything I did wrong. I don't think,

Scott Benner 7:49
yeah, you know, it's like everything else. Like, if you're going to take the compliment, you have to take the blame. Is that how they think people think about it? Right? Exactly. So you're busy being like, I'm healthy because I'm doing something, all you had to do was give that away. Just say, Look, I'm lucky that I've been healthy this long and now you're not well.

Andrea 8:05
That's right, yeah, that's, that's exactly what it made me think. I was just like, hey, roll of the dice, you know, genetics or something that you catch, or, you know, just whatever you know. I mean, sure, there's some things that we can do to control our health, but, but there's a lot that we can't.

Scott Benner 8:21
Yeah, I'm, you asked me how old I was? I'm 54 and in your 40s, a couple of people you went to high school with die, and it's usually a heart attack, right? And then in your in your 50s, a couple more get it and and it's, it's more like what you're talking about, like a cancer or something really like feels very random happens to them, and it does feel like, it feels like you're those metal ducks at the at the fair, and you're just rolling along. You're like, Oh, I'm good, I'm good. And all of a sudden you're plink, and then you're gone, yeah? And you do imagine all the other ducks looking over, going, Oh, it wasn't me. Awesome. Yeah. It's funny. I used to tell my wife when we were I've been married a long time as we were married in the first five years, the first 10 years, for 15, the first 20 when people would get divorced, I'd always say to my wife, I'm like, you know, the more people that get divorced, the better chance we have not to be and she goes, how do you figure that? I said, we all can't get divorced.

Andrea 9:20
That's right, somebody has to be in the 50% that stays married.

Scott Benner 9:24
Yeah? Well, I'm not saying we're doing anything right. They're doing anything wrong. I'm just saying math. You know what? I mean? Like, like, you know when you do you enjoy baseball? Do you watch baseball?

Andrea 9:32
No, whole lot. Okay, but we can talk baseball if

Scott Benner 9:36
you want. No, no. I'm just saying 160 some games a year. You're gonna lose some of them, yeah, yeah. And you can be on a run like nobody's ever seen and then, you know, show up on a random Thursday evening and play some terrible team, and they hand you your and you say, like, and everybody wants to go, like, oh, they didn't play as well as they could tonight. I always say the same thing, like, now the numbers caught up with them. You weren't going to win them all. Right? So, right, yeah. Last guy.

Andrea 10:00
Do you remember when sky lab was falling from the sky and it was going to break up? It was like some satellite that was, you know, like, I don't know. We must it must have been in the 70s, maybe the 80s, and sky lab was going to fall, and nobody knew where it was going to go into the atmosphere. And some people started wearing hats, because, you know, the chances of sky lab hitting you are pretty small at but the chances of them hitting you, if you're wearing a hat, are even smaller. I don't know, a little faulty logic. No, you

Scott Benner 10:27
and I have a lot in common. I used to tell people all the time, did you know that frozen urine falls out of airplanes? Have you ever been hit with frozen urine? Never in your life. You never will be ice Yeah, exactly like so you know, I'm with you. I, as I get older, I my kids, what's the last thing they came to me, where I was like, Are these kids stupid? Like, you know, I mean, it was the, it was the drones over New Jersey thing, where my where my son, like, seriously, asked me, like, Should we be leaving? And I was like, Listen, man, Everything's fine. Everything's always gonna be fine. I said, when it's not fine, you'll know. And trust me, when it's not fine, you won't be able to prepare for it. So just, yeah, enjoy your life until the frozen pea falls on your head, and then, then we'll start worrying about how to handle it.

Andrea 11:13
Yeah, you're like, I don't know if that's comforting or not. It's like, enjoy your life like an ostrich with your head in the sand, because something's coming for you well, you know, but you know, it's true. You can't walk around worried about everything all

Scott Benner 11:25
the time. That's the way I think about it, like it's not that, it's not that I don't think it's like that might be real or that it might not be worth you know, if I was in charge looking into it, but I'm not in charge, and no one's listening to me, and most of the time this stuff works out fine. So I'm just going to pay attention to the things that I actually have control over, and the rest of it I'm going to pretend doesn't exist, because most of the time the pee doesn't fall on me. So I'm good, but so my point is, is that if you, if you go along that way, then you're allowed to say, hey, you know what? Life's random. And I've been randomly healthy for 56 years. What a great thing. Knock on wood. And now I have diabetes. It's not because I did something wrong. It's just because sometimes you can't, you can't beat the Marlins for some reason. It's just they're a bad baseball team, but they show up and they kick your ass, you know? And it's just it was, it was your day, I guess.

Andrea 12:14
Yeah, yeah. And, you know, I'm really grateful that, that I got this as late as I did. You know, it's like, yeah, it sucks to have this, but, but I just look at, you know, like young kids who get this, infants who get this, who don't get to spend 56 years enjoying really good health and and not worrying about being their own pancreas. Or, God forbid, you know, like you're a parent, like, like you are with a with a child, where you have to be their pancreas for them, and then until they can figure out how to be their own pancreas and, and then I think about the people who've had this for like, 57 years, or, you know, 60 and when the technology was just insane, like you had these needles that were like, huge, and you, you, you had To wait two hours to get your, you know, you have to pee on a stick to get the result on what your blood sugar was doing, you know, two hours ago and and then you have to give yourself insulin two hours figuring out what you might want to eat and whether or not you were going to eat it or get it in time. It's just like, Wow. This is, you know, this sucks, but it could be. It could suck a whole lot worse. Like, I guess

Scott Benner 13:24
that is more than a valid perspective that I agree with and and I would also tell you that the people who are on the flip side of that coin, like you said, Well, what about the poor kids that? Like, you know, my daughter was two when she got it, like, yeah, there are things that my daughter will experience and have the opportunity to understand in life that you won't get because you were super healthy for 56 years. Six years, 50, you know, whatever, and like, so everybody there's, I don't want to say there's like, a high side to diabetes, but there, there are things that you can get from it that are positive. You just have to be on the lookout for them. And it's not like, Oh, poor them. It's you just being like, I gotta look up here and see the the good stuff that's come to me and and something was gonna have I always think something's gonna happen eventually. I think if you think you're gonna, like, live till you're 98 years old and, like, you know, randomly, like, drop dead because you choked on your bubble gum, but everything else went perfectly for 90 I don't think that's gonna work that way for I mean, maybe it will for a couple people. They end up on the cheesy local news, but it's not how everybody else's life goes, you

Andrea 14:25
know, right? And then you have to play the hand you're dealt. You have no choice, right? You have no choice. You got to do

Scott Benner 14:31
it. So let's find out about the hand you were dealt. I first of all, how did you figure out that you were not feeling well? What came first? Today's episode is sponsored by Medtronic diabetes, who is making life with diabetes easier with the mini med 780 G system. The mini med 780 G automated insulin delivery system anticipates, adjusts and corrects every five minutes. Real world results show people achieving up to an 80% time and range. With recommended settings without increasing lows. But of course, Individual results may vary. The 780 G works around the clock, so you can focus on what matters. Have you heard about Medtronic extended infusion set? It's the first and only infusion set labeled for up to a seven day wear. This feature is repeatedly asked for, and Medtronic has delivered 97% of people using the 780 G reported that they could manage their diabetes without major disruptions of sleep. They felt more free to eat what they wanted, and they felt less stress with fewer alarms and alerts you can't beat that learn more about how you can spend less time and effort managing your diabetes by visiting Medtronic diabetes.com/juicebox the brand new twist insulin pump offers peace of mind with unmatched personalization and allows you to target a glucose level as low as 87 there are more reasons why you might be interested in checking out twist, but Just in case that one got you twist.com/juicebox that's twist with two eyes.com/juicebox. You can target glucose levels between 87 and 180 it's completely up to you. In addition to precision insulin delivery that's made possible by twist design, twist also offers you the ability to edit your carb entries even after you've bolused. This gives the twist loop algorithm the best information to make its decisions with, and the twist loop algorithm lives on the pump, so you don't have to stay next to your phone for it to do its job. Twist is now available in select areas, so if you'd like to learn more or get on the wait list, go to twist.com/juicebox. That's twist with two eyes.com/juicebox. Get on the twist wait list and be notified as soon as it's available in your area. Links in the show notes, links at Juicebox podcast.com.

Andrea 16:53
Oh, so I just come back from visiting one of my kids. It was like in the middle of covid, and one of my kids went abroad because she thought her university would go on lockdown. And she started college, you know, in 2020 when it was on lockdown. And so she was and it was a horrible experience. And so she thought her school was going to go back on lockdown in like 2022 and she decided to nanny for three year old twin boys in Switzerland, it's like best birth control ever. And so I went to visit her, and I, when I came back, I just started feeling all these like I had a yeast infection, a yeast infection that would not go away, and that had never happened to me before. I went to my OB GYN three times, my eyes started popping in and out of focus at weird, you know, random times, like suddenly I could see and then suddenly I couldn't I was exhausted. I was losing weight, but I was eating like a horse, and when I started waking up in the middle of the night dying of thirst, just felt like my mouth was completely, like desiccated, like it wasn't even thirst. It was just like cellular, you know, like I had, like, no moisture in my mouth. When I started doing that, I was like, oh, man, this is probably diabetes, and you knew that quickly. Or somebody had to tell you, I knew that, because I am actually a health journalist. And so I write about that. I write about, you know, wellness stuff, you know, I don't write about, in depth about diabetes. But, you know, I've been a health No, you don't know. I've been a health journalist for about 30 years. And so I knew, you know, this is, like, one of the basic things. But I just, you know, never thought it would be type one, right? Because it was covid. I, you know, it was like 1920, 22 and I hadn't been, I hadn't gone to get a checkup in a, you know, since 2019 let's just say, you know, up until that point, I hadn't had any problem with, you know, my fasting blood sugar levels or anything. And I had no idea what my a 1c was, because, you know, my my fasting blood glucose was fine, so nobody ever had to measure it. But I made an appointment with my primary care doc, you know, I told him, I just felt horrible. And I also noticed I had like a ring around my neck of like a darker skin, and I was like, Oh, I know what that is. I even woke up one time in the middle of the night, and I smelled something crazy and fruity in my room, and I turned on the light to see what it was, and it was nothing there. And so I turned off the light and fell back asleep. And then later on, in retrospect, I think, Oh, my God, that must have been, you know, yeah, like that fruity breath thing, you know, precursor to DKA or something. So anyway, I went, made an appointment to see my primary care, and he texted me the next day that, oh yeah, my a, 1c, was 11.3 and my fasting blood sugar was, you know, close to 400 and that's why it felt like like crap.

Scott Benner 19:55
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Andrea 21:07
I was going to New Orleans to visit my my my daughter at her college, and I was bringing my nephew with me. And so he, he just yeah, he assumed I had type two, and he put me on Metformin. So I picked up my little prescription before the trip my brother in law and I remember actually asking my doctor, I'm like, shouldn't I get, like, a little kit to measure my my blood sugar, to see and he's like, no, no, don't worry about that. But my brother in law, who has type two, said to me, Here, take this extra kit I have. You know, I have many of them. And so I took it and I started measuring my blood sugar while I was on that trip. And you know, if you know anything about New Orleans, you know, the food is really, really good. And even though I was trying to eat, you know, sort of what I thought was healthy, because I really didn't know how to control this. I mean, I wasn't eating dessert, but I had no idea about carbs and stuff. And I was measuring my blood sugar, and it was all over the place. And so I'd send him a message on my chart, saying, okay, my blood sugar was this when I woke up, and this during the day, and he's like, okay, double your Metformin, you know, still wasn't moving the needle. And then the next day he'd say, okay, take one in the morning, and, you know, one at night, and then double that, and it was just not moving the needle. So I sort of live in two different cities for reasons that are just complicated and whatnot. But I got back to the other city where he is not and I started calling around endocrinology practices, and I'm like, I need to get in to see somebody, because this is, this is crazy. And people are like, yeah, we can see you in three months. And I'm like, I'm going to be in the ER, in three months. We need to, need to do this before, you know, yeah, and so finally, somebody got me in on a zoom call, and a nice doctor, and I chatted with her, and she had me come in the next day and taught me how to use insulin and did a bunch of tests, and then was like, Yeah, you have type one. You have auto antibodies. So you

Scott Benner 22:59
live in two cities for reasons that are difficult to explain. Are they that you're a spy or nothing cool like that?

Andrea 23:06
If I tell you, I have to kill you? I was hoping it

Scott Benner 23:09
was something fun, but it doesn't sound like it. It

Andrea 23:12
is fun. One of the cities is New York, and I love New York, and I love to you know, New York is so much fun. And the other one is Atlanta, and Atlanta is sort of like the antidote to New York. It's a lot of fun, but it also has much more sunshine, and so I need a little bit of both. So, yeah, do you follow the weather? Do I follow the weather? Yeah, you know

Scott Benner 23:30
that, are you up here in the summer and down there in the winter? No,

Andrea 23:33
no, no. I mean, I just thought, I thought you meant, do I follow it on, you know, like, my app? No, no, that'd be crazy. Yeah. I just basically commute every couple of weeks. You know, I go back and

Scott Benner 23:42
forth to get a different look nice. That's awesome. I would love to do something like that. It is nice. I want to dig in first. I'm going to get back to your to your story. But I want to hear about like, how are you a health journalist for 30 years, and how has that changed in the last five or six years?

Andrea 23:58
Oh, well, that's such a big, broad question. I think media in general has changed a lot. You know, like, magazines have died. We have more than, you know, three networks. We have the internet. All these things happened. You know, while I was a journalist. I mean, when I started, we almost didn't even have computers or the internet, which is crazy. I mean, like, how can you be a journalist without that? But I feel like the things that have changed more recently, you know, it's like, everybody can put up a blog, everybody can, you know, be an expert now, which is, which is great, but it's also not great, because then we have people who, you know, sort of spread misinformation and and, or build themselves a certain way. So like, sort of the guard rails in that respect flew off, yeah, taken to the other extreme, it's like, well, it's a good thing. We don't have to have license, a license, to be a journalist, and we can just, you know, do our jobs without that, because then somebody could take that license away and if they don't like what you're saying, right?

Scott Benner 24:57
Or they could own the only way you could get your information. Out the world and just keep

Andrea 25:01
you absolutely so, you know, there's, there's a balance. But I think right now, we're in a place of a lot of Miss and disinformation. And, you know, as, I guess as a journalist, you feel like a sort of responsibility to get it right. You know, you got to get it fast, but you also have to get it right and and now there's even a distrust on what getting it right means, like the studies that I used to read and rely on, a lot of people now go, you know, that that's fake science, and that's full and that was, you know, blah, blah, blah, and, well, I still happen to believe in all of that stuff, you know. And I believe in the FDA, I believe in the CDC, I believe in the HHS when they're not politically weaponized, right? You know, when they're not weaponized. So that's my little soapbox, right? I should stop now.

Scott Benner 25:47
No, but how do you make a living after the democratization is over? Like after? It's not just like I have to work for a newspaper to get my thoughts out. Then it's, well, maybe I could work for a newspaper, or I could work for a magazine. Now, it's not even that, you know, it's not even like there's a radio station. It's going to let you sit down and give like your and give, like, your health note for five minutes or something that, like, how do you still do that for a living at this point? Like, I mean, I'm not looking for your your financials, but like, how do you, like, who pay who pays you for that? How do you make that work?

