#1884 Grand Rounds: Dr. Maggie Grillo
Pediatric endocrinologist Maggie Grillo on why doctors should learn the pumps, meeting newly diagnosed families, letting patients change their own settings, and the labs nobody tells you to check.
Grand Rounds: Dr. Maggie Grillo
Cold Open & Sponsors 0:00
Welcome back, friends. You are listening to the Juice Box podcast. If your loved one is newly diagnosed with type one diabetes and you're seeking a clear practical perspective, check out the bold beginnings series on the juice box podcast. It's hosted by myself and Jenny Smith, an experienced diabetes educator with over thirty five years of personal insight into type one. Our series cuts through the medical jargon and delivers straightforward answers to your most pressing questions.
You'll gain insight from real patients and caregivers and find practical advice to help you confidently navigate life with type one. You can start your journey informed and empowered with the Juice Box podcast. The bold beginnings series and all of the collections in the Juice Box podcast are available in your audio app and at juiceboxpodcast.com in the menu. 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 or becoming bold with insulin.
This episode of the Juice Box podcast is sponsored by the only implantable sensor rated for long term wear up to six months, the Eversense CGM. Eversensecgm.com/juicebox. This episode is 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.
This episode of the Juice Box podcast is brought to you by my favorite diabetes organization, Touched by Type One. Please take a moment to learn more about them at touchedbytype1.org on Facebook and Instagram. Touchedbytype1.org. Check out their many programs, their annual conference, awareness campaign, their d box program, dancing for diabetes. They have a dance program for local kids, a golf night, and so much more.
Touchedbytype1.org. You're looking to help or you wanna see people helping people with type one, you want touched by type1.org. Make sure that you're being recorded, that I am I'm saying testing, and I'm being recorded. Try you.
I'm not sure. How do I know if I'm being recorded?
Well, you just said something, and I can see that you are being. So we're good.
There we go.
Perfect. Introduce yourself the way you want to be known.
Meet Dr. Maggie Grillo 2:58
Okay. So my name is Maggie Grillo. I am a pediatric endocrinologist and the associate diabetes director at Cohen Children's Medical Center, part of Northwell Health, which is located on Long Island in Queens in New York. Very
nice. And, Maggie, you are can I call do you want me to call you doctor Grillo? What do what are looking for here?
Please call me Maggie.
Okay.
We've had this conversation before. Please call me Maggie.
Wanna make sure. That's all. Maybe you've changed your mind. What's your connection to diabetes outside of your professional life, if any?
Honestly, I never really had a connection to diabetes before I started my pediatric training. I had a friend when I was growing up who was diagnosed with type one, but this was when I was so little that I barely even knew what it was. Mhmm. And it really wasn't until my training as a pediatric resident that I was shown what diabetes is, and I learned a lot about diabetes and got very involved in it.
Okay. What led you towards wanting to be a doctor in general?
You know, that's such a good question. I don't know if I have such a great answer. It wasn't like one day I just had this vision, and I was a doctor. Was either a doctor or a vet, and then I'm an animal lover. So the thought of having to put down animals just kind of turned me off of the whole vet thing, and I leaned into medicine.
Not not so troubling thinking of putting down a person?
Yeah. Right? That's why I do pediatrics.
Like, I get them at the beginning. Well, that's pretty cool. So what did you I mean, at what age did you have that first feeling? Did it did it impact at all any decisions you made through high school? Obviously, college, but where tell me about that path.
So I always knew I wanted to do something medical, whether it's being a vet or a doctor, even in elementary school. So all the way through high school, I knew that I was gonna go to college. At that point, I knew I was going to go for medicine. So my high school was pretty geared towards the medical tract. And then in college, I was premed, and then I studied neuroscience there.
So I I knew I was going to do medicine.
Okay. And you like you like the science, would you say? Like, I I hear people talk about this all the time. Either they're people people or they like the science or what what do
you think? I do like the science, but I really like the people. And that specifically for diabetes, I like all of endocrinology. Right? I'm an endocrinologist at at baseline.
Mhmm. But I really like talking and learning about families with diabetes because I feel like I become part of their unit. You know? And I like I love that.
Yeah. How did you find me?
Finding the Podcast as a Fellow 5:33
I found you. I was a fellow when the Omnipod five came out. So I was doing my training. For those of you who don't know what a fellow is, I was learning how to be an endocrinologist. And you had a three part episode or series on the Omnipod five, the algorithm, and and all the settings.
Right. And that's when I first listened to you and started learning about the Omnipod five. And then the rest, I just kept listening.
Well, so I I wanna pick through all this, but you are a unicorn for me. So I'm I'm excited to talk to you. I don't want people to think this is gonna be an hour of me, you know, bathing myself. But I don't need a ton of endos who are willing to come on the podcast and say, hey, Scott. I like this podcast.
There's plenty of them that suggest it to other people in whispers Mhmm. Always and things like that. But to have you come on and talk about it is a big deal for me. So I I wanted to thank you.
Oh, thank you.
No. And we'll also get to the part where I thank you for having me out to your institution to speak. Mhmm. Because, again, another situation I run to pretty frequently, emails from hospitals, would you come out and give a talk to the patient population? Would you come out and give a talk to the staff?
And then eventually, it gets far enough up the ladder and somebody says, you wanna have a guy from a podcast come talk here? And then it usually gets the kibosh put on it as it would would be. But Mhmm. I actually made it all the way to to the hospital and spoke.
You did. Yeah. You came.
So I'm interested to see, you know, what got you thinking about that because you are obviously the founder of the feast on that one. And then how, if at all, there was any difficulty getting me actually there. So let's go back first though to the Omnipod five So you're a fellow, you're learning. Mhmm. You're doing a thing that I'm always yelling at doctors to do, trying to learn about how the pumps work.
So Right. Why did you feel like you had to go get that information? Why do doctors not have it intrinsically?
Honestly, I think because the technology is ever changing. And when we're when we're learning how to be an endocrinologist and even as we're doctors, maybe we don't have I don't wanna say we don't have enough time, but sometimes we just don't have that time to sit down and really dig into it with, you know, a demo potter or something Mhmm. How the actual mechanism behind the pump works. But then when I was a fellow, so many people were learning about the Omnipod five and were trying to switch over from whatever device they had to the Omnipod five or from multiple daily injections to the pump. Mhmm.
And I just didn't know enough about it. So when they were, you know, coming to me to talk to me about it, or if they were on the pump and needed to make changes to their settings, I did not know enough about it. And that's when I sought you out.
When Doctors Won’t Learn the Tech 8:22
So that in my in my experience, and for people who are new to the podcast, my experience is 1,800 plus recordings and probably twenty years that I've spaced twelve years making this podcast. It's uncommon for doctors to take the second step. Like, that the I'll go learn about this on my own time thing. So that already puts you into a different category for me. I I no kidding.
I just recorded with a person three hours ago who found the podcast, started doing better, and their doctor tried to fire them for touching their settings. And but it was done in such a way and it made me angry when she explained it to me. It was almost like it it was like it was like the doctor went to her and said, do you want another doctor? Which I found passive aggressive in this way. Do you know what I mean?
Like like, let me pressure you now and tell you you're obviously not listening to me. So but it wasn't like something was going wrong. They gave her settings. The settings didn't work. The mom said, I think, obviously, I need more insulin.
Right. Put in some more insulin. The doctor slapped her hand, said, don't do that because now I don't know how to help you. The mom's quiet thought in her head was, you didn't know how to help me before. And so I'm not sure why me adding more insulin isn't saying to you, well, obviously, they need more insulin and adjust from there.
It was all very, very strange. And to the woman's credit, she said to the doctor, no. No. No. You and I are gonna work this out together.
And she
That's great.
Yeah. And she stuck with her. But when I asked her quietly after the recording about that, she said, truth be told, it's a small town. I didn't have a lot of options. So so she she said basically the way I put it to her was this, she found out her husband was cheating and she's like, no.
No. No. You're staying and cutting the lawn. Yep. Yep.
And I actually told her, I said, in a couple of years, I really wanna know, does this doctor come around or does this end up being your your lifetime? Is this how this doctor ends up being your your prescription pusher? And and not a a valuable part of the team. But again, do you not see that as I mean, it's a thing you thought to do, so you don't see it as special. But you do know other physicians at this point.
Like, why is that not something I should just be able to expect as a patient? And I know it's a bit I know your time is an answer, but it just you you hear that that doesn't ring true to me when you say that. Right?
Like Right. Yeah. And and it's not so true. Like, I do a lot of my listening. I still listen to your podcast even now that the Omnipod five has been around for some years where I know I don't have to Mhmm.
Listen to that podcast anymore. But I listen to you. I drive an hour to work and an hour back home once a week to go to a satellite location. And in that hour's time, I listen to you or, you know, throw in some music. But recently, I've been listening a lot to you.
Mhmm. So there is time. We just have to find it.
Yeah. I mean, it's it to me, I know I say this a lot, but it would be like if I took my car to get new tires, and the guy was like, well, I'd like to help you, but I don't know how this air gun works. Well, I I mean, you're the guy. Like, you put up a sign. You said, I put on tires.
Like, I let's come on. You know? And then they say, well, they shipped a new air gun, and I don't know how that one works. So I don't know what to tell you. Like, go find a Facebook group.
Like, wait. What?
So I mean, I can speak from my own experience.
Yeah. Yeah.
I mean, I'm you've met me, so you know that I'm, you know, I guess, relatively young in my career. But the the endocrinologists that I have worked with, both in my current position and as a fellow, they really do seek out and try and learn about all of these things. So I I really think maybe that the whole maybe that's the tide is shifting. People are really trying to maybe. Yeah.
Maybe just as technology becomes more and more advanced and it's not going away, and it's just helping people more and more. But I really do think people are trying and and doctors are trying to learn more.
Well, that's encouraging because I've been doing this long enough that, you know, I'm willing to believe that. And also, you know, looking at how technology is moving so much more quickly. It's I feel like I've had this conversation already today. But like, I said to that that person I was interviewing, I I said, you know, back when Arden was first diagnosed, we got a meter syringes. I had to I I even had to learn that syringes came in half units, by the way.
That wasn't even something someone told me. We got a we got a meter of syringes and a vial of
it. Mhmm.
Yeah. And the red lily
The glucagon. That was it.
That that was literally what they gave us. Right? And I think Arden might have had diabetes for two or three years, and then one day the excitement in the diabetes community that the people who made the meter made a new meter. But the meter the new one wasn't any more accurate. It just looked different.
And we were all happy about that. We're like, oh my god. Look. We got something new. The and that's twenty years ago.
Okay? And now things are moving so quickly. Yep. Right? Like, each one of these companies is like it or not.
They're fighting with each other to make their algorithms work better. I love it. I think it's great.
I think it's great too.
Yeah. Yeah. Dexcom is iterating, like, you know, they're out here telling you about Dexcom seven. People like, but I love the six. They're like, yeah.
Well, we're gonna do a 15 seven. So come on. And then and then about the time they tell you about the fifteen day seven, in the background, they're saying, here's what we're thinking about for Dexcom. Right. Already.
Here's the eight. Yeah. These iterations are coming. I take everybody's point. Like, it'd be great if it worked, but I I think you want them moving forward and pushing.
Because I don't think you wanna live in a world where you wait for years and go, oh, look. I I got a meter. It's a different color. This is great. You you Absolutely.
But when that's happening, I can see how an older doctor could get swept away in it. But younger people who grew up in this generation, they should be able to hang with this.
I think that I mean, I can speak to the the people that I know, and I really do think that we are.
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Evolving with the technology.
Meeting Newly Diagnosed Families 16:35
That's awesome. So when you talk to somebody about type one, when they're newly diagnosed
Mhmm.
Do you come from the perspective of, I need to tell them everything they need to know right now. I need to give it to them slowly over time. Mhmm. Or I how I'm fascinated by that because your job's incredibly difficult. Like, mine's easy.
I get the like, I put everything in one place, and you can listen to it at your own time. But you see a person, a couple months later, they come back.
Right. Right. Yeah. I mean, it really depends on the situation. Right?
So a lot of it depends on I'm pediatric, so I'm dealing with a lot of parents and the children too, of course. But are the parents distraught? Are they just so devastated that anything you say to them is gonna just go over their head? In that situation, it'll be kind of like a slow and steady influx of information. Maybe it's a family who has, you know, a cousin with type one diabetes.
Okay, they're ready for more. But usually, I like to go into a new onset diabetes patient room. I explain who I am, what I do, and then I always like to ask, what do you know that's happening so far? What is your understanding of why Jimmy is here in the hospital? Right?
Because I I usually sit in the hospital. And then we go from there. I like to talk about what is type one diabetes, what is type two diabetes, and just kinda talk about, you know, what insulin is, how insulin works, why are we giving Jimmy insulin in the hospital. Why
are
we checking blood sugars? What's insulin gonna do to those blood sugars? What is food gonna do to those blood sugars?
Yeah. Do you find yourself being a little bit of a like, an armchair therapist trying to figure out who these people are in this scenario? Are they quick learners? Are they not? Are they overmatched?
Are they
Yeah. Like to. I also like to know what their background is. Are they you know, what do you the parents do for work? Like, we have a nurse here.
Okay. Maybe I can speak in a little bit more technical terms. I try and stay away from that even with, you know, medical people because it's it's their kid. Right? Or do they just need a lot more explanation and and more simple terms to help them understand what's going on?
So I I do like to sit there and kind of learn about them as a family unit.
Yeah. Here's a little piece of advice on that heading. Architects, attorneys, people who work with numbers, that kind of their brains, like, give them the math. Like like, tell them about I
believe it.
Yeah. Yeah. Give those people the math. They they want that. You know, they're like, oh, there's math here.
I'll figure it out. That's super interesting to me. I would also tell you that of all the people I've interviewed over the years, some who struggle the most are often nurses. And I think that's because they get a a little bit of a little bit of everything, not a lot of anything. And and what they were specifically told about diabetes is so much about just, like, emergent care.
And, like, you know, that that when they hear diabetes, they go, this isn't really a problem. You, like, you do some counting, and then you give some insulin. And and then you do it again, like, like, hours later. And there's testing in between. I I have found that they can get overwhelmed by it.
It's almost like they can't some of them can't break free of the training they've had, which is obviously not not nearly enough for living with type one.
Doritos, Glucagon & Going Blank 20:00
Right. And it's their their child too. I can give you a personal story. So I have three children. When my oldest daughter was maybe seven or eight months, she had her first Dorito chip.
So at this point, I had graduated from residency. I was a fellow, so I was trained in CPR, pediatric CPR, and and what to do if someone's choking. So she's choking on this Dorito chip at a party, and I lost my mind. I could not think, okay, Maggie. All you have to do is give some blows on the back.
Right? That's what we learned. I had to run across the backyard at the party we were at to find my husband, who's also a pediatrician, to tell him that our daughter is choking for him to take her from me and just pat her on the back and out.
Doctor in the house? Is there a doctor in the house? It was say. Ladies and gentlemen, we're cruising at 50,000 feet. If there's any physicians on board, could they please come to the Dorito Bowl?
Yeah.
Oh my gosh. It was yeah. But my mind, it was my daughter.
You went blind.
Mind. I was like, what do I even do? I just went blank.
Yeah. You should have seen me holding that that Lily Red kit when Arden had a seizure when she had diabetes for, like, six months.
And I can't imagine.
And I was just staring at it. I couldn't remember how to constitute the I knew I had to constitute it, but I couldn't remember about the the needle and the Yep. Which is by the time it was over, my wife handled the whole thing with, like, glucose gel on her cheek. But, you know, I was not helpful. And and later when I look back on it's funny.
I I like to tell you on the podcast, I wasn't prepared. But I wasn't prepared because our physician said, this is glucagon. It's for emergencies. Don't worry. You'll never need it.
Right.
And I was like, well, I already have a lot going on. If I this is the thing I don't have to worry about. I'm not gonna worry about it right now then.
Right. You're gonna tune out.
Yeah. So I just never really I never really put it now, having said that, the rest of it was the panic. Like, I would've if your husband was across the yard, I definitely would've ran. Orknobbers quit my guess is what I'm saying. I would've been like, help me.
But not my wife. My wife was like she was rock solid. The next time, we were better. Yep. You
know? If she ever choked on a Dorito, again, I think I would handle that a lot better.
You think you would. Yeah.
But luckily, we we haven't had any more incidents with chips.
Hey. If I could just take an aside for a second. I know you'd love to yell, it's because of COVID Frito Lay, but a bag of Rios is $3.50. It's not $9. I don't know what you're doing.
Please stop. We can't we can't afford your stupid potato chips anymore. Please. There's a public service announcement to the rest of you. I you get you stop pushing the price up just to see if we'll pay it.
Okay? Because, you know, they're they're just chips, and we don't want them that badly. Right. My goodness. Okay.
So, yeah, you can you can panic a little bit. So when people are coming in, they're obviously panicked. Or they're quiet or sullen or sad. You're never gonna know. I mean, I've spoken to so many people that most of them will tell you the time in the hospital they don't remember.
Right. And any one of them who's reasonable when I ask them later, did you get what you needed at the hospital? Will say, no. But in fairness, I might not have been listening.
Right.
So now you're in that position of trying to, like, send them home so they don't kill anybody, and they're not even listening. And this is all very difficult, especially in the beginning. So what do you do? Do you get them back a couple days later? Do you like, what's the pathway to getting them stable?
