#1800 Super Diabetic - Part 1
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Katarina was shredded, misdiagnosed as type 2, and quietly falling apart. From parking lot naps to finally demanding antibody testing, this is her late-onset type 1 wake-up call.
Key Takeaways
- Adult Misdiagnosis is Common: Adults, even those in peak physical condition, are frequently misdiagnosed with Type 2 diabetes based solely on age. Antibody testing is essential for an accurate Type 1 diagnosis.
- Hyperglycemia Causes Physical Strain: Chronic high blood sugar leads to severe dehydration and electrolyte imbalances, which can manifest as deep, internal "organ pain" often mistaken for general aging or back issues.
- The Psychological Impact of Diagnosis: A sudden diagnosis at age 28 can trigger significant mortality fears and grief over a perceived loss of lifespan, despite modern management erasing many of these risks.
- Advocacy and Second Opinions: When medical providers dismiss symptoms or suggest "lifestyle" fixes for an athletic individual, patients should insist on specific diagnostic tests like antibody and C-peptide levels.
- The "Invisible" Onset: During the honeymoon phase, oral medications like Metformin may appear to work temporarily, but viral illnesses like COVID-19 can accelerate the total loss of insulin production.
Resources Mentioned
- Juice Cruise 2026: juiceboxpodcast.com/juicecruise
- Touched by Type 1: touchedbytype1.org
- Tandem Mobi & Control IQ Plus: tandemdiabetes.com/juicebox
- Eversense 365: eversensecgm.com/juicebox
- Defining Diabetes Series: juiceboxpodcast.com/defining-diabetes
- Wrong Way Recording: wrongwayrecording.com
Opening and Juice Cruise 2026
Scott BennerWelcome back, friends. You are listening to the Juice Box podcast.
KatarinaHey. My name is Katarina, and I am a type one diabetic.
Scott BennerHow would you like to share a type one diabetes getaway like no other? Join me on Juice Cruise twenty twenty six. You may be asking, what is Juice Cruise? It's a week long cruise designed specifically for people and families living with type one diabetes. It's not just a vacation. It's a chance to relax, connect, and feel understood in a way that is hard to find elsewhere. We're gonna sail out of Miami, and the cruise includes stops in CocoCay, San Juan, Saint Kitts, Nevis aboard the stunning Celebrity Beyond. This ship is chosen for its comfort, accessibility, and exceptional amenities. You're gonna enjoy a welcoming environment surrounded by others who get life with type one diabetes. I'm gonna host diabetes focused conversations and meetups on the days at sea. There's thoughtfully designed spaces, incredible dining, and modern amenities all throughout the celebrity beyond. Your kids can be supervised and there's teen programs so everyone gets time to recharge. Not just the the kids going on vacation, but maybe you get the kickback a little bit too. There's gonna be zero judgment, real connections, and a whole lot of sun and fun on Juice Cruise twenty twenty six. Please come with me. You're going to have a terrific time. You can learn more or set up your deposit at juiceboxpodcast.com/juicecruise. Get ahold of Suzanne at cruise planners. She will take care of everything. Link's in the show notes. Link's at juiceboxpodcast.com.
Sponsors and Name Nuances
Scott BennerNothing you hear on the juice box podcast should be considered advice, medical or otherwise. Always consult a physician before making any changes to your health care plan. The episode you're about to listen to was sponsored by Touched by Type one. Go check them out right now on Facebook, Instagram, and, of course, at touchedbytype1.org. Check out that programs tab when you get to the website to see all the great things that they're doing for people living with type one diabetes. Touched bytype1.org. Today's episode is also sponsored by the Tandem Mobi system, which is powered by Tandem's newest algorithm, Control IQ Plus technology. Tandem Mobi has a predictive algorithm that helps prevent highs and lows and is now available for ages two and up. Learn more and get started today at tandemdiabetes.com/juicebox. The podcast is also sponsored today by the Eversense three sixty five. The Eversense three sixty five 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.
KatarinaHey. My name is Katarina, and I am a type one diabetic.
Scott BennerKatarina, I am happy to meet you, and I am even happier that all those years ago, I started setting up the beginning of the podcast the way I did because for lover money, I would not have pronounced your name correctly.
KatarinaI guess I should have started with that. Yeah.
Scott BennerIt popped up in front of me. Right? It's just—and and we're not sharing your last name, but your last name just does not let into your first name. I don't know if that and makes—and it popped up, and I'm like, chat or chat. I guess I just wanted to say the h really badly, you know. So anyway, there's a little secret for people who haven't been listening that long. The reason that the podcast starts with somebody going, hi, my name is—is because I was tired of saying people's names wrong, so I just figured I'd make them say it first. And that way, I would—I'd be able to—I do it all the time, by the way.
KatarinaThat's brilliant.
Scott BennerSo, anyway—alright. So, Katarina, you have type one. Yes?
KatarinaYes. I do.
Scott BennerHow old are you?
KatarinaI am 33 years old.
Scott BennerIt's a good age. It is. It is—like I'd killed two strangers to be 33 ago, just so you know.
KatarinaI'm not mad about it.
Scott BennerHow long have you had type one?
KatarinaI was diagnosed when I was 28 years old.
Scott BennerOh, I like this. Not for you. I like it for the story. So do you have brothers, sisters?
KatarinaI have two brothers and a sister, and no one in my family, no one like, none of my grandparents, aunts, uncles. I think I have, like, a great great aunt who had type one. But no one even has, type two diabetes.
Scott BennerYou just—you're like, you were incredibly healthy people except for cat over here. And—yeah. Yeah. So—and do—do people call you cat?
KatarinaI—No. Prefer them not to.
Scott BennerTell me what to say. It's just Katarina every time.
KatarinaYeah. Yeah.
Scott BennerIt doesn't shorten to anything? To gym or anything? Nothing?
KatarinaNo. When I go to Starbucks or a coffee shop, I I say CC.
Scott BennerSo—What do you say at—what's the chicken place?
KatarinaChick fil A?
Scott BennerYeah. What do you do there?
KatarinaCC. Yeah.
Scott BennerCan I—can I share something? As a test of my wits, I—and listen. To say that I'm at Chick fil a maybe five times a year is about accurate. It's usually to pick up for somebody else. But when I'm in that line, I never say my name. I always—but I don't preplan a name. And—and the—the quality of the name that I come up with goes a long way to how happy I am with myself afterwards. I'm like, the last time I was there, I said Corey. And I'm like, Corey? I was like, so disappointed in myself for, like, twenty minutes after. So much so that when I picked it up, she goes, Corey.
Scott BennerAnd I went, that's not actually my name. And she goes, this isn't your order? I'm like, no. It's my order, but it's not my name. And then I—I make up a name every time I come here. And she goes, right? And I said, I do it to see what, like, kind of fun name I can come up with. And she—she looks at me—I mean, we've known each other for eight seconds, me and this lady, and she goes, and you came up with Corey? And—and I was like, I know I've been disappointed the whole time I've been in the line. She goes—she just goes, you should be, and she hands me the bag and walks away.
Scott BennerIt's awesome. Anyway, alright. Katarina, that's what we are. I'm not—yeah. I mean, I'm not gonna push you on the Cece thing. Although, it does make me think of new girl, and then I get very happy.
KatarinaThat's literally when I started using the nickname because I really liked Cece, and I had straight across bangs at the time. And I was like, she's so beautiful. I wanna be just like her. And people were asking me, oh, what's your nickname? And so I was like, just call me Cece, even though it has nothing to do with my name besides that it starts with a c.
Scott BennerSo I took a lot of problems for my daughter when—when, one day, she said, which one of the new girl characters is your favorite? I really thought about it. And I was like, I think Cece. And she's like, what? She's so—so upset with me. It's like everybody else feels like more like a caricature as it goes on. I feel like she's the only person who grows as the show goes on.
Buying a House and Life Insurance News
KatarinaInteresting.
Scott BennerYeah. So, anyway, this isn't either here nor there. Are you—so you're—so you don't have a lot of family background with with medical issues.
KatarinaRight.
Scott BennerTell me how your type one presents. How do you first start noticing it? Because it must be an interesting story.
KatarinaYeah. So this was back in 2020. My husband and I, we had just got bought a house, and so we were applying for life insurance. And I was like, okay. No big deal. I'm super healthy. Like, we're both super healthy. Nothing to be concerned of. And they took the blood sample. And, like, you know, within the week, they're like, you are super diabetic. There is no way you're getting life insurance. And I was like, what? Like, taken totally aback. And the reason why I bring up that it was COVID was because normally in January, I get, you know, like, my physical, and I had—or, I guess, my birthday is in March. So, normally, in March, I get my physical, but that was right in the middle of COVID. And so I had skipped it for 2020, and then lo and behold, there was some pretty big underlying issues that were unfolding. Everyone asked me, like, oh, like, did you have any symptoms? And I'm like, all of them. I—I was chugging water, peeing all the time. I went to—and this is the crazy thing—I went to an ENT doctor because my throat felt like it was closing up. And they were like, oh, you're just very anxious because nothing's wrong with your throat. But it was just that my body was, like, shutting down.
Scott BennerYou're either anxious or dying. We're not sure—we're gonna go with anxious. You are a bit of a—a conundrum, aren't you? Can I—may I make a snap judgment after seven minutes and six seconds?
KatarinaOh, go—go for it.
Scott BennerOkay. 28 years old married looking for life insurance. It is a very responsible thing to do. But yet your first name is Katarina, which makes me think that you grew up with a couple of hippie parents. Right?
KatarinaOh my gosh. No.
Scott BennerI mean, I'm onto you already. I know what's going on. Alright? So—and—and so, like, how did you—and I'm gonna—can I guess? Is the boy that you allowed to marry you, like, super straight lace?
KatarinaYes. Absolutely. Right. He's the one that keeps me in check for sure.
Scott BennerRight. Because you looked at your parents, you looked at yourself, and you're like, one of us is gonna have to pay the bills, and I'm gonna need to find a boy that thinks about that stuff. Is that about right?
KatarinaAbsolutely. I got—you took me—but we can go now. I understand you completely. So alright. So because—I mean, it doesn't make any sense. I really—can I just share with people? I'm making a judgment on your last name. But you got some old Jewish hippies parents. Right?
KatarinaMy dad is German, and my mom is first generation Greek—Actually.
Scott BennerOh, look. Yeah. See, I was wrong. I can be wrong. It's fine. But I—so I—it's funny because I laid over a couple that I know over top of your life, and I was like, oh, this is what her parents are like for sure. Like, your parents smoking a bunch of weed and everything?
KatarinaThey—I feel like, no. They're not about that, but they—both of my parents are artists. But they—they're a little bit more straight edge, but I think that's because, like—they had kids. They—they had kids. So they went into survival mode.
Scott BennerThey're not artists who don't smoke weed. Let's just say that. Okay? They're artists who hid their weed from their kids really well. Okay. Anyway, I'm sorry. So because I'm just dying—like, a 28 year old getting life insurance? Like, what the hell? You're like, we gotta get all of our ducks in a row.
KatarinaThat's—that's all my husband.
Scott BennerThis is the most Caucasian thing that anyone said to me this month so far. I just wanna be completely clear. That was fantastic. Alright. Okay. So I'm so sorry. So okay. So you—you're super diabetic from the test that they get back, and you've got all the symptoms so much so that you're going to other doctors trying to figure out what the little things are going on with you. So you're chugging water. Your throat feels like it's closing. Did you end up with a thyroid issue?
Thyroid Issues and Family History
KatarinaNo. And that is actually in my family history. So I'm keeping an eye on that, and it's, like, kind of surprising that—I think that's, like, most shocking out of all of this.
Scott BennerI don't know. It's like—I'll be getting thyroid issue. Like, like, don't worry. It's coming. So you do have autoimmune in your family?
KatarinaYeah. And my—my—my cousins, there's, like, a couple of them who do have some autoimmune diseases. But none of my siblings do.
Scott BennerThat's okay. Extended family makes sense to me. What—what are we talking about? Celiac? Are we talking about vitiligo? What do we got?
KatarinaEp—epilepsy and MS.
Scott BennerI don't like epilepsy. It's autoimmune. But—but usually no. Don't think so. I don't think so.
KatarinaThen I'm just making that up.
Scott BennerYou're too busy managing your four zero one k to look things like this up, I can see. Well, not you, but the boy. And so hold on a sec. I would be great at speed dating, I just realized. Let's see. Is there's no way. Sorry. I'm typing. Can't type and talk at the same time. Epilepsy is not autoimmune.
KatarinaOkay. Alright. I really thought it was.
Scott BennerIt's okay. Well—Listen. You're—you're busy. You—you—you have two kids, don't you?
KatarinaYes. I do.
Scott BennerOkay. What was the other thing you were talking about? MS. MS. That one is autoimmune for sure.
Scott BennerWould you like me to check just so you can feel terrible about yourself if it isn't? No. Wait. I'm just kidding. It is.
KatarinaCan you imagine—worrying me. Gosh. This whole time I've been telling people, oh, yeah.
Scott BennerThey walk away and they go, she's sweet. Don't worry about it. It's fine. At least she's pretty. Oh, so rough. Anyway, but the—okay. So but there's—there's, hypothyroidism. Is it Hashimoto's to people—are people diagnosed?
KatarinaIt's hyper—wait. Hold on. The one where that makes you sluggish. Is that hyperthyroidism? Right?
Scott BennerHypo.
KatarinaHypo. Yeah. So hypothyroidism. Yep. Yeah. Like, my mom's side is all has thyroid issues.
Scott BennerTired? Yeah. Yeah. Do they take medication for it?
KatarinaYeah. My when my mom started, it was just, like, night and day difference in her energy levels. Which is, like, really nice to see. You know? It's always a little bit sad, and that's kind of how I felt with my diabetes too, just getting diagnosed. Like, oh my gosh. I'm dying. And then being—actually addressing it, getting the right medication, and it's like, oh, you are doing so much better now that we've addressed the problem.
Scott BennerYeah. I you know, I had a conversation with somebody last night who's in a situation where they can't afford a medication for someone in their family. Ugh. And three of them need it. They can afford to get it for two of them. And I was listening to the converse—this is a private conversation, but I was listening to the conversation and you could hear they were like, well, the youngest one has time. Like—and I thought, oh, this is so sad. Like—yeah. Because I know how valuable it is when you get your answer. And you can look back in hindsight and see what you'd been missing out on or had been limited by. Yeah. It's just—that's definitely not—not fair. And—and it sucks. Like, you know, your—your mom's running around. It's like, mom's always tired, she's exhausted and doesn't know why and feels bad about it on top of everything else. So, anyway, well, I hope you don't get hypothyroidism.
KatarinaYeah. Me too.