Andrea 26:14
Part of it is, throughout my career, I've gone back and forth into one company that which I love, and it's been great. And other times, I've worked at other companies. I even worked at a nonprofit for a while, on their magazine that, you know, you'd find in a doctor's waiting room. I've also freelanced, and you know, that's the rate. We used to get paid $1 a word, and now, you know, it's like, you don't get paid that. But I think people who want to do this and who succeed at the new way of doing it. It's a lot of social media, and they get sponsors and stuff like that. You spend a lot of time having to promote yourself, which is, I imagine, is exhausting. I have had the good fortune of working for a large media company that kept me with health insurance

Scott Benner 26:57
too. Yeah, yeah. The promoting yourself part is exhausting is not the right word. Even it's, it's, yeah, it's so frustrating, like that you spend so much time doing something where you're like, well, I could be working right now. Like, I could actually be thinking of something, writing something, recording something, having an idea, right? You know, instead I'm sitting here trying to think about, like, how do I what time of day do I post this so that enough people see it, so that enough people click on this, so that somebody will still buy an ad, so that I can actually go make the thing that I think is helping people. It's, it is really frustrating, honestly.

Andrea 27:32
Yeah, I'm sure, you know, it's like I was reading some posts that you put up about, you know, the cruise ship that you took. And I think right before you went on on this cruise, you know, people had said, and I didn't see the original post, but some nasty stuff, and it's like, you also have to spend time answering that, and you you better have all your ducks in a row if you're going to go in and be like, you know, no, because of A, B, C and D, and you've got to defend yourself. And that takes a lot of energy, too. A lot of energy.

Scott Benner 27:58
It's absolutely exhausting, because that your example. There is I'm I'm quite literally sitting at a gate waiting to get on a plane, to fly across the country, to climb up on a to go to a hotel, to spend the night there, to get into a car, to drive to a thing, to get on a cruise ship, to meet these 100 listeners and spend the spend the week with them, which is going to be awesome. And as I'm sitting there, someone not me, by the way, someone put something in my face and says, Hey, look, there's this person saying this thing about you. And I went and looked, and it was demoralizing, because I like that person a lot. Oh, I'm sorry. I can't even speak for them. I wouldn't know if they misunderstood something, or if it just has become advantageous to choose me as a foil, because that works well, because I have some popularity. Like, I don't know the where in the spectrum of of that that could have fallen, but I'm sitting there and I'm just like, oh, this is such a shame. Like, this person either believes this happened and it's such a shame because it's not what happened, and if I tried to explain it to them, they think I was lying to them. So, like, I can't, like, There's no way around it. You can't answer them directly, because now that's what they want. They're dying for you to come say something so that they can look like they're part of this narrative somehow and maybe prop themselves up. And in the end, it was just like, it was just sad. And I just, I sat there and I just felt sad for two minutes. And I was like, All right, fine. Now I can't not do something about this, because now somebody knows, and they're gonna move it around, and now I have to be on the record about it and like, it's just like, and then this is stupid. If on my deathbed I remember that five minutes, I'm gonna think what a total and complete waste of my time that was. And yet, here you are doing it, because in the moment, it's somewhat important because of the way this whole system is set up. Yeah, you gotta nip it in the bud. Yeah. I'm also not saying that it was perfect when, like, you had to work for the New York Times to get your opinion out. Like, I don't think that's I'm not saying that either, but I'll tell you the you know, it's funny, when I asked you about it, you went right to the idea of, like, well, who are we holding to account? Don't if nobody's needs to be accountable to anything, and they can just say whatever they want. That's not my first like Big Bad Wolf in that situation. The thing that frightens me the most is that I agree with what you're saying, that it's great to get other people's voices out there, but there's a tipping point where, if you over saturate it, you literally you kill the thing. You can't kill the cow that's giving you the milk kind of thing. There's an amount of people that will do a good job, and they'll put out good stuff for people, whether it's through a magazine or newspaper or, you know, a podcast or, you know, a blog. But if suddenly there's 10,000 people doing that, if suddenly, let's pick some abstract idea, if 20 really knowledgeable people are making videos about how to take care of your pets, and they start making a little money out of it, then what you're going to be sure of is there's going to be 10,000 people doing it two years from now. Oh yeah, sure. Then the information gets diluted. But what happens? I think the bigger problem, I think, is that the consuming audience sees so many options that they shut down and just stop completely, and then you lose the first 10 people who were really putting good information into the world, because they can't monetize it anymore, so therefore they can't spend time doing it. And now we all lose that's how I see it as being the problem,

Andrea 31:23
yeah, and it's overwhelming. If you know you're out there, we're all consumers of news, health news, let's say in particular, Tiktok, every day, has something about not every day, every second, many, many times a second, you know, like, what supplements to take, what to do, blah, blah, blah, this, that and the other. You cortisol, belly, blah, blah, and, and it drowns out everything. There's so much. Where do you even begin? Where do you even begin? Everything is wrong with you. Nothing is wrong with you. You take things because people say you should, and then you might be creating problems. It just and then the people who are doing good work do get drowned out. People are like, Oh, she works for, you know, big television station, well, must be false. Now they're spreading bad information. Well, no, these, these people do have, you know, they have standards and stuff like that. Yeah, I

Scott Benner 32:12
watched it happen very simply in diabetes blogging, 1015, years ago. Oh, really, really wonderful, like, focused, thoughtful, good writers who had a perspective, and they were sharing. And those 10 or 20 people turned into 100 or 200 people turned into 2000 4000 people. And then one day, I think everybody was just like, there's too much to read. I can't read all this. I'm just not gonna read any of them. And then that was it. People just stopped reading those blogs. Yeah, you know, you used to have a website. I won't say the name of it, but there used to be a website. It was for profit that had actual journalists who had type one diabetes writing stories about type one diabetes. And that doesn't exist anymore, because they couldn't make money in it. In when the paradigm shifted and 5000 people wouldn't have started up their type one diabetes blog, that thing would still exist. And so, you know, I can hear both sides of the argument, like, well, I should get a chance too, if they can be successful at it. Why? Why does that mean I can't be I'm American, I'm a capitalist. I agree with you. I'm just telling you that the end result is, when you flood a market, you kill it eventually.

Andrea 33:20
Yeah, chaos. People just are paralyzed by too much, too much information, you know, myself included, I'm like, Ah,

Scott Benner 33:27
of course. And the bad and the good both fall in the garbage together, and no one steps up to do it again, because, well, that's not how the system works anymore,

Andrea 33:36
well. And you see that with all the newspapers closing down all over the country. You know, it's like everybody gets frustrated when they hit a pay wall. If you're on, if you're online and you want to read something, let's say the New York Times. You know, you're just like, it's behind a paywall. How dare they? Well, they have journalists that they have to pay somewhere. They have cameramen. They have, you know, a whole infrastructure that that, but, but it's hard to monetize it. Like you said, how do you monetize it? And, you know, how do you separate yourself from others and and make it so that people want to spend $5 on your thing, your newspaper, on Sunday and whatever?

Scott Benner 34:13
So that's also a thing that I agree with, by the way, like, and I agree that it's a problem, and I agree with people not wanting to do it. I know that people don't want to pay for things like, I understand that, especially in a world where it feels like the answer exists for free somewhere, even though it's a little harder to maybe trust. But I had a company come to me a couple of years it's been maybe more than a couple of years ago now, and they were like, listen, we should just take your podcast. Here's what we want to do. We'll put it on a server, and you'll charge people for every episode, but it'll just be a very tiny little bit of money, and they'll pay. And how many downloads Do you have? And I forget at the time how many I had, but I'll tell you right now that I'm about to celebrate 20 million.

Andrea 34:55
Wow. Congrats. Thank you.

Scott Benner 34:56
It's very exciting, actually. Yeah. That's wonderful. Really proud of myself, but at the same time, imagine that company came to me today and said, Scott, listen, you have 20 million downloads. What if you just would have charged 50 cents for each of them? You'd have $10 million and that's the pitch they came to me with. And I responded back, and I said, No, I wouldn't, because no, nobody would pay 50 cents for an episode. And they said, Your episodes are worth more than 50 cents and easily. And I said, I agree with you. That's not the point. They won't pay for it. And then they pivoted, and they said, but some people would. And I said, Yeah, but then what about everybody else? Like, if I'm putting out content that I think is going to help people, how can I, in good conscience say, like, Listen, if this intersects 10,000 people today, I think it's going to be value. Going to be valuable to most of them, but I'm going to just have it intersect 1000 of them, but I'm going to make 500 bucks. Yeah, I exchanged $500 for 9000 people, not getting the content that day, just that day. And then don't, don't forget about back catalog and every other day. And like, we're really talking about hundreds of 1000s of downloads, like every rolling, like few weeks.

Andrea 36:06
Well, how do you feed your family then, Scott, I mean, seriously, you know, because you're saying that's true, you want to help people and and, and certainly, we are all worthy of being helped. And, you know, I probably would have been one who be like, No, not going to pay for this. You know,

Scott Benner 36:25
I want, I would be too. You

Andrea 36:27
spend a lot of time doing this. How do you feed them

Scott Benner 36:31
all my time? And Right, exactly. And then the other side of the is that, then I go, Okay, well, I figured it out, like I've made it so popular that it can support advertisers. Advertisers will pay to put ads on it. That's how I feed my family. That's how you don't have to pay for it. And most people at this day, in this day and age, are okay with that. Yeah, every once in a while you get like, somebody who's like, Yo, man, like you're I'm like, Yeah, listen, you don't i You sound like you might not have bills. Like, like, you might not understand all

Andrea 36:59
this. So broadcast TV. We used to have to watch commercials, right when we had just ABC, CBS and and NBC. We'd have to sit there and watch commercials. So that's how, you know, they got us their programs for free. Now we have to buy Netflix and whatever else is out there, HBO, Max and and we have to pay for it, but, but we don't get commercials. So, you know, pick your poison

Scott Benner 37:21
exactly well that, in the end, becomes the, I believe that the model I'm using now is the most viable in the current structure, and it's the one I'm the most comfortable with. And I want to be clear. I would love to be clear to everybody. I'd love to just give it to you for free, like, I think it would be awesome if, you know, if my bills magically got paid, and I could spend my time doing this right, but that's just not reality. So yep, and you gotta feed your family. Yeah, that's all okay, so sorry about that

Andrea 37:49
detour.

Scott Benner 37:50
Here you are. You have your you, you're calling it lotta. Does that mean that it's a very slow onset and you're not using very much insulin at the moment? Or just, are you calling it lot of because of the age you were when you when you were diagnosed.

Andrea 38:04
Well, I'm calling it lot of because, I guess technically it is lot of but I when I explain it to people, I call it type one diabetes, because most people don't even know what lot of is. I do use very little insulin. I'm still like, honeymooning, I touch wood, I consider it, but it was not slow onset. I mean, I just got really sick in a month. But the hard thing to know it really is how slow of an onset was it really? I got sick and all these crazy things started happening to me. You know, in the month of February and March of 2020, and suddenly my a 1c was 11.3 it was not like a slow rise. But I also hadn't been to a doc in like, three years. I try to think back, and I'm like, Did I have symptoms before? When? When did the symptoms start? What were the symptoms and and it's really hard to pinpoint, you know?

Scott Benner 38:53
Yeah, no, I know. So it's possible that any amount of time, over maybe 36 months, even you could have been slowly moving towards this, and then right all the sudden, in the last 60 days, it hit you really hard, right?

Andrea 39:06
I hit a tipping point, and boom, like whatever beta cells I had could not do the job, because I feel like there were some symptoms. I covid came. I lost one job because the magazine I worked for shut down, and I stepped into another position that was, instead of being every two month publication which I had been working on, I was working on something where things were happening every two minutes. So it was like, literally, fire hose in my face, and I was under a lot of stress, and I and we were all quarantining, and I was up in New York, and I'm, like, running around in my apartment trying to get the yayas out. And then I'm like, Was that just me having really crazy high blood sugar, or was that stress? Or what was that? And I don't know. I don't know. It's hard to

Scott Benner 39:54
was there any like, illness, like, prior to those 60 days? Like, did you get covid? Were you sick of. Or wise or just stressful.

Andrea 40:01
No, that's the crazy thing. So when I went to Europe to visit my daughter, we were still testing. I had to test before, before I could fly there, and when I got back, and we both got sick for one day, sort of in the middle of it, that could have been covid, I didn't test until, like, a few days later, when I had to get on the plane. And we were only sick for literally half a morning, and we had, like, the primary symptom of whatever wave maybe it was, I can't remember if it was the Omega or the alpha, the beta wave, or whatever.

Scott Benner 40:33
Which transformer, uh, bad guy it was, yeah,

Andrea 40:36
right, which transformer it was. But we both had a sore throat, and then it went away. That could have been it, I don't know, or it could have been like, I don't know. The thing, the point is, you know, I sort of tried to make myself a little crazy, really, trying to figure this out and and then being like, I am not going to have answers to this good. I am just, you know, yeah, I hate

Scott Benner 40:56
for people that rabbit hole where, like, why did this happen? I'm like, oh gosh. Like, so you're maybe the 20th person this week I've seen torture the cells over this and it's going to end with acceptance, and you not really knowing.

Andrea 41:06
So yeah. And the other rabbit hole is, can it be reversed? Is there anything you can do to save like, the other thing that I and I'm still a little bit on, is, can I I still have some beta cells that are functioning? Because, like I said, I don't have to take too much insulin. I take, you know, the basal insulin, and then i i Take just a bit of fast acting, yeah, but I also donate a whole lot of carbs. I keep on thinking, I've got to save these beta cells. What can I do to preserve these beta cells and and, you know, people are doing trials and stuff, but I have pretty much aged out of that. They're doing trials on, you know, kids and not older people.

Scott Benner 41:46
It's a tough moment when you realize you're not the you're not the group that they're like, oh, you know, we should spend a lot of time trying to elongate 56 year olds lives like, oh, it's not right, yeah, right, yeah. I take your point too about that. The Panic of, like, what could I be doing to just make this be easier for longer. Yeah, it's tough

Andrea 42:05
waiting for the other shoe to drop. I'm going to wake up one day, and I feel this is one of the big differences between people who you know are diagnosed, like your daughter was really young and in childhood, versus and I could be completely wrong, but from what I see on Facebook groups and and listening to podcasts and stuff like yours is that, you know, it's a much Wilder ride if you get it really young and you're pretty much, you know, no beta cells are left to produce any kind of insulin and and so I feel like it's a bit easier for for me, and if I just sort of take care of myself and not abuse the beta cells that I have and support them with exogenous insulin and and making sure I don't, you know, eat a plate of fries and birthday cake, you know, maybe I can extend this a while longer. But I also wonder, when's the other shoe going to drop? Is it going to drop, you know, right?

Scott Benner 43:01
And what if that was your last piece of birthday cake, too? I know, I know you ever listen to a song and think, Oh, I wonder when the last time is I'll ever hear that song?

Andrea 43:11
I never do. But thanks for the new fear unlocked. Sure, no problem happens

Scott Benner 43:15
to me all the time. Like it'll pop on. I'll be like, Well, I haven't heard that song in four or five years. And then I think I wonder if I'll hear it again. And then I think, ever, like, I wonder if I'll ever hear it again. Like, was that the last time I just heard Sam Cook saying that and or something to that effect. It's very upsetting.