The First 48 Hours & Beyond 23:27
Right. So at Northwell, what we do, we have education in the hospital. And, really, it's gonna be so much information that it's almost overwhelming, and it is overwhelming. Right? So I always tell my families of my newly diagnosed patients, what I want you to learn from this is that how to give insulin, how to check a blood sugar, and what to do if you need to talk to us, if you need to call us.
The rest of it will come later. Right? Yeah. We go over it, but knowing that they're not gonna retain everything. And I always tell them that I learn something new about diabetes every single day, so I don't expect them to learn all of diabetes in the forty eight hours that they're in the hospital.
So then once they're discharged, we at North will have them come back that sometime in the next week. We'll either do a virtual visit the day after discharge from one of our diabetes nurses. They'll check-in and make sure, did you get your supplies? Are are you settled at home? What can I help you with?
They'll reiterate some education. Then they come see us. They see me one month after discharge. And then after that, they'll see me every three months.
Okay. So is it fair to say from your perspective that it's a fairly impossible task you're given? And that it's not incredibly out of line for people to feel like they weren't told anything. But it would be nice if they were a little more understanding about the situation.
Absolutely. I think it would be great if I could just go home with all of them. Right? Or if they could come to my house, we could learn all about diabetes together.
Yeah. You know, I one time I I daydreamed about starting up, like, like, a a place where you could stay for a week after you're newly diagnosed to, like, to live under, like, supervision of people who could, like, help you get through the first bits.
I thought that would Amazing.
That might be really helpful. I don't know how you would do that or who would pay for it. Obviously, none of that would ever happen, but it it felt like it felt like the best idea at the time. Like, if somebody was just here for me to look across the room at and go, am I doing this right? Like, almost a nod.
Like, yeah, keep going. Got it. It would be really helpful. But I would also tell you that with hindsight, and it's a thing I say on the podcast a lot, but every experience you have, if you allow it to be, is a great is a great building block. And you almost have to go through all this crap so that you can get to a zen place and and and move along through it.
So you don't want the experiences to be taken from you, and you don't want to not have to fight your way through them. But but what I see after talking to so many people is that that only works for certain personalities, for certain situations. Some people are waylaid, knocked on their ass, and never get back up again. And then they're stuck wherever they fall over forever, and then that's the level of care that they get. And Right.
While I think it's nice to say we'll get the next one at the next appointment, and three months from now, we'll add a little more to it. Also, it doesn't work like that because you go into the office, and it's it never just picks back up. Like, you don't, I mean, be honest. Like, six months later, you don't know me when I come back. You're I I'm words on a chart from six months ago.
And and it's not like you like, I remember our last encounter if I if you're my doctor. You don't remember it the way I remember it. And so now there's the, hey, how are you? How's the weather? How's your kids?
Like, that part. Now, boom, five minutes is going. Some people get chatty. I'll tell you, I've done a lot of in person diabetes stuff. Nothing like a person with type one who wanna sit down and tell you their story.
It's still like, you don't have to laugh, but I know I know you know. And then, like, you know, then they, you know, then we're chitchatting and blah blah blah. And you're not going, hey. When you know, it's not like the end of a Netflix series where they let you rewatch the last thirty seconds and you remember where you were. So then stuff gets missed.
Right.
Right? And it yeah. I don't know if there's a fix to that either.
I don't think there is. And it's it's a shame. I don't know if it's a shame, but we only see you guys, these patients with diabetes, every three months.
Mhmm.
That I don't know how that changes. I don't know if it should change, but we're not with you every single day. So there's a lot that happens in between each of these visits. Even if I remember every detail of our conversation from our last visit
Yeah.
It's been twelve weeks now.
Yeah. You might not even need those things anymore. Exactly. You might and then we might spend ten minutes you figuring out that I already figured out the thing that you were here to tell me today. If Right.
There's no perfect way through this. That's yeah. That's why that's why I think the podcast works really well. Because it's a la carte. At this point, I'll go out in a limb and tell you pretty much anything you need to know is in there somewhere.
And and you you know where you're at right now, and you know what you need right. So it's almost like having a bookshelf and being able to walk over to it and go, I need episode eleven fifty three. Mhmm. Because that's the thing I don't understand right now, and that's the next building block. And in fairness to doctors and and the way things are set up to begin with, you're not gonna do that.
All I all I want from doctors is, like I I mean, seriously, I'd like you to know how the the the damn pump works. Like, you should be able to speak thoughtfully about how the pump works. And if you can't, like, call somebody. Like, I you know, like, it it's it it is frustrating. Now I'm not saying that you, you know, you're gonna be able to set it up for them.
It's gonna work just right. But also, here's the next reason these things don't work right is why I'm not speaking for you, but why won't more people talk about fat and protein and around how insulin works? Why do so many people not get told about pre bolusing, not get told about the impacts of fat on their blood sugar, things that have really significant impacts moment to moment.
Definitely. Definitely. I I don't know. I from wherever I've been, both as, you know, resident fellow in my current position, we do teach that. Yeah.
We teach, you know, we have two specific nutritionists in our clinic that see our diabetes patients. We have a nutritionist in the hospital that talks to every single newly diagnosed patient. So it's there. But I think a lot of it's gonna come with trial and error, which I'm sure is frightening for a newly diagnosed parent.
Why Nobody Talks About Fat & Protein 29:36
Can I tell you something from perspective of a patient? Of course. Being sent to talk to the nutritionist feels like, uh-oh. Someone's about to tell me I don't eat well. Feels like I'm going to the to to the principal's office.
Going to detention.
Yeah. Yeah. Yeah. So like, because, oh, they caught me. I I we were getting away with it, but now the diabetes is here.
Someone's gonna notice there's crimpets in the freezer. You know what I mean? That's a probably a local reference, but still, you it it's not a thing you go into comfortably. For me, at least. You I went in there thinking like, oh, someone's gonna tell me what I'm doing wrong now.
No. Listen. Hand to god. Okay? My kid went to a really good institution while she was a minor.
And nobody ever said to me, hey. Fat slows down digestion, throws off the timing of insulin, and that's where you're getting these late rises from.
Interesting.
And and I've said that to physicians who don't know what they're talking about when you say it. So that's not uncommon either. I've I've said, like, how come you don't talk about fat and protein? They're like, what do you mean? How would I talk about that?
It's carbs. Count the carbs. Put the stuff in. The the machine takes care of it. That stuff.
You know?
Right. Right. Anyway. I think it's hard for people that don't have diabetes to understand that fully. Maybe without maybe if we ourselves were CGMs, we can see how it how it happens in our own bodies.
But maybe it's just I don't know. Maybe we need to increase our own education on nutrition specifically. But there's a lot more to diabetes than just here's a carb. Yeah. Here's insulin for that carb.
So for me, it it all of that there's a lot about life that would be nice if it worked a certain way, but it just isn't how it goes. So the reason I think that pro tip series works so well is because it really is boiled down to t shirt slogans. And but it's everything you need to know to get you going in the right direction and at least give you enough of experience and and an idea that when you see the next thing happen, you can make better sense of it. I I got you know, we send you to a nutritionist. Could you just tell me fat slows down digestion and that throws off the where the insulin hits, please?
Because I don't wanna learn about nutrition right now. Mhmm. Or or, you know, can you please just tell me, you know, that I need to be hydrated or the CGM might not work. Or, like, you know, like, these little things that are I think they're foundational. I my point is is that my experience has taught me that there is no functional way to upload all the information to people that they actually need.
So you but if you give them That's right. Yeah. If you give them these foundational things, it is enough to keep them alive and educated and ready to accept an experience when it comes at them as a learning experience. To me, that's the answer. But, I mean, I'd love to know if you think otherwise or if there's something else you think that I'm missing.
No. That I mean, that's very fair. Right? And what people need in certain situations so we have two excellent nutritionists. Right?
Maybe for a newly diagnosed patient, that's a great place to start. But maybe in six months, they need to talk to nutrition about I don't know. Maybe they're trying to increase muscle mass or something, and they need to talk to nutrition. But there's no appointments. Or when they come to nutrition, when they're able to see them or see the doctors, their needs are ever changing.
And I think that's why it's so great to have something like this podcast where, just like you're saying, you go to the bookshelf and you pull off exactly what you need for that specific moment in time.
Yeah. It just isn't it it the model isn't there. Like, it's I don't get me wrong. Like, I want there to be doctors. And I want you all to go to medical school, and I want you to be there when I fall over and I get hurt and everything else.
But there's a limit to it that that people outside of the medical field can't be aware of because, again, I go back to like doctors, right, teachers, cops. You grow up, somebody tells you, listen to these people. They know what they're talking about. Don't argue And with you're just like and look, by your own example, your kids start choking. You're like, I don't know what to somebody better help.
And so you're a person is my point. Right. And and and I try to make this point all the time. Like, you've gotta drive through traffic to get to work. You might have been fighting with your kids before you left.
Maybe your kid's sick. Maybe your husband's a jerk. Maybe, like, maybe you got cut off in traffic and you're pissed. Like, there's a lot of things impacting your day as well. You work for somebody.
They have, you know, requirements of your time, and now I'm coming in here and asking you to learn how to, like, use a pump. And you're like, look, I ain't got a time for this. Like like, I'm trying to stay alive too, you know. So I I'll tell you, it really makes me hopeful about technology in other ways too because, again, going back to this interview I just did right before yours. What she told me was she realized she wasn't getting enough from her doctor.
She found me. She got some more. She realized she needed a little more. She didn't know what to do. A friend of hers whose kid had type one diabetes was having trouble talking to their physician.
So she asked ChatGPT, how can I have this conversation better with my kid's endocrinologist? It helped it helped her to do that. She told the story to the person that I interviewed. That person said, oh, I'll try chat GPT. She went to chat GPT and said, hey.
Look. My kid's on hand to Moby. I am not having the outcomes that I'm supposed to. What do I do? And, basically, chat GPT walked her through resetting her settings.
Wow.
And then she heard I don't know if you've heard heard did you hear Laurel Messler on the podcast talking about Tandem Control IQ? I
don't think I did.
It's real recent, but you'd you'd like her. She's really good. She works at Tandem, but she talks more real world nuts and bolts about using the pump when she talks about it. And so she heard her say something about, you know, this setting had to be a certain way. And this lady cobbled all that together and gave her kid a five nine a one c.
Wow. Isn't that crazy? I think it's gonna be so cool to see what AI does for diabetes in the future.
Yeah. Me too. Yeah. Yeah. I really do.
Like and I mean, far future, I'd like to see your algorithm assessing, reassessing more than just like, here's the math and where we think it's gonna be the way they kinda work out the way they work now. It'd be cool if they could if they could think on their feet a little more than they do. And maybe they will one day. I don't know. You know?
You see, like, Beta Bionics really is behind that. Like, we don't don't count carbs idea.
Like Right.
And I've heard Medtronic, like, whisper about not at Whisper, but she was on the podcast. And she said, like, I I don't think you're gonna have to enter carbs forever.
That would be so cool. Yeah. That'd be life changing for so many people.
Well, yeah. And I I would say I would ask you to talk about that a little bit too because while it's nice to say, here's what you do and if you just do all these things, it's gonna work out. It's really not how people's brains work. It is really unfair too, by the way. Like, and I don't think we talk about that enough.
That's not how you're supposed to be living your life. Yeah. So what do you see even for people so there's people who struggle, and there's people who look like they're succeeding. There's people who are succeeding who are probably struggling quietly. Mhmm.
Like, what are your, like like, deeper kind of psychological takeaways after helping people with type one? What do you what do you think? I can tell you a story. Yeah. What's going on behind their eyes?
Emily and the Pump That Changed Her 36:59
Okay. So I have a patient. I will call her Emily. K? So Emily came to me with a very high a one c for many, many, many years.
I took over her diabetes care, and I just once a month, I made it I would see Emily every single month. And she just didn't want a bolus. She didn't want a pre bolus. She didn't count carbs. She was was on multiple daily injections.
Ugh. I don't give my Lantus every single day. Just didn't really care. After a couple months, we talked about insulin pumps, and I just saw this light in her eyes, like a switch flipped. And she said, I have been wanting a pump for so long.
So, you know, okay. We took a gamble, got her on the pump. Can I tell you something? Yeah. The entire month before her pump training, she gave insulin for every single meal.
She did not miss one dose of Lantus. She went on the pump. Her she went on the Omnipod five, and I right away, you could see that she was almost always in range. She has since had a baby. So I I mean, I, of course, no longer take care of her, but she is doing exceptionally well.
What do you think happened? Her her interest got reignited because of the pump being introduced? Her your
I think so.
Yeah.
I mean, I'm not I'm not I can't take credit for that. That was all her, Emily, did. She just did it herself, and it was just I don't know what that turning point was for her. Maybe it was just that she wanted this pump forever and no one listened and not that no one listened. She gave up.
Mhmm. But then it would just reinvigorated her to take care of herself. And now she has a beautiful baby, and she's taking care of herself for this baby. It's just it's beautiful.
My other takeaway is people will help themselves for the love of someone else, but not often for themselves.
Which is so sad.
Yeah. But I think it's very, very human. And, I mean, at least that's my takeaway after making the podcast all these years. Father has type one diabetes forever, doesn't take great care of it, wipes up his butt to take care of it. He does and he doesn't.
One of their kids gets diagnosed. Boom. He pulls it right together. Right. Like, I don't wanna be a I don't wanna be a bad influence.
So let me Right. Let me do this. A lot of young girls, you know, who talk to me, you know, I went to college, I didn't pay attention, that kind of stuff. But when I realized I wanted to have a baby, I knew and it wasn't about like, you'd be surprised. It's not about I know that my a one c has to be a certain place for me to be pregnant.
It's part of it for some of them. But for some of them, it's just the idea of, like, oh, I it's important that I be alive. It is is really
And I'm healthy for this thing that I just made.
Yeah. I'm responsible for something now. Now I have to act responsibly. It is super I it is sad. Like, it's sad that we all don't just feel that way out of the box, and some people obviously do.
But I overwhelmingly, I think that's another thing that holds people back is they're like, well, I mean, what's the point? Like, I'm just here going to my dumb job doing this, blah blah blah. Like, you know I mean, can you imagine, like, skipping your Lantus on injections? And by the way, you said you took a leap. What's the what's the common medical idea behind not giving someone a pump?
It's that at least they're shooting their basal insulin? What if they don't put the
pump on? Is that the The thought is, like, what happens if, let's say, the pump runs out of insulin, and now you have no insulin going. And it you can go into DKA, of course, very quickly. But she wasn't giving her Lantus anyway, so she was at a high risk of going into DKA anyway.
Yeah. I find that to be backwards thinking a little bit. Like, I mean, what happens if the pump runs out of insulin? What happens if they don't put insulin in through the needle? I mean, isn't it the same thing?
And and what happens when the pump drops their average blood sugar? Like, I don't know what Emily's a one c was, but, you know,
14?
Well, that see, that's what I was gonna say is that I have the it's the benefit, but it also gets dubious at some point because most people who come on here are aggressively trying to help themselves. Right? So I don't get to talk to enough people. There are not a lot of people who are excited, I guess, Maggie, to run out and tell you the story about how their a one c is 14 and they don't shoot their insulin all the time. Right?
So you don't hear from those people as frequently. But those people make up a larger percentage of people with type one diabetes than not, I think.
I think so too.
Right. And so if you put a pump on that person and their 14 turns into a 10, isn't that amazing? Then what if victory. Yeah. And what if some of their brain fog lifts?
And then they're like, I I have more of, mental space now. Like, let me put a little more into this. I think there's all those different pieces of it that nobody's considering. Like, get their blood sugar lower and stable and see if it doesn't help them reignite themselves somehow. Right?
Like, I talk about this all the time, but the drift to poor health, generally speaking, happens so slowly that you don't see it happen. It's the same way when you see somebody get divorced. They're like, what happened? I don't know. We grew apart.
That's not what happened. You didn't grow apart. A million little things went wrong over the last fifteen years that you didn't notice. And now at the end, you don't have an answer for what happened. And health is the same way.
Gaining weight is the same way. You don't you don't gain 75 pounds on a Tuesday. You gain a quarter of a pound a day and a half a pound tomorrow and three pounds next week. And a year and a half from now, you're like, hey. What happened?
And and so if bad health works that way, you know, you don't know you don't know what's going on in a person's brain. And and if their blood sugar's 40 and then it's 65 and then it's 400 and then you're and you and you get them aside, you go, I need you to pre bully. They're they're probably not thinking straight. And but they're still gonna come in your office, put a big smile on their face, and try their hardest. Right.
You you know?
And she showed up, which was
It's a big deal.
Coming, which was awesome. And I tell you, Scott, I could see the change in her face. And just the way when I would open the door when I first met her in the first couple months, she was just always down and just not really happy with herself because she knew it was gonna be not, you know, in her eyes, the best visit.
Yeah. Here comes the warden.
Exactly. Yeah. Yeah. But then as she's on the insulin pump and as she's doing better, I would walk in the room and she would have this giant smile on her face, and she couldn't wait for me to see the download. And I was just
Proud of herself, and she wants to show somebody.
Yep. Yeah. Yeah. Yeah. So proud of her.
Well, this is the see, this is the message. If you're a doctor and you're listening, it it's all right there. Like, you just I can give it to you from my perspective. People ask about, you know, more business minded people. I mean, Maggie, it's it's a bit of a feat to keep a podcast going for twelve years.