Scott BennerYeah. Me too. Thank you. You're very welcome. Oh, you're—it should be a card, like a greeting card. I hope you don't get hypothyroidism. Happy birthday. I should just start sending those to people. That's hilarious. So you're—have kids or don't have kids at your diagnosis time?
Eversense and Tandem Mobi Break
Scott BennerThis episode of the Juice Box podcast is sponsored by the Eversense three sixty five. Get three hundred and sixty five days of comfortable wear without having to change a sensor. When you think of a continuous glucose monitor, you think of a CGM that lasts ten or fourteen days. But the Eversense three sixty five, it lives up to its name, lasting three hundred and sixty five days. That's one year without having to change your CGM. With the Eversense three sixty five, you can count on comfort and consistency three hundred and sixty five days a year because the Eversense silicone based adhesive is designed for your skin to be gentle and to allow you to take the transmitter on and off to enjoy your shower, a trip to the pool, or an activity where you don't want your CGM on your body. If you're looking for comfort, accuracy, and a one year wear, you are looking for Eversense three sixty five. Go to eversensecgm.com/juicebox to learn more.
Scott BennerLet's talk about the Tandem Mobi insulin pump from today's sponsor, Tandem Diabetes Care. Their newest algorithm, Control IQ Plus technology and the new Tandem Mobi 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 Mobi 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 tandemdiabetes.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 gonna help you learn about Tandem's tiny pump that's big on control. Tandemdiabetes.com/juicebox. The Tandem Mobi 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.
Starting a Family and High Sugars
KatarinaI don't. Okay. So we had been married for a year, and we were kind of talking about it. Like, when do we wanna start? And then I get this news. And so that kind of tables everything, and we're just, like, very focused on getting me healthy. And that's, like, even on the doctor's suggestions too because we were like, oh, like, we kind of wanted kids, and the doctor was like, "well, I don't even know if a baby would survive in your body at this point. Like, your sugars are so high." Oh. And so, yeah, I I worked really hard to get my sugar levels in a good place.
Scott BennerMhmm. How long did that take?
KatarinaYou know, it—it was only about, like, six months to a year where I I was, like, really buckled down. And it's funny. I I know you've had other people you've talked to who have also, like, been diagnosed later, and they get diagnosed as type two. But—can I paint a picture of what I looked like when I was diagnosed?
Scott BennerOkay.
KatarinaSo I have always been very athletic, and I was in peak shape. I was, like, very, very lean in an athletic body fat percentage, so very shredded. I call my doctor to get further testing done after this, and she's like, "oh, you're type two. You just need to lose weight."
Scott BennerYou're like, "lose weight, lady. I got abs."
KatarinaYeah. I—yes. Literally. And I was like, "from where on my body? Do you want me to cut off my arm? Like—I'll lose weight. I don't have weight to lose."
Scott BennerI might call your episode "very shredded super diabetic." And so you—I—wait. Wait. So does—does this doctor physically know you? Have they met you?
KatarinaNo. Oh, okay. Had switched. And so I had switched my, like, primary care because I got a new job during COVID, and she never met me in person. It was all online. And so finally, I, like, requested, like, let me come in so you can physically see me. She—she looks at me, and she was like, "that's kinda surprising. Well, here, start taking metformin." And I'm like, even still? What? Like, just because I'm 28 years old, you're gonna write me off as type two diabetic?
Scott BennerWell, did she—did you have any confidence? Like, when she says take metformin, I mean, are you at the point where you're like, "you might not know what you're talking about"? Like, did it—
KatarinaI was very skeptical—
Scott BennerOkay.
KatarinaBut I also was so taken aback by having diabetes that—Okay. It was—it was like, "okay. I guess I'll start this." Because the way she—she even presented it was like, "you need to get on medication right away." And metformin, you can—like, you'll probably be taking this for the rest of your life because she was under the impression I was type two, But it won't—it won't, like—you could get off it if you need to or, like, switch it up or something.
Scott BennerI—I don't—yeah. I don't—I—none of that makes sense to me. Everyone needs a healthy amount of, "no. I don't believe you." Like, you—yeah. Not not enough where you're like that person who's just, you know, saying, like, every time somebody says something, like, "you're wrong." Like, not like that. But just enough where you can stop and go, "I don't trust you enough. I don't know you well enough yet for me to make a big decision about my health just based on this thing that you've randomly said after you've been wrong about two things already." But I get your point. Like, you just—you're dizzy by the whole thing. Right?
KatarinaYes. Yeah. Absolutely. I was—I was so shocked. And it's funny in retrospect, looking, like, looking back, I could just feel what I was feeling. But my husband and I, we would, like, go on walks every evening, and there were so many times where I would just be sobbing to him because I was just in total shock. And I was like, "I'm gonna die before, like, we start a family." It just felt like all of a sudden, I was immortal up until this point, and then it—like, life really hit me. Like, "oh, wow. Out of nowhere, I just get this, like, disease, and now we have to change our whole lives around it."
Marriage and Cheesy Love
Scott BennerYeah. And he's thinking, "oh, I picked the wrong girl. I dated a girl before this. She didn't seem to have anything wrong with her." And so, like, I mean, she was annoying, but not like this. The—but does that pop into your head too? Because you're not married that long. Do you think that he's got buyer's remorse? I I know that's not how I should say it, but, like, do you—does that worry you?
KatarinaYou know, he was so supportive and still is. I should never say was, but, like, especially during that time, it makes me—like, thinking back, I'm—I fall in love with him all over again just to be super cheesy.
Scott BennerThat's nice.
KatarinaHe—he was immediately like, "okay. Like, there's been some studies done that say, like, keto can help with type two diabetes. Let's try a low carb slash keto diet"—and which we did, which is not the thing that you should be doing when you're actually type one. But he was, like, very supportive through the whole thing. We did make a ton of lifestyle and diet changes, and he was just, like, holding my hand through the whole thing.
Scott BennerHe's willing to make adjustments with you and all that. Hey. Did you just say you shouldn't do keto if you're type one?
KatarinaYou know, it was—
Scott BennerI mean, those people are gonna come get you. I just want you to know. And I have nothing to do with this. I just wanna say—no. No. I just wanna say out loud. It's not gonna be hard to find her. There can't be that many Katarinas, and I'm not part of this. Okay? No. I'm just kidding. I—you—you can do keto and have type one.
KatarinaWell, I think because I—I had an experience where I kind of was, like—when I was doing keto those first couple months, I—or, like, let's be real. It was, like, a week that I lasted.
Scott BennerI had four chicken breasts got, and when they were gone, I gave up. Okay? Yeah.
KatarinaGive me my carbs.
Scott BennerOh my god. But—But he was willing to, like, make adjustments with you and try things.
KatarinaYeah. Yeah.
Scott BennerThat's awesome. I mean, I was just asking if you had, like, an underlying concern that, like—because you hadn't been married that long. And it is a big switch in—I know, bait and switch is the the wrong way to say it, but it—it could feel that way to the other person. Like, this isn't what I thought I was getting involved in. But he sounds like a good guy, and and you—you love each other, and you're all good. So that's not a problem. Also, you said it sounded cheesy to say I could fall in love with him all over again. I want you to know, this August, I will be married for thirty years. And it doesn't sound—no. No. That's awesome. We're just—we're trying to outlast each other. That's all. Nobody wants to give up first. My point is is that last year for my—for my birthday, my wife said to me, and I believe this is a quote, "I didn't have time to get you anything. Happy birthday." So—so my point is is, like, I don't think that sounds cheesy. I think it's nice. You know? And then two times a year, my wife says, "I love you." It's always very touching to me. Just hang in there for a little longer. Wait a year in your fifties. Oh my god. And you're still trying to pull off Katarina? That ain't gonna work either, by the way. You'll be CC by then. Oh my gosh. I'm so sorry. I don't know why. I think your laugh just makes me happy. I'm not sure what's going on exactly. Do people generally like being around you, do you think?
KatarinaI—I hope so. I I feel like I—I have a plenty of friends and really good company that I hang out with.
Scott BennerYeah. No. You're making me not like my friends. I'm like, ugh. These people aren't trying hard enough is what I'm thinking. So okay. So you're trying a bunch of things. You're kinda—you're still whacked out of your mind a little bit trying to, like, make sense of all of it. I mean, the—when you say you're out for walks crying, is it, gosh, what I've lost or what I don't understand? What do you think is making you sad right then and there?
Lifespan Anxiety
KatarinaIt just feels like my lifespan has been shortened in front of my eyes. And it does seem—it felt like the odds were against me. Like, we had all these dreams of getting old together. You know?
Scott BennerOh, you didn't think you were gonna live as long?
KatarinaI—like, I want to live till I'm 100 and be super healthy and then—
Scott BennerAnd rich. And I'm like—right. I want a spaceship and a giant penis. I got a lot of things I want. Yes. Yes.
KatarinaAlright. And then when I find out I have diabetes, it's like, oh, this is, like, something that, like, it just—if I—I don't know. In—in the moment, it really felt like, "oh my goodness. Like, that just took twenty years off of my life, and it's gonna be something I'm dealing with for the rest of my life." Mhmm. And all of those things are still true, but I'm not as emotional about it. And it does seem like I am able to have more control than I was giving myself credit for.
Scott BennerDo you not have Google? I do. Oh, okay. By the way, that sound—whatever that was—I would marry you. That's delightful. I—I did—that—that's how you got the guy right there. You were like, I do. And he was like, alright. That's cute. Let's do it. So listen. Does type one shorten your lifespan? It's all you had to type into the thing, and it would have said, "no. Probably not." And—and—and, you know, and they would have told—like, listen. Biggest factors: chronic high blood sugars, severe hypoglycemia, DK, smoking inactivity, poor access to care.
KatarinaI'm looking at, like, what is the average lifespan of a—and I was at this time, I still thought I had type two diabetes. And so "what is the average lifespan of a diabetic?" It doesn't matter type one or type two. Okay.
KatarinaAnd then, you know, I get into the, like, dark part of the Internet where it's like, "you're probably gonna lose three limbs and go blind."
Scott BennerWould you make it to Reddit? Are you on Reddit? Is that what you kids do?
KatarinaNo. No. I not know how to use Reddit.
Scott BennerI mean, it's a—it's a message board. It's not that hard. So but then—oh, so you just got into people online talking about the worst things that had happened to them. Yeah. Yeah. And you thought that must be the rule, not someone—
KatarinaAnd I was looking up averages too, like, "what's the average lifespan?" And it was, like, ten years shorter than someone who doesn't have anything. And so I guess you kinda think, like, okay. That kinda makes sense.
Scott BennerBut Listen. Type one diabetes—this is my Googling—does not automatically shorten your life—or control over many years can, but good consistent management can largely erase any gap. Are plenty of people living right now in their sixties, seventies, and eighties who are complication free or minimally affected who have had type one diabetes for most of their life, and they're older now. Imagine, you know, the next thirty years of algorithms keeping your blood sugar in check and you know, all that stuff. Yeah. You'll probably live to a 100.
KatarinaI hope so.
Scott BennerYeah. I mean, I don't think I will, but I think you could. And then, you know—and by the way, I don't—do you know a lot of older people? If, great grandparents or great grandparents? Yeah. How's their life? Oh—
Katarinayou know, it's actually really sad because both of my grandparents are widowed. So it's like my dad's dad is still alive, and my mom's mom is still alive. And I think they were doing great up until the point their spouse passed away. Yeah. And how old are they? Oh my—oh. They're eighties? I don't not know. Yeah. Late eighties. Yeah. I'm gonna say wrong, I'm gonna be totally embarrassed. So next question.
Scott BennerDo you think that lady is really looking for twenty more years of this—is what I'm asking you? Like, maybe you're—Right. Right. Maybe your goals will change then. Fair. Yeah. It's weird, isn't it, as a young person to recognize that there might be a time in your life that you've been here for so long that you're just like, "I could go now."
KatarinaI'm—I'm a good life. Yeah. I'm done. This was good. I'm done. Thanks. Yeah. Yeah. It's hard. I can't fathom that right now. I mean, I realize that's how people feel at some point, but I can't wrap my head around that. When I was 28, like, I would not have been able to for sure. You know?
KatarinaYeah. It—it—it definitely came as a shock. But, no, that's a—that's a good point. I think, especially, like, when you're younger, it's like, there's so much out there, so much to learn, so much to do, so much to see. Mhmm.
Scott BennerWell, that's back when—that's when you're not peeing when you're sneezing and having trouble wake standing up. You know what I mean? Yes. Yeah. Exactly. That's when you've never called a friend to say, "hey. I'm stuck on the toilet." Once those things happen, you start looking for exit ramps. You're like, "okay. I—maybe this is enough."
KatarinaYeah. Yeah. Like, sitting on an airplane for over five hours is just like, "nope. Not gonna happen for me." So—Yeah. You know, like, when you're—I don't know. My—my grandma was such an avid traveler, and now she's just like—she lives in Northern California. And making the flight down to Southern California, she's like, "not for me."
Scott BennerYeah. You can FaceTime with grandma if you wanna see her. She—she's not leaving. Yeah. No. I mean, that's just what age does. Like, I don't think he'd even mind me saying this. Like, I have a neighbor who's in his seventies, and, you know, we're just in New Jersey and he—he visits—he and his wife visit their son in, like, the Michigan area. And he said to me about a year ago, he said, "Scott, the—it's getting hard to make the drive." Like, just—just the drive is getting difficult for him. Like, he said, like, know, things are moving a little fast and, you know, I don't feel as comfortable on the highway anymore. Like, you know, all that stuff. And he's completely with it. Like, you know what I mean? Like, there's nothing wrong with him. And he's just a little older and, you know, his reflexes are a little slower, and it's, you know, it's nerve racking. And he said then because it's nerve racking, it's exhausting.
KatarinaYes. Absolutely.
Antibody Testing and COVID
Scott BennerI Anyway, I told him. Was like, get him one of those cars, drives itself. You'll be fine. Yeah. But not—not the point. The point is is that you're panicked, you're young, you see your life changing in completely different ways, and you're getting a misdiagnosis at the moment as a type two. How long does the misdiagnosis go on for?
KatarinaSo that was in October. And then finally, I'm—I had been asking my doctor pretty much, like, right away. "Hey. Can I get tested? Like, can you test my antibodies?"
Scott BennerYou learned that online? The Internet told you that?
KatarinaI had talked to a friend who was a doctor who was like, maybe you should, like, ask about this. And I—I asked and asked and asked. And finally, I got COVID in December 2020. And the metformin had kind of been like—I was waking up—my sugar levels between ninety nine and one thirty, and that was fine for, I guess, like—
Scott BennerEverybody said it was okay. Yeah. Yeah.