Andrea 43:33
It is, it is I do something similar. I'm like, I wonder if this is the last time I'm going to, you know, see this person again. You know, like, every day I think about like, people walk out in the world and they don't think today I'm going to get in a car accident and maybe I'll die. You know, nobody thinks that when they step out the door today I'm going to go into d k and, you know, people don't think that and and so, but sometimes you kind of do. You're like, oh, is this the day that I'm going to step off the curb and be hit by a bus? But then you can't think like that has

Scott Benner 44:01
your diagnosis made you a little more pondering of things like that than you were previously?

Andrea 44:07
Maybe just a little bit, I find that a little bit pondering that kind of stuff will just, you know, it's a rabbit hole. It'll make you crazy. Yeah, I just can't. I've got so many other things to think about that are not philosophical questions that are, like real to really sit there, and I don't suffer from anxiety, and I think that that would be something that would give me anxiety.

Scott Benner 44:29
You know, it's so interesting, the way you just said that, like, you know, there's things I have, like real things for me to think about, not philosophical ideas. I was listening to, like a news clip recently, and I realized, like, while I was listening to it, I'm like, I find this interesting. I find the politics of this idea interesting, and I know how I feel about it. I'm interested in listening to somebody else how they think about it. And at the same time, none of this could possibly matter less for me to be listening to. I am not the position to do. Change any of this, I'm never going to be in a position to change any of this. Like, it's an interesting thought exercise, but yeah, it is an abstract idea for me. Like, and I think that we all can get caught up in that feeling of that our participation just by passively listening in on something else, like we're participating in it. And I don't know that that's true. Like, I'm sure it'll impact my vote one day on something, you know what I mean? And it is good for me to understand it big picture, but I didn't need to hear a 15 minute conversation about it, you know? I mean, like, I understood that the idea in the beginning, I knew both arguments, and I was like, here's where I fall. The rest of it is just, is me educating, and I'm making quotes around that myself on a thing that I'm never going to be asked about ever again. And is this just a waste of my time? And is there something that's functionally more important that I should be doing

Andrea 45:52
right now? Yeah, yeah, yeah. I was going to ask, were you procrastinating?

Scott Benner 45:56
I was probably in the shower. I do consume a lot of stuff in my free time, like when I'm not sitting here doing the making the podcast, as much as I miss music. If I'm in the car, I'm probably listening to somebody talk about something. I have a playlist that, you know, I listen to in the shower when I'm getting dressed like I try to cram as much information into my day as I can. I tend to believe that it's helping me to think about stuff that's actually impactful to me, but sometimes I find it valuable to listen to to abstract conversations about something I don't have input on, just to hear how people are thinking about it, to see if there isn't a slice of how they're thinking that I might co opt and bring into my own thoughts on something different that I think is valuable, yeah, like the news, for example. Like my son went to my wife one time. Like, I think it was during was during covid, and he's like, Listen, do you want to be happy or stop listening to that? And he's like, nothing's going to happen different for you, but you're going to stop worrying about this thing that you don't have any agency over. And it ended up being really great advice for so How old's your son? He's 25 now. Yeah?

Andrea 47:02
So, like, I was gonna say, sometimes you listen to things that that are just useless because you enjoy it. It's like the birthday cake that, you know, it's like, like eating birthday cake.

Scott Benner 47:12
Oh, man, no, don't worry, I have plenty of stuff like that. I do. Yeah, yeah. I've re watched a couple of shows more than I should have, and I am right now. I'm right now about halfway through the second season of Mr. Robot. It's been fun. I'm not without my my the things that I'm interested in that that are, you know, entertainment for me, I just think that it just was very interesting the way you said that. You know, that's not a thing you have time to think about. So anyway, yeah, what made you want to come on the podcast?

Andrea 47:39
I don't know. I just, I feel like, feels like, and this might not be your listeners, but a lot of people don't know that. People can get you know type one later on in life, that Lada even exists. I think Lance Bass the musician who was recently diagnosed with

Scott Benner 47:55
it. Are we calling Lance Bass a musician? Now? Okay, well,

Andrea 47:59
yeah, okay, he was a singer or whatever. It's so terrible. I grew up like a little bit before him, and he's his music is nothing I've ever listened to, but that I've been watching some of his little tick tocks, and they're really funny. And I think it sort of brings awareness to this. But, you know, I think also, like, I was looking up statistics for like, the number of people or the percentage of people who are diagnosed in different ages. And I'm going to pull up a study here that was published because I'm the good journalist that I am, that it was published in the Annals of Internal Medicine, and it found that 22% of people were diagnosed after the age of 40, of all the people that have type 120, 2% were diagnosed after 40. That's one in five. That's more than one in five. That's almost one in 457. Are diagnosed after 20. But the 43% are diagnosed, you know, from zero to 20 and you know, but that's a lot of people who are waking up one day and going, Oh, I did not know I can get this. This was not on my bingo card. You know, we all worry about cancer, we worry about heart disease, but this was not on my bingo card. It's was surprising to me. You know, my massage therapist said something to me. She's like, Oh, how did you survive this long without taking without treating it? And I'm like, No, I didn't have it this long.

Scott Benner 49:14
Oh, you met a person who thought, because it's type one, you've had it since you were a child,

Andrea 49:18
right? And she's like, how did you not know? How did you, you know? And I was like, No, it wasn't. I didn't always have it. I just developed it. And yes, you too can develop this, yeah, so that was kind of like the surprising, yeah. I guess that's why I wanted to come on and sort of chat about that,

Scott Benner 49:35
a terrible commercial, even you could develop diabetes,

Andrea 49:38
right, right? New fear unlocked again, kind of like that expression,

Scott Benner 49:43
no, yeah, of course. Because right, like you're, I mean, listen, you and I are about the same age, like it's you do get that unreasonable feeling like you hit a benchmark or a milestone, and you think, Oh, well, this can't happen to me anymore. Like I've been married for 20 years, I'm not getting divorced. Or I made it through my I made it through my 40s. I'm not having a heart attack like, that's when, you know, like, it's that kind of stuff that's not real. But I think we sometimes pin our our hopes on,

Andrea 50:10
yeah, well, it's good that we can, you know, change it. You know that we can by living well or exercising more, or eating right? You know, sure, all these things do help with that, sometimes you're just still gonna get

Scott Benner 50:22
it. Does everyone not learn when you turn the news on and like some long distance runner had a heart attack, and they no body fat, and they've been running every day their entire life. I just interviewed a guy a couple weeks ago. It's not out yet. Well, I guess by the time years comes out, it'll be out early 40s. Just had quadruple bypass, like quadruple, right? And he was, and he's a runner, but also has had type one diabetes most of his life. And the beginning part was harder going than the end, the part where he's at now, but when he had his like, first, like, Hey, what's going on? Moment, he really thought, like, This isn't me. I'm super healthy, you know. And so I think this stuff happens, you know, every day to somebody. I think it's important to bring up just like you're saying, Yeah, my gosh, yeah, you find the podcast or the Facebook group. How do you intersect me? Initially, the,

Andrea 51:13
I don't remember if it was Facebook group, probably first, and then that led to the podcast, okay, you know. And it's super helpful, you know, these fun tips and and your new beginning series. You know, I recommend, like, whenever I this other Facebook group that I'm on, I always recommend your podcast and the book. Think like a pancreas for anybody who is, you know, just recently diagnosed, and I remember took me like three months after getting this to finally wrap my head around, getting out of the house without thinking I was going to be stranded somewhere in New York City without access to the right food and water and everything. It just took so long to get my act together and you know, but I think that by informing and educating ourselves that can be cut short. And, you know, I sometimes read posts from people who have had this a long time, and they're only just beginning to understand either, because they didn't have parents like you who were really, really caring and hands on, and they were just sort of left, you know, adrift to figure this out on their own, and it's a hard thing to figure out on your own, and you don't need to, you know, nobody needs to figure it out on their own.

Scott Benner 52:29
Yeah, no, I am fully behind the idea that people should have good information so that they can find a way to educate themselves that jives with how they learn and how they think, because you're only going to make better decisions when you know, when you have more facts you know, and access to people who are willing and able to share with you in a way that is hopefully, you know, not one sided like I love it when people are just like, look, this is my finding. And here's 10 other people. This is what they found in this situation. Go through that and see what makes sense to you, and start like trying to learn for yourself. I agree with you completely. Yeah, it's really important. How old is your daughter now? Oh, she just a month ago, turned 21

Andrea 53:16
Oh, happy birthday to her. So what has been the hardest thing for you? Know, Like as you let her go and let her become the person she is, you know, developing into, especially with, with type one, what's been, you know, what? What's been the most challenging thing for you?

Scott Benner 53:34
Yeah, challenging. I don't know might be the wrong way to put it, but I just think that there's this moment where there's stuff you always knew, like, right? Like, you could sit down and be academic about it. While you're raising a young kid, you're like, you know, there'll be a day when they're gonna, you know, not want you to be as involved in this, or they're gonna, you know, maybe not taken as seriously as you do, or more seriously than you do. Like, I hear people say all kinds of different things, right? There's gonna be a moment where you're to be a moment where your kid starts to see this thing through their own lens, and isn't look and is and is looking to build their own identity around it. And you know it's coming. Like it's, I mean, if you're halfway reasonable, you know that's coming. If you've, you know, ever raised a kid, stuff like this happens every three weeks about something, yeah, so not surprising, and surprising would even be the wrong word, but the part that's most difficult when it begins to happen, and it's been going on in our lives for a long time now, but when it begins to happen is how connected you are to their good outcomes, the realization of that as she's building her own understanding of all this, she's going to go through speed bumps, just like I did when I was learning about it in the beginning, and I didn't realize that it was going to make me feel like she was in a dire situation. And the irony is, of course, she's not a dire situation like you know, she goes. Off to college. When she left for college, she probably left for college like a five, nine, a one, say, Nice. And when she was a year into college, she was doing more like a six two on her own,

Andrea 55:14
6263 still very decent.

Scott Benner 55:18
Yeah, exactly my point is that that's awesome, right? And if she has trouble and she her six two goes to six seven. Like, why would we argue about that? Like, that's amazing. Like, that's a 20, you know, 1920 year old kid in college with type one diabetes, keeping a six, seven, a, 1c, and I, and I did not initially see that as like, Wow, what an amazing accomplishment. This is like, instead, I thought, instead, what I saw was her a 1c was almost a point higher than when she left. And I didn't like go at her with that. It's it felt that way to me, and it took me a little time to recognize that this was really a great thing. Not like, we didn't lose something, we're winning something, yeah, and that's been, I guess that was probably my biggest hurdle during this time, and now still, like, you know, she, she'll go back and forth sometimes where she's like, you know, I need help with this. And then there'll be a day where she decides she doesn't want help with it anymore, but nobody sent me the memo, and I'll be like, hey, you know, did you take this or do that or whatever? And she's like, I don't need your help. And I'm like, oh, okay, there's that part of it. Like, if this and does, by the way, when this stuff kind of happens with your kids, with any other thing, any of the things that you expect it to happen with, you know, boys or girls, or driving or drinking or weed or whatever. The thing is that you're expecting to have these arguments with your kids about it's not until it's about what feels like their mortal end that you realize that it takes a lot of emotional maturity and self control to continue to be the person you are and that you're trying to be, when you feel like, how do I mean this? When she was first diagnosed, it felt like diabetes was trying to kill her, and that my misunderstanding of it was going to be the tool that it used. And then we we figured the whole thing out, and it it runs like clockwork. If I'm a little involved, it runs like clockwork. And then to watch that feel like it's going away, and now it's not diabetes trying to kill her. It feels like it's her trying to kill herself. But that's obviously not what's happening, because if you step back far enough, you realize that a 20 year old kid in college with a 678, 1c, is a absolute, like, it's a celebration, yeah? And anyway, definitely that, I think right there psychologically was the part that took a lot of bobbing and weaving for me to, like, really wrap all my head around,

Andrea 57:55
yeah, yeah. Because again, it goes back to that whole thing that you've been responsible for her health this whole time. And how can, how could she let it slip? But she's not, she's taking control of it, and she's learning how to, you know, and I'm sure she it isn't one moment where you hand over, you know, one moment, it's been like years in the making, where you're letting her have more autonomy with this and then, you know, then she's out of your house. And they always need you, right? They always need you at two in the morning, no matter what, no matter what it

Scott Benner 58:25
is. It's not a rom com. It's not one lunch and shopping montage, and then everything's okay afterwards, right? You're right. It's been years of like, slow hand off, yeah, yeah. And at the same time, you know, to say that it feels like, like, if she was listening to this right now, I would tell her like she's not trying to kill herself, and it doesn't feel like that to me, right? Good, right? It feels like she's putting together her own plan for this success and that, and I think it's going incredibly well and but when something like you said, what is it like? I don't exactly know what it's like, but it feels like you're a bystander. It's something that you know the answer to, and you speak up, and everybody goes, no, no, thanks. We're going to figure this out on our own. And you say, Yeah, but the basement's flooding, and I know how to stop it right this second. And they go, no, no, we'll get it figured out. And the truth is, they are going to get it figured out and it is going to be okay and and that you have to be willing to pass that knowledge forward, because if I don't pass it on to her, then it dies with me, and then she struggles forever, right? So I got, you know, it's

Andrea 59:33
part of maturing too for her, exactly, you know, aside from studying, right? I feel like my my younger daughter, the one that has Crohn's, you know, she looked at me before she went to college. She's like, I'm going to drink anyway, because we had this whole talk with, you know, the nutritionist about food that, you know, she should, shouldn't, whatever, eat. And she's like, I'm, you know, I'm about to go to college, I'm not going to not drink. And I like, I looked at her, and I'm like, it's your party. It's your party. You. You, this is your life. This is your life. You've got to live it the way you want to. There will be consequences and or, you know, maybe not that, maybe something else, but it's, it's your party.

Scott Benner 1:00:09
Yep, you know, yep. That's it, and that, and that's the thing you have to get over. Now, listen, if it's something like, your daughter's like, Hey, listen, I'm going to have a couple of beers at a party. And I know it's not the right thing for me to do, but I'm doing it anyway. That's one thing. If it's, you know, I'm gonna take a year or two to really pull myself together about how I Pre-Bolus and how I do things, and how I handle, like, you know, the stuff about diabetes, that's also fine. I don't think a, you know, I don't think a little bit of time of her figuring that out is gonna be the end of her. As a matter of fact, I think there are plenty of people who are living through much worse outcomes for many more years than that, and those people are, you know, sometimes seeing complications, sometimes they're even not so like, Am I worried about this time? I am absolutely not. You're not wrong, right? That it's still still happening. It can be tough to sit there and say, like, Oh, it's okay. Like, I'll watch you figure it out. Like I but it is there. It is absolutely their life and that, and that is the other side of it, right? Like, if my daughter decides to go out into the world and fundamentally not take care of herself and walk around with a nine, a, 1c, I'm maybe down to, like, 18, more, 24, more months where I have any sway over that whatsoever, right? So in the end, everybody is going to go be who they're going to be, and you're not in charge of it, and that goes for diabetes or anything else. And there's just days where I just feel lucky that I'm not having these conversations around some of the truly horrific things I hear people come on on the podcast to talk about, like, what if? What if? What if this conversation wasn't like, oh, you know, my daughter is thinking of having a beer. What if it was my daughter is, you know, shoots heroin, you know, or, or, you know, runs around. And my daughter really loves Robin, banks Scott. And she said, it's her life. And I said, Okay. Means like, yeah, yeah. As bad as this can feel sometimes,

Andrea 1:02:04
right? It certainly is.