It's not a thing that normally happens. How do you do this? They they think there's some, like, magic business idea that they're gonna I said, I just wake up in the morning. I think about other people. I just get up and I think, what'll help these people?
What what am I hearing out in the world that they're talking about that maybe I could reframe for them or find in my bookshelf and deliver hand deliver to them or something like that? Like, how can I be helpful to these people? Oh, well, what about making money? I said, you help people, you make money. It just happens.
Like, like, right? Like, I I sell the ads. It's fine. Like, I'm good. Why don't you wanna make more money?
I don't I don't want to. Well, you could paywall this. You could sell them that. Like, right now, I have 50 adults. Here's the thing nobody even knows.
Pro Tip Practice: 21 Days, Free 44:22
Let me take a drink. I have 50 adults demoing a twenty two day how do I explain this to you?
It's I'm excited.
Yeah. I'm glad you are. So hold on a second. Because if you weren't, then you wouldn't be the right person to be here. So I can't give it away yet, but it's basically called Pro Tip Practice, a twenty one day guide of reflections on living well with type one diabetes built the Juice Box podcast pro tip series.
Five minutes a day, free, reflective, not prescriptive. And so it doesn't cost anything to do. You can skip a day, come back, etcetera. It's up to you. The browser remembers where you are without keeping any of your personal private data, and I am not charging you for it.
And trust me, I know I could charge people for this. Absolutely. I am not doing that. Just so you all know, click on the ads. Okay?
So I'm my personal I'm personally going through it, and I'm on just to see how it works day to day. And I just finished day three. There are people online that are ahead of me. So now day four says the number is the smallest part. Most people read their CGM the way they were taught to read a finger stick meter, glance at the number, react to the number, forget the number, repeat, and that's not what a CGM is for.
A finger stick gives you a snapshot. A CGM gives you a story. The number is one frame of the story and not even the most important one. Today's idea, a CGM shows you three pieces of information, the current number, the direction it's heading, the speed in which it's heading there. Most people use the first one, the second, and the third are where the actual decisions live.
Mhmm.
A one thirty with a flat arrow is fine. A one thirty with a steep up arrow is on its way to one eighty in thirty minutes. A one thirty falling fast is on its way to 70 in 20. Then that the number three different the same number three different situations, blah blah blah. And then it says, here's it gives you a quote from the pro tip series.
The number on the CGM is the smallest piece of what it's telling you. The direction, the speed carry, the rest of the story is from episode one zero three. For the next four days, you're gonna relearn how to read what you've been looking at the whole time. And today's affirmation is the number is a piece of the story, not the whole story. And it gives you something to notice for today.
Every time you look at your CGM today, name the direction out loud or in your head before the name, before you name the number. Even if you don't change anything, just practice that. It gives you a link to a small sip episode that'll reinforce it, and it gives you a reflection of the evening. What did I notice when I started reading the first the arrow first? And once you mark that day complete, it'll move you to the next day.
And at the very
That's very cool.
Thank you. And at the very end of all of this, it helps you write a letter to your doctor to tell you about what you've learned doing it and what you're hoping to do.
Nice.
Right? And so, anyway, the the key to helping people if you're a doctor and listening is just have people's best interest at heart. Go to work with some enthusiasm and treat them like human beings. And realize that they have a lot more going on than you think. This is not a cold calculated we're not you're not buying a bagel and a and a yoohoo from these people.
Like right? It's just it's not a it's not that kind of interaction. Right. And if you're not good at that part, find someone in the office that is. Because I can tell you that one of Arden's endocrinologist had the personality of wet paper.
I mean, she I'm sure she was good, but my goodness, she couldn't talk to you. And when she touched you, it felt like a robot was touching you. Oh. You know? I'm not kidding.
She I used to talk all the time about, like, I used to believe that for insurance purpose, she she had to physically touch Arden once a year or they weren't allowed to bill us. And I don't know if that's actually true.
Oh my gosh.
But but so Arden was only ever managed by the practitioners. Right? But once a year, this endo would come in and do this very awkward, like, hand on knee thing to Arden. And you could see Arden was like, why is the robot touching me like this? And, like and it was all very awkward.
Now I don't think that doesn't mean she's not a fantastic physician
or her brain She wants to help, I'm sure.
All of that, I believe, is true. She just was not good at this part. You know? And so then she'd leave the room and then the other ones would start their song, you know, they they they the music would start back up again and the the personality would come back in the room kind of a thing. But, I mean, if you can't do the thing that Maggie's explained to you or the thing that I'm telling you has helped, Maggie, I'd like to be humble here, but I think I've helped tens of thousands of people with type one diabetes.
Like, right?
I'm sure you have.
Yeah. And and the truth is is that I've never met any of them. So ask yourself, how am I able to help people when I don't even know who they are? And the answer is that all their needs on a basic level are the same. You you know, like people just need to know how to use their insulin.
And if you don't teach them how to use insulin, if you don't teach them that, you know, having the ability to change their settings is a paramount skill that they need to, you and they together need to develop. Like, you know, the the most successful people have the knowledge and bravery necessary to make changes to their settings.
I And I think they need to be empowered to make changes to their settings too.
Yeah. And and, yeah, that's up to you because they're scared. They think Of course. Yeah. They think you know, then it goes poorly.
And that that assumption is, well, I I listen to the person who knows, and it's not going well. I guess this is my life. Right.
Yeah. So And you have to remember you being, you know, a patient that's coming to see me or a parent of your child that has type one. I only see the data for the past two weeks. Right? Mhmm.
So I can make decisions on the past two weeks. And, generally, they're they're good decisions on what's happening now. But just because it's happening now doesn't mean that next week is gonna change.
Yeah.
It very well might.
You think there could be a list of rules? Like, you're doing a good job. I'm talking to you because you're forward thinking, obviously, or I wouldn't have ended up at your place talking. No. Or there are probably some people listening that think it was malpractice that you had me there.
But they listen. That's it's between them and Jesus. And so, like, is there a way to automate this? Or Mhmm. Is it just is it as lucky as I get a good one, I get a bad one, I get a new one, I get an old one?
Hopefully, altogether, it all shakes out. Like, is that is that really the
I think if you are unhappy with the person usually, happens, right, is when you are when your child or you are diagnosed with diabetes, the on call physician becomes your primary endocrinologist.
Okay.
I will urge you if you don't not everyone clicks with each other, and that's totally fine. If I'm not right for you, there are zero hard feelings. I want you to find someone that you click with and jive better with and seek that out.
But that's a top down thing in your organization, though. Like, that has to be something that somebody told you it's okay for us to to be like this. Like, how do
At Northwell yeah. We so the way I didn't mean to cut you off. No. Sorry. The way that we do it in our practice, if we all see each other's diabetes patients.
So we have, of course, you know I I'm Jimmy's endocrinologist. I still wanna see him every three months, but maybe he can't make that three month appointment with me because he has soccer practice, and I don't have any time. So if he sees my colleague and that we share patients in in that way that if I'm unavailable, there's another provider that's available. And maybe Jimmy likes this other provider better. Mhmm.
That's fine. I'm I'm female. Maybe you wanna see a male provider.
But you're confident. You're confident in that. There's also gonna be doctors who aren't confident who don't don't need 10 Jimmy's bailing on them because it isn't gonna look good for them. You know what I mean?
I guess that's true. Yeah.
See, you you work in a good place. You don't you don't probably see a lot of these problems.
Or if they if they happen, maybe I'm not privy to them.
Yeah. You guys have watched that person out already. Mhmm. Okay. So when you have the bright idea to have me come out and speak at this Yep.
Yep. You calm I remember us talking on the phone.
Into My DMs: Bringing Me to Northwell 52:31
I went into your Instagram DMs. I DMed you.
Mhmm. Yeah.
And you called me.
Yeah. I get the least sexy DMs of people on the planet, by the way. So so I I called because and tell me if I'm remembering this incorrectly. I was calling to tell you this isn't gonna work out, and I appreciate you asking, but why don't we not always start talking?
Pretty much. Yeah. Pretty much.
And not because I didn't believe in you, but because this was countless times, number, whatever, that this has happened to me. So you are not nearly the first person to reach out from a place and say this to me. You are the first person that worked it out. So Nice. How does that happen?
When you go back to people like, I mean, because, right, you're you're gonna go pitch to somebody who doesn't know me. And you're gonna say, hey. There's a guy that barely got through high school. He lives in New Jersey. He has a podcast, and I want him to come here and talk to a couple 100 of our patients and the staff.
And medical background consists of he doesn't have one. So where does how do you please explain that conversation to me. I would love to know how to Well,
first of all, I didn't pitch you like that.
Well, you should have. That would have been honest. Okay? What'd you I
explained that you are a parent of someone with type one diabetes, that you've learned how to manage your daughter's diabetes, and you like to share that information with others. You actually gave me a blurb about yourself that I included. And then I just encouraged, you know, the higher ups to listen, to listen to you.
Think that happened? Or do think I got tired of you and just said that, like, oh, it's fine. You're gonna bring him
Go fine.
Just leave us alone, Greg. What the hell? No.
I'm sure they did. I'm sure they did listen to you. Wait. It helped to some of our diabetes nurses listened to you as well. Mhmm.
It was a great group, by
the diabetes since oh, they're the best. Yeah. Yeah. The best. Some of them have type one and have listened to you, and their families have listened to you.
So they were in your corner too. So it just
So you just created a buzz?
Yeah.
Yeah. Look at you. You're marketing. You're was there anybody who pushed back?
Not that I'm aware of.
Okay. And even though in any
of those meetings where it had to be, you know
Because I had to go into a I had to do a Zoom with a group of people. And it's funny because my eye, of course, show up imagining these are the people who really don't want me to come and they're trying to, like, bet me. But I did that's not the vibe I got from them. Like but they still were quiet and reserved. And I I realized I am not a professional person, so sometimes people just acting professionally seems odd.
Like, why are they sitting up so straight and smiling? It's But but I had a I I had a really nice conversation. And, you know, I I went over some things that I wanted to say. And if I'm gonna be completely honest with you, they asked me not to talk about fat and protein, and then I just did it when I was there.
So did that get you any trouble? Bold move, Scott. No. It did not.
Oh, okay. Because I was asked directly not to talk about that.
Oh, gosh.
Sorry, Maggie. You went out of the limp for me.
That's okay.
And so I I was asked directly in that meeting, please don't talk about that. And not because I think they thought I was wrong. I just think maybe they thought it was too nuanced or something. But I do I don't know. I mean, you were there.
Part of I don't think I was part of that meeting.
No. No. Not that meeting. You were there when I spoke. And so Yes.
I I mean, tell the people. I am really good at this, aren't I?
You are you are a good speaker.
Thank you. And and but I paint a nice picture that kinda coalesces together. It feels it feels actionable when you leave.
Yeah.
Yeah.
Yeah. So did have a couple people call the next day asking to change Basils, which I will say maybe we can put a little disclaimer on your talk.
Go ahead.
That for those on the Omnipod five that are in automated mode, maybe changing the Bazel is not gonna do much.
Yeah. So it it is become a tough world to talk about all this in because when I put that Pro Tip series together originally, there were no automated systems.
Right.
And so you're you're hearing me talk about how I was acting as an automated system. Like Right. And so my my point to people would be is, like, those are foundational ideas. Now when you start applying them to these other systems, most of it still tracks. Like, you still if you you need to understand how insulin works, you need to understand how your food's impacting you, you need to understand timing.
That's the you know, that stuff. That's all never gonna change, like, for for the foreseeable future. But in a system like Omnipod five, for example, like, you put your settings in, then you flip into auto, and then what you typed in yesterday doesn't is meaningless.
Doesn't matter.
Yep. And I don't know how that's gonna be with their next version. I they're very close to getting that next version through the FDA and in people's hands. Nice. I I'm not allowed to tell you why I think that.
Are you gonna be doing a three part series on how the technology works and the algorithm works?
I don't know if we'll be doing that, but I'm I can't say. Oh, wait.
That was very helpful.
I'll tell you, Rob. Bleep all this out. Alright, Rob. I'm gonna say I just went to, and then after that, everything goes. Leave it as blank for people.
I think it'll be amusing. I just went out to California to shoot a commercial celebrating the new target of 100 for Omnipod five.
Oh, that's awesome.
Okay, Rob. Now the people can hear when she said, oh, that's awesome. And and going forward so my point is I don't think they would have done that if it wasn't close. Fair. That's how I figured through that.
And then and and I think they have said publicly, what are they shooting for? Lower target? And then there's some other adjustments being made to the algorithm that aren't specifically been named yet. Okay. And then I think they're working on the next version of it now too, which would be Omnipod six
maybe? Maybe.
Yeah. I don't know. I mean, remember when it was Horizon, then it was Omnipod five?
Oh, I forgot that it was Horizon.
Yeah. That whole time that they were trying to build this thing and get it out the door for years, they called it Omnipod Horizon.
I forgot about that.
Yeah. And then there was a changeover in leadership, and then they switched it to Omnipod five. Wow. Yeah. So anyway, you can't just there are settings in Omnipod five specifically.
That when you're in automation, if you change the settings in the pump, it's not actually changing anything in automation. It's changing your manual settings, which might surprise the hell out of if you ever flip back into manual again because you've been yakking the knobs all over the place that are not actually doing anything. I would tell you that that three part series I made describes very well what's impactable and what's not in automation on eight five five. You should check it out. Yeah.
Having said that, so you had people call in and say, hey. I'd like to look at our Bazel. Yep. Was it valuable for them, do you think?
I think so. I think a lot of people really got benefit from it. So there were there was a freshly diagnosed family there, maybe a week out from diagnosis, all the way up to people who have had diabetes for decades. Right? So I think a lot of it was good for everyone.
Maybe the nuance that, you know, it took you years to become comfortable with it, maybe that wasn't there so much, but you really only had, what, forty five minutes to speak.
It was a quick talk. I would tell you this is that I've learned that my goal at those is to leave you with the idea that there's more that could be done. It's not that confusing, and I should ask. Yep. That's that's that's my goal when I give that talk, usually.
I think you achieve those goals. I really do. Mhmm. And then very next day, we have people calling to make changes, and that's awesome. Good.
Yeah. Because how would you know otherwise that they felt like they were in need of those changes?
I don't think we would. I think they would I think they think they have to wait until their three month appointment to come to see us. And then at that point, we can make a little tweak to the insulin to carb ratio, hope that works, and then see you in three months from now, and you can tell me how it works.
Yeah. Which is not which is not it's not a recipe for success, really.
No. And I always tell my patients, please, if this doesn't work, call us, email us, reach out to us. We're we don't have to wait for three months.
Yeah. But, you know, they don't wanna bother you too.
I know, but that's my job.
I understand. But they don't wanna bother you. They don't have the time to be calling you all the time. They're also I think there's a learned helplessness that comes eventually too, where you just feel like nothing I do is gonna work. It doesn't matter.
You you know? And that's not true, obviously, but I do think it it's a wet blanket that can lay over top of people.
I can I can see that? Yeah. So the tell like, come to us for help. We wanna help you, Please.
Yeah. I hope so. Did you did I send you the the link that I made for doctors to share the show with?
You did. Good. You did.
Is it did I do a good job with it?
I think so.
Good.
I really I liked it.
Good. I'm glad. Thank a nurse practitioner in Toronto, Saskatchewan, somewhere in Canada.
Okay. Reached out
to me and she was like, I need a better way to share your show. Like, That's great. Yeah. She bullied me into it, basically. And they say Canadians are nice, but she was very aggressive.
No. She was she this poor lady was like, I need help. And I was like, will you get on the phone with me and tell me what you want? And she was like, I guess so. So we we jumped on the phone.
Tools for Clinicians 1:02:18
Was like, just what do you what do you wanna do with this thing, and what do you need from me? And she told me, and now, I guess listen. I'll I'll put it out there for people. It's juiceboxpodcast.com/clinician-share. And what it will give you is just simple buttons.
You can, like, bold beginnings, pro tip series, small sips, and define diabetes are at the top. You can print a handout, generate an email or a text with all the episodes and links that it needs, or you can hit copy so you can paste it into something yourself. Or like I said, can click print and just print out the list. I've also added there like, it's a short seven minutes from some ladies some conversation from the show where this lady named Bethany describes how her diabetes educator, her daughter's school, and the community she lived in had already been shaped by Juice Box podcast around type one diabetes before their her child was ever diagnosed. And how all the little things that those people had learned along the way created a community around her she didn't even know existed till her child was diagnosed.
And then I put my search bar in there, which if you guys haven't looked at it yet, the search bar on the pod on the website. My pod my website does not get enough play, Maggie. It's a it's a, like, a language like, a real language search. So I'm just gonna type in, how do I fix Basil? As soon as you type that in, it gives you links to episodes that apply to what you've typed in.
If it doesn't give you something that you want, you can open up the full frequently asked questions page, which is awesome. And it produced, like, hundreds of results that might attach to your question. And then once you're there, you can look and change your question around if you want to. But, you know, how do you calculate how much to change your basal rates using overnight IOB math and loop popped up. You know, what should I do if I miss or forget my MDI basal injection?
How and when should you use a temp basal? Raising my max basal should help my algorithm on the pod five. Like, you know, basal set too low. Like, all this stuff, click on it, it gives you like quick quick access to listen to that episode. So that's there as well on the clinician page.