KatarinaAnd so then in COVID, I was waking up regularly 02:50, and it never went back down. And that's when I started being like, "I think this is a problem. Like, this is late January, and I'm still, like, haven't gone below 200."
Scott BennerYeah. The honeymoon was ending for your type one. Yeah. Yeah. And you're—you're counting on metformin. Is that what that—was happening?
KatarinaYeah.
Scott BennerDid you lose more weight on metformin?
KatarinaI did.
Scott BennerDid you get an eight pack? A rail. I was gonna say, how much better could you get? Was it messing with your activity? Because you said you're athletic. You must be working out and stuff like that too.
KatarinaYou know, it was—so it did help a little bit because I was very sluggish. Like, some of the other symptoms—basically, after lunch, I would have to go to my car and take a nap because I physically was so exhausted. Like, my blood sugar levels were through the roof, must have been, that I couldn't—I couldn't get through the day if I didn't take a nap. Oh. And I thought, this isn't a problem. This is just what everybody deals with.
Scott BennerOh, really? Yes. You're—you're in the parking lot at your job, like, snoozing, and you're like, "this is okay?"
KatarinaI didn't think anything of it. I was just like, "well, I—it's—it's probably because I'm so active." I I don't even know, like—
Scott BennerWhat you were thinking about. Reasoning—was. And—
Scott BennerDid you feel foggy? Did your mind feel foggy?
KatarinaYes. All the time. Okay. And when I went—when I would go to sleep at night, my organs hurt. And 28 year old me was like, "it's just because I'm getting old."
Internal Pain and Dehydration
Scott BennerYour organs hurt. Please put that in context for me.
KatarinaLike, it felt like my kidneys—I—because I imagine—it was, like, in my—it was in my back, and so I'm imagining my kidneys. Mhmm. And then, like, just it felt crampy and in pain. I—like this dull pain that was always there, and it kinda makes sense. Like, your kidneys would be impacted because they're, like, trying to filter out all this sugar, and they're getting bogged down. And so—
Scott BennerAnd you're just like, "well, you know, I'm 28. This is what happens."
KatarinaYes. Yeah. Yes. You're asleep in the parking lot with four addicts that you work with at lunchtime thinking this is all completely normal.
KatarinaI think I was the only one. It really did—I feel—feel like—nobody sees me. You're like—in—in that movie Dune walking through the desert by yourself just waiting for, you know, the earth to swallow you up. So are you, at some point, gonna tell me you were in DKA, or did someone finally figure it out and give you insulin?
KatarinaSo I—I asked to get tested, asked to get tested. And finally, they were like, "okay. We'll test your antibodies." And, like, again, a week later, they were like, "oh, wow. You're actually type one." I'm like, "thank you."
Scott BennerJust so you don't think you're crazy, I did a little, ISR overlords about that—that organ thing. And it said if you've undiagnosed type one diabetes, you could be dehydrated, which puts your organs under strain. You know, you were—you were obviously—had lost more weight. So, like, electrolyte imbalances, reduced blood volume, fluid loss in general, that can feel like deep internal aching pressure or a dull widespread pain that doesn't feel muscular. That sound familiar?
KatarinaYes. Absolutely.
Scott BennerAlso, ketones, ketoacidosis perhaps could be like a—what they're calling, like, a "chemical irritation." Irritates the tissue, triggers inflammation, affects nerve signaling. People describe it as quoting, "my insides feel raw." Everything hurts, but I can't point to one spot or, like, a heavy sick pain rather than a sharp pain. Yeah. Wow. That—is what's happening. Okay. Well, here's a little more for you just so you can feel better. Your liver could be dumping glucose, producing ketones, processing stress hormones like cortisol and adrenaline. It's overloaded—that could cause the liver to swell. Your right upper abdominal discomfort could come from that or a sense of internal pressure or soreness, not a stabbing pain. Also, your muscle and tissues are breaking down. So—Without insulin, your body starts to break down muscle, fat, protein, which will feel like deep aches, weakness, or a flu like "everything hurts" sensation. And then let's see. Nervous system distress. This can distort pain signals and body awareness making sensations feel bigger, more diffused, or hard to localize, which actually leads to people saying "my organs feel like they hurt." There you go. Yeah. You weren't crazy. You're just sitting in a parking lot by yourself. That's all. My gosh. But you—you know what? It—you know how many people—go—you—you listen to podcasts. Right?
KatarinaYeah.
Scott BennerYeah. This happens to people all the time. Yeah. Really terrible. Yeah. Yeah. I feel very fortunate. I never had to be hospitalized, so we were able to, like, get me on medication. But yeah.
Scott BennerA relief to hear you had type one?
KatarinaIt was. It—it would—it made so much more sense because I just kept questioning, like, "type two, really." Like—and—and then I'd have friends who—it pisses me off, but also it's like, okay. That's kind of warranted. But they were like, "well, you do eat a lot of carbs, so it—you—you kinda deserve it."
Scott BennerSo—really? You got that from people you know? Yes. My god. So you have a—you have a general misunderstanding of what it means to have type two. They have a bigger one. And—apparently aren't afraid to, like, share their misgivings with you.
KatarinaOh, yes.
Scott BennerLovely. These people you knew a long time, I hope?
KatarinaThey were coworkers, like, year.
Scott BennerOh, they're parking lot zombies. I see. Oh, that might be your title. Well, that's terrible, by the way. I—I—have you disconnected your friendship with them at this point, or how did you handle that?
KatarinaOh, you know, it's just something that—it's like—
Scott BennerYou think it was like, well meaning, like, they were joking with you?
KatarinaYes. Yes. And as you kind of pointed out, I do laugh a lot, and so it's like, brush it off. That's fine.
Scott BennerIs that really who you are, or is that a—a psychological thing that you do to stop from crying?
KatarinaDo you—do you wanna unpack this right now? Because—should I start crying on the podcast?
Scott BennerWhich—which—which is it? Is that you—are you coping, or is it, like, just how you feel?
KatarinaNo. I think—I think I'm generally pretty—now I have no idea. Now I'm gonna second guess myself, and I'll be thinking about this for the next month. Yeah. It'll give you something to do when you're living to a 100. Go ahead. No. I think I'm generally a pretty, like, positive person. Yeah. For the most part. Do you have any trauma in your past? No big ones? No. Drinking, drug use in your house, parents hit each other, nobody's been to prison?
KatarinaNo.
Scott BennerHappy go lucky person?
KatarinaI—I would say I am very blessed compared to so many other people I meet. Putting into perspective, like, there is nothing I—have that really is that bad. So—
Scott BennerThe Joe Walsh song applies to you. Life's been good to you so far?
KatarinaYeah. Yeah. Yeah. Gotta say so.
Scott BennerYeah. So this is what happens. So—so this is what happens when you raise a child reasonably. They can actually laugh about things—unlike when I—the way I was raised where I have to laugh to hide my feelings. Is that right? That's fine. I don't mind. I like wondering about stuff like that. I really do. Like, I think it's important to wonder, like, are you laughing to stop from crying or are you laughing because you're generally amused? Because I see both sides of it. Like, I—I feel like I have a pretty good sense of humor. And, like, if somebody were to come up to me and, like, in the middle of me struggling with, like, a diabetes diagnosis that I couldn't get together, they were like, "well, man, you do eat a lot of carbs." I'd be like, "fair enough." You know, like—like—and—and I don't think I'd hold a grudge about it. But in other situations, like, I do laugh sometimes because it's hard for me to be, like, honest about how I feel, you know. So, I mean, I'm sure we all do that at some point, but generally speaking. Okay. We're fine. So you've been to therapy already?
KatarinaYeah.
Scott BennerYeah. No. I know. I can tell you have been. Because your parents sent you, like, pre—they—your parents are like, "why don't you go to therapy before you have a problem?" Just make sure you understand how to talk to people. Am I right?
KatarinaYeah. I—my parents have been very supportive my whole life.
Scott BennerNo. I can tell. Yeah. This is what you get. You get decent parents. It is—it is funny. Like, there are times where I'm like, "do I have an—like, buried trauma that I just, like, haven't unpacked?" Gonna have trauma in a second because you sound far away from the microphone. What just happened?
KatarinaOh, sorry.
Scott BennerThat's okay. Can you hear me?
Scott BennerYeah. Get in there. Okay. So you're not—you're not sure if you've got trauma?
Outro and Part Two Teaser
Scott BennerThis episode was too good to cut anything out of, but too long to make just one episode. So this is part one. Make sure you go find part two right now. It's gonna be the next episode in your feed. The conversation you just heard was sponsored by Touched by Type One. Check them out, please, at touchedbytype1.org on Instagram and Facebook. You're gonna love them. I love them. They're helping so many people at touchedbytype1.org. Head now to tandemdiabetes.com/juicebox and check out today's sponsor, Tandem Diabetes Care. I think you're gonna find exactly what you're looking for at that link, including a way to sign up and get started with the Tandem Mobi system.
Scott BennerThe podcast episode that you just enjoyed was sponsored by Eversense CGM. They make the Eversense three sixty five. That thing lasts a whole year. One insertion? Every year? Come on. You probably feel like I'm messing with you, but I'm not. Ever since cgm.com/juicebox. Thank you so much for listening. I'll be back very soon with another episode of the juice box podcast. If you're not already subscribed or following the podcast in your favorite audio app, like Spotify or Apple Podcasts, please do that now. Seriously, just to hit follow or subscribe will really help the show. If you go a little further in Apple Podcasts and set it up so that it downloads all new episodes, I'll be your best friend. And if you leave a five star review, oh, I'll probably send you a Christmas card. Would you like a Christmas card?
Scott BennerIf you've ever heard a diabetes term and thought, "okay, but what does that actually mean?" You need the defining diabetes series from the Juice Box podcast. Defining diabetes takes all those phrases and terms that you don't understand and makes them clear. Quick and easy episodes. Find out what bolus means, basal, insulin sensitivity, and all of the rest. There has to be over 60 episodes of Defining Diabetes. Check it out now in your audio player or go to juiceboxpodcast.com and go up into the menu. If you're looking for community around type one diabetes, check out the Juice Box Podcast private Facebook group. Juice Box 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 Juice Box podcast, type one diabetes on Facebook. If you have a podcast and you need a fantastic editor, you want Rob from Wrong Way Recording. Listen. Truth be told, I'm, like, 20% smarter when Rob edits me. He takes out all the, like, gaps of time and when I go, and stuff like that. And it just—I don't know, man. Like, I listen back and I'm like, why do I sound smarter? And then I remember because I did one smart thing. I hired Rob at wrongwayrecording.com.
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#1799 Bolus 4 - Krispy Kreme
Scott and Jenny talk about bolusing 4 donuts.
Companies that Support Juicebox
Key Takeaways
- The Meal Bolt Roadmap: A strategic approach to bolusing includes measuring the meal, evaluating yourself, adding base units, layering a correction, building the bolus shape, offsetting timing, looking at the CGM, and tweaking for next time.
- Total Sugars as Pre-Bolus Timing: While not a rigid medical rule, a helpful starting strategy for pre-bolusing high-sugar foods is to use the total grams of added sugar as the pre-bolus time in minutes.
- Algorithm Dynamics: When using an automated pump algorithm, be mindful that the system might pull back basal insulin during a blood sugar climb, which might require a larger upfront bolus or an extended bolus to compensate.
- Don't Underestimate Frosting: Add-ons like icing and fillings carry a massive carbohydrate load. A regular glazed donut has about 22 carbs, but adding icing can increase that by 15 carbs alone.
- Wait for the Downward Tick: Before diving into a high-sugar, fast-hitting food like a donut or cookies, aim to see a diagonal down arrow or a slight drop on your CGM to ensure the insulin has actively started working.
Resources Mentioned
- Juicebox Podcast Meal Bolt: juiceboxpodcast.com/meal-bolt
- US Med: usmed.com/juicebox or call (888) 721-1514
- Omnipod 5: omnipod.com/juicebox
- Diabetes Pro Tip Series: Episodes 1000 to 1025 in your podcast player or at juiceboxpodcast.com
- Krispy Kreme: krispykreme.com
- Oreo: oreo.com
- Wrong Way Recording: wrongwayrecording.com
Introduction & The Meal Bolt Roadmap
Scott Benner Hello, friends, and welcome back to another episode of the Juice Box podcast.
Scott Benner In every episode of bolus four, Jenny Smith and I are gonna take a few minutes to talk through how to bolus for a single item of food.
Scott Benner Jenny and I are gonna follow a little bit of a road map called meal bolt.
Scott Benner Measure the meal. Evaluate yourself.
Scott Benner Add the base units. Layer a correction.
Scott Benner Build the bolus shape. Offset the timing. Look at the CGM.
Scott Benner Tweak for next time.
Scott Benner Having said that, these episodes are gonna be very conversational and not incredibly technical.
Scott Benner 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.
Scott Benner So while you might not hear us say every letter of Miele Bolt in every episode, we will be thinking about it while we're talking.
Scott Benner If you wanna learn more, go to juiceboxpodcast.com/meal-bolt.
Scott Benner But for now, we'll find out how to bowl us for today's subject.
Scott Benner While you're listening, please remember that nothing you hear on the juice box podcast should be considered advice, medical or otherwise.
Scott Benner Always consult a physician before making any changes to your health care plan or becoming bold with insulin.
Sponsor Messages
Scott Benner US Med is sponsoring this episode of the Juice Box podcast, and we've been getting our diabetes supplies from US Med for years.
Scott Benner You can as well.
Scott Benner Usmed.com/juicebox or call (888) 721-1514.
Scott Benner Use the link or the number, get your free benefits check, and get started today with US Med.
Scott Benner A huge thanks to my longest sponsor, Omnipod. Check out the Omnipod five now with my link, omnipod.com/juicebox.
Scott Benner You may be eligible for a free starter kit, a free Omnipod five starter kit at my link.
Scott Benner Go check it out. Omnipod.com/juicebox. Terms and conditions apply.
Scott Benner Full terms and conditions can be found @omnipod.comslashjuicebox. (2:19) Jenny, we are gonna do some bolus four stuff.
Bolusing for a Krispy Kreme Glazed Donut
Jenny Smith Oh, fun. These are always fun.
Scott Benner I have a list.
Scott Benner These are,
Jenny Smith Are we gonna do McDonald's again?
Scott Benner No. No. We can't do that again.
Scott Benner That was, that was good though. People were very That's
Jenny Smith way fun.
Scott Benner People had a good time with that one. So no.
Scott Benner We're not gonna do that, but we are gonna look at the list, a pretty extensive list that people sent in. Do you wanna do a well, we did McDonald's, so that one's done.
Jenny Smith Okay.