Scott Benner 1:02:08
There you go. Raise a glass to that. That's awesome. Well, have I let you down? How is this going? How do you feel about it?

Andrea 1:02:16
I feel fine. I feel good. You've, you've put me at ease. I feel really good. It's been a really nice conversation. Scott, I really appreciate the you know, how, how flowy this has felt.

Scott Benner 1:02:28
Oh, awesome. I will say that you were like, let us tell people that before we were recording you said you were pretty nervous. But did that go away?

Andrea 1:02:35
Yeah, yeah, pretty much. I didn't, and I didn't even curse a lot. I don't think, yeah, no, was I okay? Did I say good things?

Scott Benner 1:02:43
You were awesome. I think you did curse once, but it was mild. Well, at the beginning you said, I have a good potty mouth, like I'll try not to use it.

Andrea 1:02:53
Yeah, yeah. I forget you forget. I forget that. People don't, yeah, the people, some people really get offended at the cursing and stuff, you know, yeah,

Scott Benner 1:03:01
oh no, I know. I've gotten plenty of I have this one email. I have a folder of people who, like, you know, complain to me. It's because I keep it for fun. And I still have a folder that's marked like, if I die, suspiciously, one of these people did it, but, but in my just like, for fun folder, there's this very passionate email from this person who tells me all the ways that the podcast has helped them, like their for their health to be better, and their mental health and their life. I mean, it's really, it's a lovely, lovely email that goes on for a couple of paragraphs and then in the last few sentences, says, But you said, God damn, so I can't listen anymore. I was like,

Andrea 1:03:38
Oh my gosh, I'm sorry. Whoops.

Scott Benner 1:03:43
I felt like responding back and going. I said way worse things than that. I was like, What do you like? There's tons of cursing in this thing, but that's the one that got to That's what God. I took the Lord's name in vain and they were out. And I was like, okay, yeah. So I was like, okay, yeah. So I, I tend to take the perspective of, I know what the podcast is doing. I know how many people it's doing it for. Everyone can possibly like me. I understand that. I'm not trying to make I'm not trying to make everybody happy. Like and I think if I did what you'd have as a podcast that nobody would enjoy, that

Andrea 1:04:13
wouldn't be popular at all. So and you'd be crazy trying to make everybody happy. I mean,

Scott Benner 1:04:18
how would I even begin to like, put a list together of everybody's desires and needs, you know? So, yeah, definitely, it would make conversation literally impossible. You'd just be standing there measuring every word as it came

Andrea 1:04:32
out, right, no, and it wouldn't. Nothing would flow. It'd be terrible. Yeah, yeah, you'd get, you'd get

Scott Benner 1:04:36
more unhelpful content, like exists all over the place. Now I'm not trying to not trying to be part of that.

Andrea 1:04:41
So, speaking of a fun content, there's a Facebook group called diabetes, but it doesn't have, it's like, got an asterisk in there somewhere, and it's all these memes, you know, fun diabetes memes. I get

Scott Benner 1:04:54
a fair amount of traffic from that. People must go in there and talk about Juicebox in there, because I get all. Lot of good traffic from there. So, oh, good, yeah. No, I'm glad you like that one. I have some pretty simple rules about how I create content. One of them is, I might be members and stuff before I made the podcast, but I haven't seen them in a long time. But I'm not a member of another private group. I don't look at other people's content. I don't listen to other people's YouTubes or anything. I try very hard to just assess my own situation and the situations of the people who are listening and, you know, make the podcast from here. I don't want to, I don't ever want to feel like I'm ripping somebody off or being led one way or the other by, you know, either I don't know, like positive or negative stuff that's coming from people. So, yeah, well, you guys that are talking well about the podcast out there, thank you very much. I'm talking about, like, some great places where people are really positive about it, so I appreciate it. Yeah, thank

Andrea 1:05:51
you. Oh, good. Yeah, no, thank you. Thank you for your dedication to this endeavor of educating us. It's my pleasure. It's so helpful. I mean, really, you're very, incredibly

Scott Benner 1:06:03
helpful. You're very, very kind. And I do, I do appreciate it. And like I said, it really is a, I don't know, like, I want to say joy. Like, it really is lovely to be able to get up every day and to be able to put some effort and thought into, like, I wonder what would help you, or somebody like you, or a person that said to me today her name was Ruth, she said, I wish I would have found this like 34 I wish this would have been available 34 years ago. And what I said was, I really appreciate that. I'm glad you found it now, and I'm going to do everything I can to make sure it's here for the next Ruth that comes along. So that's yeah, that's kind of how I try to think about it.

Andrea 1:06:41
But thank you. Oh, that's nice. Yeah, like, I guess you're a caretaker at heart, first, you know, with your daughter, and then the rest of the community extending out. So that's very,

Speaker 1 1:06:51
very nice. I feel like that might be the case. There

Scott Benner 1:06:55
are some days when I walk around, I'm like, I've listed things I should be doing for myself that I'm not doing. I'm getting better and better at blending it all together, so fingers crossed that I'll get it figured out before I'm done. Yeah, well, thank you so much. I really appreciate you taking the time.

Andrea 1:07:10
Thank you so much.

Scott Benner 1:07:21
Thanks for tuning in today, and thanks to Medtronic diabetes for sponsoring this episode. We've been talking about Medtronic mini med 780 G system today, an automated insulin delivery system that helps make diabetes management easier day and night, whether it's their meal detection technology or the Medtronic extended infusion set, it all comes together to simplify life with diabetes. Go find out more at my link, Medtronic diabetes.com/juicebox,

I'd like to thank the blood glucose meter that my daughter carries. The contour next gen blood glucose meter. Learn more and get started today at contour, next.com/juicebox and don't forget, you may be paying more through your insurance right now for the meter you have then you would pay for the contour next gen in cash. There are links in the show notes of the audio app you're listening in right now, and links at Juicebox podcast.com to contour and all of the sponsors. The episode you just enjoyed was sponsored by the twist a ID system powered by tide pool. If you want a commercially available insulin pump with twist loop that offers unmatched personalization and precision for peace of mind. You want twist, twist.com/juicebox, you Juicebox. I can't thank you enough for listening. Please make sure you're subscribed or following in your audio app. I'll be back tomorrow with another episode of The Juicebox podcast.

If you're looking for community around type one diabetes, check out the Juicebox podcast. Private Facebook group Juicebox podcast, type one diabetes. But everybody is welcome. Type one type two, gestational loved ones. It doesn't matter to me, if you're impacted by diabetes and you're looking for support, comfort or community, check out Juicebox podcast type one diabetes on Facebook. If your loved one is newly diagnosed with type one diabetes and you're seeking a clear, practical perspective, check out the bold beginning series on the Juicebox podcast. It's hosted by myself and Jenny Smith, an experienced diabetes educator with over 35 years of personal insight into type one, our series cuts through the medical jargon and delivers straightforward answers to your most pressing questions, you'll gain insight from real patients and caregivers and find practical advice to help you confidently navigate life with type one. You can start your journey informed and empowered with the juice. Box podcast, the bold beginning series and all of the collections in the Juicebox podcast are available in your audio app and at Juicebox podcast.com in the menu, the episode you just heard was professionally edited by wrong way recording, wrong wayrecording.com you.

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#1634 Grand Rounds: Inhaled Insulin

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.

Pediatric endocrinologist Dr. Michael Haller explores inhaled insulin and the evolving approval process for children under 18.

+ 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.

Scott Benner 0:00
Welcome back, friends. You are listening to the Juicebox podcast.

Dr, Mile Haller 0:15
Scott, good morning. Thanks for having me on I'm Dr Mike Haller. I'm chief of pediatric endocrinology at the University of Florida. Story is a long one goes back to desire to be in medicine as a child. My grandfather, living with type one diabetes, was also part of the inspiration.

Scott Benner 0:33
My grand rounds series was designed by listeners to tell doctors what they need, and it also helps you to understand what to ask for. There's a mental wellness series that addresses the emotional side of diabetes and practical ways to stay balanced. And when we talk about GLP medications, well, we'll break down what they are, how they may help you and if they fit into your diabetes management plan. What do these three things have in common? They're all available at Juicebox podcast.com, up in the menu. I know it can be hard to find these things in a podcast app, so we've collected them all for you at Juicebox podcast.com. Please don't forget that nothing you hear on the Juicebox podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin.

The show you're about to listen to is sponsored by the ever since 365 the ever since 365 has exceptional accuracy over one year, and is the most accurate CGM in the low range that you can get ever since cgm.com/juicebox us med is sponsoring this episode of The Juicebox podcast, and we've been getting our diabetes supplies from us med for years. You can as well us med.com/juicebox or call 888-721-1514, use the link or the number get your free benefits. Check and get started today with us. Med. This episode is sponsored by the tandem mobi system, which is powered by tandems newest algorithm control iq plus technology. Tandem Moby has a predictive algorithm that helps prevent highs and lows, and is now available for ages two and up. Learn more and get started today at tandem diabetes.com/juicebox

Dr, Mile Haller 2:29
Scott, good morning. Thanks for having me on. I'm Dr Mike Haller. I'm chief of pediatric endocrinology at the

Scott Benner 2:34
University of Florida. Oh, wow. How'd you get that job?

Dr, Mile Haller 2:37
Well, story is a long one. Goes back to desire to be in medicine. As a child, my grandfather, living with type one diabetes was also part of the inspiration. Then working with some of my mentors here at the University of Florida. Early on in my career, even in high school, I was had the opportunity to work in the lab on some of the early diabetes prevention trial work where we were learning that auto antibodies can be used to predict type one. Then I went off to college at Duke, and came back to UF for medical school and went to diabetes camp. And diabetes camp was the final sort of nail in the coffin for me in terms of pathways. It was pretty clear after that experience that I wanted to be a pediatric endocrinologist. And then I've been here at the University of Florida. My entire academic career, started as a assistant professor and then worked my way up, and almost nine years ago, took over from one of my mentors, Janet Silverstein, as the

Scott Benner 3:30
Division Chief. What was the experience at camp that made you feel that way? Well, I was always

Dr, Mile Haller 3:35
just really enamored with kids and being in in the care of young folks, so I kind of knew I was going to likely lean towards being a pediatrician, but the 24/7 experience there is what really did it for me, just seeing what living with type one is really like, being with these kids, doing all the things that you do at camp, going out on the lake, going to do archery, playing land Olympics, getting up at 2am in the morning with them to check glucose, as this was in the era where we just had glucose meters and an NPH in regular so didn't have nearly all the tools we have today. And that experience was definitely transformative for me, just wanting to have relationship with those kinds of kids going through those struggles and helping them find a way forward to live their best life with diabetes.

Scott Benner 4:22
Would it surprise you to know you're not the first endocrinologist to tell me

Dr, Mile Haller 4:26
that? Not at all? Yeah, I think diabetes camp is actually our, probably our strongest single recruiting tool for convincing young medical students or physicians to have a interest in it. It's why, it's why I actually require anybody who wants to come shadow with me to volunteer at camp, because I think a you can't really know what it's like till you've seen it in that setting. Sort of been with a person for a week, 24/7, and B, just that that experience tends to be so transformational, foundational for people, that it captures some folks who otherwise wouldn't have been interested. The field.

Scott Benner 5:00
Is it true that a lot of times people want to be endos, but they almost get saddled with the diabetes? Is that why you have to make them interested in it like, you know, I'm saying that they're more interested in other endocrine specialties, but because they're the endocrinologist, they handle diabetes as well. Is that? Is that a thing, or is that something I've just heard that isn't true.

Dr, Mile Haller 5:22
I think that's probably true in the adult side, on the pediatric side, since about 50% of what we do is diabetes care, more than not actually, the folks who come into endocrinology on the pediatric side are interested in diabetes care management in some significant way, even if that's not their core academic pursuit or what they become, sub sub specialist expert in our place is a little biased, because we're such a well known, strong historical type one diabetes clinical and research center that most of the folks who come train with us already have that desire to be in that space, but it is a harder sell. Unfortunately, diabetes care requires a whole lot more team members, is therefore more expensive to provide. Well, isn't super well reimbursed. And so, you know, in terms of running a business for people outside of academics, it does make a lot more sense to focus on the endocrine side of things, standard endocrine and not do the diabetes care. So in the adult world, that's that is a common thing. There are lots of endocrinologists who don't do diabetes at all. The pizza that's not, not very common

Scott Benner 6:27
at all. I see, can I ask a couple more questions before we get to the inhaled insulin? Yeah, of course, this is interesting. So I did a series a couple of years ago. We called it grand rounds, and we went to So Mike, you don't really know a lot about me. That's fair enough. I have a private Facebook group that supports the podcast that as of this recording, has 72,000 active members in it. I went to those people and I said, Let's make an exhaustive list of what you wish would have happened at your diagnosis. And that list turned into what they wished would have happened and what they wish wouldn't have happened. And I think we put together about 90 pages of notes from people and responses, and called them down and, you know, put them together and created this, I think, about seven or eight part series. It was really aimed at physicians to say, like, look, this is what people said. You know, their experience was almost like them filling out a survey after after service, and I found that the series also served for people listening to say like, well, this is what I should be expecting from myself, or here's the things I should be looking for. And we kept it going by bringing in endos to talk about what their experiences were. So I'm going to ask you the question that I asked them, and very simply, I want to know what you think endocrinologists need to be doing, should be doing to make the experience better for people. And what do you guys find yourself sitting across from the patients wishing that they would do to make the whole thing be smoother?

Dr, Mile Haller 7:53
Yeah, that's a great question. I think at diagnosis, a lot of it depends on where the family is coming into the diabetes space, and and physicians providers need to do a better job of recognizing that there are big differences, you know, than somebody who has nobody in their family with diabetes and comes in DKA and they're worried about their kid making out of the ICU, let alone understanding what a CGM or a pump is, versus somebody who's, you know, got a parent with type one or sibling with type one is picked up by way of antibody screening, and, you know, is never even symptomatic at the time of their diagnosis. So I think that the heterogeneity of presentation is becoming even more broad as we pick up more and more people pre clinical and physicians need to understand that that heterogeneity is part of doing a better job of presenting what people need to know at the right time to make that transition to life with diabetes easier. And I've erred in this before, personally, so I'm not suggesting I do it perfectly. I think listening and hearing people's story. Instead of jumping right into everybody who gets diagnosed needs to know x, y or z in this order, is really helpful. Probably what physicians need to hear is remember, and this is true in every part of medicine, is remember to listen before you go in and talk, and then take that information in before you figure out what you're going to say, and then help use that to guide the conversation. I think something that our team does really, really well, though, is tell folks from the very day of diagnosis that you know, we're all part of a big team here to help you, the patient, manage your diabetes. And it's different than, you know, almost every other diagnosis out there and in that, you know, we serve as coaches, but you, at the end of the day, are the player on the field of the sport, and you've got to make the, you know, the day to day, minute to minute, game time decisions. Our job is to give you the skill set to do that as well as humanly possible. Yeah. And I think when we set that philosophical tone from the beginning, it really helps our patient. And families sort of embrace that, so that in our goals, by the time they graduate from our pediatric clinic, they frankly, don't need us or their adult endocrinologist for much obviously, they still have to have them to write prescriptions and help with some of the screening for complications and obviously giving medical advice when it's necessary. But the reality is, we haven't done our job well if we aren't putting young adults out into the world who can do all this really well without anybody's help.