And then I kinda boldly, I think at the bottom, there's a little button down there that just says for clinicians. And you can go listen to the grand round series, which is conversations like this one with Maggie, where doctors just talk about what they think their patients need. And then there's takeaways from the ground rounds the grand rounds series and a place where you can put your name in for juice box docs if you think you're the kind of doctor that people listening to the podcast would enjoy. You can put yourself on my community source directory for providers. It's all free, obviously.
So Lots of great information there. Yeah. I'm working hard over here, Maggie.
I believe it.
Me and my assistant, Jean Claude Van Chachepiti. Actually, it's Claude. So because I don't know how to code crap. And when you get to that website, you're gonna be like, wait. Somebody who doesn't know how to code a website did this?
Pretty impressive. But but nevertheless, like, there it is. Hopefully, people will use it. I know that the podcast grows through word-of-mouth, and it's it's probably fifty fifty patients and doctors. So would you explain to me from your perspective why you're comfortable sharing the podcast with a patient?
Because I really think there is such genuine information. Right? I I can't go home and, you know, figure out your routine and figure out your insulin needs with you every second of the day. I can't live life with you. Maybe I'd like to, but I can't.
Right? So I need people to understand that they can reach out to other sources and learn more about diabetes and figure out how to make diabetes work in their lives. It doesn't need to be this awful burden on them. And, of course, I'm sure you're always gonna feel that there's a burden. I hope not, but I can imagine it might feel that way.
But I really want patients to feel empowered to search for their information themselves and learn more than what I can give you in thirty minutes.
I have to thank you because I I I just realized something. I've been doing this for so long that the the tone and tenor in which people see the Internet is completely different now than the way they saw it when I started doing this. And it's possible, like, I'm somehow rooted in old ideas when I think about this at times. Because you didn't say anything about, like, well, yeah, I'm a doctor suggesting a podcast. That's ridiculous.
You don't think of it as ridiculous. You don't see me as the person who you shouldn't be introducing other people to. But I've been doing this long enough that it used to be crazy. Right? Like, they it used to be a lot of see you know, a lot of practitioners would tell me, I'd stand in the room, let the endo talk, grab them, take them out so they can make their next appointment, and then slip them a sticky note that said juiceboxpodcast.com on it.
And they and she's like, I've had people directly tell me, I don't even speak. I just hold it up and I go, mhmm? Mhmm. And then I hand it to them. Because I know they just got bad information in that room.
They know it because they're walking out looking at me like, hey. What the hell just happened in there? And, like and and they don't know what to do, and I can't suggest this. But the world's changed.
Yeah.
And I Yeah. And I'm I just realized that while you were talking, like, I gotta stop acting like I'm some, like, I don't know, guy skulking out of a you know, from behind a dumpster as you're walking down the road. Yeah. I know a thing about basil. And so, I guess maybe I've you made me feel like I might have elevated myself and was unaware of it just now.
I think you have to give yourself more credit.
Thank you. I really do
appreciate that. In this world where we use qual and chat GPT, everyone is expanding their knowledge and trying to learn more about everything.
Mhmm.
Right? I mean, we all are on our phones all day long. Maybe reading more and learning more, why not listen to a podcast?
Yeah. No. I mean, I agree. But, like, I was you understand that when I first started talking about this, I sounded crazy to people. Like, because the world hadn't because I was ahead of the role on podcasting.
Right? I've been listening to podcasts forever, way before most people have been. And so, like, it but so when I started doing it, it seemed normal to me, but it wasn't normal to everybody. But now it is, but I'm still a little stuck in the idea of, like, I'm doing this crazy Lenny Bruce thing over here, which is not true. And also a reference that no one under 50 is gonna get along.
And so but that was really thank you so much. Like, I I really do appreciate it. It I don't have impostor syndrome. Like, if you ask me to be direct, I'd tell you this podcast is awesome. It'll definitely help you.
And and I think I do a fairly good job of of making it. But the idea that you would like, you're an actual under you're a doctor. You went to medical school. Like, I met You're not crazy. Like, you have all the prerequisites for me being very impressed by the idea that you like me.
And so, like, that you would say that out loud is really it's valuable to me because it's not a thing I thought somebody would say. You know?
I have learned from your podcast. I've learned I think I can take care of people with diabetes better from listening to your podcast.
Basically, I'm a doctor. You're saying I should get
So go back to medical school. Alright? I will say
The TSH Mic Drop 1:10:03
You're
thing one thing we should talk about is the TSH. So I want everyone to imagine Scott at the end of his talk. Now he's already talked apparently about fat and protein, which he was not allowed to talk about.
I wasn't?
And then at the end Oh,
I just randomly threw in about your test your TSH as I left the seat.
Literally almost a mic drop. He says something to the effect, if you have positive antibodies for Hashimoto's, which can cause hypothyroidism, for those who don't know, and a TSH above 2.1
with symptoms. I said if you're if you're 2.1 with symptoms and your doctor won't give you medication, ask them why. Yes. Did I cause a problem?
Exited the stage. You didn't cause a problem.
Very good.
But I would just like to dissect that a little bit
Please.
If that's okay with you.
Please. Please.
So you have to remember that we're in a pediatric population. Right? So a lot of pediatric people don't like getting their blood taken. And if you have anxiety when the blood work is being taken from your arm, that can elevate the TSH. Okay.
Now you're also talking to a room full of people with type one diabetes, so they have an autoimmune condition. So it's not so farfetched to think that maybe they have the antibodies that are positive for Hashimoto.
Mhmm.
So in not every situation where the TSH is above 2.1 and there are antibodies, not every patient needs medication.
No. No. I wouldn't imagine. I what I'm saying is and maybe I could have stayed thirty more seconds and been more clear. What but it's a thing that I find that if I don't say it, people don't hear it.
And, again, colloquially, from talking to people over and over again, there are a lot of people walking around with untreated thyroid issues.
I believe that.
They create them a lot of problems for them. And when and doctors will very frequently tell them, no. You're in range. Even though they're standing there with seven symptoms. It's Yeah.
Completely obvious they need thyroid medication. Somebody goes, yeah. But your TSH is free. We don't treat that. So, like, that's you know, again, if they if they bugged you a little bit for a week after that, I'm okay with that.
You might not have been, but I'm okay with it. And at least it's in their head now. Yep. That's how I think about it. They at least it's in their head.
More knowledge, and that's I think that's wonderful.
Well, it's a good way for them not to turn into a 16 year old kid who's sixty pounds overweight, tired all the time, can't pick their ass up off the ground. And and their doctor's like, I mean, listen. We checked here. It's not that. And and then I look at their labs and I'm like, I mean, pretty obviously is.
And and and where does that come from from me? It comes from personal experience watching people not treat my wife well. It comes from my daughter being diagnosed, getting medication right away, and going from the smallest girl in her school to one of the tallest people her age. And it comes from episode four thirteen, which is with an endocrinologist named Addie Benito, who just retired, very sadly, because her husband got a great job and she's gonna go live in Paris. And I guess I'm wishing her well, but I would be like, behind and take care of us.
Or take us all with you.
You know? And and she deserves it. She's helped a lot of people over her life. But she's the person that tells you, once I'm helping you with your your your thyroid, I want you managed under a 2.1. And, you know, and if you have if you have symptoms, we were going to try to get rid of them with your thyroid medication.
And she's not just throwing pills at you. She's doing math. She's like, take one on this day, take two on the first Sunday of the month. Like like, she's really, like, thoughtful about it. But most people aren't going to be.
And listen, my wife will eventually come on this podcast one day and tell you all how she didn't get her thyroid medicated for seven years, and it ruined a lot of her adult experience. So Yeah. You know, you don't get the you don't get the hit reset and live again. So, you know, I'd rather I'd rather you push, especially in a world where a doctor is not gonna is most doctors are not gonna look at a 2.6 TSH with symptoms and do anything about it. Is that fair?
That's fair.
Yeah.
That's
fair. So I'm like, Robert
lot of it depends on what the thyroid hormone level itself is too. Let's say it's very, very normal. Then maybe we watch for a little bit.
Exactly. And nothing wrong with that. But, like, let's not forget about it. Also, let's not pretend I'm a doctor. I don't know what the hell I'm talking about.
I'm just telling you that, like, I I've had enough conversations with enough people to know that you should pay attention to this because it has the opportunity to ruin your life.
Yep.
Yeah. And you won't know it because, again, slow drift into nothingness, it'll all just seem like because you I swear, every time I bring it up, especially to middle aged women, they're like, well, I'm older. I'm supposed to feel like this. I'm like, I don't think you are. I don't you're not supposed to be tired all the time.
You know? The same thing with, you know, if I if I could've picked that mic up and dropped it again, would've told them to, you know, get their their iron panels done.
It really was a mic drop moment.
Because seriously, like, also, how many of these type ones are running around anemic? Right. Nobody does anything about that either.
And that's why it's so important to know as someone with type one that every year, at least once a year, we're gonna run blood work, and we're gonna check these things. But if you have symptoms in between, please reach out to us.
Yeah. No. A 100%. Also, for you, don't see somebody's ferritin at 20 and go, we'll take a supplement. Oh, cool.
Thanks. I'll be I'll feel better in 1979. Mhmm. Like like, when it comes back around on the calendar again, it's gonna take so long. Like, you know, have a steak.
Awesome. Can you get me an infusion, please? Like, what are we messing around for? Like, you know, 2026 and all. But yeah.
Listen. Low b twelve, low vitamin d Mhmm. Iron, thyroid. You have type one diabetes. I want you looking at all of this.
You know? And then I want the doctor to actually not tell me, well, it was green on the test so we didn't look at it, which I hear people say. Really? Yeah. It was green.
It was green. Come on. No. You get you get to talk to people who are happy because they come to a good practice. I get to talk to people who are out of their minds because somebody's been ignoring them their whole life.
Anyway, why did you wanna come on here and do this? I mean, I invited you and all, but, like, what made you say, yeah. This is a good idea. I should do this.
I just thought it would be a really good conversation.
Has it been?
I think so.
Okay. Good. Because I I I'll get pressured pretty quickly. I think I messed it up. Yeah.
I I appreciate that. I I love having listen. You are you fall right into my sweet spot of how I hope people's endocrinologists are.
Thank you.
No. Seriously. I I'm so happy you're out there and and helping people. And truth is I'd like to have more conversations with people like you and and you Yep. In general.
I hope that doctors who find themselves in a position of not feeling that they're doing the same kind of work that you are can listen and hear that there's nothing nothing special about what you're doing. Like, you're you're staying up to date on things. You're listening to people, trying to see a bigger picture, you know, and putting them in touch with community and ideas that are. He can't be so ego driven that it all has to come from you. Like, that's you know what I mean?
Like, any good teacher is gonna show you other teachers. Not not just say what they don't hear from me, then I don't want them to hear it. Right. You know? That's all.
Also, you could stand for days and talk about this and see how the world has meaningfully changed. Like, you know you know, in the last handful of years, if not the last twenty years. And if you if you're a 70 year old doctor right now, I get that you don't understand what I just said when, you know, when when somebody said, oh, somebody went to chat GPT and talked it through with them. There's no way anybody, you know
No. It's intimidating at that point.
100%. Listen. That the the frequently asked questions page on my podcast, I took I have who have no no knowledge of how computers work other than I I'm an operator of them, but I don't know how they work behind the scenes. I took I think I took the top 250 most googled type one diabetes questions. I took a list of struggles that listeners made for me.
So it was like 90 pages of returns from people about things they struggled with. We distilled it down into, like, you know, into categories and subcategories and stuff like that. So I took the 250 most Googled questions about type one diabetes. I took the struggles list, and then I mapped it against all of the management series of episodes of the podcast.
So
so then you can say like, I just clicked in the search bar again because I was talking about it. It gives you a populates with, like, 15 things that you can like, says, like, try asking this. Can my child eat cake at a party? And you click on that, and it gives you a bowl beginnings episode, a mental wellness episode, and asks Scott and Jenny a bolus for, like, right away just around the that question. Wow.
But I don't know how to do that. I literally sat down at Claude, and I said, I have this and I have this. And I spoke to it in plain English. I want it so that when people do a search, they're get mapped the episodes that might have an answer in it for them. And it took me a couple of weeks, but it works really well now.
That's really cool. Yeah. And so having said that, let me ask you this question. This is where we'll Sure. We'll probably end.
Bolus & Basal Estimators 1:19:37
You just probably you'll hang up and say, I'm sorry. I can't answer that question. Mhmm. But on my website, I have an estimator. It's a bowl it's a bolus estimate.
Right. You put in your insulin to carb ratio, your sensitivity factor, the target blood sugar you want, and then carbs, fat, and protein in a meal. You can put in your current blood sugar, any insulin you know of onboard, and the the trend line of your CGM. And it will give you I mean, let's do it together real quick. Let's just what what's an average insulin to carb ratio for a 10 year old?
Mhmm. You could do 20.
20. And then what do you think their sensitivity is?
Maybe 80. 80?
And let's say that they listen to the podcast, their blood sugar is one ten. Or let's say their target is 90. Okay? And they're gonna eat how many carbs? What do you see in a kid's meal usually?
Oh my gosh. It really depends. My own kids Mhmm. They'll just crush chicken nuggets. But I don't know.
Just maybe we can make it easy. Maybe say they're gonna have 50 grams of carbs because everyone's different. We never know.
How much fats in those 50 grams of carbs?
What do they happen?
I don't know. Let's say they're gonna have fries with it. You wanna put 15 grams of fat in there?
Sure.
Okay.
Sure.
And protein. Chicken, you said. So let's put in five grams of protein. Okay? K.
I'm gonna make their current blood sugar one ten, and no insulin on board, and let's give them a stable arrow. Right? You hit simulate strategy, and it gives you a 2.75 unit bolus. It wants you to do a point three nine based on the Warsaw method over three hours. So that gives you the theoretical requirement as 3.14, and it says you should probably pre bolus around eleven minutes.
Wow.
And let's say that you just believe that that works. Okay? Is that a thing you would share with people, or is that a bridge too far?
I might share this with people. You can make this into an app too because there's that bolus calc app that we it it helps people with with the math behind insulin doses.
Mhmm. So on
this I think one we would have
I actually have a show calculation step. So it it it shows you everything that it did if you wanna see the math behind it. And it actually gives you a a very significant breakdown of what the pool is, what it isn't, what it's doing. I mean, it's a it's kind of like a a short master's class on bolusing and fat and protein. Right?
I can tell you it is one of the most popular pages on my website. Now I can't make it into an app because then I think the FDA might talk about it being, you know, Fair. A medical device. But I feel like I've done a good job of setting it up so that it's a teaching tool because the because the way you really like, what I love about it most for teaching is you can go right back and say, okay. Well, what if this was actually 75 carbs?
And what if there was 25 grams of fat in there? Mhmm. And then resimulate it and to see like, wow. That moves at the four units up front and point six over. Now it's four hours instead of three hours that I'm gonna see an impact.
Oh, and the but the pre balls didn't change. Isn't that interesting? Like, I think that, like, it's I think it's valuable to sit and just change the numbers around and watch how it changes the bolus to give you kind of an idea. Anyway, I have that on my site. I also have one that just does fat and protein.
There's a fat and protein estimator. There is a basal estimator that uses weight. You can just kinda drag your weight around. Like, say, you weigh a hundred and thirteen pounds, you're a pre puberty child. You have activity level, your active.
These are all sliders that you can change to see how it changes things. And then you can just say estimate my basal. And it, of course, it changes your weight into kilograms, does some math and everything. And then shows you that your estimated base will range between, like, ten point three and nineteen point three a day. And then it shows you how it calculated all that.
Like, I just that's the kind of stuff I don't think I don't think people know that when you come into the office and ask your doctor, Where should we start with settings? They take your weight and just do that. You know what I mean?
Right. And that's where we have to start. Right? It's just a math equation. It doesn't mean that it's perfect for everyone, and certainly needs change.
Right? Girls get their period. They go through their, you know, menstrual cycle, and your basal changes
Yeah.
Yeah. During that cycle. So please understand that what we it's a very good estimate, but it's it's just math.
And it's also not perfect too. Like, I think I Right. I would tell anybody, because I have another page that you'd it starts with weight too, and I'll I'll put it to, like I'll I'll put it to one thirteen again because that's what we use. You can also tell it, like, am I on this one, am I highly sensitive? Am I standard sensitive?
Am I resistant? Am I highly resistant? You can kinda, like, make a choice there. And then it shows you, like, when you make that choice, it's just using different math to figure out what your theoretical total daily insulin is. So one thirteen at resistant, it has you at about 33 a day.
At standard, 28. Highly sensitive, 23. Then it uses that same information you scroll down, it tells you your basal's probably about eleven and a half units a day, maybe about point five an hour if you're on a pump. Using the 500 rule, your insulin to carb ratio theoretically should be about 21 and a half. Your insulin sensitivity using the 1,800 rule should be about 78.
It's all just on one page. It's it's super simple. Like, because it's all just simple math, all based off of
Right.
Now having said that, those numbers could be completely wrong. Like, I'm not saying, like, go type in your weight and be like, Like, you you know, but but what I do think is that it if if you did that and you're it says, hey. My total daily insulin's around twenty three units and your total daily insulin's around fifteen units and your a one c's high, maybe that'll make a person go, I wonder if I'm not using enough for too much insulin, vice versa, you know. So anyway, they're pretty cool things. They're all built from, you know, stuff I've learned on the podcast and, you know, Claude, basically.