Scott Benner Should we do another restaurant, or do you wanna just wanna do a donut?
Scott Benner Why don't we do a short one here?
Jenny Smith Do a doughnut. Sure.
Jenny Smith We've not done that. Gosh. That's something I guess I would think that we would have already done.
Jenny Smith It's a pretty common
Scott Benner Let's just do a Krispy Kreme doughnut.
Jenny Smith Oh my gosh.
Scott Benner Have you ever had one?
Jenny Smith I have actually had a Krispy Kreme doughnut. Yes.
Scott Benner Alright.
Jenny Smith When I was in college, I worked with Habitat for Humanity.
Scott Benner Okay.
Jenny Smith And our, spring break trips, I was never I never went and laid on a beach.
Jenny Smith My spring break, we took what were called collegiate challenge trips. Mhmm.
Jenny Smith And so we took, like, a big, huge or a couple of, like, 15 passenger vans, and we would pack it all up, all of our supplies.
Jenny Smith We had to get donations, and we would go somewhere out of state And many of the places we went because we still wanted it to be warmer on spring break, we would go or we would pick a location that was somewhere in the South.
Jenny Smith So I'd gone to New Orleans, and I've been to Mississippi and to Georgia and North Carolina and West Virginia.
Jenny Smith Oh my gosh. They were all of my spring break trips were spent with Habitat.
Jenny Smith It was an amazing thing. But my point being that that's where I had Krispy Long story, that's how I got Krispy Kreme.
Scott Benner Travel the country to have a have a doughnut. Well, I'm on their website, krispykreme.com.
Scott Benner Is that what it is called? Let me make sure. Yeah.
Scott Benner Krispykreme.com.
Scott Benner And I'm starting with I think we're gonna do a few of them.
Scott Benner Original just the original glazed donut. When I think of a Krispy Kreme, I just think of, like, a glazed donut.
Scott Benner Okay.
Scott Benner You ready?
Jenny Smith I'm ready.
Scott Benner Alright.
Scott Benner Well, I'll tell you the calories just for fun. It's got a 190 calories in it.
Scott Benner Calories from fat, a 100. Total fat, 10.
Scott Benner Saturated fat, five.
Scott Benner No trans fat, no cholesterol, a 100 milligrams of sodium. Total carbs?
Jenny Smith Maybe 15 or probably oh, a glazed one. Glazed. Sorry.
Jenny Smith I was thinking of a cake doughnut. Probably about 40 to 50?
Scott Benner They say 22. Really?
Scott Benner They say total carbohydrates 22. Dietary fiber less than one, sugar's 10, protein free.
Jenny Smith I wonder how big their glazed donuts are.
Jenny Smith Because that's and it's also then not a terrible amount of glaze.
Scott Benner Okay.
Scott Benner Would you mind all the carbs are coming from,
Jenny Smith you think? From the sugar?
Jenny Smith Would think I mean, the donut itself obviously has the majority of the fat in it. And Mhmm.
Jenny Smith For that many calories, half the calories are coming from fat.
Jenny Smith And there's not really any protein. So that makes sense that it would be approximately 20 some grams of carb Mhmm.
Jenny Smith Based on the calorie value at four calories per gram.
Jenny Smith That's about right for the math of the calories.
Applying Ratios and Algorithm Nuances
Scott Benner Let's do it for you.
Scott Benner What's your insulin to carb ratio?
Jenny Smith It depends what time of day it is.
Scott Benner Alright. Well, let's say you're having a donut in the afternoon.
Jenny Smith So in the afternoon, it's a one to 12.
Scott Benner Twelve. And sensitivity?
Jenny Smith My sensitivity is 85 in the afternoon.
Scott Benner 85 in the afternoon.
Scott Benner We're gonna make it what would you target if you were targeting a blood sugar?
Jenny Smith My target is 85 in my system. 85.
Scott Benner Okay.
Scott Benner 22 carbs and fat 10. No protein in this. Right? No.
Scott Benner Oh, three.
Jenny Smith Oh, there is a little protein.
Scott Benner Little bit of protein.
Scott Benner What's Jenny's blood sugar in the afternoon before she eats this doughnut?
Jenny Smith My blood sugar in the afternoon generally is somewhere between, like, ninety and one twenty.
Scott Benner I was gonna put 96. How we do that? Okay.
Scott Benner I'm gonna assume you have a nice stable arrow because I'm gonna use my strategy simulator online. Okay.
Scott Benner But I wanna hear about you first. So how's Jenny bolusing for this doughnut?
Scott Benner So it's just the doughnut.
Jenny Smith Okay. I have a stable blood sugar.
Scott Benner Stable blood sugar.
Jenny Smith My blood sugar is 85. Yeah. Right? Mhmm.
Jenny Smith Or no.
Jenny Smith What did you say?
Scott Benner I I made your blood sugar 96.
Jenny Smith But the target was 85 96. Okay.
Scott Benner How is Jenny Prebola saying? Ten grams of fat, 22 grams of carb.
Scott Benner Does it tell how many grams of added carb or or added sugar?
Scott Benner Added sugar.
Scott Benner Sugar's 10 protein. It doesn't quantify anything as added sugar.
Jenny Smith So total carbs are 22 and sugars are 10.
Scott Benner Yes.
Jenny Smith So my pre bolus is fifteen minutes in the afternoon.
Scott Benner Okay.
Jenny Smith Sometimes twenty depending on the time of the month.
Scott Benner Mhmm.
Jenny Smith But fifteen.
Jenny Smith Let's say this is a sensitive normal time.
Scott Benner Does this need an extended bolus for you?
Jenny Smith With only 10 grams of fat, this type of thing doesn't need an extended bolus.
Jenny Smith No.
Scott Benner For you.
Jenny Smith Not at all.
Scott Benner You would
Jenny Smith For take me, I would take all the carbs.
Jenny Smith I wouldn't even I wouldn't cover fat or put it into my system, which I could if I wanted to.
Jenny Smith I wouldn't put it in there. I would just put the carbs in.
Scott Benner Okay.
Scott Benner And that's a thing that you think you'd have success with.
Scott Benner So what would your what do you think the bolus would be? Two units?
Scott Benner Are you considering the fat or just not stretching it for the fat?
Jenny Smith I'm just not stretching it for the fat.
Scott Benner Okay.
Scott Benner Well, then it's gonna be more like what? 2.8? Something like that?
Jenny Smith Two point I mean, with my ratio, again, I Yes.
Jenny Smith Can't do the math in my head anymore. Yeah. Is. Was my fault.
Jenny Smith Does it for me?
Scott Benner Well, then just just put me in the world.
Scott Benner You grab the doughnut, How much do you throw in for it?
Scott Benner Somebody goes, that's 22
Jenny Smith cards. I would put I would put if I was just out in the world and I was bolusing on my own, I would take two units for it.
Jenny Smith Okay. So I'd be a little bit heavier than my one to 12 calls for.
Jenny Smith It would be less than two units if it was a one to 12.
Jenny Smith Okay. Right?
Jenny Smith But I would just say two.
Scott Benner The, the the thing on the website says two units up front, point eight five over three hours.
Jenny Smith Oh, okay. For the fat, I'm assuming Yeah. For the website.
Jenny Smith Because it does always consider the fat free.
Scott Benner Not gonna not you know but this is interesting.
Scott Benner So but you know from your own life that that's not gonna need that for you.
Jenny Smith I do. And I can also say that experience for many years on MDI
Scott Benner Mhmm.
Jenny Smith I would never have covered extra for something like this with the system I use now, which is Trio.
Jenny Smith I also would not cover extra mainly because I know that the system is already got my back.
Scott Benner Okay.
Jenny Smith Especially with dialed in settings. Right?
Jenny Smith I mean, all of this bolus thing for anything boils down to are your settings in a pretty good place to begin with.
Jenny Smith Mhmm. And so on other systems, however, I wouldn't have even done it on a basic pump that doesn't have an algorithm in it because, again, nothing is being taken away.
Jenny Smith Right? Mhmm. I might consider other algorithms and the potential response algorithms that are the adaptive algorithms that do more of a hard set, just pull back, suspend based on what the trend looks like, that maybe you need to consider what ends up happening because it's pulled back, and that then adds in to some potential
Scott Benner Yeah.
Scott Benner So you make
Jenny Smith Lingering.
Scott Benner You make this two unit bolus for these 22 carbs, which seems pretty small, but it's got a lot of sugar.
Scott Benner It hits you fast. While you're climbing, the system has pulled back basil.
Scott Benner It's not resisting anything there at all. So maybe you do need that point eight five
Jenny Smith Correct.
Scott Benner Pumped in over the hours afterwards.
Jenny Smith And, again, it may not be just because of the fat.
Jenny Smith It might be because of what your system has actually tried to help you with. Yeah.
Jenny Smith I also think, you know, if pre bolus has been pretty well done, then on some of these systems, may actually see some pretty nice containment of your blood sugar.
Jenny Smith You started my blood sugar at 96, and if I pre bolus right and I eat this, I'm I'm also not one to, like, shove it all down my
Scott Benner might go slowly while you're eating.
Scott Benner Yeah. Yeah. Yeah. Right.
Jenny Smith If I'm gonna eat a donut, I'm gonna, like, enjoy the bites of the donut.
Scott Benner I would imagine if you're bolusing for this, you would wanna see, like, a down like, a diagonal down arrow or a falling blood sugar before you started to eat.
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Pre-Bolus Strategy with Total Sugars
Jenny Smith Yeah.
Jenny Smith I usually say, you know, if you were stable, like, a trend of one or two dots kind of already headed down, each dot on Dexcom at least is a five minute incremental shift.
Scott Benner Mhmm.
Jenny Smith And so you've got some visual of momentum from the insulin already. Right?
Jenny Smith Kind of that tug of war game that you talk about.
Scott Benner Yeah.
Jenny Smith It's the insulin's got a little more tug now. Great.
Jenny Smith I can put the carbs in because the insulin is definitely showing impact, and I know that these carbs, especially with glaze, they're gonna start to hit.
Scott Benner Yeah. The original glazed cake doughnut, Jenny, has 15 grams of fat in it and 40 carbs.
Jenny Smith Oh, see, there's where I probably was think I guessed originally 40 to 50. Yeah.
Jenny Smith So the doughnut you gave that was 22 isn't a isn't a cake doughnut.
Scott Benner No. It's a regular old just glazed doughnut. Yeah.
Scott Benner This is the the cake doughnut, which I prefer I prefer a cake doughnut over a regular doughnut if we
Jenny Smith I was thinking more of a cake doughnut, honestly.
Scott Benner Just to see what that does with Jenny's settings, that turns this into 3.46 up front, and then it wants 1.2 over three hours.
Scott Benner It's like four and a it's over four and a half units even for you.
Scott Benner K. And I say even for you because your your sensitivity is 85 and your your carb ratio is 12. So
Jenny Smith And that's also a lot of insulin at one time Mhmm.
Jenny Smith For me.
Scott Benner For you. Yeah. Yeah. What would that do?
Scott Benner Do you think you'd do you think you'd have success with this or do you think you'd struggle with this?
Scott Benner Think you'd get low?
Jenny Smith I think I'd have to have it as my first experiment.
Jenny Smith And evaluate. Again, a true experiment is always without an algorithm.
Scott Benner Yeah.
Jenny Smith It just is because you get the true action of your decision and timing and the true action of insulin that's just solidly there.
Jenny Smith There's nothing giving and taking. I've grown very much connected to my algorithm.
Jenny Smith I like it a lot, as do most people.
Scott Benner Yeah.
Scott Benner Fills in a lot of holes and takes away a lot of your thoughts later.
Jenny Smith Right.
Jenny Smith So as you ask about, do you think I'd get low?
Jenny Smith Do you you know, what do you think would happen?
Jenny Smith I expect because my system does a a pretty darn good job of preventing lows.
Jenny Smith I think it would try really hard given the load of insulin though being units.
Jenny Smith Mhmm.
Jenny Smith Right? And depending on what my assumed timing would be, I might actually dip a little bit initially that it maybe it couldn't pull back enough.
Jenny Smith That one has 15 grams of fat. Right?
Scott Benner Yes.
Jenny Smith And so I might also expect I mean, I like fat.
Jenny Smith I'm not like low fat by any means. So 15 grams is what I'm saying is 15 grams isn't really a concern to me either.
Jenny Smith Mhmm. But if it did do any pulling back, then the end effect might also be a little bit of a curve up.
Jenny Smith So I would view it as anything that's new. It's an experiment. Mhmm.
Jenny Smith And I see how it works.
Filled Donuts and Fast Hitting Sugars
Scott Benner You know, marketing is a thing because I, for some reason, in my head, thought Krispy Kreme doughnuts were, like, cleaner somehow.
Scott Benner And I know now as I'm looking at the ingredients, I'm like, this is ridiculous.
Scott Benner Why would I even why did I think of them as a better alternative than, like, say, Dunkin' Donuts?
Scott Benner I think it's just the colors. I think it's because they use green around I think it I actually think the marketing works.
Jenny Smith That could be or it looks the the, logo Yeah. Also looks really old school.
Scott Benner Yes. I think Right? Yeah. Krispy Kreme says to me, hey.
Scott Benner We're gonna have a doughnut like a gentleman.
Jenny Smith Or your grandma baked it.
Scott Benner Right.
Scott Benner And Dunkin Donuts says to me, let's go. We're all gonna die together. Yeah.
Jenny Smith Yeah. Actually, Dunkin Donuts is kind of like it's like plastic doughnuts compared to crispy crispy creams.
Jenny Smith And because, you know, Dunkin Donuts, it's a very, like, bold. It's pink.
Jenny Smith It's like it's almost like
Scott Benner It's loud. Yeah.
Jenny Smith Loud. Yeah. Kind of.
Scott Benner It really I think that might be it.
Scott Benner I think Dunkin' Donuts says to me, like, let's get in this pickup truck, set it on fire, and see how long we can drive it before it blows up.
Scott Benner And Krispy Kreme does feel like, oh, my mom my grandma made it for me.
Jenny Smith Right?
Jenny Smith It's just the label and every I mean, I don't even know Krispy Kreme's clearly been around a lot longer, I think, than Dunkin' Donuts.
Jenny Smith I don't
Scott Benner even know. Alright. They have filled doughnuts.
Scott Benner You wanna do chocolate iced custard, or
Jenny Smith do
Scott Benner you wanna do original glazed cream filled?
Scott Benner Oh, there's also a New York cheesecake filled doughnut.
Jenny Smith Oh my gosh.
Scott Benner I can't even this stuff. Almost like
Jenny Smith Imagine what
Scott Benner Right.
Scott Benner Let's do the chocolate iced custard because that's really just Boston cream. Right?