Scott Benner 10:26
Yeah, I have to tell you that. So this podcast has been it's 11 years old. It has over 1600 episodes. It's been downloaded over 20 million times. It charts in 48 countries around the world, and I think that that's because I started making a podcast in 2015 and we used to tell people, like, everything you need is in those episodes. Like, just listen and you'll and by the way, Mike, this is there's no no BS. Like, if you just listen to the podcast back then you'd wake up with a 681 say, at some point it was that all the answers were in there, but, you know, they weren't. They weren't on a bullet list. They weren't like, learn this, then learn this, then learn this. It was sort of what I got out of it was just kind of what you were just saying, is that there, there, yes, there's tools, right? And I need to know what they are. But how am I supposed to guess which one you need right now? Like, where are you on that journey? What's the thing you need to hear today? And that what the podcast allows is for people to jump in and out of it, at their leisure, at their home. And I think the limitation of going to see your doctor is very much that it's, you know, if you're lucky, a half an hour four times a year, and you know? And if you have something in your head the day they show up, and it's not the thing they need, I mean, there you go. It's six months between meaningful interactions. Again, I don't know how you're supposed to do the thing you're supposed to do. It really is incredibly difficult. Eventually we were able to put together, you know, the podcast had gotten so large that I was like, Well, I can't just keep asking people, just keep asking people just listen to 400 episodes like, you know, like, at some point it became ridiculous. So I took what I thought were my foundational ideas, and Mike, I want to be clear, just the guy who started writing a blog when his daughter was diagnosed in 2006 I have no medical background, no training, but what I realized was I was a stay at home dad. I figured out how to take care of my daughter, and one day I realized that I had all the tools and all the ideas that I needed to keep her a 1c in the fives, actually, that diabetes no longer felt like unknown to me. Things happened. I knew what to do. I knew how to react this thing that you were describing earlier, and I sat down and very thoughtfully put together what I thought were the, you know, the hallmarks, the bedrock of this idea. And I contacted a friend of mine, Jennifer Smith. She's a CD ces works for Gary at Integrated Diabetes. You might actually know her. And I said, I have these foundational ideas. I want to put them in a series. And we made something called the diabetes Pro Tip series. And now what people say is, I grab the list, I listen through it at my leisure. My a, 1c, ends up in the sixes. So many people are angry at their physicians because they feel like I have a question. They don't know the answer. They don't listen to me that what you just said. I just think it's an unfair paradigm, like, I don't know how either of you are supposed to succeed in that setup. Let's talk about the tandem Moby insulin pump from today's sponsor tandem diabetes care. Their newest algorithm control, iq plus technology and the new tandem Moby pump offer you unique opportunities to have better control. It's the only system with auto Bolus that helps with missed meals and preventing hyperglycemia. The only system with a dedicated sleep setting, and the only system with off or on body wear options. Tandem Moby gives you more discretion, freedom and options for how to manage your diabetes. This is their best algorithm ever, and they'd like you to check it out at tandem diabetes.com/juicebox when you get to my link, you're going to see integrations with Dexcom sensors and a ton of other information that's going to help you learn about tandems. Tiny pump that's big on control tandem diabetes.com/juicebox the tandem Moby system is available for people ages two and up who want an automated delivery system to help them sleep better, wake up in range and address high blood sugars with auto Bolus. When you think of a CGM and all the good that it brings in your life, it's the first thing you think about. I love that I have to change it all the time. I love the warm up period every time I have to change it. I love that when I bump into a door frame, sometimes it gets ripped off. I love that the adhesive kind of gets mushy sometimes when I sweat and falls off. No, these are not the things that you love about a CGM. 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Dr, Mile Haller 15:32
Yeah, I agree with you. I think Aaron Kowalski from breakthrough T 1d once you know, did this analogy that really struck me, which is that, you know, patients spend less than 30 seconds on a 24 hour clock of their diabetes time with their provider. And when you think of it like that, like, of course, it's, it's not a fair fight, in that sense, of trying to impart all the wisdom we need to give to patients and families to do well. And I think that's why families need the kind of things that you put out in the world, and why they strike home so strongly, because people are yearning for access to information that's accurate, that that speaks the same language they do, that doesn't have sort of any bias, necessarily, from a physician, and they don't feel judged by listening to or, you Know, trying to impart So, yeah, yeah. I think that's why everybody with type one lives that that unique experience and and why it's so important that there are resources, you know, like amazing podcasts and like social media chat groups, which I try to be in a lot of, because I find out i That's where I do a lot of sort of nowadays. That's my version of active listening, I just see what people and patients and families are writing about, thinking about saying, you know. And sometimes I interject because I see something that I think is really, really incorrect. But more often than not, I just listen by way of reading, because it helps me when I then see the next patient in real time to hopefully appreciate better what it is they might be thinking or going through, or the question they are uncomfortable to ask, and I can try to impart some wisdom to help

Scott Benner 17:05
them. One of the most valuable tools I have is that community, because you know, where people's like, I don't know how I hear from people all the time. Like, the podcast always seems to have the topic or the answer that I need, and I tell them all the time like, Yeah, I'm watching 70,000 of you talk to each other, I know where you're struggling like I know where the pain points are. And it's because of you that I understand what content it is you're looking for, what answers or ideas that that you're lacking. Anyway, it's just, I think I bring all this up because that toolbox, from what I understand from everyone who's tried inhaled insulin, that toolbox would be really enhanced by being able to break a 250 or a 300 blood sugar, even if you didn't use inhaled every day all the time, if you just had it with you for those high blood sugars, that it might be a significant reduction in Stress and time spent dealing with diabetes. I don't understand inhaled insulin enough. I can tell you, I've had people on it, on the podcast, who use it. Who are they proselytize about it. They love it so much. But every person I've ever interviewed struggles to explain it to me. It's tough to sell something when a person who loves it and tells you that it's amazingly beneficial for them. And I say, okay, so how do I dose it? And they go, I know, two of four and eight. Like, I'm like, I'm like, Yeah, you know, like, you're not selling it anyway. You're you're on today because inhaled insulin. What have they done? They're doing research for a younger segment of people, right? Can you tell me more about that?

Dr, Mile Haller 18:38
Yes, I had the pleasure of being the lead the principal investigator for the inhale one study, which was the study designed to try and get FDA approval for inhaled insulin in the pediatric space. It's been approved in adults for quite some time, and there are many pediatric and adult endocrinologists who prescribe it in the pediatric side. It's, you know, it's currently still off label, but much of what we do in pediatric medicine is off label, just because it takes pharma companies much longer to get those studies done. Yeah, and you're right, it is a very different paradigm to use inhaled insulin. And so it does make it, I think, harder for people to describe it sometimes to folks who are? You know, taught from day one that this is how we get insulin. It's through a needle and syringe or a pump, and this is what basal is, and this is what Bolus looks like, and these are carb ratios, and these are correction scales. All that gets a little fuzzier with with inhaled insulin, and so it requires a reframing of thinking about how you're going to use it and when and what situations, but your initial analogy, I think, is absolutely right. I think it's just one more really nice tool to have in your toolbox, one that I think many more people living with, type one should have and should feel comfortable understanding how to use. And if they did that, you know, they would see that it serves an important purpose. And. And we we get through to more folks. I think the first step to doing that is just convincing more providers out there that it's an important enough tool that they should be using and trying with their patients. I think because of the previous historical commercial failures of some of the earlier inhaled insulin products, it's just been hard to break through that, that sort of shell for physicians to say, I'm going to try this different paradigm, because people are comfortable with what they know, and getting people to do something new is always hard. This, this idea of therapeutic inertia is a very real thing in medicine. And so you've always got, you know, some of your early adopter kind of people, which I usually am, in that category, so I'm always excited to try these new things. But there's the larger majority of folks who absolutely are are not going to do anything until they see many more of their colleagues using it and having success with their patients. Yeah,

Scott Benner 20:52
it's interesting that there are spread out across this country, there are nurse practitioners and endos who will look their patients in the face and go Listen, go listen to Scott's podcast. And in that same world, there are people who would say, I would never, ever suggest anything like that to a patient. And I think it always does boil down to that what you just said, there's some people are kind of like they're out on the, you know, out on the edge of the surfboard. And there are some people are in the back waiting to see everything flatten out before they'll say, yes, they they're risk averse in a way that, and I'm not saying you shouldn't be risk averse, especially in medicine. There's a tipping point in there. I don't know where it is exactly, but you have to try new things, like right now, I think I've been well out ahead of this for a couple of years now. But GLP, ones for people with type one are incredibly valuable for those of them who have insulin resistance. Yeah, absolutely, yeah. That's how I'm seeing it coming back to me. Like, if, if you have type one diabetes and no real like, insulin resistance issues, like, you know, anything that would make you look type two if you weren't type one, I don't see people having as much benefit there. Those that have the trouble a reduction of 2030, 40% of their insulin is not uncommon, and I've seen people have conversations right on this podcast of there are two great episodes with the mom of a young girl who should type one for four years, using like 5060, units of insulin a day, starts gaining weight. The mom had had PCOS and was put on a GLP one for weight, and PCOS, she saw it really help her. Thought she was seeing her daughter having PCOS symptoms, got the GLP to her, and, no kidding, had to take their pump off. Was using like a unit of injected basal a day for a long time. Now, you know, is it gonna stay like that forever? It's not, and they're seeing a trend in the other way, but it lasted for years, like there's gotta be something to learn from that, you know, and I think with the inhaled insulin, like the same idea, like, because I still see people running around going, well, glps are not for type ones. I saw a very respected person in the diabetes space, somebody I respect, who's been around forever and ever, one of the smartest people I've ever said, just kind of like philosophizing out loud today, like, these GLP ones might have some value for type ones. I'm like, You're not just in the obvious, yeah, wow, wow. You're not just in the caboose of the train, right? Like, you're back at the station, like looking up, going, like, I think I might be seeing a train up there. That's a person who's a thought maker with the inhaled, yeah, I guess what I'm wondering is, is, when you go to another, when you go to a colleague and say, Look, you should be learning about this and giving it to people, when they push back, what do you hear them pushing back on? You've probably heard me talk about us Med, and how simple it is to reorder with us med using their email system. But did you know that if you don't see the email and you're set up for this, you have to set it up. They don't just randomly call you, but I'm set up to be called if I don't respond to the email, because I don't trust myself 100% so one time I didn't respond to the email, and the phone rings the house. It's like, ring. You know how it works? And I picked it up. I was like, hello, and it was just the recording was like, you asked. Med doesn't actually sound like that, but you know what I'm saying? But you know what I'm saying. It said, Hey, you're I don't remember exactly what it says, but it's basically like, Hey, your orders ready? You want us to send it? Push this button if you want us to send it, or if you'd like to wait. I think it lets you put it off, like, a couple of weeks, or push this button for that. That's pretty much it. I push the button to send it, and a few days later, box right at my door. That's it. Us. Med.com/juicebox, or call 888-721-1514, get your free benefits. Check now and get started with us. Med, Dexcom, Omnipod, tandem freestyle, they've got all your favorites, even that new islet pump, check them out now at us, med, Comm, slash Juicebox, or by calling 888-721-1514, there are links in the show notes of your podcast player and links at Juicebox podcast.com to us, med and all of the sponsors.

Dr, Mile Haller 24:54
I think there have been a number of barriers to it that are sort of systemic. Of. US healthcare. So certainly in the pediatric endocrine world, when things aren't FDA approved, that puts up a barrier. There are some physicians who just won't prescribe it, and patients and families who won't feel comfortable. And I understand that, but we've now not quite yet, but we've effectively taken that barrier away. The clinical trial we just completed, you know, showed that for all practical purposes, inhaled insulin is non inferior to injected rapid acting insulin in the basal Bolus setting. And to your point about GLP ones, it was associated with lower weight gain and improve patient satisfaction. So if you got those things, why wouldn't you consider it as an important tool? But because historically, insurance coverage has been more challenging for non FDA approved things, it's created a bit of a disparity where you have only families who could afford to get inhaled insulin and pay for it or figure out the logistics of getting it directly from the manufacturer when they were offering it at a discount, has led to just it not being used as much. I remain very hopeful that, you know, as it works its way through the FDA approval process and kids, that that barrier will go away, and people will have more opportunity to try it. And, you know, the offices will receive samples, because pharmaceutical companies won't bring samples for things that aren't approved, you know, to a pediatric office. So I think all those things are going to help it get past that, that big hurdle. I think it was just lack of awareness and understanding, you know, it is the fastest acting insulin we have, objectively, by quite a bit. It because of you inhaling this, you know, this biomaterial technosphere that regular human insulin is bound to it goes into the lungs. It disassociates with the pH change, and the insulin is absorbed within a couple minutes. You know, take sub q insulin 15 minutes on a good day to even be detectable in the bloodstream. Inhaled insulin is in and working and peaking in almost that same time frame, and is completely gone within 3045, minutes. Is the other big advantage. So you don't get that tail effect like you get from inject. From injected insulin, right? So it has so many sort of use case advantages that I really think it's just getting people past that inertia, that therapeutic inertia, of trying it, using it, you know, getting those barriers out of the way so that they will, will try it, I think will, in this case, you know, finally lead to success.

Scott Benner 27:19
Could this be like a beta, Max VHS thing. Are you too Am I too old? Are you young? You old enough to understand that reference

Dr, Mile Haller 27:25
I am, although I use that, I use that analogy all the time with patients, when I'm talking about CGM, and I say, you know, imagine telling me your favorite movie with an old VHS tape versus a Blu ray Disc. And they look at me like they don't know what either those things are anymore, because everybody stream stuff, yeah, as I'm just writing CDE CGM is more like using a Blu ray and then checking blood glucose with a meter, was more like six still frames on an old VHS tape. But, yeah, I think it's just technology uptake. It's moving with the times. It's getting past, you know, enough people with experience and and comfort with it that that it reaches the critical mass, and then it will take off. More

Scott Benner 28:01
Well, Mike, I sort of more meant that back I'm 54 So back when, like before, BCRs, people are like, I don't even know what that is, but you didn't used to be able to watch something that was recorded in your home. And there were these two competing ideas. Betamax was one tape. VHS was the other. VHS was bigger. It didn't look as good quality on the screen. Beta Max was smaller. It looked better. And for reasons that I don't know that anybody completely understands, the public drifted towards VHS and Betamax went out of business. Oh, yeah, right, yeah.

Dr, Mile Haller 28:33
No, that kind of thing that plays into, Sorry, I misunderstood the analogy you're making. Yeah, I think it's just injected insulin has such a stranglehold on the psyche of how you manage diabetes that even when offered something that has objectively advantages over it, people kind of shrug their shoulders and say, no, no, this is how we manage type one. We're going to stick with this stuff, right? This is faster, easier in some ways, to take doesn't have some of the risks associated with it, and yet people still choose the VHS tape to your point. So, yeah, I think there's going to take, take some work to get people to get

Scott Benner 29:06
past it. What are some of the risks that it doesn't carry?