So and so it and if you don't wanna use my thing, don't. Like, I don't care. I don't get anything out of it. You but go do it yourself. It's Yeah.
Yeah. It's it's you can you can learn this on your own if you try. You can learn anything on your own at this point.
So That's very true.
Yeah. Head out there. Alright. Maggie, what have you not said that you wanted to? Anything that was on the tip of your tongue that didn't get out?
I don't think so. I think I just I mean, I wanna reiterate to everyone listening. Please try and, know, learn for yourself and and come to us with your questions. We we want to help you. We as your providers and your diabetes educators, nutritionists, we want to help you.
So please come to us with questions. Do some research on your own. Ask us questions. Ask us how we can help, and we wanna be a team.
Yeah. And, ma Maggie, if somebody lives, like, tell them where you work again in case they they're interested.
So I work for Northwell Health. It's kind of on the border of Queens and Long Island in New York. So come see me.
Yeah. Good luck getting there. But Oh
my gosh. I know.
I came out to speak in the afternoon. I don't know. I I think I was total time in the car both both ways, I think seven hours. Unbelievable. I believe I drove, I don't know, 80 miles.
Was just so much fun. Know the
so bad.
You know the next day, I left to go to, Atlanta to do a talk for Touched by Type one.
It probably took you less time to get there.
It's so funny. I had this I had this thought in my head after having driven for the first seven hours headed to to Atlanta. I'm like, I drove from my house to Long Island and back again in the same amount of time it took me to drive to, like, I think it was, like, the the the bottom half of Virginia.
It's brutal. The traffic here, it's pretty rough.
Yeah. Yeah. But it's worth it. I mean, to get a doctor like Maggie or or one of the people she works with. I'll tell you, like, everybody I met there was was really thoughtful, patient forward.
And I'm telling you, like, they had me out then, and you like this podcast and you're near there, these people would be a great fit for you.
So Thank you.
Yeah. Of course. Well, I really do appreciate you taking the time, and I know I kept you longer than an hour. But but thank you very, very much.
Thank you so much. Thank you.
Of course. Hold on one second. Okay?
Yep.
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. This episode was sponsored by Touched by Type one. I want you to go find them on Facebook, Instagram, and give them a follow, and then head to touchedbytype1.org where you're gonna learn all about their programs and resources for people with type one diabetes. A huge thank you to Eversense CGM for sponsoring this episode of the podcast.
Are you tired of having to change your sensor every seven to fourteen days? With the Eversense CGM, you just replace it once every six months via a simple in office visit. Learn more and get started today at eversincecgm.com/juicebox. Hey, kids. Listen up.
You've made it to the end of the podcast. You must have enjoyed it. You know what else you might enjoy? The private Facebook group for the juice box podcast. I know you're thinking, oh, Facebook, Scott, please.
But no. Beautiful group, wonderful people, a fantastic community. Juice Box podcast type one diabetes on Facebook. Of course, if you have type two, are you touched by diabetes in any way? You're absolutely welcome.
It's a private group, so you'll have to answer a couple of questions before you come in. We'll make sure you're not a bot or an evil doer, then you're on your way. You'll be part of the family.
- A CGM tells a story, not a snapshot. The number matters less than the direction the arrow is pointing and the speed it’s moving. Practicing “name the direction before the number” is a skill worth building.
- Foundational ideas — how insulin works, timing, and the impact of fat and protein — still carry over into automated systems like Omnipod 5. But in automated mode, changing your pump’s basal settings may do little, so confirm any changes with your care team before acting.
- The most successful people have the knowledge and confidence to adjust their own settings — in partnership with their provider. Maggie stresses that patients should feel empowered to make changes, never punished for it. Always work changes out with your care team.
- If you don’t click with your endocrinologist, it’s okay to ask to see someone else in the practice. Maggie encourages it with zero hard feelings — finding a provider you trust is part of building a good team.
- People with type 1 should keep an eye on thyroid (TSH and Hashimoto’s antibodies), iron/ferritin, B12, and vitamin D, and reach out between visits if symptoms appear rather than waiting three months. Discuss any lab concerns and treatment decisions with your care team.
- Eversense CGM — Implantable CGM rated for long-term wear — an episode sponsor.
- Tandem Mobi — Tandem’s smallest pump, powered by Control-IQ+ technology — an episode sponsor.
- Touched by Type 1 — Scott’s favorite diabetes nonprofit and an episode sponsor — programs, conference, and more.
- Clinician Share Page — The shareable hub Scott built so clinicians can hand the podcast to patients.
- Bolus Estimator — The Warsaw-method teaching tool Scott and Maggie walk through near the end.
- Pro Tip Practice — The free 21-day reflective guide built from the Pro Tip series.
- Juicebox Facebook Group — “Juice Box podcast type one diabetes” — the private community group.
#1883 Take Your Hands Off It: The Settings
Jenny on why diabetes overwhelm means doing less, not more: basal first, stop fiddling, fix timing, and trust good settings enough to take your hands off. Part 1 of 2
Take Your Hands Off It: The Settings
Cold Open & Sponsors 0:00
Hello, friends, and welcome back to another episode of the Juice Box podcast. 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. 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. 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. 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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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. The show you're about to listen to is sponsored 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.
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 US Med. Usmed.com/juicebox or call (888) 721-1514.
US Med is where my daughter gets her diabetes supplies from, and you could too. Use the link or number to get your free benefits check and get started today with US Med. Jennifer. Yes. Welcome back.
Hello. How are you?
Oh, you know how I am. I'm doing great.
You're good.
Welcome. You. That's what's important.
I'm doing fine. It's oh, it's summer has started. It's the last day of school.
Okay. Alright. Is this really the last day of school for your kids?
Yeah. They're done at half day today, and then they're done. It's the end.
Congratulations to them. Another year? I imagine they passed?
They they passed. Excellent.
I never knew. At the end of the year, I was like, not sure how this is gonna go.
Yes. They have passed. They have moved on. They have been we've been told that they are absolutely ready for the next journey forward next fall.
Well, I trust the teacher that said that, so I think you're gonna be fine. I do too. Do they have good teachers? Do you like them?
They do. We've yeah. They have exceptional teachers that are really fantastic.
Well, that's a
great age.
Great time great time in life. A lot I of am gonna just ask you a few questions.
Yay.
And then later, while recording with Erica, I'm gonna ask her similar supporting questions to the question that I asked you, and this will all make sense in a second.
So Fantastic.
Overwhelmed: Where Do You Start? 3:39
When it comes to diabetes care, when you see somebody who's overwhelmed, just overwhelmed, and we're talking about settings, what do you think that they should be looking at? And I know this is a very broad question. I really just want you to start talking. I'm not looking for you to say anything specific. So we've got overwhelmed people, and you look at their graphs, and they seem wonky, and it's hard to see what's going on.
What do you look at first? Just go ahead.
Sure. So first, I look to see if there is too much interaction, honestly. Right? Is it their interaction? Many times, those who are overwhelmed often are interacting too frequently and not trusting as we've talked millions of times already about.
They're not trusting the settings that are there either because they are poorly set by another practitioner or, you know, by them after not having great help from another clinician to get things set the right way. So they've turned knobs and adjusted settings, and then it becomes a daily kind of thing. So when I when I look at data along with somebody who's pretty overwhelmed, it's usually do things look like they could be easier by just dialing back? Not specifically dialing back insulin, but dialing back their interactions. Okay.
Right? The touch The manipulation is too much. So not only am I not getting a clear picture of what actually their system is doing, especially if they're using one of, you know, the automated insulin delivery systems we have now, but I can't also tell what the setting should be.
Okay. Do you think this would go for people who are MDI or just on a manual pump as well? Touching it too much usually one of the the keys?
Yes. Okay. Definitely. I think MDI is a little harder to evaluate mainly because unlike a pump where it captures all of the little ups and downs with insulin delivery. Mhmm.
MDI, you have to really rely on the person's account of what they've put in and where they've put in and how much it actually is. But the interesting thing about CGM data today is if you don't have a pretty nice looking flow over the course of a day, and it is really variable, like big roller coasters up and down, even with MDI, you can also get a sense that there's a lot more manipulation there than needs to be. And I don't mean manipulation like bad, bad, bad, like slap the hand, but it's more manipulation because they don't know what else to do. Okay. And they don't know how to smooth it out, which you can have smooth data with injections as well as a pump.
Okay. But it starts with knowing that your settings are in a good place. And to do that, sometimes you have to be willing. I think the willingness is the hard part to step back and see what the settings you have are doing Mhmm. To then step in and make a slight adjustment at a time.
Start With Basal 6:47
And, you know, we've all where do you start there? We've always talked before about where do you start? It's with basil.
Yeah.
Let's look at just the basil to begin with, and what does it look like it's doing?
Mhmm. So people can get into a situation where maybe they were set up incorrectly Mhmm. And then things bounce around, and then they go back and touch settings or add or subtract insulin in places. You get variability up, down, up, down, up, You start chasing. You get low.
You're eating food. You're going up. You're not bolusing again. This whole thing starts. At some point, you have to just stop, take your hands off it, see what it's doing, and then make an adjustment.
First adjustment, basil.
Correct. Okay. Absolutely. Because basil basil really does lead to enough background smoothing. And if it is not set well enough for you, absolutely all the other pieces can be thrown off.
Mhmm. Right? If you are planning to exercise first thing in the morning, for example, and there is no bolus in the picture, there's no food in the picture, you're just waking up and going out for a walk fasted, but your basal hasn't been tested, then you won't have any idea what to do with what ends up happening to the glucose shift Mhmm. During the walk or the run or the bike or the yoga or whatever, the soccer game, whatever it is. If you don't know the base, then how are you going to adjust the variables that you're adding in?
Right. When you finally see somebody get their basal right, do they stop worrying the touchers or do they just shift to something else?
Like, the touchers.
The touchers. That's not the right word.
It's a funny word, though.
I don't know. You should hear the thing in my head that I came up with next. I saw it's worse than that. So
The manipulator?
They're fiddling with it too much.
The fiddler. That's there you go. The fiddler. That's better. Yeah.
Fiddler is not the second thing I thought of. Seriously, like, when when you've got your hands in it too much and you finally meet somebody like you or you go to your physician, your physician says, This is all out of whack. Let's they're gonna tell you, like, let's basal test first. Right?
Mhmm.
And get basal nice and stable again. Do those people generally in your experience step back or do they just I'm trying to figure out if they're just fiddlers by nature. Do you know what I mean? Like or can they wait then to see the next thing? What do you what what's the experience you have with people?
I think it can go many ways, definitely. We all have a different perspective on where we want things to be. Mhmm. Right? And how we think about getting it there.
And there are people who are much more willing to say, okay. I can step back for a bit because I've been given direction now. Before, I had no idea. I had nothing to start with. You've given me some direction to get started and have that base, that foundation Right.
Hold me. And I think one of the places that basal adjustment helps things get a little bit easier, so to speak, is usually the overnight time.
Okay.
And that being a big complaint and a big reason most people love their CGM, if we can get that overnight well set, it then leads into where you start your day. Mhmm. And even if those basils in the day yet aren't quite right, if you've had a stable overnight, that leads you into starting the morning in a place that's not too high, it's not too low, extra insulin, that then you're you're gonna be less likely to manipulate or fiddle
Yep.
With extras right away in the morning. Okay. Extra carb, extra insulin. What do I do? Where do I, you know, titrate this?
Whatever. And as you can see then that flows through the rest of the day.
The Tennis Ball in Space 10:32
I also think that's where the overwhelm comes from too. Yes. Because you start adding all of these different, like, small decisions and they all knock you. I I I would think of it a little bit as like a you know, if you think about traveling through space, if I if, you know, if we could go out into space right now and just take a a tennis ball and just just let it go.
In a drift?
It's going to go in a direction forever and ever until something intersects it and knocks it off. And the more things that touch that tennis ball, the further off course you get. It's sort of how it seems to me. Like, go, well, I've learned I've gotta get up in the morning and bolus. Okay.
Fair enough. That works. But what happens if you're getting up in the morning having a couple of carbs, then you're putting in insulin, then you're changing the setting, and then you just keep touching that tennis ball, and we don't know where it ends up all of a
sudden. Correct.
Yeah.
Absolutely. And I I think there is a inherent desire to even if you weren't the controlling type of personality before diabetes was in the picture Mhmm. You usually learn to be controlling, and you can be controlling to a degree that's not healthy. And then and you can be controlling to a degree of just knowing healthy healthy habits.
Yeah.
And the control of those habits keeps things on that steady path. I love the idea of a tennis ball in space that's just floating around and never gets hit by an asteroid. Right? Like Straight line. Lovely.
All the way to forever. Forever.
Wherever it's going. But it our day is also in life not like that. There will always be some type of variable potentially thrown in even if you have the plan for the day set in front of you.
But you don't need to be one of them. But yeah. Yeah. Right. Right.
Yeah.
You shouldn't be the asteroid Mhmm. All the time or the the asteroid belt kind of always, like, ducking and dodging something. Because if you are, then that's where so much of your brain power goes.
Yeah.
And it can become really not only defeating, but it can be a huge energy sock.
I also think it just starts piling confusion on top of confusion because you don't see where it's coming from anymore. Yes. Honestly, it just feels like you're being shot at from all sides. You're getting hit, but you can't you can't hear the bullet, and you don't know which way it's coming from. And why is it, you know, it's it's on my left, it's on my right, it's above me.
And then then boom, you're overwhelmed, you shut down, and now you've shut down with bad settings. And, you know, and they're so wacky your doctor can't figure them out. You can't figure them out. What I'm telling you is that I see people because of these conversations I've been able to have, this feels like it could just be like a momentary problem. But if you get caught in that wrong trajectory, you could stay there forever.
Like, because I've seen it happen to people. Like, they just
Mhmm.
They become complacent in such that they feel like, well, this is just what this is. There's no getting out of it. There's no answer. I don't have an answer. The doctor doesn't have an answer.
This must be what diabetes is. Then the brain fog comes in and all the other stuff. And before you know it, you're just you're adrift. You know?
Right. It's constantly being on the defensive.
Yeah.
Really. Right. It's constantly waiting for the next, like, the next thing to hit, and then assuming you have the right trick in the bucket to pull out to hit it with so that you don't get sidetracked by that next thing, but that's not what ends up happening. So, I mean, settings in general base Basil to start with. Yes.
Right.
And then you really do have to take some time out to say, you know what? There are always going to be birthday parties. There are always going to be vacations. They're always going but not, for the most part, not day after day after day.
Yeah.
So make the effort to find something that has a structure in a couple of days.
“We Have to Start Over” 14:14
Yeah. When things would get out of hand with Arden when she was younger, before I even knew what I was talking about, I would say to my wife, we have to start over.
Yes.
I'm like, we have to stop and start over because there's too much happening right now. We'll never make sense of any of this. Mhmm. And that's where the ideas that I talked about in the podcast, you know, for all this time came from. Like, I realized I was like, okay.
Well, if the basil's right, a lot gets better all of a sudden. Right? Mhmm. Carb ratios work better. Sensitivity, you know, factor works better when when basil's right.
So let's get the basil right. And, you know, again, without a CGM, I don't know that I ever would have figured that out to perfectly honest.
Right.
So then, you know, we talked about what gets better when the basal's right. What gets better when your carb ratio is more accurate? Diabetes comes with a lot of things to remember. So it's nice when someone takes something off of your plate. US Med has done that for us.
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They accept Medicare nationwide, over 800 private insurers, and all you have to do to get started is call (888) 721-1514 or go to my link, usmed.com/juicebox. Using that number or my link helps to support the production of the Juice Box podcast. This episode is sponsored by Tandem Diabetes Care. And today, I'm gonna tell you about Tandem's newest pumping algorithm. The Tandem Mobi system with Control IQ plus technology features auto bolus, which can cover missed meal boluses and help prevent hyperglycemia.
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Ratios That Work (Until Vacation) 17:24
You have confidence with the majority of the things that are your day to day norm. Mhmm. Right? And as adults, there's not a heck of a lot of growth that ends up happening unlike kids. Kids settings will shift and change, not that adults won't, but less frequently, so to speak.
And if you do test within a time period to see that your carb ratios are in a certain place, then you can count on those ratios working for days, weeks, months at a time. They should really work. Where it gets thrown out is you test for two days on the apple first thing in the morning. You measured it. You weighed it.
You've got your ratio figured out for that. But now you go on vacation for the next week to wherever, and the apple is no longer your breakfast. And there are a whole host of other things in the picture. Well, this is where it doesn't mean that the ratio is wrong.
Right. It just doesn't work for this meal. It worked for the apple.
It worked for the apple and or it worked for your typical foods at lunchtime, your typical foods at dinnertime. And those ratios, there's a little wiggle room to them. Right? They're not hard set started set in stone. You're a one to 10.
I mean, right, there's a little bit of wiggle there. But in general, I think it's the other pieces that often end up had you been on a good trajectory of habit, you get thrown off by the variables of vacation, illness, digestion looks different, whatever. And then you come out on the other side of that thinking, well, now I have maybe bad habits coming out of that. I'm adjusting this way. I'm throwing in more insulin here because that clearly didn't seem enough or it was way too much.