Scott Benner Isn't that what that is, basically? Woo.
Scott Benner Let's go.
Scott Benner Not as much as I thought because you take the cake factor away. Oh, that's interesting.
Jenny Smith He's filling it with something.
Scott Benner Yeah. So it's 37 carbs, 17 sugar, 16 fat.
Scott Benner There's more fat than I thought getting away from the cake aspect, but still that's, you know, okay.
Jenny Smith So it's interesting and that's why I asked about the original doughnut that glazed kind of doughnut that you mentioned before in terms of total carbs versus sugars.
Scott Benner Mhmm.
Jenny Smith Most often, I've seen a lot of people doing it, and I think if you don't really know from a pre bowl strategy where to possibly start with a time is I've seen a lot of people having success
Scott Benner Okay.
Jenny Smith With taking the total sugars or the added sugars if it is on a label and using that as a default starting pre bolus.
Scott Benner Say that again for me.
Jenny Smith Yeah. I've seen so this one has what?
Jenny Smith 30 some grams of total carb?
Scott Benner Total carb, 37. Sugar, 17.
Jenny Smith 17. Yeah.
Jenny Smith So it's about half sugar.
Scott Benner Okay.
Jenny Smith Right?
Jenny Smith But what what I've seen people doing, again, this is not medical recommendation or anything disclosure, blah blah blah.
Jenny Smith I am just saying what I have seen people do and some people have real good success with a starting place.
Jenny Smith They need to tweak it, but as a starting place taking the total sugars, which are the hit point.
Jenny Smith Right?
Scott Benner Okay.
Jenny Smith And they're using that as a marker of how many minutes do I even need to pre bolus.
Jenny Smith Let's start with the total sugars as a pre bolus time. So this seventeen minutes. Right?
Jenny Smith I mean, you might just round it to fifteen to be easy, but
Scott Benner Is there a scientific reasoning behind that?
Jenny Smith I have looked and looked. I don't see a scientific reason.
Scott Benner But you see people have luck with it.
Jenny Smith I have seen people have luck with it, and I have seen commentary on people using that as a strategy.
Scott Benner That's interesting. I'm making a note about that. Okay.
Jenny Smith But I I wanted, you know, more about it just that when you do have a label and you can see, gosh, this is this many grams of carb, but, oh my gosh, 50% of it is added sugars or or the total sugar, you know, kind of added stuff in. I mean, donuts have flour, so that's carbohydrate from natural grain.
Jenny Smith Right?
Scott Benner It's
Jenny Smith processed, but that's another but at least it's not added.
Jenny Smith It's something that came with the flour that they use.
Scott Benner I see.
Jenny Smith Whereas the added is really what you're aiming to see the hit from Mhmm.
Jenny Smith Because it's so fast. And so it's often, like I said, it's often a starting place that I see people using and saying, gosh, I'm just gonna use the added sugars here as a marker.
Jenny Smith Now that also deeper level is where's your blood sugar? Where is it heading?
Jenny Smith Where is it come from? What insulin on board?
Jenny Smith I mean, there are many other factors to consider too, but it's a starting place.
Scott Benner I'm gonna do this just for this one.
Jenny Smith I can't believe you've never seen that, by the way.
Scott Benner I mean, I feel like I have, but, you know, as a good podcast host, I had you repeat it so that people could hear it for yeah.
Scott Benner Yeah. It's a trick of the trade, Jenny.
Jenny Smith Hopefully, I explained it well enough because
Scott Benner I think you did. Okay. Hey.
Scott Benner Here's the ingredients for this chocolate iced custard filled doughnut.
Scott Benner I'll only do this for this one doughnut, then we're gonna go do a couple more doughnuts from Krispy Kreme.
Scott Benner Oh. Enriched flour, wheat flour, niacin, reduced iron, thiamine, mono nitrate, riboflavin, folic acid, water, palm oil, soybean oil, sugar, yeast, hydrogenated soybean oil, soy flour, leavening, you know, baking soda, salt, mono monoglycerides, weak gluten, soy lecithin, skim milk, cellulose gum, ascorbic acid, calcium propionate to maintain freshness, egg yolk enzyme it says egg yolks, comma, enzymes.
Scott Benner In the filling, water, high fructose corn syrup, corn syrup. I like that there's two different corn syrups.
Scott Benner Right?
Scott Benner Hydrogenated coconut oil, modified food starch, sucrose fatty acid esters, salt, natural and artificial flavor, phosphoric acid, sodium benzenate, polysorbate 60, potassium sorbate to maintain freshness, colored with beta carotene.
Scott Benner Icing is sugar, water, cornstarch, cocoa, corn syrup, solids, palm oil, soybean oil, chocolate liquor, soy lecithin, salt enzyme modified soy protein, mono and diglycerides, polysorbate 60, sodium, and something called hexametaphosphate.
Scott Benner Enjoy your doughnut. Damn. That is a lot more in that than I thought there was gonna be.
Scott Benner What the hell?
Jenny Smith Wow. I yeah.
Jenny Smith I I mean, in doughnuts like, you've ever looked up, but doughnuts aren't that difficult to honestly make.
Scott Benner That's what I thought when I was looking at it. Yeah.
Scott Benner Like, it's just a little cake. It's a little piece of cake. Right?
Scott Benner With
Jenny Smith And the funny thing as you're going through them, I'm thinking like and you brought it up.
Jenny Smith Like, they've got not only high fructose corn syrup, which is really corn syrup that they've essentially added some enzymes to, and the fructose in it makes it a little sweeter than regular corn syrup, but they use both high fructose corn syrup and corn syrup.
Jenny Smith Because clearly, there's something fancy in the recipe that makes it taste the right way.
Oreo Cookies Deep Dive
Scott Benner Some of that in too. Alright. So I'm gonna do one more, one of their fancier donuts, and I almost did the I almost did the New York cheesecake one.
Jenny Smith I was gonna ask if, you know, tomorrow is Valentine's Day whether you celebrate it or not.
Jenny Smith Do they have anything special? I know a lot of times
Scott Benner Yes.
Scott Benner There are Valentine's donuts here. After we do this one, I'll look at one of the Valentine's sauce.
Scott Benner I instead of going to the New York, cream cheese or whatever it was, I went to the Oreo cookies and cream filled donut.
Scott Benner And those Oreos really throw on a little punch.
Scott Benner This one has 49 carbs, 28 sugars, 20 fat. That's that's that's a big jump.
Jenny Smith It's a loaded donut, man.
Scott Benner It's a loaded donut.
Jenny Smith I wish I could see what these things look like.
Jenny Smith You have
Scott Benner a you have the Internet know.
Jenny Smith I don't I usually like to let you
Scott Benner I know. I know.
Jenny Smith There's a way we do this. Yeah. Yeah.
Scott Benner The 49 carbs, 20 fat, four protein.
Jenny Smith How much sugar?
Scott Benner Sugar, 28. Now would you tell somebody to pre boast twenty eight minutes for this?
Scott Benner You Jenny's like, I might.
Jenny Smith Look at how much. So 49 grams of total carb?
Scott Benner Yeah.
Jenny Smith Is that what you said? And 28 of that is sugar.
Scott Benner That's a lot of sugar.
Jenny Smith That's added sugar.
Jenny Smith That is more than half of this doughnut is sugar.
Scott Benner Yeah. You know what?
Scott Benner That makes me feel like Do you
Jenny Smith know how many teaspoons of sugar that is?
Jenny Smith I gave you the math for this before.
Scott Benner Oh, you think I remember that? Stop it.
Scott Benner Go ahead. You tell me. Mhmm.
Scott Benner I don't know.
Jenny Smith It's seven teaspoons of sugar. Seven? Seven.
Scott Benner Measuring teaspoons of sugar. Goddamn.
Scott Benner Yeah. Yep. In one of those donuts.
Jenny Smith That's just added sugar. Right?
Jenny Smith That's just the added sugars. So just as a reference, you said I mean, you were very surprised, like, twenty eight minute pre bolus.
Jenny Smith I'm thinking, if there's nothing else in your stomach and you're eating this and
Scott Benner You might need the insulin to be running away to grab this when it hits you.
Jenny Smith Right? Absolutely.
Scott Benner By the way, this pushed me.
Scott Benner Know this was supposed to be about donuts, but this pushed me to oreo.com because those Oreos really shushed up those so chocolate.
Scott Benner Let's see. Chocolate sandwich cookie. I'm trying to just find a regular Oreo.
Scott Benner Wait.
Scott Benner This website is fancy as hell. You ready?
Jenny Smith Even know who makes is it who makes Oreos?
Scott Benner I mean, Nabisco, I Nabisco.
Scott Benner Think. Is that right? Isn't it all like some oil company now or a
Jenny Smith Oh, absolutely.
Scott Benner Or a missile manufacturer or something? A 100%.
Jenny Smith They're all people that you're like, yeah. You should make my food.
Jenny Smith That sounds like a great idea.
Scott Benner Honestly, I think listen.
Scott Benner I don't know a lot about a lot, but I think if you look into it, a lot of the big, like, agri companies are just owned by consortiums of finance of money that, you know, I think that Yes.
Scott Benner The same group that used to own cigarettes or maybe still does.
Scott Benner Like, it's possible RJ Reynolds is making your your bread or something like that. Oh.
Scott Benner But let's say that Jenny gets out of her mind and is gonna eat six Oreo cookies.
Scott Benner Jenny, it's all over. Life's gotten sideways. Alright.
Scott Benner You're
Jenny Smith I go to the store and I'm just gonna sit in my car and Yeah.
Scott Benner You're you're gonna sit and you're gonna eat six Oreo cookies. Now Okay.
Scott Benner Three Oreo cookies is sorry. This website, I think, is meant to is not to it doesn't want you to be able to read it.
Scott Benner So three Oreo cookies has seven grams of fat, so I'm gonna put in 14 grams of fat.
Scott Benner And I really have to pick through this trans wait. Wait.
Scott Benner I'm not put the carbs anywhere near the top.
Scott Benner Carbohydrate oh, it gives you total carbs 25. So six of them is gonna be 50.
Scott Benner Protein?
Scott Benner Is there a protein? Yeah. You're gonna get two grams of protein.
Jenny Smith Woo hoo.
Jenny Smith My muscles are saying, thank goodness.
Scott Benner Things are coming together now.
Scott Benner The my muscles are saying thank you. The added sugar for this is 14, but you're having six, so it's 28. The calculator, which by the way, I you know, the estimator is I don't think even able to take into account the idea of, like, how hard the sugar's gonna hit right away because Right.
Scott Benner It's still like, look, for you, it'd be 4.3 upfront, 1.12 over three hours, like a five and a half unit bolus Mhmm.
Scott Benner With a ten minute pre bolus. But I want you to talk more about it again from your perspective.
Scott Benner You're gonna eat six Oreo cookies. Mhmm. How are you gonna bolus for six Oreo cookies?
Jenny Smith Go for a run after I eat.
Scott Benner And he's like, I'm gonna eat them while I'm running.
Jenny Smith I'm sorry.
Scott Benner Would that work? Can you just eat them while you're running with that, like
Jenny Smith Oh my god.
Jenny Smith I'd probably throw them. Like, there's nothing to drink along. Oh god.
Jenny Smith I can't even imagine doing that.
Scott Benner Have you had an Oreo in the last ten years?
Scott Benner They're not as good as they used to be. I just wanna say that.
Jenny Smith I probably the last time I honestly had an Oreo cookie was in college. Okay.
Jenny Smith Probably.
Scott Benner Yeah.
Jenny Smith Yeah. I mean, I know what an Oreo tastes like.
Jenny Smith Yes.
Scott Benner So these you think about how you're gonna bowl this for the 50 carbs for the regular six Oreo cookies.
Jenny Smith Which again
Scott Benner Well, I look at the double stuff.
Jenny Smith My estimate would be so it's 50 grams of carb because you said three has 25. Right?
Jenny Smith Right. And my expectation is that half of that total carb is coming from sugar would be my guess.
Scott Benner 28. Right. I
Jenny Smith think it was. 28. Okay.
Jenny Smith So I would absolutely let's say my blood sugar is in target, the unicorn number of 100, nice and level.
Jenny Smith Mhmm.
Jenny Smith Let's just say it is. It's not moving.
Jenny Smith I'm going to give this a minimum of a twenty minute knowing my response to a minimum of a twenty minute pre bolus.
Scott Benner Okay.
Jenny Smith And if in twenty minutes, I'm I should be seeing already a downward tick just with my knowledge of how insulin works with me in this situation.
Scott Benner Okay.
Jenny Smith I should be seeing I would give this it's coming down.
Jenny Smith I might even be hitting 80 before I take my first bite.
Jenny Smith So again, here is that time frame is an estimated pre bolus time Mhmm.
Jenny Smith But I'm really paying close attention to my CGM in a scenario like this where I've been eating Oreos since college where I didn't have a CGM and it was my best guess and I I don't have any clue what happened after I ate the Oreos in college.
Scott Benner Do you think it's a mistake that on the mega stuff Oreos, it's harder to find the nutritional information on the website because I don't think it's a mistake.
Jenny Smith Aren't they they're double stuffed. Right?
Scott Benner They're calling this one mega stuff.
Jenny Smith Oh, so they're more than double stuff.
Scott Benner It feels by the way, it feels funny to type in Oreo mega stuff and then nutrition afterwards.
Scott Benner It feels like those are two, two words that don't go together.
Jenny Smith I'm also curious what the portion size would be because the regular Oreos are three is a single portion.
Scott Benner Yeah. I'm finding a bag right now to look at the label
Jenny Smith on I'm curious if because they're mega stuffed, maybe only one is a portion, or are they telling peep or are they suggesting to people that it's two?
Scott Benner I see what you're saying.
Jenny Smith Do you know what I mean?
Jenny Smith Like, are they
Scott Benner Serving size is two cookies
Jenny Smith Okay.
Scott Benner On the mega stuff.
Scott Benner Total carbs for those two cookies are 25, and total sugars are 17. So because you're getting the same cookie amount.
Scott Benner You're just getting more of the cream inside. I mean, I'm calling it cream.
Jenny Smith Sugar actually goes up. You get one less cookie, but you get more stuffing.
Jenny Smith So the carbs remain the same as three regular Oreo cookies. Yeah.
Jenny Smith But the total carbs are actually the total amount of added sugars is slightly more.
Scott Benner Yeah.
Scott Benner And then if you had six of six of these, you'd have 75 carbs.
Scott Benner You'd have seventeen, twenty, 36, 46, 49, 54 sugars. Is that right? Is that 17 times three?
Scott Benner Fifty four? And I think I just let people in real time see my my poor math.
Scott Benner I could have just multiplied, but for some reason, that's not how my brain does it.