Dr, Mile Haller 29:09
You know, I think really that's that post injection hypoglycemia that a lot of, certainly young, active people see around sports that it really helps reduce the risk of those exercise induced insulin potentiated hypoglycemia, because inhaled insulin is in does its glucose lowering and is out in such a short period of time, you can send your young athletes out on the field with a Normal blood glucose not worrying that you know their lunch injection from two hours ago is going to keep pushing them further and they're going to plummet and have a hypoglycemic event out on the field. So it really has have an advantage in that kind of situation.

Scott Benner 29:51
So in a very specific use case, your kid comes home from school and has soccer practice at five. Child's incredibly hungry. You're not going to tell them, Look, we don't want active insulin during soccer practice, so don't eat. We'll eat after you don't do that. So you feed them, you give them the insulin. They go upstairs, they get changed. You drive them to soccer practice. They're running around. They have a ton of active insulin, and they crash low. Now they're eating bars and drinking Gatorades and having a bad time. You're saying if they eat that same meal and took insulin, inhaled that by the time they got the soccer their blood sugar would be stable, the food would be handled, and there wouldn't be any active insulin to make them low while they were running

Dr, Mile Haller 30:29
around. Well, I can't promise that meal coverage would be part is definitely yes. That's the idea. The latter part is absolutely true. The lack of active insulin on board is just huge, a safety advantage in situations where we know you go out there and exercise and any insulin that hasn't been vascularized is going to get there much quicker. And kids tank all the time, and it's a huge distraction. It affects their performance. It forces them to take on extra calories that they may not want to. They feel full and bloated because now they've chugged a juice, you know, a protein bar or something. So, right? It definitely has those advantages. I think the challenge is just getting people to kind of work around the different paradigm, you know. So because the inhaled insulin only comes in currently, four, eight and 12 unit cartridges, and the units, unfortunately, don't equate to injectable insulin units. It just takes some time to get used to the notion that, you know, the inhaled insulin units you need two, if not three times more, to equate to the same injected amount. And I wish we could sort of call them different, different things. So we refer to them as a phrase of units when we talk to patients and families, and we did that in the study. And that always takes people a while to get used to, get used to, because, you know, nobody wants to suddenly take three times more insulin than they're used to. And again, it's not really that much more insulin. It's just the way that the units are. The numbers counted when you give it inhaled, but, but yeah, you know, if you're willing to give an inhalation and you're willing to top it off, so to speak, you know, every couple hours, you can really see a marked reduction in glycemic variability, far less risk for hypoglycemia. And so, you know, I think the sports case is just one really good use case, right? I think really pesky highs from challenging meals is another one. So you know, you're out eating your Chinese or your pizza, notoriously, requires, you know, three or four boluses or a square wave or dual wave, you can effectively, you know, approximate those things with inhaled insulin, just by literally watching the rate of change of your CGM. And so it requires patients who are willing to put in a little bit of that work to kind of notice that. But if you're an attentive person, and, you know, nowadays, almost everybody wearing a CGM can see their arrows in real time. And you just start to redo when the arrow starts to change its direction, and you see it blunted back to a flat or, you know, a downward trend is quite remarkable. You really just can't do that with injected insulin, because by the time you wait for the arrow to change, you know, everything's already happened, good or bad, and so it gives another significant timing advantage in those kinds of settings that I just don't think what you can't achieve with injected insulin. So I'm not suggesting that the inhaled insulin is going to replace injected insulin for everybody. That's that's just not likely to happen. But there are all these use cases where I think it can be, you know, an important tool and toolbox to help people achieve better control, you know, to wake up with those agencies in the low sixes, like you said, without, you know, having to fight as many battles with diabetes as everybody living with a disease knows, is just the reality of it. It just makes things a little bit easy if you have that extra school skill set.

Scott Benner 33:38
Yeah. Is it possible? You already outlined the problem when you started talking, because you said, we, you know, give people tools. You can give them their scripts and everything, but in the end, they've got to go home and make a decision to actively be part of this. I mean, maybe that's it just there. If you have to do all the things that you just said, to learn how to use it and to figure out where to put it in the right situations and everything. Like, maybe that's just the bridge too far already, like, maybe the VHS of it all is that, you know, a ID systems are, you know, it's one insulin. I don't have to mess with different versions of insulin. I put the pump on, the algorithm makes the decisions. And, you know, it's not perfect, but I'm also not involved all the time, and I don't need to understand this like a science experiment, like, I wonder if that isn't maybe just the simplicity of why usage isn't being done more. I think it's simple to say, like people are scared to put stuff in their lungs, because that is the first thing that scares me about it. But I'm also assuming that you wouldn't be here talking about it if you hadn't seen it be very successful for people and not an issue. I know there are some people who get that cough and stop, but that's not overwhelmingly what happens. Am I right about that?

Dr, Mile Haller 34:47
Yeah, so the safety issue is one that commonly comes up, but is has been pretty well put to rest in all the studies. There really is not any concerning safety signal. In fact, in the pediatric study, the. That the pulmonary function changes that everybody sees with inhaled insulin were actually more significant in the group that was randomized to injected insulin than it was in the group randomized to inhaled insulin. He would have presumed it was the other way around, perhaps, if he thought there was an issue with with the inhaled insulin causing any any issues, the long term studies so far really don't show any concern unless, of course, you know you're a smoker, or have known pulmonary disease, like, you know, recurrent asthma, that's severe, then that wouldn't be a good choice for you, right? But, yeah, that you know that too is a barrier for people to say, I'm willing to try this new thing. Yeah, I think you know you're right. The other things that we have now do a pretty darn good job, if you use them appropriately, but not for everybody, in fact, not for a majority of patients who still aren't getting to goal. So I think we always have to be striving to generate new tools to hopefully get, you know, even a few more percent of the population across to the, you know, to the desired side of the A 1c threshold for reducing their complications, and an inhaled insulin can definitely do that for folks. I mean, there are, there are definitely patients for whom they are using a basal insulin and inhaled insulin as their only rapid acting insulin. And they take, you know, inhalations, you know, before each meal, an hour after each meal, and in between those meals and snacks to correct. So they might be taking, you know, eight, nine inhalations a day, but they don't have to do nearly as precise carb counting, because it's a bit more of a paradigm. They it's more like sugar surfing by giving a little bit more when the, when the, you know, the arrow directionality changes, or certainly, if the number is higher, is that modality going to work for everybody? No, it's just not. But definitely works for some, and I think it would work for many more who were given the opportunity. The other things I'm really excited about in terms of use cases are, to your point about pumps, are using inhaled insulin in combination with the pump algorithms. So we all know that the, you know, the biggest reason the current algorithms don't get us to goal as well as we'd like is that meal coverage is just not optimized. The insulin is not fast enough to do meals right? But if you had a Bluetooth enabled inhalation device for your phrase, and you could essentially announce a meal by way of giving, you know, a single, four, eight or 12 unit cartridge that you didn't even really think about dosing on. You just knew every time I'm going to eat, I'm going to give this little bit of inhaled insulin. I'm fairly confident that in the next few years, the algorithms would be able to do the rest of the meal work without you having to do much of anything. And so I think that's a place where I'm already seeing patients do that. And I think that could be come sort of a commercially available use case for inhaled insulin over time.

Scott Benner 37:44
It even occurs to me that with the aggressive nature of some of the DIY algorithms, like you maybe wouldn't even have to announce the carbs right, like you'd let the inhaled handle the spike absolutely right, and then let the algorithm mess with whatever drift you see. That's

Dr, Mile Haller 37:59
right. I was just having that exact conversation with the patient I saw this morning before I came over to do this podcast, and he's on a T slim and was interested in how he could further optimize his meal control. And while that algorithm does a pretty darn good job overall, you know, he asked that exact question, what would happen if I if I took inhaled insulin and then didn't do anything? I said, you probably get about the same results as you're getting now. He said, Well, that would be a lot less work. Less work for me. I might be interested in trying that, right? And so I think exactly as you're suggesting, as we start to evaluate, you know, the safety, the clinical outcomes, and then the mental burden, which, at the end of the day, I think, is still the biggest thing that people living with diabetes have to deal with day in, day out. You know, if I can do something that gets me the same result with less burden, and I can think about all the other things in the world I'd like to do that don't define me as a person living with diabetes. I think that would be great for most patients. So I just think that's another space where inhaled insulin has got an opportunity to make a difference.

Scott Benner 38:54
Yeah, this is the first time I'm seeing it like in my mind, like my daughter's using trio, just so you know which one I'm what algorithm I'm talking about. But what I'm seeing is, if the inhale takes 15 minutes to peak, and basically food takes 15 minutes to hit you. You sit down, you inhale the insulin, you eat, maybe you tell the algorithm I had a few carbs, like, just give it like a number, so that it knows food is happening, but not enough of a number that it's going to make an aggressive Bolus, and then it'll address the drift up if it sees one like, I think there's a way to game that up and make that work. I mean, I bet you people could figure that out as they were going but no matter what algorithm they're on, actually

Dr, Mile Haller 39:34
agreed. But like, to your point, that will require some tinkering and people figuring out what works individually for them, depending on which algorithm or DIY system they're on. And they're definitely people who are doing exactly as you just described, and finding that it works well, because the, you know, the pharmacokinetics and pharmacodynamics of that little hit of super rapid acting insulin, you know, inhaled and then the pump system following up with the rest to clean up what's left. Shift works quite nicely, and again, still reduces the risk of that post meal tail insulin causing a low in any situation, whether that be exercise induced or even just hanging out watching a

Scott Benner 40:13
movie. Mike, you alluded to something a minute ago. I'd like to go back to I think that it's lost, maybe on people listening to a podcast about diabetes, people who either are already seeing a one season, the sixes or the fives, or have goals of it and are moving towards it. But that's not most people's reality, right? Like, if, if I said to you, you know, take 100 of your patients, you know, what percentage of them have an A, 1c, over nine? Do you know what I mean? Like, like, how many people aren't playing the same game that you and I are talking about right now?

Dr, Mile Haller 40:43
Yeah, I think there's like, sort of three distinct populations of people. There's the folks who are just struggling so, so hard with their diabetes. They aren't able to adhere to whatever regimen we suggest, that their agencies are, like you said, above nine. And sadly, you know, that's still in our clinic, probably about 20% of the population. So that's a lot of people, yeah, and so any tool we can use to get them down is meaningful. So, you know, we we've had many more conversations in our group now about offering the islet system to those patients, because for them, we know it will get them down to an A, 1c in the mid sevens. Is that where we want them? You know, no. But is it a lot better than their double digit, a, 1c Absolutely. We have to sort of shift our thinking to what works for the patients in those populations.

Scott Benner 41:24
When I interviewed somebody from beta bionics, I said I would probably skip right over endocrinologist office and go right to GPS and just tell them, like, hey, you know, all the people you have with type one diabetes or have, you know, double digit a one sees, like, slap this thing on them, give them a seven.

Dr, Mile Haller 41:38
Yeah, it's funny, you mentioned that. So we, we here at UF and also with our colleagues at Stanford, ran a diabetes echo program extension for community health outcomes, where we used tele education sessions to educate GPS. And I was shocked at the huge number of type one patients, not so much the adults, but even kids in both of our states that weren't seeing an end. Chronologist regularly at all, and they were relying on their GP for pretty much all their their management. And none of these GPS had any comfort level at all with using a pump. Not a single one of them, right? It took a large lift just to get them to use a CGM. But, yeah, I think there is a space for a system that's, you know, doesn't require anything of the physician, other than entering a weight and getting comfortable with prescribing CGM, to consider improving control for those patients out there, because there's plenty of them. Yeah, so we've been working towards, you know that in in our echo sessions, and I think we will get to a point where we certainly have increased physicians out in the general community who aren't endocrinologist comfort level with, with using technology, and they're, they're sort of that pre contemplation phase, I think, with using pumps. And I think pumps like islet could certainly be a good opportunity for them.

Scott Benner 42:50
Is it? Is it ever get heavy for you? It does for me? Like, does it ever get heavy for you? That idea of, like, you know, the slow nature in which this all moves forward, that these tools exist and that you've got to talk someone into it, or worse, wait for a doctor to age out so that the next one comes in and that community and you can, you know what I mean?

Dr, Mile Haller 43:09
Yeah, many of my colleagues and staff will tell you, one of my traits is definitely not patients. So I'm probably the least patient when it comes to waiting for people to adopt things that the evidence prove work well, and yet we still see this, you know, this therapeutic inertia towards them. So it is frustrating, but it's also part of, like, you know, my passion project for helping improve the lives of people with type one by getting these tools out there. And so, like, you know, like, like, we're talking about, like, with inhaled insulin, I just think that it's, it's an inertia game, and we have to figure out how to win it by explaining it to people well, demonstrating the use cases for it, making sure there aren't other barriers in their way to use it. And then, you know that will happen, and whether that's inhaled insulin or pump use from general providers for the folks who aren't coming to endocrinologist, I think all those things need to happen and need to happen much faster.

Scott Benner 44:02
Yeah. Listen, I made a decision about 10 minutes ago that I'm going to take your recording and I'm going to make it part of the Grand Round series, because you're you're given a little Master's class here about how to think about taking care of people with type one diabetes. So I appreciate that. I'll say inhaled insulin, and so people understand what they're getting still, but this is part of a bigger conversation that I've been trying to have for a long time. There are just little dials to be turned, and things would be so much better for so many more people. I believe that doctors don't believe it half the time that it's even possible for people to to improve, but this making this podcast has shown me that there are many, many different ways to get information to people. A lot of people like to listen. A lot of people like to learn by talking to someone else online. They want to do something visual. You can't possibly know who all those people are. You can't know all the things they've been through before they get to you or how. All, you know, upbeat, they are depressed. Like, you know, I'm always fascinated, like, you'll talk to someone who just has the greatest attitude about everything, and they can't tell you why they have it. It's they've been like that their whole life, and they got diabetes, and they just carry that attitude right through diabetes. And there's the next person who, you know, it's a woe is me right away. You know, the world's been coming for me forever. This is just the next thing on the list. I can't beat this. I can't fight this. There are so many different psychological, social, financial impacts that people with type one have that like, I don't think that it benefits us to try to figure out each one. I think you just throw all the tools at them. You go, look like, here it is. Like, you go, find the part that helps you. And the way I've done that is by I have dumbed down diabetes into t shirt slogans, basically, like ideas that, like, I see somebody every day, tell somebody about a high blood sugar, go crush it and catch it. Like, that's me, Mike. I made that up. I made an episode where I said to somebody like, Don't stare at a high blood sugar. You have to get it down. Don't take three hours to mess with it, like, just just crush it and then be ready to catch it on the back end. And then we talked about how to do that. And now I see people all over the place doing that. I explained pre bolusing in a way that relates it to a tug of war that neither side is trying to win now, people, I see people all over the place go I finally understand Pre-Bolus like the way we talk about it from the doctor's office doesn't jive with most people.