And then on the back end when you're adding your apple back for breakfast, you don't trust it.
Yeah. It's an it is super interesting that because I've I've lived through it and I've talked to a bunch of people that have. It really should be just as easy as, I'm going to a restaurant now. This food is just gonna hit differently.
Yes.
I'm a very sedentary person, and I'm running around on the beach for the last five days. It's not a thing I usually do. Why am I getting low all the time? You should be able to just see it, turn it on, turn it off, but, boy, that's not how it works in people's minds. You know?
It's not.
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And, you know, outside of just the settings, there are settings once they are in a good place. There are adjustment strategies as well Okay. That you will typically also find advantageous. Right? And it takes experimentation.
This is not a one and done. Gosh. I tried this. It worked, and I'm gonna go forward and just use this all the time for exercise. Exercise of one thing versus another is going to require a different type of strategy.
But once the base is set, now you've got again that foundation. It's like very solid to build your strategy off of. Right. And then you don't end up making little nudges here and adjustments there and plugging in and adjusting that and taking more away, which again is just it's not purposeful and it makes it worse.
The Hardest Part: Pre-Bolusing 21:30
Guess the next thing to talk about, I think is maybe the most difficult part, again, based on conversations, but also based on watching my daughter, is pre bolusing a meal. It's incredibly difficult for people to remember to do. It's incredibly difficult to want to do. I saw Arden the other day. She just finished a college semester.
Yay.
Yeah. So she's she's so close right now. And so she slept in. And I was recording with somebody and somehow the conversation got around to, like, touching it too much, like, touching the CGM and looking too much and everything. I stopped and I said, I honestly don't know the last time I saw Arden's blood sugar.
It was, like, 02:00 in the afternoon at that point, and Arden's still asleep. And so I opened up my phone, and for the last I think it was five and a half hours, I apparently did look around 8AM, and I put in, like, point two or point three of insulin or something while she was sleeping. I mean, to adjust, a one ten blood sugar. You you know what I mean? And I just felt it I could see it was heading in the wrong direction.
I put a tiny little bolus in, and I didn't look at it again. And the person asked me, how did you manage to not look at it again? I said, well, my alarms haven't gone off. So it's in between 70 and for me, it's between 70 and one twenty. And I was like, so there's no reason to look.
The thing I expect is happening is happening, you know.
Right.
The person was, like, stunned. They're like, you're between seventy one twenty for, like, five and a half hours. Like, well, she's on automated system. Her settings are great. She's not eating.
She's sleeping. Like, you know?
Right. There's nothing happening.
I'm at the point now I with automation and good settings, I don't know how long you couldn't fast for, but
Mhmm.
I've seen it go for twenty four hours without a problem when somebody's sick or something like that. But nevertheless, she gets up and then 21 years old does not pre bolus enough for her food.
Right.
And I watch her blood sugar just go whoop. It's heading up. The algorithm's pushing back, pushing back, pushing back. She gets to two twenty. It comes back down again.
And I'm gonna tell you that I wish she would pre bolus, but that's still gonna be like a 6.4 a one c, you know, over over the long time. And to be able to just walk away from that and say that is a big step for me even because when I was in control of it, I would have thought, like, we cannot I don't want this to happen. And by the way, I don't want it to happen. I don't think it should happen. And if she would have pre bolus 10
It wouldn't have.
It would not have happened. Mhmm. But I also think she'll get there one day. Yes. And so and I've had conversations with people, Erica being one of them, about this topic.
And I asked her, like, I said it to her one day, like, why would I'm trying to wrap my head around, like, why would people with type one not just pre bolus once they know to do it? And she said, Scott, I have trouble doing that. And she's like, I've had diabetes for, like you and Erica are in a race. You both have had diabetes for, like, over thirty five years. Right?
And she was like, I've had diabetes for, you know, almost four decades, and I struggle with that every day. She's like, it's not a thing your brain wants to do or mine at least. So, anyway, when you talk to people about pre bolusing, I'm sure you explained that to them, but is there a way you can get them to it? Is have you figured anything out?
Some of the way is especially with those who are fiddling
Mhmm.
As much. Some of it's actually bringing up data and looking at it together in a framework of what are they eating, you know, if it's about the same like, I usually look at the same time of the day. Right? Focus in one place before moving on. And for people that are more visual, it's interesting to see how they react once you show them their own data and the timeline of the bolus and the carb entry both went in here, and your blood sugar is going up within five minutes or ten minutes of that entry.
I can tell without asking you. I can tell that there was no pre bolus there.
Mhmm.
The c I mean, the CGM data may not be accurate number wise all the time, but that trend line should be a really good friend.
Yeah.
It is telling you the direction your glucose is going. Mhmm. And that for many people, it's an eye opener of, well, gosh, how do I stop that? And for the fiddlers, it's I just add more insulin.
Mhmm.
I get add more. I add more. I'm like, this is not a more insulin because if we look at the data on a day where you were willing to hold your hands off
Yeah.
Did the blood sugar actually respond eventually and come back down? Then it's not a more insulin issue. Timing. Instead, this is timing. Yeah.
It’s Timing, Not More Insulin 26:10
This is you ate within five minutes of taking that bolus, and that was definitely noticeably not enough time. Mhmm. So let's let's do an experiment. Right? And, again, I would say most people are very willing to at least experiment with prebolising.
Try. Yeah.
And try to. Right? And once you start seeing progress and you start seeing that positive result, it builds positive reinforcement. Certainly goes a long way. Right?
It builds that. And for many people will then become enough of a habit that they keep doing it because they see the results that they want. And as we started out with, like, the overwhelm Mhmm. Drops down because they aren't having to follow-up outside of alarms Yeah. Wherever those are set.
And I would say that some people even then step in and say, well, maybe I'll adjust my alarms to be a little bit tighter so that I can take that overwhelming look at the data, look at the data, look at the data, do something about it. I can take it out of the picture because I've got my alarm set, if it goes off, then I need to pay attention to it. But, otherwise, my settings are doing what they should be doing. My ability to pre bolus or time this well, it seems to be working out. Mhmm.
Most of the time, it decreases that load of interaction.
Yeah. I don't know that we I because some people are great multitaskers. I don't know if you if you I've been looking into this lately, and I'll probably bring it up when I talk to Erica. The human mind can actually only focus on one thing at a time. Even when you think you're multitasking, you are swapping one thing out of the spotlight for another thing.
There's a a bubble around the focus of things that you can hold in your head, and it's only, like, three or four things. Like, so when you start thinking about actual life and then you add diabetes on top of it, that's already too much. You can't then go adding more stuff on top of diabetes. Like like, diabetes is enough already. Don't give yourself 50 extra things to think about.
Right.
Why People Won’t Pre-Bolus 28:17
I'm gonna try to figure my way through that. But back to the idea of pre bolus thing, I think it's interesting that I'm trying to understand the psychological aspect of the person who tells me, I know I could wait, but I don't want to. Like, I it's one thing if you're eating because you're getting low. I that's different. But if you tell me, I'd love to have a handful of pretzels tonight while I'm watching television.
Well, then grab a handful of pretzels, put the insulin in, and wait. Right?
Like Right.
That doesn't seem insane to me. I was like, but people's answer back, and this is the thing I'm gonna have to dig in with Erica a little bit, but I am gonna I wanna ask you from your perspective too. What is that, like, that feeling? Maybe you don't experience it of, like, I don't wanna be told what to do by diabetes because I think that's what it is after talking to people. Like, I don't want diabetes to dictate how I eat my damn pretzels, but I don't know if I'm right about that.
It's just me talking to people.
It's a situation of where are you socially in that moment.
Okay. Yeah.
I can definitely tell you that it is while I'm over the I don't care if I'm sitting here and everybody else is eating, like, that's well beyond me any anymore at this point. But I can understand the perspective of you grab the bag of popcorn or whatever from the cupboard, and you're gonna watch the movie, and it's starting right now. And you wanna dig into the popcorn. Yeah. Right?
I get that, and and I think it's harder to wait when you see everybody else is digging into that popcorn right now. And there is no there's no need for them to wait. There's no need for them to take anything else into consideration when you're the one sitting back and
Does it hurt?
And waiting.
Do you know what I mean?
It's an emotional feeling of just, I guess, you feel irritated that they can't wait for you. So I think there's a piece there. Like, why don't they just get, like, I'm not eating yet. Can't they just wait like that? Can we all do this?
And some families do. Mhmm. I will say that's that's the way that some families work it or they work the parents work the pre bolus in so that by the time they're all sitting down, the pre bolus has already been working, and then the child can start to eat with the rest of the family and whatever. Right? But I think there there is twofold.
And then there's the personal attack on yourself, like, and now I have to sit here and I'd really like a piece of popcorn. Right.
Also, and Erica Erica talks about that body grief too. Yeah. That sadness that your body doesn't do what it's what it's supposed to do or what you would expect it to. I should say too, for me, I could sit and wait, but I don't have any of those outside pressures. I'm not looking.
I don't have that feeling of, oh, I can't believe I can't just start. Like, I'm deciding instead of being told. Maybe that really is the answer. Hopefully, we'll come to a way to figure out their way around that. Yeah.
I have a couple more for you. Do you have time?
Okay. Yes. I've got some time.
What Automation Handles (and What It Doesn’t) 31:14
So if auto modes are supposed to carry, like, a little bit of a load, what's the algorithm actually handling, but what is it not handling? Where should our effort be put in, and where should it not be? Big question maybe.
So it is it's a really it's a big question because I I know that algorithm in general doesn't speak to the algorithms that are available. Each of them has their own set of rules that it follows
Yeah.
In terms of how it's going to step in and help to handle things with and for you. Right? I think a good example in this conversation does go along with what you said about what you watched with Arden the other day. Right? It's okay.
She didn't pre bolus when she got up. She wanted to eat right away. That's what she did. She's young. Her brain isn't fully formed yet in the track of I can do this because this is important.
Right? So she ate. Her blood sugar went up, and you watched. You you sat on your hands despite Scott in younger ages with a younger daughter, you would have stepped in and also done something. But you also have a couple of things in hand here.
One is an algorithm. That's an aggressive algorithm. Your algorithm, you trust the settings Mhmm. Because you know what she needs. And you could watch and you could wait knowing that despite not liking the 200 blood sugar that it was going to address it, and you wouldn't have to step in and help.
And it was also not going to cause her to go low.
Right.
So I think there are a couple of things to define within an algorithm. It's what kind of algorithm is it? How heavy handed can or can it be or how heavy handed could you set it up to be? Mhmm. Some of them are adjustable, others are not so much.
And then when we're talking about food, none of the algorithms will really hold your blood sugar without announcing food.
Yeah.
Across the board, DIY, the open source, as well as the FDA approved systems. What people adjust is their expectation of target range.
Mhmm.
That is what I have truly seen is parents who are stepping back from navigating with their teenagers and letting them take over and letting them figure it out with some of the set guidelines that they've done. They have to widen their their target range. They have to widen it and say, you know what? My kid isn't gonna pre bolus for thirty minutes. They're sitting down at lunch, and they only have fifteen minutes to eat.
School doesn't do anything because they don't step in and help anymore. My kid boluses as they walk to the to the, you know, cafeteria. But my settings are really good, and I'm okay allowing them to get to one sixty, one eighty because I know that the algorithm will carry it out as long as they at least announce the food.
Yeah. It's difficult to expect a a child or an adult, honestly
It is.
To do that. It is interesting when you're doing it for somebody else. Like, you brought up popcorn at the theater earlier. We'd be driving to the theater, I'd ask Gardner, are you thinking of getting one of those slushie drinks? And if she said yes, I just threw in 10 carbs in the car.
And then, like, as we were walking through the door, I bolus for, like, more, and then hit her, like, a third time when we sat down, and she wasn't gonna do that. You know what I mean? And I don't know that I wanted her to, to be perfectly honest. So No. Then there is a separation later when you have to say, well, they're their own person.
They're getting older, etcetera. When people are still doing things manually and they shouldn't have to be, like, what do you think that's them trying to protect themselves? Like, what do you see from people? Like, when you're going, god, stop touching it. Like, we got it set up.
Like, it should be working. What's the feeling you get back from people?
I get a sense from looking at so much data
Mhmm.
That what people are doing manually that steps outside of what they should be doing is much relative to expectation. And, again, kinda goes back to which a lot of this does is what is their target? What are they aiming for? What range are they aiming to stick in? And what are they willing to wait to see happen before they step in?
Right? They're doing a lot manually of a little bit a little bit a little bit. I see it across the board in a lot of the systems and even, you know, the open source systems that you can step in as a caregiver remotely and add a bolus or nudge it or enable something or disable something. Well, some of that's necessary depending on the situation you know is coming, but a lot of the manual manipulation, you're stepping in before you're even allowed the system to do something to help you. Mhmm.
You're not using the technology to your advantage.
Yeah.
And then you have to start thinking, well, do I have to go back to the basics? Am I doing this more and more and more recently because I don't trust my settings? Then, gosh, step back and reanalyze your settings. Yeah. Get back to just normal, you know, meals without going vacation meal and see is it the fact that I've been eating vacation meals more.
That's the problem. And my settings when I eat normal chicken and broccoli Right. Goodness. They look just fine.
I hope it's comforting to people to know that there's still times when I look and I think this needs, like, an extra unit and a half here. Mhmm. I think. But I gotta wait a minute to find out for sure. It's too soon for me to decide.
And the difference between now and ten minutes from now is not gonna be that big of a deal. There are just times I look and I go, oh god. Like, we got arrows up. This is all wrong. More insulin.
Blah blah blah. But there's also times I go, I feel like more insulin, but let's wait a minute and see. Or if I put in an amount here, is it an amount the algorithm can take away on the back end? Because then I'm not as scared.
Right.
Am I pushing it to a point where the insulin on board is gonna be too great for the algorithm's ability to take away basal later to balance it if necessary? That's happens pretty fast in my head, but it still pauses me sometimes. So I'm like, I'm not sure. You know?
And what you have and what all people should get to the point of understanding, and we've talked about many, many times, is just understanding your insulin action.
Yeah. Yeah.
Right? Because you have that in what you've just described, you can take the scenario happening right now. You can look at what's happening. You can say, give like a whole extra unit, but it's subconscious, honestly. It is.
The way that your brain thinks through
it Yeah.
Yeah. You can see what's already been happening. You know the algorithm that that Arden is using, and you can say, I can hold off because I'm either expecting in the next fifteen minutes of waiting that the system's got it and I'm good. Or if I am thinking in the direction that maybe we undercounted or maybe we misjudged or whatever that I could throw in an extra unit. And yes, based on her insulin needs, the system can subtract enough or suspend enough or whatever.
So it will catch it and I won't even need to step in there either.
Right.
But you have to understand insulin and how it works Mhmm. How to time it, and you have to understand your algorithm and what it's going to do and not do for you.
What “Done” Looks Like 38:41
Okay. My last question for you is MDI manual pump algorithm based system, doesn't matter to me. When you see somebody who has it set up and it's working right, their CGM is working right, you know the data you're getting back, everything looks solid, like, when you see that, what does that look like day to day life? Like, what does a well set up running system look like as far as people's interactions and their outcomes?
Right.
How do I know I'm in the promised land? I guess. You know what I mean?
Yes. How do you know that, like, there's not much work to hear to do here. Please be on your way
and come back. Yeah. How do I know I'm done? Yeah.
Yeah. Yeah.
Yeah. That that's my question. What's what's done look like?
And done being, like, short term. Yeah. Right for now. Right? You're done.
Right.
Right. Right.
It looks like, I guess, defined by the person's target range. Are they nicely rolling through that target range? Can you see where the meal entry was? Can you see where the bolus was? Does it look like there's a nice swing up that should happen if you are eating carbohydrates?
There is a bell curve that happens in the aftermath of a meal. You can see in the data where the insulin really took hold
Mhmm.
And the action of the system if they're using an automated system or even with multiple daily injections, can almost see the peak and the clearance of that and where the basal, which is well figured out in either scenario, where it caught that and then things just sat nice and stable for them.
Okay.
Right? So it is a lot more, I say, gentle rolling hills.
Mhmm.
And when I look at automated systems and the data, I can typically tell when somebody is stepping in mainly because when I look at their total daily insulin use, automated systems, especially the the open source systems, have little tiny extras in assistive that it pops in along the way. It's always giving and taking. All of the algorithms are Mhmm. Of any system. But you can see it's got tiny little nudges to things on their typical day to day, and it's smooth transition of data.
Okay.
Whereas larger boluses in between, and the frequency of those boluses that are not coming from a system generally tends to create a lot more jagged looking Up and down. The up and down. The true roller coaster, I say the Rocky Mountains, it's up, down, up, down, up, down kind of look. And those boluses are often much larger than what the system would auto populate in.
Yep. Okay.
And all of the systems also give I should not say all of them, but some of the, you know, other systems like Tandem, for example, the the Control algorithm. The nice thing about looking at the data is actually that it tells you when the bolus was overadjusted or underadjusted by the user. So Control IQ has automated give that it will pop in as needed as well as positive temporary basal changes. But anytime a bolus is requested based on a blood sugar, if the system was gonna give a bolus, it has information about whether that bolus was overridden or underwritten by the user.
Oh, nice. Yeah.
Which is quite nice.
Yeah.