Scott Benner That in this three and a half. So three, six, nine, ten and a half.
Scott Benner It'd be 10 and a half if you had six of them. Yeah.
Jenny Smith So there's less fat in the double stuff? Yeah.
Jenny Smith Must just be all sugar then the cookies must have the fat because the other ones have more fat in three cookies.
Scott Benner Mhmm. That puts your balls up to about seven and a half, by the way, in case you're wondering.
Valentine's Day Donuts & Hidden Icing Carbs
Scott Benner Anyway, let's go back to the Krispy Kreme real quick because Jenny asked about the Valentine's.
Jenny Smith If they had anything fancy.
Scott Benner Yeah.
Scott Benner Well, I mean, though, I think the Oreo one, looks it's fancy.
Jenny Smith It looks fancy.
Scott Benner Yeah. They put extra stuff
Jenny Smith on it.
Jenny Smith You know, the funny thing is that when consider this is where my brain goes in consideration of, like, my intake, which you can take it as it is.
Jenny Smith If I'm gonna eat 75 grams worth of carb,
Scott Benner it's gonna be donut. Yeah.
Jenny Smith Yeah. It's not gonna be a donut. It's not gonna be cookies.
Jenny Smith But again, that's me. Yeah.
Jenny Smith This is not a you should do this or whatever.
Jenny Smith It's a if I want that, I'm going for really good sushi someplace.
Jenny Smith And I like want this to be food that I can enjoy, that I'm
Scott Benner sitting on next you.
Scott Benner A year Jenny sends me a picture of her plate from a restaurant. She's like, I'm doing it.
Scott Benner Like like, look at me look at me eating. You know what?
Scott Benner I take your point about the Valentine. It'll be beyond Valentine's Day, obviously, when people get this.
Scott Benner Also, you're reminding me that tomorrow is Valentine's Day.
Jenny Smith There you go.
Jenny Smith Lovely for your wife that you remember now.
Scott Benner She was gonna get flowers.
Scott Benner I love you, chocolat. Oh, I love you chocolat doughnut, teddy bear cookies and cream doughnut, your berry sweet doughnut, and sprinkled with love doughnuts.
Scott Benner So they have four here's why I'm bringing this up because if someone ends up at Krispy Kreme tomorrow or this week, they're gonna go, oh my god.
Scott Benner It's Valentine's Day.
Scott Benner And there's gonna be one in there.
Scott Benner And then it's gonna come home and it's gonna go on your counter. Right?
Scott Benner And then your gonna walk by and there's gonna be a Red Heart donut with a bow on it.
Scott Benner They'll be like, mom, I'm gonna have a donut, the thing.
Scott Benner And you yeah. Yeah.
Scott Benner And then the Red Heart donut has 44 carbs in it and 26 sugars and 18 fat. Okay.
Scott Benner Yeah.
Scott Benner It's not getting crazy beyond what they're No. What they're doing with most actually, will say they do seem to keep their donuts.
Scott Benner They're all pretty similar. Like, the stuffed ones are
Jenny Smith Okay.
Scott Benner Hitting nutritionally about all the same. Like, one doesn't seem oddly different than the other.
Scott Benner The teddy bear is 46 carbs, 28 sugar, nine fat. Yeah.
Scott Benner These these are all sort of, like, you know
Jenny Smith If I was to pick one, honestly, I don't even know I don't know what they look like.
Jenny Smith You said there's like a red heart one. Right?
Scott Benner Mhmm.
Jenny Smith And then the I'd probably pick the teddy bear one, honestly.
Jenny Smith Like, if I was gonna pick one just out of cuteness and but then I'd feel bad eating it if it had a face
Scott Benner or something.
Scott Benner I'm gonna send it to you so you can see it. Hold on a second.
Scott Benner And then they have a a regular it looks like they're glazed donut, but with icing on top and just up with, like, red and sprinkles and stuff.
Scott Benner That's 37
Jenny Smith Okay.
Scott Benner And 15. That's interesting.
Scott Benner Like so so their glazed donut with icing on top is 37 carbs, and it really does look like that's all it is.
Jenny Smith Okay.
Scott Benner Right? And 50. So the glazed donut says 22. You put icing on top of it, it takes it up 15 more carbs just for the icing.
Scott Benner Anyway, I think that's
Jenny Smith partly heavy.
Scott Benner Yeah.
Scott Benner I partly, I feel like that's some of the value in these conversations actually is that yeah.
Scott Benner I just don't know that our brains do the math real quick when we look at things.
Scott Benner Like, oh, donut. It's Valentine's Day.
Scott Benner Like, you know, that kind of stuff.
Jenny Smith Or underscore I know I I think a lot of people unconsciously undercount for things like frosting.
Jenny Smith Like, it I know that there's sugar there, but Mhmm.
Jenny Smith Gosh, it can't have 25 extra grams worth of carb in it. Yeah.
Scott Benner Right? Yeah.
Scott Benner Especially you make a good point because if somebody's eating the the glazed doughnut as part of their life with 22 carbs, then you're like, oh, this glazed doughnut has icing.
Scott Benner There's no way you're gonna add 15 carbs in your mind to
Jenny Smith Right.
Scott Benner To that.
Scott Benner I sent you the the teddy bear so you can see it. Oh.
Scott Benner I know it's a little I don't know if it's cute or odd. You like it?
Scott Benner Jenny likes it.
Jenny Smith It's kinda it is kinda cute. Honestly.
Scott Benner Aw.
Scott Benner Yeah. Well, you'll eat that cute teddy bear and it'll go inside you and try to kill you from the inside out.
Scott Benner That's
Jenny Smith right. There
Scott Benner you go.
Jenny Smith I was so cute.
Jenny Smith You shouldn't have eaten me. Yeah. You
Scott Benner you'll you'll experience your own bear attack.
Scott Benner Not the way you see in the YouTube videos.
Jenny Smith You're right.
Episode Wrap-Up & Closing Remarks
Scott Benner Jenny, thank you for doing Krispy Kreme doughnuts.
Jenny Smith Thank you.
Scott Benner I appreciate it.
Scott Benner I'll talk to you soon. And happy Valentine's Day.
Jenny Smith You too.
Scott Benner Is that why you're wearing red?
Jenny Smith Kinda. Yeah? Yeah. Yeah.
Jenny Smith I mean, we don't really do anything for Valentine's Day, honestly.
Jenny Smith I mean, Nathan will usually bring me flowers or something, but honestly, it's truly is just like a money making.
Jenny Smith No. I I It's like, you know, it's so
Scott Benner I expect my wife to apologize to me tomorrow around 03:00.
Scott Benner And she'll go, I did not get you anything from Like,
Jenny Smith she says I didn't get you anything, and you're like, great.
Jenny Smith Here are your flowers.
Scott Benner I got flowers for you. And then she'll say thank you.
Scott Benner Actually, Jenny, I think this is a good point to place.
Scott Benner I don't think I've ever said this before. I'll just slide this in at the end of the episode.
Scott Benner On all occasions, birthday, Valentine's Day, anniversary, those sorts of things.
Scott Benner I go out on the morning of, I hand select flowers and come home and arrange them myself.
Scott Benner Oh. I think it's a nice little addition. It's like, it's not just here I bought flowers.
Scott Benner It's like I saw these I
Jenny Smith took time.
Scott Benner They look like they were nice together. I put some time into it.
Scott Benner She's never once seemed impressed by that, but I think it's a big deal.
Jenny Smith I think that's lovely. It really is.
Scott Benner Don't don't marry an Irish Catholic girl.
Scott Benner They their their hearts are buried under ice. That's all.
Jenny Smith I'm just saying I married an Irish Catholic boy.
Scott Benner Yeah.
Scott Benner He knows what Jenny knows what I mean. Okay. Alright.
Scott Benner No shade on the rest of you.
Scott Benner I'm sure some of you are very warm and cuddly.
Scott Benner Not as cuddly as that donut. Right. On it though. See you guys.
Scott Benner A huge thanks to US Med for sponsoring this episode of the Juice Box podcast.
Scott Benner Don't forget, usmed.com/juicebox. This is where we get our diabetes supplies from. You can as well.
Scott Benner Use the link or call (888) 721-1514.
Scott Benner Use the link or call the number, get your free benefits check so that you can start getting your diabetes supplies the way we do from US Med.
Scott Benner Today's episode is also sponsored by Omnipod. Check out the Omnipod five now with my link, omnipod.com/juicebox.
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Scott Benner Omnipod.com/juicebox. Terms and conditions apply.
Scott Benner Full terms and conditions can be found at omnipod.com/juicebox. (38:45) Okay.
Scott Benner Well, here we are at the end of the episode.
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Scott Benner My diabetes pro tip series is about cutting through the clutter of diabetes management to give you the straightforward practical insights that truly make a difference.
Scott Benner This series is all about mastering the fundamentals, whether it's the basics of insulin, dosing adjustments, or everyday management strategies that will empower you to take control.
Scott Benner I'm joined by Jenny Smith, who is a diabetes educator with over thirty five years of personal experience, and we break down complex concepts into simple, actionable tips.
Scott Benner The diabetes pro tip series runs between episode one thousand and one thousand twenty five in your podcast player, or you can listen to it at juiceboxpodcast.com by going up into the menu.
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#1798 Is Alison Saving Levemir?!
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 Alexaor wherever they get audio.
Alison Smart returns to share vital updates on the ongoing fight to save Levemir insulin. Discover recent FDA progress, bipartisan support, and why this insulin remains crucial for healthy pregnancies. Alison is a returning guest, 1652 Save Levemir.
Key Takeaways
- Alison Smart has spent over two years advocating for the continued production of Levemir (detemir) insulin, securing bipartisan congressional support and engaging in positive, high-level meetings with the FDA.
- Levemir is critical for many individuals because of its unique profile (binding with albumin, lasting 8-14 hours), which avoids the unpredictable hypoglycemia and long-duration issues that can occur with glargine and degludec.
- Levemir is highly proven and widely prescribed during pregnancy for managing both gestational and type 1 diabetes without causing complications linked to poorly controlled blood sugar.
- Novo Nordisk has signaled a willingness to assist a new manufacturer with ingredients, though finding the right non-competing partner capable of navigating the complex biosimilarity process remains the final hurdle.
- Despite excitement surrounding potential future cures like islet cell transplants, ensuring steady, reliable, and accessible insulin production remains a critical necessity for current and future patients.
Resources Mentioned
- Alliance to Protect Insulin Choice
- Juice Box Podcast - Small Sips Series
- Eversense 365 CGM
- Juice Cruise 2026
- Wrong Way Recording
- Juice Box Podcast Type One Diabetes Facebook Group
- Chicago Policy Review article (mentioned in episode)
Introduction and Podcast Updates
Scott BennerWelcome back, friends, to another episode of the Juice Box podcast. Well, everybody, we're gonna jump right in. I'm back with Alison Smart. She was in episode sixteen fifty two called Save Levemir. It actually was out in October 2025, and she's back with us today to give us an update about what's happening and where are you right now.
If you'd like to hear about diabetes management in easy to take in bits, check out the small sips. That's the series on the Juice Box podcast that listeners are talking about like it's a cheat code. These are perfect little bursts of clarity, one person said. I finally understood things I've heard a 100 times. Short, simple, and somehow exactly what I needed.
People say small sips feels like someone pulling up a chair, sliding a cup across the table, and giving you one clean idea at a time. Nothing overwhelming. No fire hose of information. Just steady helpful nudges that actually stick. People listen in their car, on walks, or rather actually bolusing anytime that they need a quick shot of perspective.
And the reviews, they all say the same thing. Small sips makes diabetes make sense. Search for the Juice Box podcast, small sips, wherever you get audio. Nothing you hear on the Juice Box podcast should be considered advice, medical or otherwise. Always consult a physician before making any changes to your health care plan.
Today's episode of the Juice Box podcast is sponsored by the Eversense three sixty five, the one year wear CGM. That's one insertion a year. That's it. And here's a little bonus for you. How about there's no limit on how many friends and family you can share your data with with the Eversense Now app?
No limits. Eversense. Well, everybody, we're gonna jump right in. I'm back with Alison Smart. She was in episode sixteen fifty two called Save Levemir. It actually was out in October 2025, and she's back with us today to give us an update about what's happening. And where are you right now?
The Advocacy Journey in DC
Alison SmartI'm in Washington DC right now working on this.
Scott BennerHow long have you been at this now total?
Alison SmartIt has been two years. Well, just over two years. We started November 8 was the announcement that this insulin, Levemir insulin, would be discontinued in The US, and we started really later that month. So it's been just over two years.
Scott BennerOkay. And what what has you in DC today?
Alison SmartThere are several conferences this week, and I've had some appointments with congressional offices. So conferences with, health and human services members, and, it's it's been a good week.
Scott BennerOkay. What what do you think I I guess, why don't you catch me up on what's happened since you were on the podcast last?
Alison SmartGreat. Yep. So this is just so we're in March, and it was October. So in just the last several months, we've had a lot of progress. We've had, bipartisan congressional support. Congressional members of both parties have sent letters to health and human services asking for a path forward for production of Determa insulin. We've had high level meetings with the FDA that have been a much different reception than we had when we started this two years ago. Two years ago, there was the FDA is used to dealing with large large companies, not not a small patient advocacy group. Mhmm. Well, small. We're we're getting a lot bigger. And the reception with leadership of both the drug shortage staff and the office of biologics and biosimilars was very positive, very understanding, and caring. The response now is we understand you've made it very clear that there's a distinct need for this insulin, and we're hearing about it from more than just your organization, which is excellent. And they said they really want to emphasize there's a clear path forward. If Novo Nordisk will come and assist, there are multiple pathways that could work, not just one. Okay. So congressional letters, FDA meetings, physicians are reaching out. We have maternal fetal medicine specialists and those that specialize in diabetes and pregnancy specifically and other physicians who are reaching out about the need for this insulin and willing to be, part of meetings with congressional staff. We also have multiple manufacturers that we're talking with ready to go that could make this insulin if they get the needed help from Novo Nordisk. And then at this point, we are asking health and human services to engage Novo Nordisk executives in discussions for production of this insulin. So that's that's our progress.
Scott BennerThat's astounding, especially because it started with, what, you in your living room?
Alison SmartWell but yeah. But I was already initially, you know, communicating with others who needed this, and all of us were saying, ah, what do we do?
Scott BennerRight. Right. Yes. You you pulled together some voices who were concerned. And if it takes two years to get them to, okay. We understand this is a thing we should be supporting. I mean, does it take two more years to get the next step? Is it do you think this is gonna go more quickly? Do you think Novo Nordisk is gonna be receptive to this?