Dr, Mile Haller 46:32
Yeah. I mean, you're clearly a gifted communicator, and being able to teach back things to people you know, like they're in kindergarten, is extremely effective. Your average physician is not, yeah, not, not, not, because you're kidding them, like they're not an intelligent person, just keeping it simple and making sure the message actually hits. You know, we often over complicate things to the point that patients don't use the skills we're trying to teach them how to use. So, yeah, I think it's, it's

Scott Benner 46:58
important. I often think, like, if you made me the lead salesperson at beta bionics, I'd sell a billion of those things. And I know exactly what to say to people. I know exactly how to make it attractive. I know what you got to go into the doctor's office say, look, go find me five of your worst cases. And like, watch over the next six months while we've improved their life. Go find me these people, and we'll show you how to use glps like that'll really help them, and then let the doctors go off and replicate that over and over again. The glps are fascinating to me. Really, the the amount of people are like, you know, Oh no, it's dangerous. I'm like, you know, you threw everyone on a GLP when you heard about it. And you've got some poor person here with type one for 35 years who's had an A, 1c, in the eights and the nines for 35 years. Then they had they had a digestive issue and a GLP. Like, well, no kidding. Like, right? Like, they probably have some version of gastroparesis to begin with. Then you slow down their digestion more with this drug. That doesn't mean everyone's going to have that problem. And I was feeling that when you were talking about the too, because what I'm thinking is is the healthier you you launch into this endeavor, the fewer problems you're likely to have along the way. Like, you know, if you just hand it to a guy who's been smoking cigarettes for 35 years, and his a one sees been in the eights for a while, like, well, he might cough. I get that. You know what I mean? Like, he's 50 pounds overweight, like, but I don't know. Like, I sometimes with these new things, the first thing people see is not usually the right answer, but it is the thing that sticks with them forever. Does that make sense?

Dr, Mile Haller 48:27
Yeah, I think most physicians and many families are risk averse, and so they're going to be extra tweaked to look for a bad outcome, and then, like you said, kind of focus on that even when it doesn't reflect the majority experience. I think there's always something to be learned from you know, when things don't go right, that doesn't mean that a drug or a modality isn't a really good option for many people. I personally love using GLP ones. And, you know, 30% of type one patients are obese in the OS. It doesn't, you know, doesn't get away from them just because they have type one Americans are are heavier than the rest of the world, and therefore they have more insulin resistance, and it makes it, you know, Snowball forward when they need to use more insulin. So I've had great success with using GLP ones as an adjunct for the right patient, just like I've had great success using inhale insulin for the right patient, you know, as an adjunct, and sometimes even as they're only rapid acting insulin, you know, I think we have to continue. It's why I like diabetes care. I think, you know, the field continues to evolve. We have all these tools, and figuring out which set of tools works best for the right patients, to me, is the fun of trying to, you know, figure out what works best for for people, and helps, helps more people get to that a 1c target and

Scott Benner 49:43
don't throw the baby out with the bath water. The first thing that you see isn't, you know, like, it's not a rule for everybody. So tell me something. What did this study show, and why are you so excited about it for the new population that it's now available

Dr, Mile Haller 49:56
for? Yeah, so the inhale one pediatric study. He randomized kids to either getting inhaled insulin for all their meals, corrections, all the rapid acting use, or they stayed on a basal insulin and did multiple daily injections, you know, with rapid acting injectable insulin. And after 26 weeks of being on whichever group, they were randomized to the the A, 1c at the end of the day was basically the same between the inhaled insulin group and the injected insulin group, and it was really well tolerated. Very few kids stopped using the inhaled insulin. There was actually only a small number of kids who reported having cough beyond the first couple weeks of use. So people definitely got got used to that and figured out how to mitigate that issue. You know, interestingly, there was increased perception of enjoying using the insulin that was inhaled versus the injected insulin, amongst both the parents and the kids who are actually using, you know, using the phrase. So I think at some point that is something that's important to keep in mind, that it made their perception of living with diabetes a little easier. And that's something that's really an important endpoint for folks, as we get more and more people to target, you know, the next thing is, well, how can I get to target with less burden? So I think that's important. And there was less, you know, weight gain in the in the group that was randomized to inhaled insulin. So that too, as we were just talking about, you know, it's a big problem with obesity and type one in our patients, and any therapy that can potentially reduce that risk somewhat is something that we should be considering as an option. So, yeah, I'm excited to see it move forward and get get that FDA

Scott Benner 51:33
approval. What's the reasoning behind the less weight gain? Do you think, I think it has to

Dr, Mile Haller 51:38
do with more physiologic dosing? You know, you're really talking about giving insulin much more, like insulin that would be coming out of your pancreas into the portal vein directly and deliver and so you don't have excess insulin being around that you then have to feed to avoid the low, post meal, post snack, you know, exercise related, so likely, that's the modality.

Scott Benner 51:57
That's it. And then what's this is with the FDA now? Or what's the process like?

Dr, Mile Haller 52:01
Yeah, the company has filed for approval with these data. It can be a six to nine month process to get all the way through, but with any luck, at the end of that timeline, they'll have the stamp of approval from the FDA and then be able to start marketing it and selling it to pediatric offices, and that means their sales force will be able to visit and provide samples. And I think you know that that will be one of the key things to getting over that therapeutic inertia, to have people have access right in their offices and say, Oh, look, here's the phrase. I Why don't we try it? And then I think you'll have many more patients and families who get to experience what we were talking about in the last hour, right? And say, Oh yeah, this, this really is a nice tool to have in my toolbox for those pesky highs, or for these particular meals or for this sports situation. And then it will get out there. And hopefully, you know, be part of the of the thought process when people start to enter a room and say, what's going to be best for the patient in front of me

Scott Benner 52:56
today, it just occurred to me, as you were saying that, like, great. This is the, this is maybe the most hopeful inroad to making people understand how well this works, because you're not going to, you don't change adults minds about anything, right? So you get people when they're younger and they can become accustomed to it, see how valuable it is for them. They'll carry they'll carry that into adulthood,

Dr, Mile Haller 53:16
exactly to that point. I'm really excited about a study that they're planning coming up, which is going to be offering inhaled insulin at diagnosis. So imagine, go back to when your daughter was diagnosed in the first thing they walked in the room and they said, we have this way of managing diabetes. You'll take this one injection a day, and then everything else will be inhaled, and you never were presented with the need or the option to give multiple daily injections or be on a pump, my hunch is that's going to play really well with a certain population of folks, and that they'll, you know, they'll learn from the very beginning that this is the paradigm for how we deliver insulin, and they'll see that they have great control, and they'll want to stay on it, versus trying to convince people to change what they're already doing when it's working pretty Well for most.

Scott Benner 53:59
Yeah, well, I hope that companies in general realize at some point that it's not just a sales person that you need. At that point, it's a person who understands it, you know, like somebody who can actually talk about it with the care and concern that you and I have, but doesn't feel salesy and doesn't feel like a doctor. Like, I know that's strange, but like, if somebody could sit down in that moment and go over those things with you, here are the options for how we do this. Here's the, you know, the pros and the cons. Yeah, then let people make a decision that fits best for them, and they'll be more successful once they've done that. And you'll get more people who will do what is considered like a different idea the way this is all set up. I know it's no one's fault. Like, I really understand that. Like, most people are not sick most of their lives, you're suddenly diagnosed with something. Your expectation of the way medicine works is that you go to the Magic Man and the magic man gives you a thing, and then you're better. Like, right? Like, that's really people's understanding. Standing of medicine. I broke my arm, and one day it's not broken anymore. I got sick. I took these 10 pills three times a day for 10 days, and when it was over, I wasn't sick anymore. You don't grow up with an expectation that you're going to be managing, you know, like, I've put it in the past, like, diabetes is like trying to remember to make your heart beat. It's like, if I put you in charge of, like, you know, breathing and I said, like, breathe in, breathe out. You had to say that to yourself every couple of seconds for the rest of your life. It feels like that. It's not the way people imagine their lives. They need to be set up for success very early on, when they are what I'm telling you, I see Mike, is that when you set them up for success early, they don't struggle as much, and they actually have that success when it's over. So I hope that we can all find a way to that. It's right there. The beta bionics thing is one arm of it. The inhalable is one arm of it. GOP is one arm of it. You just have to get the right message makers out there to let people know. I think so.

Dr, Mile Haller 55:56
You're again, very perceptive. The thing that ironically, made the biggest difference in outcomes in our echo programs was, was exactly as you described, peer coaching. Wasn't the docs were the last to be important in all this. Frankly, it wasn't sales reps. It wasn't the tools. It was having somebody who had lived shared experience, who could talk to people without, you know, bias and without judgment, and say, Oh, here's some other options you might consider. And boom, we saw people seeing marked improvements in their

Scott Benner 56:26
outcomes. Let me pitch my last idea with your mic as you go out the door. I think people's endo appointments for their type one diabetes should be in a group setting, not one on one.

Dr, Mile Haller 56:35
We have done just that. It's extremely effective. The only challenge is the US healthcare system and figuring out how to make it all billable. All billable. Yep, it's another reason camp is so great. Camp is like a one week long group education session, highly effective for everyone. I'm

Scott Benner 56:50
sure you can do the same thing, but I have a crisp one hour talk. I could give it to you, and you'll know how to take care of yourself when it's over. Yeah, and if you came back and build on that through Q and A's. Like, if the same group of 500 people showed up in an auditorium once every three months and build on their knowledge through Q and A's together a year later, they'd be done. They wouldn't even need you anymore. I see how the podcast works, and it could be replicated in real life. But like you said, like every time I bring it up to somebody, the next thing they say is, well, we don't know how to bill for that, and so

Dr, Mile Haller 57:22
somebody's got to break the system. Well, the system's broken. Somebody's got to come up with a better way to do it and deliver it. And I agree, there's, fortunately, there's a growing number of people who were setting up for success early on, like you described, who we've achieved that goal. They don't need us. They're doing great. We don't need to see those people every three months and make them come in for, you know, a check the box, visit. And we've, we've started to not do that as much in our clinic, so we can put more energy in the folks who really need it. But even those folks need need better ways of of getting them

Scott Benner 57:50
information. It's difficult because you don't build lifelong customers. I had to early on with the podcast tell myself, like, you know, my goal is for you not to listen to the podcast anymore, which is tough for me, because it's hard for me to keep it going then, but I found ways to keep it going. And, you know, other physicians could could as well. Like there's a way to put people out into the world healthy, in charge of themselves, where they're not going to see problems down the line nearly at the same rate. And right now, at best, we give people don't die advice. It's, you know, you're not gonna die, but you're not really gonna live well, and at least it's not on me. And that gets passed down the line, and then some poor doctor at the end of the line manages you out at the end of your life. And it just, it's a weird setup, like, I mean, we all know, like we're probably preaching to the choir here, but there's ways to accomplish this, so I appreciate you giving your opinions today and adding to the conversation. Thank you very much. It's been a pleasure being here. Awesome. Hold on one second for

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#1633 Bolus 4 - Pancakes

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Jenny and Scott talk about bolusing for Pancakes.

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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 back to another episode of The Juicebox podcast.

In every episode of Bolus four, Jenny Smith and I are going to take a few minutes to talk through how to Bolus for a single item of food. Jenny and I are going to follow a little bit of a roadmap called meal bolt. Measure the meal, evaluate yourself. Add the base units, layer a correction. Build the Bolus shape, offset the timing. Look at the CGM tweak for next time. Having said that these episodes are going to be very conversational and not incredibly technical. We want you to hear how we think about it, but we also would like you to know that this is kind of the pathway we're considering while we're talking about it. So while you might not hear us say every letter of meal bolt in every episode, we will be thinking about it while we're talking. If you want to learn more, go to Juicebox podcast.com. Forward slash, meal, dash, bolt. But for now, we'll find out how to Bolus for today's subject. Please don't forget that nothing you hear on the Juicebox podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin.

A huge thanks to my longest sponsor, Omnipod. Check out the Omnipod five now with my link, omnipod.com/juicebox you may be eligible for a free starter kit, a free Omnipod five starter kit at my link, go check it out. Omnipod.com/juicebox Terms and Conditions apply. Full terms and conditions can be found at omnipod.com/juicebox Jenny, we are going to do pancakes. Oh, pancakes. Now we have two different pancakes sitting here. We have the ones for those of you who are in the grocery store buying the Betty Crocker Bisquick, shake and pour pancakes. And don't put your heads down. Stay proud. I know you'd buy them out there. Jenny, do you even know what this is? It's a plastic bottle that you pour water in and then you shake, shake, shake, shake, shake it up, and you have pancake mix when it's over. You don't know this. They

Jennifer Smith, CDE 2:25
didn't know that they made them that way. I thought you still had the powdery stuff that you had to mix in a real bowl at home. I did not

Scott Benner 2:32
know you can buy it like that too. This is, like, this is next level, I'm not gonna say lazy, but this is next level, easy, okay. Like, it's a plastic jug. You pour cold water and you shake it up, you have mix. I have tried to Bolus for them, and it ain't easy. So, like, I could do it, but it's not easy. It takes pre bolusing. It takes extended boluses. It takes increased basal over top of like eating and Arden does not use syrup with sugar in it. As a matter of fact, she oddly eats pancakes dry. Sometimes she won't even put butter on them. Sometimes. Now I have those. We're going to look at those. But then I also have a very simple to make on your own pancake recipe that has been on my blog for years that does not cause any consternation the way these the mixes do. But let us start with the mix nonetheless, and that's

Jennifer Smith, CDE 3:26
interesting. I would expect what I'd expect from both of them in the extended nature of insulin need after has is not the upfront, but it's the long term. Would be the because of the way that you cook them.

Scott Benner 3:41
Okay? Yeah, I'm not sure. I don't know why, but, like, all I know is simple ingredients that are real seem to be I'm not, listen, they're still pancakes. It's not like bolusing for you know

Jennifer Smith, CDE 3:53
what I would expect? Your recipe is real flour, right? It doesn't have all of the added preservatives. It

Scott Benner 4:01
doesn't. And I do spend a little extra money when I buy flour in the house. It's a little better, but it's still it's got butter. You'll see. You'll hear it when you hear it. But let's start with, let's, let me turn to a new, clean page on my shaking bottle. Let's start with the Benner cake. This quick shake and pour buttermilk pancake mix, 10.6 ounces a serving size is a this is hilarious. A half a cup of mix is a serving size, and they're calling that three pancakes.

Jennifer Smith, CDE 4:29
And is that dry mix before you've mixed it with the liquid ingredients, that's the next question.

Scott Benner 4:36
I think if it's three, I don't know, I don't know what they're saying. So let's look on the it's 10.6 ounces.