So
Okay. We have all this as good as it can be. What are the things we can't fix? Like, what are things that are gonna happen even with great settings and even with great timing? Like, what are the just the, like, okay.
I have to just give myself over to like, what do you think of when I ask you that question?
What You Can’t Fix: Illness & Growth 42:28
Yeah. I think it makes me think of the times that you do have to do some fiddling. You do have to do some stepping in. Honestly, that's not incorrect. Illness, growth times where because you know that more is needed or less is needed.
Let's say illness, for example. More is needed, but the base settings weren't adjusted to accommodate for illness. Mhmm. So you may have to step in, and you may have to do things more frequently. And in that, I usually tell people to also get an idea of about how much did you nudge in or about how much did you pull back because going forward, at some point, you're going to get sick again.
Yeah. Something's gonna happen.
Right? And something's gonna happen, but now you have a base to use rather than just fiddling every fifteen minutes with more more more or adjusting with temporary rates or adjustments or whatever they are. Right. You can use that to have something to start with the next time. Gosh.
Last time I had a cold, I needed 10% more insulin. I use this much more in a temporary basal really helped. Great. That should mean you're not fiddling as much then.
Yeah. I can't thank you enough for doing this. I I like this is a different kind of conversation around stuff that we talk about all the time. Hopefully, it helps people think about a different way. I would urge people if any of this made sense to you and you wanna dig deeper into any of it, the pro tip series that Jenny and I made will probably help you walk it through, more granularly.
Yeah.
Wrapping Up & What’s Next with Erika 43:55
Yeah. So Awesome. Thank you very much. And then the next part that people hear either I've worked it out so that in editing, you've gone back and forth with Erica, or the next part right now is gonna be Erica kind of addressing the mental health side of, you know, some of these things. Questions like, you know, okay.
I've, you know, I've I've reduced the load on myself here, but I still feel overwhelmed. What can I do to help with that?
So No. I'm super excited that you're gonna add that piece in with this because I think that overwhelm is a real it is a real thing. And even with settings adjusted well, we have to also know, as we just talked about, how to address a variable and then getting off of that roller of adjustment again and finding some ability to step back and feel okay just settling.
And yeah. Yeah. I would like people to know and if you're comfortable sharing how you feel as we go out here, even though you're, I think, very good at this, obviously, and you've got a ton of practice and time and professionally and personally, you still feel that overwhelm too, I would imagine.
At times, I do. I think that my overwhelm is more relative to a busier life in general.
Mhmm.
Right? I compare my navigation before children to navigation now with kids that are really busy. Right? And being the taxi driver and the parent that does things at school as well as working full time and, you know, all of the things I think that that's where the piece of navigating almost like a third child. Right?
Could my consideration of diabetes is kind of like a kid that doesn't really grow up. You do have to still always step in and take care. There's more there to consider because as you mentioned, we can only have one or two things on our mind
Yeah.
To navigate in the clear moment. Right. And mom, I need this, and I didn't get that for the project and, like, whatever. And I'm like, I just really need the bowls for dinner. Yeah.
Like,
that's all. Jenny, what I hear you telling me is that diabetes is like a it's a child you have that never stopped in its pants. Is that what you're telling me?
There you go. You always have to you always have to change its diaper at some point. Yes.
Anyway, you'll know if you have a baby. I'll see you later. Jenny, thank you very much. I appreciate The conversation you just enjoyed was brought to you by US Med. Usmed.com/juicebox or call (888) 721-1514.
Get started today and get your supplies from US Med. The 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.
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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. Okay. Well, here we are at the end of the episode. You're still with me? Thank you.
I really do appreciate that. What else could you do for me? Why don't you tell a friend about the show or leave a five star review? Maybe you could make sure you're following or subscribed in your podcast app, go to YouTube and follow me or Instagram, TikTok. Oh, gosh.
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They're active talking about diabetes. Whatever you need to know, there's a conversation happening in there right now. And I'm there all the time. Tag me. I'll say hi.
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 bolus ing 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. 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 wrong way recording dot com.
- When management feels overwhelming, the first move is often to do less, not more. “Fiddling” — touching settings and stacking insulin all day — usually adds variability instead of removing it. Taking your hands off and watching what your settings actually do is a real skill.
- Basal first. A well-set basal is the foundation that makes carb ratios and correction factors work — if it’s off, everything downstream gets thrown off, and a stable overnight tends to set up a calmer day. Always test and adjust settings with your care team.
- The CGM trend line is your friend — it shows the direction glucose is heading. A rise right after eating usually points to a timing problem (pre-bolus), not a “more insulin” problem. Confirm any changes with your provider.
- Automated systems still need you to announce food, and changing manual settings in auto mode may do little. Knowing how insulin acts and what your specific algorithm does (and doesn’t do) is what lets you wait instead of over-correcting. Discuss your settings and targets with your care team.
- Some things can’t be “fixed,” only managed — illness and growth will need extra stepping-in. When that happens, note roughly how much you adjusted so you have a starting point next time instead of fiddling from scratch. Work those adjustments out with your care team.
- Eversense 365 CGM — The one-year implantable CGM — an episode sponsor.
- Tandem Mobi — Tandem’s smallest pump, powered by Control-IQ+ technology — an episode sponsor.
- US Med — Where Arden gets her diabetes supplies — an episode sponsor. Or call (888) 721-1514.
- Diabetes Pro Tip Series — The Scott & Jenny fundamentals series — episodes 1000–1025.
- Small Sips — Short, single-idea episodes that make diabetes make sense.
- Juicebox Facebook Group — The private community — “Juice Box Podcast Type One Diabetes,” 74,000+ members.
- Wrong Way Recording — Rob — Scott’s audio editor, and the reason he sounds 20% smarter.
#1882 Eric Benjamin, Omnipod's COO, Live from ADA
Eric Benjamin, Omnipod's COO, Live from ADA
Live from ADA, Scott talks with Insulet COO Eric Benjamin about Omnipod 5's new 100 mg/dL target, Omnipod 6, an updatable pod, and a closed-loop system for type 2.
Jump to a moment
- Omnipod 5’s lowest glucose target is now 100 mg/dL. Eric Benjamin said roughly half of users aren’t set to the lowest target — if tighter control is your goal, which targets are available is worth reviewing with your care team.
- An Omnipod 5 algorithm update (rolling out by app, started June 3) is designed to keep the system in automated mode longer and ask for fewer manual interventions during prolonged highs. It requires compatible pods.
- Insulet says Omnipod 5 also added compatibility with the Freestyle Libre 3+ sensor this week.
- Omnipod 6, described as due to launch in 2027, was framed around a new algorithm, hardware changes for more wear locations (less ‘line of sight’ dependence), and an updatable pod that can update during priming.
- Insulet is developing a fully closed-loop system with no required inputs, aimed first at people with type 2 diabetes in primary care; for type 1, Eric described continuing with ‘bolus-optional’ systems so users can choose how engaged to be.
- Omnipod — Eric Benjamin is COO of Insulet, maker of Omnipod
- SugarPixel (CustomType1) — John's device; Scott sat at the SugarPixel booth at ADA
- Diabetes Pro Tip Series — Foundational management series (verify URL)
- Bold Beginnings Series — For the newly diagnosed, with Jenny Smith (verify URL)
- Juicebox Podcast Facebook Group — ~85,000 members (verify URL)
- Juicebox Podcast — All series and free resources
Every word of the conversation
A First: Recording Live at ADA0:00
Welcome back, friends. This is the juice box podcast. Well, this is new for me. I have never, in twelve years and over 1,800 episodes of making this podcast, recorded anywhere but here at this desk on this microphone. But recently at the ADA conference, the scientific sessions, I had the, the pleasure of interviewing Eric Benjamin, is the executive vice president and chief operating officer at Omnipod.
Eric and I talked about enhancements to Omnipod five and some things that they're thinking about for Omnipod six and a few other little items. I think you'll find an interesting conversation. It was a new thing for me, not just not recording here, but as I sat down at Omnipod's booth, they have a beautiful setup where they make other podcasts and audio content and video content for themselves. I sat down and realized that I had never had a camera pointed at me when I made a podcast once in my life. I've never done it in front of other people, and I have never actually sat across from the person live who I've interviewed except for a couple of conversations that I've had with my daughter, which I don't think counts.
I'll tell you a little more in just a second. Nothing you hear on the juice box podcast should be considered medical oh, I haven't done this in a while. Live? Hold on. Nothing you hear on the juice box podcast should be considered advice, medical or otherwise.
Always consult your physician before making any changes to your health care plan. I can't believe I forgot that. I'm gonna get you to Eric right away. I just wanna let you know that being at ADA was really a terrific experience. I met a lot of people, many of whom are gonna become future guests on the podcast.
I really think it's gonna enrich the the show and its content. Met some people from the DIY community who are gonna come on. I actually just got an email from one of them today. I'm gonna get that set up. I met a lady who's writing a book, and she wanted to interview me for it because of how much the podcast has helped her.
So she's gonna come on and interview me here where you can hear it. Hope that's interesting. Had a great had a great time, like I said, and I and I I sat most of my time at ADA at the SugarPixel booth with John, the owner, and his family. Just wonderful. If you don't know what SugarPixel is, check out customtype1.com/juicebox.
Just a great little device, and and John's doing a lot of fun things for people with diabetes. He and I will actually be at ADCES and Friends for Life together. So if you're gonna beat any of those events, please come out and say hi. We'd love to meet you. And now without any, further ado, which I hate when people say on podcasts, but here I am saying it, this is Eric Benjamin.
Meet Eric Benjamin of Insulet2:40
Welcome to the Juice Box podcast. Could you please introduce yourself and let everybody know, who you are and why we're here today? Hey, Scott. I'm thrilled to be here on
the Juice Pucks podcast. I think I mentioned when we were standing aside that, you know, you're a celebrity in diabetes circles, so it's my privilege to be here with you on the show floor at here at ADA at the Omnipod booth. My name is Eric Benjamin, chief operating officer for Insular Corporation, and excited to talk to you about what's going on.
Oh, that's awesome. Can I learn a little bit about you before we jump into everything? Would love it. How do you end up with this this job?
I came to Insulet about eleven years ago, and I had worked with some people once upon a time at a company called Guidant making coronary stents and catheters. And some of them had found their way to insulin in 2014, and they knew me. And they said, hey, Eric. You should come join us. And I came, and I fell in love.
I fell in love with our mission to improve the lives of people with diabetes around the world, the culture and incredible people who are driven to build a remarkable business while we improve the lives of millions of people. And those two things are still true, and we have a huge job to deliver the innovation and impact that inspires all of us.
Back then before you came, what do you think your core skill was that was gonna be valuable here? Did it end up being that, and what have you figured out since then?
I'm not sure I have a core skill. Okay. I'm my my I I've always found myself, you know, as the person that challenges are handed to, Scott. And I spent my first ten years orbiting manufacturing quality and r and d. And I came to Insulet actually to sell licensing deals for our technology to pharma companies.
We have some partnerships with pharma companies to supply custom versions of our device to deliver other medications. Sure. And I came to do that and ended up finding my way applying some of my learned skills, you know, leading the team to develop our products, bring them to market around the world. And it's been an amazing eleven years. That's interesting.
I'll tell
you that my mom had a battle with cancer. And one of the moments that I think she actually enjoyed doing that was telling my daughter, like, look. I have your pump on. And because she was having she was getting medication delivered through a pod.
Through new the Neulasta Onpro device.
Yeah. That's exactly right. It it was like honestly, I don't know that my mom ever really understood my daughter's diabetes completely, but they had a moment together where she's like she got on the phone. She's like, hey. Wait.
Can I can I video chat with Arden? I wanna show her something. So, anyway, it's it's
an amazing moment. And it's amazing what people connect with about fully appreciating life with diabetes. Sure.
No. It it it really is. So you get here. You're the how do you end up in the job you're in now, though? Did you put up an you put out enough fires?
They were like, hey. This guy really knows what he's doing, what happens?
Yeah. It's not so much fires, Scott. It's just, you know, we're we're a company that in order to grow 20% a year for the last ten years, we're on our way to doing it for Yeah. Year 11. There's just a lot of new challenges in the organization.
And so in some of my early years with Insulet, when I was done selling licensing deals to pharma companies, I stood up our external supply chain and, you know, helped build the reliability and quality that we now rely on in order to get high quality components into all of our factories around the world. And then took responsibility for our R and D team starting in 2018 and have grown from there.
Oh, that's an interesting job, isn't it? So you know what's so when at the end of this, I can ask you what's coming with Omnipod six, and you actually know.
I do know. At this point, I think most a lot of people know, Scott, but I I have the the pleasure of working with the people who do the remarkable work that makes products like Omnipod six a reality.
I'm gonna ask you questions later, and maybe maybe we can get some details for people. So what what do you see as the goal of being at ADA for Omnipod this year? What what's your messaging? Scott, the thing
Omnipod's Message at ADA6:31
that is so amazing about being at ADA this year is the amount of data, clinical data, coming out to support so much innovation. Earlier this week, we launched some algorithm updates for Omnipod five. Mhmm. And over the weekend, we're gonna be showing the first clinical data of how those algorithm updates are helping people achieve better outcomes and stay in time and range more Interesting. Tomorrow at the show.
We released data on Omnipod six, the which is anchored by a new algorithm designed to give people even better glycemic control with less effort to get good outcomes. And we also released some data on the feasibility studies that we're working as we push towards a truly disruptive, fully closed loop product for type two diabetes. And we released that data earlier today too. Awesome. So it's been, you know, just a a show of inspiring clinical evidence paving the way to meaningful innovation for people's diabetes.
Can we pick third a little bit? Please. Okay. So Omnipod five, now I know that there's now a target of 100 because I was lucky enough to be involved in an ad where we all stood around on a set all day yelling 100. So I know that's one.
The Case for the 100 Target7:40
What are you seeing by lowering that target? What do you think is the value for people wearing the pod? The 100 target
is a is a big impact for folks. We actually we showed data at a d excuse me, ATTD a couple of months ago that first, only about half of customers use the lowest target. So we're actually out educating people that there are lower targets available in Omnipod five that are options to get tighter glycemic control. I can see you're surprised.
Well, no. You stunned me because I and I I sometimes I think I'm in a bubble. I think the people listening to this podcast are incredibly motivated to do well for themselves. I I don't know that I know one person not using the lowest target on Omnipod five. So but tell me the
number again. How many people don't? It's about half are not using the lowest target. And I would bet that even among your very engaged listening community, specifically, I bet there are parents of kids who are not using the lowest target. Okay.
So there you know, what we see is that parents of children choose to use higher targets for a variety of reasons, often fear of hypoglycemia. Mhmm. And then, you know, adults who are in care settings where they may be getting a little less attention on how to adjust Omnipod five to get the best clinical outcomes, a lot of them are still using higher targets too, and they could they could get a pretty significant benefit. We started down this road because you asked what's the benefit from a 100. Yeah.
And, you know, we showed at ATDD, it can be as much as five points of time in range of moving from one twenty to down to a 100. So it's a it's a big change for folks that can be available.
I have to tell you two things. First of all, I my brain works in such a funny way. When you just said, well, we started with your question. I thought, oh, did I ask that? And now I realize that was forty five seconds ago, which is, I guess, how my conversations end up going the way they do usually.
Reaching Patients Through Clinicians9:27
But tell me how you're gonna educate people to to to use that lower target. Like and how I mean, does it go through the clinicians? Right? Because you don't have a lot of contact with the the patients directly. So how or do you not do it?
You just hope that the the the community
Oh, no. We definitely do it. Okay. We have we have a we have a few levers. Before we started, you and I were having a chat about, you know, what's the value of companies like us being here at ADA.
And, actually, this is one of the vehicles that we rely on in order to get attention of clinicians and help them connect with the fact that, hey. But you may have a lot of patients who are not at the lowest setting. And if you want tighter glycemic control, have a look at, you know, the settings that they're using when they come into your office. So moments like this are part one. The second thing is, you know, our field teams that are out supporting clinicians in the market all the time are gonna be having conversations with providers to make sure that they know that the 100 target is available and that they have an option now to give people even tighter glycemic control.
And so that's a big part of what they'll be doing over the next few weeks and months as we pull through the launch. Additionally, there's two other levers. You know, we we do have direct contact with our customers, and so we have the option to make them aware of the fact that this lower target is now available, and we'll pull that lever. And we've actually we're just announcing and launching the full market release of Omnipod Discover, our data platform, which, actually has weekly insights in it for people with diabetes. And that also gives them some nudges and some ideas that maybe maybe they wanna explore Yeah.
A lower target to get titerglycemic
control. Website's coming soon?
Yeah. It's rolling out clinician team by clinician team. So as as an office sort of ops in, then our team gets them set up, and then people with diabetes who are cared for by the office can then get access to the part of it that faces people with diabetes, and that provides weekly insights directly to them on their care with support when they've done well, celebration when they've done well, and some ideas for how they might take better care of themselves.
So based on your experience, what do you think stops a clinician from either getting the information themselves or sharing it? Like, you you put yourself in because I really have trouble with it. I don't I I can't wrap my head around when, for example, someone says to me, oh, I tried to get x pump, but my doctor said they don't know how to use it. And my follow-up question is, could you not take an hour and figure it out and then help them? But, like, I talk to doctors and bring it up, they'll say, we don't I don't have time for that.
And so is there is there a lever in there to be thrown that would be valuable for everyone? Or, I mean, what do you see from your perspective?