Alison SmartSo they're signaling recently that they will help. They've signaled to some congressional offices that we will be willing to assist with drug ingredients with the right partner. I don't know. You know, we're we're I I don't know. I don't know the timeline and but I just boy, we're making great progress, and there's a real need.
Scott BennerThat's so cool. So I don't wanna be, sour, but but let me ask you a question. So when you go to Novo Nordisk and say, hey. Stop don't please don't stop making this or let somebody else make it. They go, we don't care. And then you get some congress people to write some letters to some people and somebody calls somebody on the phone, and now suddenly it's a thing they care about. I mean, is it that simple, or is there more to it than that?
Alison SmartHonestly, I think it might be that simple. I I do. I I just I've I've stopped. Our organization is not reaching out as much on our own. It it needs to come from bigger voices.
Scott BennerMhmm.
Alison SmartBut I it absolutely makes a difference. I mean, manufacturers care. They care what people think, but they really care what influential members of health and human services and the and our administration think for for certain.
Scott BennerSo so is this a situation where it's just kind of like business where, okay, it's not really something we want to do, but people who we count on for pathways, decisions, etcetera, seem to think it's important. If it's important to them, it's important to us. It's like that.
Alison SmartI'm hoping.
Scott BennerWow.
Alison SmartWe'll see. Right?
Scott BennerIs it funny how the world works?
Alison SmartIt is.
Scott BennerSo when you're down there in those meetings, give me give me an example of, like, you're gonna you you have a meeting today, for example?
Alison SmartDon't this afternoon. I have a conference this afternoon I'll be attending.
Scott BennerA meeting you were at previously in days past. You walk in. Are these people that you've met previously? Are you giving them updates? Are these new people you're trying to get on board?
Alison SmartAll of the above. We're we're in contact with quite a few congressional staff at this point that we've been working with for quite some time. Had a meeting yesterday afternoon with a congressional aide that I've been communicating with for over a year. But some of them are new, and sometimes it's just me, but often will include virtually physicians at the last minute or or others, you know, maybe constituents. So it's all different.
Scott BennerExplain to me how you go from a person, you know, a few people focused on something to a slightly bigger group of people to someone who can get a congressional staffer to sit in person with you. How do you build that? Because you're basically a lobbyist now for one very small idea. So, like, how does that work?
Alison SmartIt takes time. It takes connections, and it takes constituents reaching out. So, you know, we've been saying a lot. You know, reach out to your congressional representatives. It works best if we work in conjunction if constituents reach out to their cons congressional aids. And it even just to get to the right aid or the right staffer is difficult. You get to that point, and then if they can talk to our organization, then we can reach out here from Washington DC, and it it works better if it's if it's in conjunction. And and but sometimes the staffers will talk to each other through connections. It's it's been quite the journey.
Scott BennerDoes it need to be it's funny because I'm I'm thinking about the, you know, kind of everything you're hearing people talk about about islet cells right now
Alison SmartMhmm.
Scott BennerRight, as an example. So, you know, there's, you know, couple of people here and there on social media who are like, you should write a letter to somebody and, you know but, I mean, that's not very coordinated. Like, do uncoordinated things do you think somebody like you who understands this needs to kinda grab hold of those ideas and coordinate them? Is that is that really the key to getting it off the ground and and getting it taken seriously?
Alison SmartI do. I it's easy to disregard a form letter or a form email. These congressional staffers get many, many emails. And so if it's just forwarding some form letter, it doesn't get very far. It needs it needs some some personal contact, you know, constituents or just a real you know, maybe some offices are more concerned with certain areas than other, and it it yeah. It's it's interesting.
Scott BennerSo it's it's as easy like, just sending off, a you know, I don't know. Some guy on Instagram told me to send this somewhere, and I found it. That you don't think that's gonna get much traction?
Alison SmartNot necessarily unless there are many, many. Just a few here and there. People people get frustrated when they'll say, well, I sent one message. One message doesn't get very far.
Scott BennerYeah. Hey. How many? Many what is many many?
Alison SmartYou know, I mean, I've asked that myself, and and some have said, you know, if I get 10 or 20 letters, I pay attention. I think it depends.
Scott BennerRight. 10 or 20 letters makes them pick up makes the staffer pick up their head and say, I wonder if I shouldn't mention this to the congressman. That kind of
Alison Smartthing. Or or you can have a few that are really persistent. Just sending one or two messages is really not gonna bend move the needle. Yeah. But persistency and volume makes a difference.
Scott BennerTime. Not and maybe not just months either, but maybe years.
Alison SmartYou know, it depends.
Understanding Insulin Profiles
Scott BennerYeah. Well, you're you're I mean Your thing is I mean, I guess, take two minutes here for people who maybe didn't hear your last episode and tell them how this started, what the impetus was that got it all moving for you, and why you thought it was so important to do.
Alison SmartSure. So my daughter was diagnosed with type one diabetes at age 13, four and a half years ago, and we started on a glargine. So let me just lay out the the different insulins just as a update. Mhmm. You can newly diagnosed are typically placed on a glargine insulin, which is Lantus and biosimilars, and even TUJO is a is glargine, but but it's more concentrated. Those are those are 40% of the market. So they're the largest part of the insulin market. Some don't tolerate glargine well, and the two alternatives are just made by Novo Nordisk. They are Levemir, which is Dedamir, or Tresiba, which is deglidec. And I'll use the the second the generic name even though there aren't generics of those insulins. The basic differences, they they have different pharmacokinetics. Glargine insulins need to form microprecipitates under the skin and have a slow release, and that can be a problem if glargine insulin is injected into a blood vessel. It can produce an unpredictable hypoglycemic event. Also, if if glargine is exposed to heat, it can also produce unpredictable hypoglycemia from a shower or a sauna, and it's also acidic. So some people don't tolerate well the inconsistency of glargine, and some just don't feel well using it. So then some will use and glargine lasts approximately twenty hours. Detamir lasts approximately well, eight to fourteen hours. So it's typically given more than once a day, but there are some people who only need insulin at night for fasting blood glucose. So that's why that insulin is ideal for many. It also acts differently. It binds with albumin. It doesn't form those microprecipicepts, so it doesn't have that same potential for unpredictable hypoglycemia if injected into the bloodstream or if exposed to heat. Mhmm. Degladec lasts forty two hours approximately, which can be a real problem with people who are used to being able to change the amount of insulin to correspond with different times of the day or to correspond with a menstrual cycle, or teenage boys often have multiple more needs in the day versus the night. Pregnancy, we'll we'll talk about pregnancy in a minute. Mhmm. And then we're we haven't included NPH in our argument, but NPH is needed for pregnancy, but it doesn't have a stable profile. Defined peak that can be difficult for type one diabetics but is needed for gestational and type two diabetes. And then there are insulin pumps. Less than half of those who need insulin use insulin pumps, and even insulin pump users need backup insulin, and women with gestational and type two diabetes would not typically use an insulin pump. So those are the insulins that are available. Back to my journey, my daughter initially used Glargine, switched to Levemir, had excellent management for several years. We went back and tried Glargine again. It's just more difficult for her to maneuver with being a she's an athlete and dealing with a menstrual cycle. She also tried an insulin pump, and in her case, it made the activity difficult. I understand some people can make it work, but, we have many in our organization who used an insulin pump for years who appreciate the ability to go back to shots. And then just back to the journey, so two years ago, it was announced that Novo Nordisk would be removing Levemir insulin from The United States. We started working on this, formed a nonprofit. Our goal is continued access to this insulin produced by a new manufacturer. Of course, we'd love it if Novo Nordisk would just continue to make it. They're not going to, but they're signaling that they might help a new manufacturer make it. That's kind of the journey. Can I talk about pregnancy for just a minute?
Scott BennerYeah. I wanna talk about pregnancy. Give me one second, though.
Alison SmartGreat.
Scott BennerIf I take you in a time machine back three years and ask you to explain insulin, do you go, I don't know. There's fast acting and long acting? And now
Alison SmartOh, absolutely.
Scott BennerAnd now you have a a granular understanding of it? Yeah. My question would be, when you talk to somebody at Novo Nordisk, did they always have this understanding? Like, is is there a world where this got this far because four people in a room said, why do we need this old one? We have the new one, and didn't have that understanding. This episode of the Juice Box podcast is sponsored by Eversense three sixty five. And just as the name says, it lasts for a full year. Imagine for a second a CGM with just one sensor placement and one warm up period every year. Imagine a sensor that has exceptional accuracy over that year and is actually the most accurate CGM in the low range that you can get. What if I told you that this sensor had no risk of falling off or being knocked off? That may seem too good to be true, but I'm not even done telling you about it yet. The Eversense three sixty five has essentially no compression lows. It features incredibly gentle adhesive for its transmitter. You can take the transmitter off when you don't wanna wear your CGM and put it right back on without having to waste the sensor or go through another warm up period. The app works with iOS and Android, even Apple Watch. You can manage your diabetes instead of your CGM with the Eversense three sixty five. Learn more and get started today at eversensecgm.com/juicebox. One year, one CGM.
Alison SmartThe variety of understanding is fascinating to me. So Novo Nordisk executives, some understand it, some absolutely don't. The pregnancy piece, some understand, some don't. Here's another fascinating group to talk to. Former, drug reps from who worked for Novo Nordisk, they were extremely well versed in the differences of pharmacokinetics of glargine versus desmir versus deglidec. That was prior to 2015. 2015. So levemir came out in 2005. Tresiba came out in 2015. And at that point, Novo Nordisk reps were switched to promoting Tresiba to physicians. So it's older reps who really, really understand the value of Levemir insulin. But, yeah, the the level of understanding is certainly different.
Scott BennerWell, I was
Alison Smartdepending on
Scott BennerThat's interesting. So I wonder if everybody can, like, understand. I'm sure if you're in a business that's, you know, a a huge company like Novo or other companies like that, you makes sense to you. But for the average person walking around who's running a cash register somewhere or, like, you know, listening to this while they're plumbing, like, it's it seems crazy to think that the company that makes the insulin might not completely understand the value of the insulin. And to understand that the the reps were the ones that were really educated about it, and they were probably the ones keeping the doctors educated, which kept the need up.
Alison SmartExactly.
Scott BennerRight?
Alison SmartExactly.
Scott BennerYeah. Yeah. And then and then you lose that pathway or things become digital. I I also you know, I I'm not lost that you that what you said earlier was you need to look I don't know if you used this phrasing or if it's how it popped in my head, but, like, if you wanna get somebody on your side and get them to understand what you're talking about, you have stand with them in a room and look them in the eye. You can't send them an email or and say, this is really because you seem crazy, like, when you do stuff like that. Like, I'm watching people now, again, with the eyelet thing. I think it's very important. I I don't talk a ton about politics on the podcast, and I probably never will, to be perfectly honest. But, you know, in that eyelet thing right now as an example, you know, they're like, you should have somebody talk about it. I keep saying, I'm waiting for, like, an ad. I shouldn't say this like this, but, you know, I'm waiting for somebody who doesn't look crazy to to be talking about it. Like, right now, I just see people ranting on social media, and I'm like, I'm not interviewing you. I want Alison who can sit down and go, wow. Here it is. You you what know I mean? Like, wanna have an adult conversation about it. Not that I don't think those people are well intended or that, you know, their efforts might, you know, bear fruit or anything like that. Just when I sit and talk about it, I want somebody who can break it down the way you you can. And that person then needs to be in the same physical space as the person they're trying to explain it to because look at all the words you just used. Glargine, the like, you know what mean? Like, deglade like, who under no one understands that. And so, like, you know, you what are you trying to get a congressional staff? What are those people, like, 23? They've been out of college for eight minutes. Right? And you're, and you're, like, degladeck, and they're, lady, listen. Know, like, I I I don't know what you're talking about. Right? It's hard work, but it's really important.
Alison SmartWell, yeah. And I just gotta say it varies. Some of the congressional staff are college interns, you know, majoring in political science, but some congressional and senate representatives will hire a physician, a fellow to be the one conducting these meetings. I had a recent meeting. No.
Alison SmartGo ahead.
Scott BennerNo. That's just awesome. I'm sorry. Like, yeah, tell me. I'm sorry. Recent meeting?
Alison SmartWell, I had a recent meeting with with and the physician who was meeting with me, and there were a few others. She's a nephrologist, which is specializes in kidney conditions. And she says, oh, we don't use Tresiba with our advanced kidney failure patients because of the long duration of action. So it you know, that and so it was interesting because we were able to just sit down and really go the nitty gritties of this this insulin. But you're right. Often, I've had to learn to, I used to when I started this, I think, well, let me give give me ten minutes to really explain the situation, and now I have to be able to concisely present this in two minutes sometimes.
Scott BennerI wanna just tell you, you're better at it now than the last time I spoke to you, actually. Like, I can Thank you. Yeah. Like, you can tell that it really felt I'm glad you brought that up because I didn't wanna say it without you saying it, but it felt like it felt like you sat in a room and you thought, I need an elevator pitch for this.
Alison SmartRight.
Scott BennerYeah. Because because that was, like, super clear. Like, that would that that was really awesome. Like, you're doing that's awes You know what? I I I keep imagining. We're talking about the islet cells and, like, you'll get this you get this insulin back on the market, and they'll find a way to, like, do that, like, the aisle itself that your kid will get that. You'll be like, oh my god. Are you kidding me? How old is your daughter now?
Alison SmartShe's 17.
Scott Benner17. Do you think that she understands the the value of this, like, in the amount of work and effort you're putting into it? Because, I mean, this is most of your time now at this point. Right?
Alison SmartOh, for sure.
Scott BennerYeah.
Alison SmartShe does. She's great. She's she's very supportive, and she'll occasionally talk about it. But she's much happier to just live her life and let me do my thing. Yeah. As you can probably understand.
The Importance of Levemir in Pregnancy
Scott BennerNo. No. Please. My kid doesn't, you know, care about the thing I'm doing either. Okay. I'm sorry. Go back to pregnancy. Why why is this so important for pregnancy?
Alison SmartOkay. So I wanna bring this up in light of the Isla Act because I think people dream of this day when insulin is no longer needed. Right?
Scott BennerMhmm.
Alison SmartPregnancy is a unique situation where there are pregnant women with gestational diabetes. Over a hundred thousand women in The United States a year have a pregnancy with gestational diabetes and need insulin for just the duration of that pregnancy. We're not gonna you're not gonna inject someone with islet cells that's pregnant with gestational diabetes. Right?
Scott BennerYeah.