Jennifer Smith, CDE 4:44
That would be my consideration. It's that you've got a half a cup of dry mix, and what you add to it, liquid wise, it sounds like it's just water. You don't have to add milk or other nutrient containing foods. So if it's just water. So the whole container, I would expect, takes a certain amount. So if you break it down to a half a cup of the dry mix, how much water goes in? That probably makes three. Does it give a diameter? To

Scott Benner 5:13
be honest, I think it might mean the mix with the liquid in it. Oh, yeah, because it's saying there's five. I'm trying to think of, I have used this before, so five servings of a half a cup? Yeah, I bet you there's about two and a half cups of liquid in there. Yeah, I'm gonna go ahead and say that this means a half a cup of the actual mixed is there some tiny pancakes? Man? Well, that was my point. Is that this is where they're three pancakes. It's got to be like three inches Exactly. They got to be the tiniest goddamn pancakes you've ever seen in your life, is my point. So again, this is where they're going to mess you up, because no one's making a pancake that's two and a half inches across. No, no. So anyway, a grain of salt on the on the serving size. But let's just say, why don't we just say that you eat half of the container? That makes sense. Okay, so, so let's call it servings in the container. Yeah, there's five servings in the canner you're gonna have. Let's just say you're gonna have two of them. You're gonna have two servings. So this is six grams of fat. It is. Where are the car? Oh, it's 9090, carbs. 45 for a serving. 45 for a serving. So 90 for two servings, you get 90 carbs. You're getting six grams of fat, a lot of a lot of sodium, by the way, you're gonna see we're eight, almost 1000 milligrams of sodium. Wow, 480 per serving. Five or a gram for a serving. So two grams sugars, including nine grams of added sugars. You're getting, you're getting 10 grams of sugar in a serving. So 20 grams of sugar in that because there is at, I mean, most of it's added. Actually, they are adding a lot of sugar to it. Protein six, so you're getting 12 protein total. Okay, don't worry, there's calcium and iron in them. You're gonna live forever. The ingredients are enriched flour, bleached wheat flour, malted barley flour, niacin, iron, thiamin, mono nitrate, riboflavin, folic acid, sugar, Defatted soy flour. I don't know what that means. Leavening agents like baking sodium, sodium, sodium aluminum phosphate and mono calcium phosphate. There's also palm oil, dextrose, buttermilk, salt, something that's called da temp, but it's all in caps. That scares me, for some reason. I'm gonna look that up later. Contains wheat, soy and milk ingredients. Okay, well, let us go to our breakdown list. We have measured our meal. Our meal is 90 grams of carbs. We are one unit for 10. So that's going to be nine units of insulin. We're going to evaluate ourself again, this is the morning, I would have to say another evaluation here is, I mean, how many people are making pancakes and not putting bacon or some sort of, like a breakfast meat with it, which is, I know that's not what we're talking about right now, but like, you know, like, that's going to hold up the whole, the whole thing well,

Jennifer Smith, CDE 8:24
and I think in the realm of, again, your listening body, a lot of people are all actually trying to do that. They may not have before, but they may be trying to do that to mitigate the impact of what they expect the pancakes to do?

Scott Benner 8:41
Yeah, I'm saying the only the issue there is, like, you're trying to add protein with it. So in the morning, protein might mean bacon, and then bacon is going to mean fat, and then you're going to have, you know, you're going to get the lift from the fat later too, right? Okay, calculate our food. Bolus, we've done that. We have nine units. What do you think? Jenny, you want to you wake up in the morning, it's Saturday morning, you are having the experience that Arden has been having lately. A hot shower is shooting her blood sugar up. Never used to happen. All of a sudden, hot showers, boom, like she's

Jennifer Smith, CDE 9:12
going and it's not just her CGM that's being weird. It's actual, by finger six, she's rising too.

Scott Benner 9:17
She's jumping up in hot showers lately. Okay, so you get out of the shower, you come downstairs, Mom, it's Saturday. What are we doing? Oh, you're lucky. I'm a great parent. I've bought you a bottle of pancakes, and again, I've made them so you know, if there's shade, it's for everybody. There you go. And my blood sugar is 150 Oh, now I need a half a unit to move the blood sugar, probably more. Your blood

Jennifer Smith, CDE 9:40
sugar still rising according to the CGM trend, or is it stable at 150 let's

Scott Benner 9:44
call it stable, just to make those okay. Okay, so I need a correction for my one unit moves us 10 carbs. One unit moves us 100 points. That's for our examples. So now I'm looking at a nine and a half unit meal, uh, meal, Bolus. Do you. And what I hear from people all the time is like, oh, big Bolus to scare me. So I think that they can, often people look at them go, that's a lot like, you know, I don't know if I'm gonna put all that in there. I would say, you know, I think your rule of thumb here for double whatever you find works for you. So if you found, like Jenny used in other examples, if 12 minutes is a good Pre-Bolus for you, for something like this, you're going to need 25 minutes. This episode is brought to you by Omnipod. Would you ever buy a car without test driving it first? That's a big risk to take on a pretty large investment. You wouldn't do that, right? So why would you do it? When it comes to choosing an insulin pump, most pumps come with a four year lock in period through the DME channel, and you don't even get to try it first. But not Omnipod five. Omnipod five is available exclusively through the pharmacy, which means it doesn't come with a typical four year DME lock in period. Plus you can get started with a free 30 day trial to be sure it's the right choice for you or your family. My daughter has been wearing an Omnipod every day for 17 years. Are you ready to give Omnipod five a try? Request your free Starter Kit today at my link, omnipod.com/juicebox Terms and Conditions apply. Eligibility may vary. Full terms and conditions can be found at omnipod.com/juicebox find my link in the show notes of this podcast player, or at Juicebox podcast.com

Jennifer Smith, CDE 11:30
and the Bolus size really does scare you. A stepping stone to getting there, if you really love this product, would really be do that 25 minute Pre-Bolus with half of what the Bolus recommended is, if it's nine units, take four and a half. Take that with the Pre-Bolus, and then as soon as you start eating, take the other because we all know the insulin action time is not right here and now, as it's delivered, still takes a little build up time to get it working. So that's it's this strategy that, while it may not be beneficial for keeping your blood sugar under 180 at least you're getting the whole Bolus without as much fear. Is truly what's in the picture?

Scott Benner 12:13
Yeah, I'm gonna say, you know, just from a person who's, you know, raised a kid with type one diabetes, I like Carrie's sugar free syrup. Of all the ones that we've tried over the years, that one seems to taste the most like syrup carries, yeah, S, C, A, R, y, s, do you have one that you tell people about?

Jennifer Smith, CDE 12:31
You know, there are two that I think have quality flavor, which I've heard from a couple of people. They really don't like one of them, the LE conto brand. I don't have an issue with the flavor of it. The other one is the RX sugar. That one has a really nice maple sugar. It's all yellows, sort of non sugar alternative, kind of in it. So those tend to work well, I've never seen an issue with the RX sugar. I while there are, again, on all of these alternative sugars, carb counts on them, probably like the carries. I don't know if Arden has to count any of the carb grams on there, but I don't for the RX sugar. But I'm also not eating, like a half a cup of it.

Scott Benner 13:17
I don't see the carries doesn't add rocket fuel to pancakes for her. So okay, I take that as a way that she probably doesn't need to cover it. Now, listen, I happen to know because during covid, I went on an extensive research to find out why the waffles at a local diner were so good. I was really bored during covid, and I found out what syrup they were using. So I'm going to tell you that the one you get in a diner that you probably think of is tasting good has a serving size of two tablespoons, which no person in the history of the world has ever used on pancakes. But let's just say two tablespoons, not only are you going to get 100 calories from that, but you are going to get 26 grams of carbs from two tablespoons of this, if you're doing 90 grams worth of pancakes and a quarter of a cup of syrup, which I'm still being generous for people, but let's say that. Let's say it's, it's another 52 grams, yes, yes. It's another 52 grams of insulin of carbs, which is now putting your, I'm gonna have to do some math here. That's 142 but that is that 14 plus the correction, that's just about 15 units for that. Then if you're gonna put, yeah, Jenny's like, I haven't taken 15 years, and it's less than three days, that's not true, but not all at once. Oh, my God. My point is, is that you can't, you can't come online all the time and tell me I don't know how to Bolus for pancakes if you're not addressing them for what they really are, that's all like, you're gonna have to come at it for what it really is. You can't say, oh, that number seems too big, or I've never Bolus that much before, like this is what it is.

Jennifer Smith, CDE 14:53
And I think a valuable piece to point out too is, you know, you brought up a waffle house for. Waffle right? Let's say you have figured out your pancakes at home. You know the portion size. You know exactly what goes into them. When you go to your local pancake place, it will be different. Is it a little easier to swag the pancakes you're eating? Sure, because you have something that you've figured out to work, but also your pancakes at home might be four inches, and this pancake that comes out to you now is the whole, the whole plate, right? And so then you end up, let's say you swag it pretty good in terms of the grams of carb, but now in terms of worry about that amount of insulin, you put that in your pump and you're like, my gosh, 14 units of insulin. I usually take five for what I eat at home. Yeah, what you need is what you need, right? Based on how much you're eating and how much you're calculating. So as long as your insulin to carb ratio is the same, sure, you might use five units at home, but you may very well need the 14 units because of the difference in portion.

Scott Benner 16:04
I would say that, you know, when we talk about, you know, looking at your CGM down the line an hour, three hours, and evaluating what happened, so you can tweak it for next time. If that amount of insulin scares you to the point where you're like, I can't, I just can't do all that. Like, I don't, not understand. But then when you're doing your valuation, and you end up having to make a correction. Look at that insulin. Like, the amount that you use to correct with, is that the amount you skipped in the initial Bolus? Like, is it close? Like, that'll help you get to the idea of what you actually need. I'm not saying run out there and make some like, super aggressive Bolus. Like, you might be the person who doesn't need it. Like, you know, like, you're gonna have to work into this. But this is the thought process for going through this and and I'll just say here at the end, if you go to Juicebox podcast.com and type pancake into the search bar, you'll get a simple recipe that I use when I make pancakes home. It's a cup of flour. It's all purpose flour. It has two tablespoons of sugar in it, and it has two teaspoons of baking powder, a teaspoon of baking soda, a pinch of salt, a cup of milk, one large egg, two tablespoons of melted butter and some vanilla extract. And is it like drinking water and bolusing? It's not. It's still like pancakes, but it's not like the packaged pancakes, the box pancakes that were there. So

Jennifer Smith, CDE 17:21
what is your since you know and you have had both, what do you see is your difference in strategy, knowing that who you're feeding it that she's still going to eat the same amount of pancakes either way, right? She's

Scott Benner 17:37
tough, because she'll like, she'll grab them and then start eating. And they go, can I give me another one of those? And some days she's like, give me some syrup. Or someday she's like, I'm just gonna eat them dry. Like, see, it's a little bit the syrup sugar free. But what I like is I take a couple of different strategies and I throw them together nice long Pre-Bolus. It's gotta be 20 minutes at least, right? I like to see a falling blood sugar when the food hits. And then I put a basal over top of the first hour, at least, right? Like, because my goal is not to leave 90, right. Like, especially on stuff like this. Like, I'm more aggressive on the things that, like, could possibly lead you to an afternoon of 350 blood sugars, right? I don't mind missing on something that goes to 160 and we have to fix it, like, whatever, like, but I don't want to get I don't want it to ruin the day. So I would lay a basal, like an attempt basal, over top of the Bolus. And, you know, Arden's using trio right now the do it yourself. App, it's very simple to do. I'd put the Bolus in 20 minutes before, you know, if she had a lower, stable blood sugar going in, if she came downstairs out of that hot shower, and she was 170 and she said, I want pancakes. The next words that would come out of my mouth are Bolus, like, before I even go to look to see if we add an egg in the refrigerator now, like, just now, you know. And it's momentum, like Jenny, it's timing and amount. Like, I know this is fun to break down like this, but like, it's the right amount of insulin at the right time for the situation. So and then I like that you can bail on the temp basal if you start getting too low. And then to me the L or the look at the CGM in meal bolt. I keep watching. If I see a drift up, I'm right back on. I smack its hand like it's trying to shoplift. You know what I mean, like right back at it again.

Jennifer Smith, CDE 19:22
And with trio, you've probably like me, I've been using trio for a year now, and honestly, what I've found is it's less likely to need to do that back end slapping, mainly because it does a good job of that additive. Depending on how you have your dials turned in, it does a pretty good job of hitting for you before you have to step in, which is nice, because you can kind of step away for a bit right in

Scott Benner 19:50
the end. It's in the podcast somewhere. Jenny and I've talked about it. I've said it over and over again, but I leave a over heavy carb situations, I lay a blanket of insulin over top of it. Like a weighted blanket so it can't stand up and

Jennifer Smith, CDE 20:02
and in this case, I think that weighted blanket effect, so to speak, is relative to, as I pointed out initially, both types of pancakes require cooking them in oil

Scott Benner 20:15
or butter, or I do butter on the pan, and very little like, I actually butter the pan, and then I wipe it off like so I just don't want it to stick. That's all I care about. But I do see you're not wrong. I've seen people look like they're deep frying their pancakes. Yeah, that's a more southern thing, too. I've noticed when I'm traveling sometimes too. Is that maybe what could be?

Jennifer Smith, CDE 20:34
Yeah, could definitely be. I think it's also restaurant style is definitely heavily cooked in some type of oil or butter on the surface,

Scott Benner 20:45
they're trying to kill you, for sure. Yes, actually, I guess what they're trying to do is give you enough butter that you're like, I'm coming back there one day. Yes, yeah, okay, all right, this is good. That's, that's, that's

Jennifer Smith, CDE 20:57
that long term effect. You're not only thinking about carbs, but you're thinking about that lingering, yeah.

Scott Benner 21:02
So, I mean, I'm gonna tell you this all changes. You add bacon to this, or we're from the Northeast pork roll to this, and now, yeah, right. And now my checking, like, isn't just one, two hours later, because if I get pancakes right, two hours later, I'm done. It's good, but you add bacon or some fatty meat to it, now it's three, three and four hours later, like you still have to be looking Sure. So okay, all right, I appreciate it. Awesome. Thanks. Thank

you. A huge thanks to my longest sponsor, Omnipod. Check out the Omnipod five now with my link, omnipod.com/juicebox you may be eligible for a free starter kit, a free Omnipod five starter kit at my link, go check it out. Omnipod.com/juicebox Terms and Conditions apply. Full terms and conditions can be found at omnipod.com/juicebox

Unknown Speaker 22:00
you in

Scott Benner 22:04
each episode of The Bolus four series, Jenny Smith and I are going to pick one food and talk through the bolusing for that food. We hope you find it valuable. Generally speaking, we're going to follow a bit of a formula, the meal bolt formula, M, E, A, l, B, O, L, T. You can learn more about it at Juicebox podcast.com, forward, slash, meal, dash, bolt. But here's what it is. Step 1m. Measure the meal, E, evaluate yourself. A, add the base units, l, layer, a, correction, B, build the Bolus shape, O, offset the timing, l, look at the CGM and T, tweak for next time. In a nutshell, we measure our meal, total carbohydrates, protein, fat, consider the glycemic index and the glycemic load. And then we evaluate yourself. What's your current blood sugar, how much insulin is on board, and what kind of activity are you going to be involved in or not involved in? You have any stress hormones, illness, what's going on with you? Then a we add the base units, your carbs divided by insulin to carb ratio, just a simple Bolus l layer, a correction, right? Do you have to add or subtract insulin based on your current blood sugar? Build the Bolus shape? Are we going to give it all up front, 100% for a fast digesting meal, or is there going to be like a combo or a square wave Bolus? Does it have to be extended? I'll set the timing. This is about pre bolusing. Does it take a couple of minutes this meal, or maybe 20 minutes? Are we going to have to, again, consider combo square wave boluses and meals, figure out the timing of that meal and then l look at the CGM an hour later, was there a fast spike? Three hours later, was there a delayed rise? Five hours later, is there any lingering effect from fat and protein? Tweak, tweak for next time. T What did you eat? How much insulin and when? What did your blood sugar curve look like? What would you do next time? This is what we're going to talk about in every episode of Bolus. For measure the meal, evaluate yourself, add the base units, layer a correction, build the Bolus shape, offset the timing, look at the CGM tweak for next time. But it's not going to be that confusing, and we're not going to ask you to remember all of that stuff, but that's the pathway that Jenny and I are going to use to speak about each Bolus. I can't thank you enough for listening. Please make sure you're subscribed or following in your audio app. I'll be back tomorrow with another episode of The Juicebox podcast. The episode you just heard was professionally edited by wrong way recording, wrong wayrecording.com.

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