Alison SmartSo this is a unique situation. For example, let me just give you another example as I talk about the pregnancy situation. Yesterday, I talked to a maternal fetal medicine specialist who's an OBGYN who leads a diabetes and pregnancy program at a major university, and he sees their their division sees over fifteen hundred women, pregnant women each year having pregnancies that require insulin, and Levemir has been their go to for pregnancy. NPH has been a back up if the woman has gestational or type two diabetes, but NPH is difficult for type ones because of its defined peak. But he said you know? And he he even considered glargine and deglidec as off label for pregnancy. He said and and they always wanna emphasize any of these agents is more important than nothing, but we're losing the one that's that works well because a main need when someone has gestational type two diabetes, they often need most insulin for their fasting blood glucose levels at night. So you want this, you know, eight to fourteen hour insulin. So that's just an example, but I'll just lay out the pregnancy argument. Everyone should be aiming for good blood glucose control, but when a woman is pregnant, that nine month period of time, if she has chronically high blood sugar, she has a much higher likelihood of a a large baby that's early, you know, preeclampsia in the mother. A lot of complications come from not well controlled blood sugar in pregnancy, and that's why the need for levemir in pregnancy is so clear. It was well it was shown by the FDA to be proven in pregnancy. It was involved in multiple well done randomized controlled trials, which glargine was not. There's been one randomized controlled trial with Tresiba in pregnancy, but that study was problematic. It didn't it didn't show, outcomes, and the pregnancy argument is huge. And that's why we have physicians, many of them specializing in diabetes and pregnancy, that wanna be part of these discussions and be able to explain why this insulin is needed for pregnancy.
Scott BennerRight. And even you know? I mean, listen. I've I've talked to plenty of people, who have had type one diabetes and used a pump through pregnancy with success. I've also talked to some who offset that pump use with an injected, you know, basal insulin. There's a lot of different ways to to get to the end. You know what I mean? And taking the tool away does seem ridiculous. Also, the idea that, you know, I like the way you started with that. Like, you know, everybody hopes that one day we just won't need it. But the process to get to that, even though they have you know, I just had someone on the podcast, I don't know, a couple weeks ago, right, who's had the islet cell, transplant. They're using the new Tego, autoimmune sup the immune suppressant thing that's not having a lot of side effects or none maybe they're saying so far. And, you know, big success, it it seems like this is a trial. It's not FDA approved. They don't have, you know, a a warehouse full of islet cells to pump into all the people who have type one diabetes. It it hasn't gone through the process of, you know, scaling up or trying to get it through, you know, the insurance process. I always like to say, like, if they figured that out today, if it was perfect, if they had, you know, they had a building full of islet cells to cover for everybody, and they'd still be ten years away from figuring out how to get it to you. And when it got to you, it might not be affordable to you to begin with.
Alison SmartExactly. Totally agree.
Scott BennerYeah. And it's fine to like, I live hopefully constantly. I think it's I think it's actually very important. But I get scared that there are people out there that are like, oh, I heard they cured type one diabetes in this. I I don't really need to take great care of myself anymore because this will probably be over pretty soon. Right. I I do worry about it because it it does happen to people. They get a little laxed in their care because they think, oh, it's common. You know what I mean? Like, they'll figure it out.
Alison SmartAnd Totally agree.
Scott BennerYeah. So it's just important to keep your eye on the real way things work. I mean, Allison just explained that it took her, like, the better part of two years to get people to, like, take her seriously
Alison SmartRight. Exactly.
Scott BennerTo get through that system. So when you reached out, what did you wanna share? I'm I'm I'm asking you a bunch of questions, but I wanna make sure that there's not some like, a message that you wanted to get out or or something you wanted to tell me about.
Alison SmartThat's honestly, that's the main thing. Just that and if we can if anyone wants to reach out, it it really works best as a coordinated effort. So if if people are interested in this, they can reach out to our organization, to me, and then we can work on it from both angles. That would be super helpful. There was and I also just want to let you know if anyone kind of wants a overview of the situation, there was a recent article by the Chicago policy review that maybe I could send you the link for that that just really explains the the problem well. This does require funding. If people are interested, if you could could reach out with that, you can just reach out to our website, alliancetoprotectinsulinchoice.org. I just wanted you to know that there we really have had a lot of momentum, especially in the last few months. So if we can get some more, both physicians, patients, just everyone reaching out about this, it really helps. More hands makes this work a lot better. So and I just kind of wanted to describe the situation again that with all the with all the focus on as you exactly as if you said, you know, this excitement about possible cures, we're not gonna outgrow the need for insulin. We're just not. The newly diagnosed, the pregnant people just and and even the typical type one patient, it's we're years away from that solution. So if we lose sight of maintaining access to insulin I even had I had a physician reach out to me that in her state, NPH was removed from basically the Medicaid formulary, which having an insulin removed from a form from a major state run formulary plan is often the first step to discontinuation. Can you imagine if they removed NPH? I'm I know in our type one community, it's not looked on highly, but, boy, it's used a lot around the world, and it's very important for pregnancy. And new manufacturers are working on glargine. I mean, that's we're gonna be left with glargine. And glargine works well for a large amount of people, but for some, it definitely does not. And so removing choice and not focused on just being able to have sustainable manufacturing of this product that is required to sustain life and pregnancies is problematic. So just wanted to spread the word about that.
Scott BennerAlliancetoprotectinsulinchoice.org.
Alison SmartYes. Uh-huh.
Scott BennerOkay. And you said things have been picking up recently. What do you attribute that to?
Alison SmartInitially, two years ago when we wrote so for example, when we reached out to the FDA, the FDA didn't wanna meet with us. They basically sent a response that, oh, you've got available alternatives. We were getting the response from Novo Nordisk. Oh, you've got seven alternatives to Levemir. You can take glargine. You can take Semglee, Resvaglar, Basaglar, TUJO. They gave us several names for the same drug, and occasionally, that still happens. So here's another example. The Utah Medical Association, I'm from Utah, voted in favor of resolutions that would enable manufacturing of this insulin. And then when when or or that organization went to other states and other organizations, there was a lot of pushback. And they basically said, no. There's all these alternatives, and we know of one physician who's doing fine with pregnant women using glargine. I think so back to your question, why the recent, momentum? I think more physicians are reaching out and more patients are reaching out as they're being forced to switch and saying, I'm my control is worse. I have I have a man who just reached out who said, I've had type one for twenty five years. And the first twenty years, I had horrible control. I just thought I had this horrible condition. I got on Levemir, and I was able to dial it in, and I had great control. And then I've had to switch back again, and it went back to those initial twenty years of that horrible control. I think the increased momentum and the increased interest is people reaching out. Yeah. I think that's what it is.
Scott BennerThat's awesome. Well, has this been a uplifting experience for you, or does it show you a side of life that is depressing? I mean, how do you think of if you can step out of it for a second, are you motivated by what's happening, or is it is it taking the life out of you?
Alison SmartOh, I'm motivated for sure. But, absolute everything you've said. I mean, it's every part of the journey. It's the highs and the lows, the certain I've got this big you know, we've got this big meeting coming up. This is gonna be the golden ticket. And then, you know, it doesn't always happen, but excellent advancements that we didn't think were gonna happen, and then certainly disappointments from others that we we organizations or, you know, entities that we thought would be engaged and involved that aren't. I wouldn't change it for anything other than I would change. I I want this done. I want this to get done, but I wouldn't go back and say, wish I hadn't done this. This this this has to be done. This this needs to happen.
Finding a Manufacturing Partner
Scott BennerWell, you're pod committed now. There's no way out now. You you gotta you gotta fall through to the end. Hey. You said, that Novo said if the right company comes along to make it, do you have an eye on who that is, and are they happy with that choice?
Alison SmartThat is the mystery. So that's why we're compiling multiple because we're hoping for the opportunity to come before them and say, okay. These are the all the ones that we've talked to that are ready to go. But, of course, it could be someone they choose. But that's been a big mystery. We've wanted to be able to present the an optimal idea to them, and I don't know if we've reached that yet. We're hoping. This is definitely it's like it's like working a detective novel, trying to see inside someone's mind. Okay. What what situation will be ideal for you? And we're we're trying.
Scott BennerWhat do you think the time frame is to to finding out if they're agreeable? Because I I I guess for people to understand completely, they've got a kind of I'm gonna use the wrong terminology here, but they've gotta release something or okay something so another company can it's about ingredients. Right? So they probably have Exactly. Well, they probably have what stuff that's their formula that they don't wanna just give away to somebody else unless they get to a situation where they feel comfortable doing it. For whatever reason, they'll feel comfortable doing it. Do you think that's a thing that you'll know about in months, or what's the
Alison SmartAbsolutely. Yeah. I so I used to view this as a puzzle with a lot of missing pieces, And now I picture this puzzle in my head, and all the pieces have clinked into the place into place even just the last month or two, especially the FDA piece was huge. Meeting with several departments with their leadership was a big deal. So all these puzzle pieces are linking into place except for the main one, the Keystone. Yeah. You know? Nova but because all we felt like we had to get all those other pieces in place so we would be ready, and we are. So now is the time. I really think this will happen soon.
Scott BennerWhat do you think their main focus Nova's main focus is on choosing? Do you think it's do you think they're trying to put themselves in a position with a partner that they're helping or giving themselves a financial win out of this? Do you have any idea what their goals are before they say yes?
Alison SmartI think it's, all of the above. I want them to come out looking, you know, the hero in this Mhmm. And and to find the right situation where that's the case. And then just to just to step back, some people wonder why another company can't make this without their help. Even though Dedomere is now off patent, for a new manufacturer to make this would take five to eight years and $200,000,000. I mean, it's just and the uncertainty of proving biosimilarity to the FDA to a product that's not no longer available, a company is just not because I've had people say to me, certainly, companies in India or China are working on this, and they were. But to our knowledge, they're not now. So it will require it will absolutely require assistance from Novo Nordisk. It will require them sharing some drug ingredients for a few years and sharing some of the knowledge, and and the right partner to do that will involve someone that won't be a competitor for them. We'll put them in the best light, and we're doing our best to find that right solution. And we we really feel like we have multiple options that that would be good good options.
Scott BennerYeah. I do wonder if people listening understand that when when a company develops a drug, right, like you said, there's ingredients in it. But it's not like, hey. I use, King Arthur flour, the, the bread flour, and I use, Domino's sugar. And I you know, it's not it's not like there here's a list, and then I can go out and buy that same stuff and whip it together in the same way you describe in your recipe. Like, it's if if if a company says, oh, I wanna make those cookies too, you know, they have to go buy the cookie and then break it down in a lab and figure out what's inside of it and then remake it. And they never remake it exactly the way it was made the first time. They they make a similar of it, which is, you know, where I guess where the word biosimilar comes from. But it's not as easy as like, oh, just tell me. So you're actually asking them like, hey. You've got a you know, you've got the recipe for the flour here, and and you have they you gotta tell us what that is so we can make it. Because we don't want somebody making a similar that doesn't work the way the original works. We want it to be the original. And then Novo has to give away those secrets, and that's scary to them because that's probably something that they've, you know, they've made money on and and developed, and they probably just don't wanna give it away. And I think I understand that too.
Alison SmartSo You explained that super well. Exactly the way you explained. I kind of think of it as, you know, grandma makes amazing cookies, and you can try your best to make them, but you just can't get it just right. But if she shows you how to make those cookies Yeah. It it it goes much better. And and the way you explained it is is exactly right.
Scott BennerBecause it's not just as easy as, like, whip the concoction for sixty seconds. Like, it's it it's happening in a certain mixer, in a certain temperature. The number of variables that go into making a medication and then reproducing it over and over again, it's much more complicated than somebody might imagine.
Alison SmartAbsolutely. And it required so much, research and and studies to bring this to the market. But to be fair, you know, they there was some taxpayer money involved in that, and and I just think there's there's obligations on both sides.
Scott BennerIf you're making me vote for my personal voice, I say, what are you doing, Novo? Just let it be. Like, you you know what I mean? Like, just let somebody do it. Right. If if you ask me to sit here as the host of the podcast, I can see everybody's side in it. Yep. I I know why they don't wanna give it away, and and I understand why we need them to and and all the reasons in between. So yeah. I mean, get off your ass and do it. Like, let's go. Yep. Allison's gotta go home. She what are gonna do after this? Do you think you've made a skill that you'll continue to use, or do you think you'll, like, you know, head back to the farm and stare out the window?
Alison SmartI have no idea. I it will be nice to use some free time to do some take my dogs for a walk. You know? It's been a fascinating educating journey for sure, but we're just feel like we're close. We're not there yet.
Final Thoughts and Resources
Scott BennerIf someone else came to you a year from now, you're done with this. It's all working and we you worked the whole thing out. And somebody else came to you and said, hey. We'd like to hire you to do this again for us. Is it something that you found invigorating, or is it not something you'd wanna be involved in twice?
Alison SmartI can't even go there. I'm just so focused on this end goal and exactly what you said, though. Three years ago, I never ever, a million years, would have thought I'd be doing what I am now.
Scott BennerYeah.
Alison SmartBut I just feel like this need, I have to do it, and I have to do it well. The motivation for me, I really feel like lives are at stake absolutely now and in the future. And the more I get into this, the more people talk to me. I mean, I really feel the literal lives are hanging in the balance, and the pressure is huge to succeed.
Scott BennerI can't wait. I I please keep in touch with me. Like, I I wanna know, like, yeah. I wanna know if you end up working, like, in a Michael's Craft and Floral Warehouse next. And you're just like, I needed something with just just fun, Scott. Or if if this has ignited something in you. Because what did you do before this? I'll let you go after this, but what did you do previously?
Alison SmartI was a part time physical therapist. I don't know. I just
Scott BennerIt sounds
Alison Smartdid my thing.
Scott BennerYou know? Allison, that's awesome. And a part time physical therapist who just spoke about insulin in a way that probably made somebody from Novo think we should probably hire her. She seems to really understand this. That is really awesome. I appreciate you giving me an update. Tell me the website again.
Alison SmartAlliancetoprotectinsulinchoice.org.
Scott BennerAnd you're looking for people's stories, their money, their whatever they can give to to help?
Alison SmartHonestly, biggest thing, their ability to to reach out and say, k. I I wanna I wanna help. I wanna reach out to congressional offices. But, yeah, funding helps with that, but, your time, you're really saying, k. This this this is worth some of my time to reach out to congressional offices to coordinate with this organization and help this happen.
Scott BennerYeah. I don't know if this will actually ever impact my daughter, but I really do appreciate all the effort and, you know, just your of your life that you've put into this so far.
Alison SmartOh, thank you, Scott. I I really appreciate this. You're you're doing great things spreading education, and it's just it's just the world needs people who are willing to engage and share and make good things happen.
Scott BennerWell, I appreciate you putting your foot forward on this one. Thank you so much, and thank you for the kind words. Hold on one second for me. Okay?
Alison SmartOkay. Thanks.
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