I we see the reality that you're describing, which is, you know, we have huge empathy, respect, and gratitude for the work that HCPs who care for people with diabetes, you know, for the care that they put in. Right. They are incredibly busy people. And and I actually I have high empathy for the fact that they don't hear our messages the first time. You know, I'm I'm out in the field a lot with our team.
Okay. And, you know, it's a common theme actually that, you know, Rip will say to me. I I Eric, I I swear I've told them that five times, but they heard it for some reason in this conversation. And, you know, part of it is just about creating a moment where somebody can slow down enough to absorb new information. And if you're a health care provider charged with caring and delivering clinical care for the patients that you're responsible for, I think it's natural that they wanna understand the technology well.
What that means for us, Scott, is two things. The first is we dramatically simplify the technology. And so we work very hard during design so that there are as few inputs for health care providers to put into the system and to manage sort of as they're caring for patients. And second, you know, our teams out in the field are working hard to make sure that health care providers have the support that they need so that when somebody does want Omnipod, if that's the if that's the answer back, our team's there to say, hey. We'd love to have a conversation with you to help get this patient who really wants Omnipod.
We can help you through that and help you support that patient in having a great experience.
Outcomes, Simplicity, Fewer Barriers13:33
Yeah. So my perspective here on that is I feel like what it is you're doing. So making the the target lower at 100, but there's also other enhancements to the algorithm right now that I wanna know about. But you're doing that because it's your overall feeling that the less somebody has to touch it or understand it, the better off they'll be because maybe they weren't going to to begin with or maybe the doctor wouldn't. Like, are you trying to just take the I mean, I'm sure you have a tagline around this that I'm supposed to know.
But, like, like, you're trying to take the the the work out of it so they can have an outcome that's great. But then there are people who are lever pullers and knob turners who are probably irritated that they can't make more adjustments to it. So then if I'm putting myself in your position, my expectation is is you're trying to get to the point where the knob turners are happy and the people who would never learn are gonna be healthier. Is that the goal?
Yeah. You got it. Yeah. When when we if we just take a big step back, there's less than half of people who live with type one diabetes benefit from automated insulin delivery in The United States. So despite the fact that it's been a technology renaissance for ten years, you know, we are we're touching less than half of people who live with type one, and we're touching approximately five percent of those who use multiple daily injections live with type two diabetes.
The unmet need is huge. And, you know, what that means for us is we're focused on three things, basically, and all of the product development efforts that we think about and all the commercial go to market. It's first, how do we deliver better clinical outcomes? So why do we do something like a 100? Because we want people to get better clinical outcomes.
And we saw that we could offer tighter glycemic control with no additional increased risk of hypoglycemia. That's that's exactly the kind of bull's eye innovation that we go after every time we can. Okay. The second thing is we wanna simplify the technology, and we wanna do that because we know that diabetes is an incredibly burdensome disease. And giving people an option to use a 100 may, you know, at the margins, mean the system does more for them.
There may be a couple of moments in their day when they don't have to think about their diabetes because they know the automation's working harder for them in those moments. Similarly, you mentioned some other changes. We also adjusted how the automation keeps people in automated mode more and requires fewer manual interactions, especially during moments of prolonged hyperglycemia. And that's, you know, again, sort of pointed straight at this notion of simplification. Yeah.
We wanna make it as easy as possible for people to stay in automated mode because we know that's how they get the best experience.
What did you have to change to make that a reality?
So we adjusted how some of the safety controls that we'd built into the first generation of the algorithm, we adjusted how they operated. And in that first generation, there were moments where when the algorithm worked as hard as it could for a long period of time, it would ask for manual intervention. Because, you know, if you wind back the clock five or six years, we weren't sure how well CGM was gonna work, and we weren't sure, like or or pods gonna be not delivering insulin. And, you know, do people need to check something in moments where the algorithm had worked as hard as it could for a few hours? Mhmm.
What we actually saw in real life is we didn't need that safety constraint. We were asking people to put work into the system that they don't need to. And so we said, great. Let's design that out. Now people don't have to do that.
And so Omnipod five works harder for people in exactly the moments that they need it. Okay. And the final thing that we're always innovating for is to break down barriers. And, you know, that's part of why we think so hard about simplification for providers is part of the reason that penetration is low is that it's still challenging for providers to prescribe AID. We were just talking about that burden of all that they have to know.
And so if we have an opportunity to take away something that a physician might need to know to confidently prescribe, we're gonna do that because that'll make them more likely to offer AID to their people in their care.
You know, it occurs to me that instead of trying to change the way humanity works or the way people think or how things have gone for so long that we can't break free of them, just take them out of the loop. Right?
Yeah. You got it.
Getting the Omnipod 5 Update17:31
That's awesome. Okay. So Omnipod five is where it is now. How do people get it? Is it available now?
Are they gonna need new pods? They need a download? They need a what do they need?
They need an app update that's rolling out now. Mhmm. I sat next to a gentleman on the flight here who already had the latest iOS update. I happened to see his Omnipod five app as he was flipping between a couple of other things that he was doing, so we had a conversation. And, you know, I bump into Potters all the time, Scott.
And I I always tell him, look. I'm not a clinic clinician. I don't have opinions about your care. But if you want me to tell you a little bit about the technology, I'm happy to help. And so yeah.
No. He was all in. He wanted to know about a 100. He had just gotten a new iPhone, so he that had been how he'd gotten the app. But the app's just rolling through our customer base.
Started on June 3 and will be done in the next couple of days. A lot of people have it already, and you do need compatible pods. There's a little indicator on whether they're compatible. We've been shipping those for a while. So a lot of people do have compatible pods Okay.
To use the 100 target.
And those who don't, the next time they get a shipment, they will. Yep. That's awesome. And what does that leave? I hate saying that.
I always feel I always feel ungrateful. Like, people are like, here's more. And I'm like, but is there more? So is there more for Omnipod five, or is this gonna be what it is until we see Omnipod six?
So we also launched compatibility with Freestyle Libre three plus this week. So we had we made the algorithm changes, the lower target glucose and compatibility with Freestyle Libre three plus. At this point, that's what we've disclosed about Omnipod five because we are looking ahead with enthusiasm to Omnipod six Mhmm. Which data we're presenting this weekend, the STRiVE data, and then it's due to launch in 2027. So Omnipod six is coming quickly, Scott.
It is. Yes.
Okay. So I should imagine a bunch of people behind the scenes toiling away working for Omnipod six. Omnipod five is about where it's gonna be.
Again, we know that it's important that we keep delivering what customers need. And, you know, we have experience sustaining multiple platforms in the market today. And so, you know, we're not gonna leave customers behind, but we do also need to turn our innovation focus to make sure that we can put full force behind Omnipod six, which is gonna be a pretty remarkable product.
A Closed Loop for Type 219:48
You're good at this part of the job, but not the podcasting part. You save the Omnipod six stuff for the end. What are you doing? Everybody's gonna tune out if you tell them about the Omnipod six. Alright.
Don't you wanted to know about the closed loop system for type twos?
Absolutely. Let's
talk about that now. Alright. Alright. Well, we'll do it we'll
do it in the year order, Scott.
Why tell me how this is gonna help type twos, what this system does for them, and then get ready for the question when I ask you how come type ones don't have a closed loop system like that. So please. So
as you described, we've we're working on updates to Omnipod five, Omnipod six, and a fully closed loop system for type two. The the reason we started with type two is two things, Scott. The first is back to that, how do we break down barriers to access for technology? About seventy percent of the people who take multiple daily injections and live with type two are cared for in primary care. Mhmm.
And despite all of the work that we have done simplifying Omnipod five, despite our efforts, it's still too complicated for broad adoption by primary care. Mhmm. The amazing thing about the flake closed loop system for type two is that it's designed so that physicians can write it. It's as easy for them to write as CGM. Customers pick it up from a local pharmacy, bring it home, and they can start it without any required inputs.
There is an option to adjust the glucose target in so folks can do a little personalization. Okay. But there's no required inputs in order to get it started. And, you know, what that means and then folks can self start in their own home. Mhmm.
And what that means is it breaks down these critical barriers to prescribing where the GPs who are doing the writing don't have to be educated on things like basal rates and insulin to carb ratios and all the things that today are obstacles for primary care physicians writing AID. And similarly, customers don't have to be educated on BolaSign or, you know, what what it what's required in order to safely dose insulin. So it's a dramatic simplification designed to help bring AID to the millions of people cared for by primary care who use multiple daily injections of insulin.
Will those users have access to those settings through something you give them, or will it be through a phone, or is there are multiple ways to get to it?
You know, we imagine a pretty simple experience where just like in today's Omnipod products, there's an easy to understand target that offers just a tiny bit of personalization, but there's nothing clinically required Okay. In order to use the system.
But when somebody does put something, input something, they do it through a phone app?
Do it through a phone or a controller. Through a controller. Yep.
Where GLP-1s Fit In22:20
When you're testing that, do you have to take GLPs into consideration now because they're so widely used? Is that I assume. Right? Is that a thing you're gonna be thinking about about for type ones too? Because I fully expect GLPs to be I mean, you're seeing a lot of people use them off label now.
Right? So do you have any background on that for me? I'm just super interested in this.
So Yeah. Maybe to hit type two first and go to type one. Please. So yes is the short answer. GLP ones have been used in the treatment of diabetes for almost twenty years at this point.
I'm sure you know this well, Scott, but maybe for your listeners, you know, they began as diabetes medications and have been, you know, in use as part of the treatment paradigm, usually ahead of insulin and often with insulin as complementary therapies in the treatment of type two for a long time. Right. And what we see is that actually people who live with type two diabetes get the best clinical outcomes when they are using a GLP one and on AID. Mhmm. Because once they're at the point that they need insulin, they need insulin.
And then the question is, how do you make that insulin delivery as effective as possible? And guidelines now recommend automated insulin delivery, and what we see in our clinical data is that the people who are on AID and the GLP one do even a little bit better. And so we don't so we do take them into account, but actually we we celebrate that innovation for the fact that it works really well with AID.
No Settings, Self-Start at Home23:40
Before you move forward with the type two, it's like, I'm it's just hitting me what you said now. So I'm gonna get this device. It's gonna I'm gonna bring it home, and I'll put it on myself. There's no settings? How does it how do it know?
I
I love this moment, Scott.
Because we we we had a
few of these over the
last few months. Wait. Did you just say that I don't have to do anything when I get it? How how is it gonna figure me out and do the thing?
The short answer and actually, so Trang's gonna present data on this at during product theater tomorrow, but actually, we're gonna show how we started in evolution three, the the data presented this weekend. We started everybody. They put on the pod, and the system adapted to the individualized insulin needs, adapted to the individual individualized insulin needs of each participant in the trial and, you know, delivered overall time and range. It was really compelling and you know, significant improvements in time and range. And so, yeah, the intelligence in the system is there in order to start safely and then adapt to the insulin needs of people with type two diabetes.
That's awesome. Because you're reaching a population that just from my personal experience, it's just a a a close friend of mine who, you know, came to me three years ago and said, Scott, I have neuropathy, they tell me. And I said, well, you have type two diabetes or prediabetes? No. I don't think so.
And I went, you probably do. And I said, here's a meter. You you know what I mean? And I gave him a meter, and I said, you know, here's what I want you to was like, test yourself here, here, here. Make a little graph.
I'll come back next week. We'll look at it again. Right? I came back next week, and he said, I couldn't figure out how to get the strip in. And the and I I said, okay.
And I showed it to him again. Then I came back a week later, and I said, how are doing? He goes, I forgot. I didn't do this. Now between you and I, like, he's definitely prediabetic.
And if somebody could step up to him and just say, like, look. There's nothing to learn. There's nothing to do. I'm I'm imagining him in my heart right now. Like, he would be helped immensely by this.
How how are you gonna get from this amazing innovation through? Because you gotta go through GPs. Like, what's the new process to to get them out there? Is it you send the staff out and and tell them to tell the story, I guess?
Yeah. And it's moments like this where we show the clinical data and the potential impact of the technology. Clinical data and then physicians creating the opportunities for clinicians to learn from other clinicians is really impactful. And then the last piece, yes, is that we will we will staff and support our team in going and taking that message to primary care providers when we've got that technology ready to go broadly.
Yeah.
The the good news, actually, we're we're learning a bit about that now as we as we pull through the launches of Omnipod five this year. We're actually gonna be calling on a few GPs that actually care for about a hundred and fifty thousand more people with diabetes in the second half of this year. But it's good because it helps us start to appreciate the practice differences in GPs compared to endo. And so it exactly as you said, like, it's a different world, and we're getting ready for that so that we can do it with impact when the technology is ready.
When you look up at those GPs, are they anxious for this? Do you find them saying, oh, I'm glad there's something here finally to help these people. We haven't had a lot of success, or do you find that it's difficult to do they get scared of the idea of insulin, I guess, or or about pumps?
The the kinds of folks that we are building relationships with are people who are already prescribing insulin and already prescribing CGM. And when they see the pod and they see what it can do, they're incredibly interested. And then, you know, they they in some cases, you know, the ones who are at the leading edge, we're teaching them to prescribe Omnipod five today. You know, as the market leader, we spend a lot of our energy broadening the prescriber base because that's the key barrier to access for a lot of people's diabetes. Yeah.
But then we bump into a lot of them who are like, look. This technology is amazing. I don't have fourteen minutes to do that in an office visit. So, you know, they need the product that I was just describing, which is the one they just send it to the pharmacy. The patient picks it up.
They self start at home, and away they go.
When you hear stuff like that personally, does it frustrate you or make you sad? Like, what's your response when you because I'm a person who I deliver information to people that I know helps people.
Yep.
And when you put so much into putting it together and finding the right way to package it and deliver it, and there it is, and you feel like you're like, here it is, and they go, I don't have time. I I get frustrated sometimes. So I'm wondering how it feels for you.
It actually doesn't trigger frustration. It triggers motivation for me, Scott. And I think, like, that's the inspiration for the product we were just talking about that, you know, has nothing in it in order to start was we looked at we looked at the real unmet need. The real unmet need is caring, well meaning physicians do not have the time in order to prescribe today's AID systems to give the people in their care the benefits of technology. That's a super clear problem statement that we have been working on in order to deliver the technology to the world that's gonna help address that problem.
Okay. And and so, you know, look, challenges are just motivation. And, you know, there's there's probably fourteen million people insulin requiring diabetes thereabouts in the markets that we serve today. Mhmm. And only about ten percent of them benefit from automated insulin delivery.
And it's problems like this, barriers to access, barriers to prescribing that motivates us keep innovating and keep broadening who can benefit from technology.
Why Type 1 Isn't Fully Closed Yet28:55
So the question is, this type two system, is it informed by what you learned from Omnipod five, or is it about to inform what we're gonna see with Omnipod six?
Both is the answer to that. We have been we have been thinking about, you know, how do we simplify physician interactions? How do we simplify the wear experience for people with diabetes since the launch of Omnipod five, and I've been learning quickly. And so that, you know, Omnipod five is sort of the precursor for both. And but the spirit of simplicity, going back to our three pillars, you know, simplifying the experience to the greatest extent that we can, How do we eliminate, you know, bolus burden for people and reduce the amount that they have to manually bolus?
How do we increase clinical outcomes? Those two goals underpin both Omnipod six and the type two fully closed loop product, and we've taken technology learnings to both of those from Omnipod five. Okay.
So people are listening or hearing fully closed loop for type twos. Like, why is that not a thing that type ones can have?
Folks who live with type one, I think, will get there in an iterative fashion. I think what we see is that a lot of what is talked about as fully closed loop today are really bolus optional systems. And, you know, a few minutes ago, were talking about what about tinkerers and people who are highly engaged. And I think what we see is that within the type one population, in fact, even a little more broadly, within the population cared for by specialists, which are the folks who've been prescribing technology for, you know, ten to thirty years, the the the people with diabetes cared for in that call point want options. They wanna choose how engaged do they wanna be in the technology.
And and so and so for us, that says, okay. We need a a bullish optional system. We need to keep pushing the envelope of how good can the automation get so that the hybrid closed loop systems invite people to engage as much or as little as they want to. So I guess that's our vision, is that the people with type one diabetes, yes, we are innovating towards how can they choose to interact not at all with the system. But I think what we see is that a lot of them are going to choose to interact with it a little bit because of the realities of how quickly insulin works.
Right. And, you know, they may choose to bolus once a day or every other day or a couple times a day. But that notion of choice is, I think, what we see that's the right product for people cared for in what have been the traditional settings for AID systems.
From what you've seen so far, is there a tuning that one day gets us to a hands off, or is it about the insulin at some point? Like, do you think it do you think you get there eventually where you just you slap it on somebody and you're like, go ahead and that's that, or do you not see that in the near future?
I think it depends what clinical outcomes folk folks are targeting, Scott, and how carb heavy a diet is. So, like, today's technologies could deliver that experience for folks who are eating very few carbs. I think for the for the average normal diet person living with type one diabetes, for for them to feel like they're getting acceptable time and range, which I'll say is somewhere in the seventies probably for a motivated type one who's eating a normal diet, We're gonna need some help from faster insulins in order to deliver a truly hands off product. But I I think what's inspiring to us is that the journey to getting there is better and better automation where people may choose, yeah. Okay.
You know what? Maybe I'm only gonna bolus once a day
or maybe
I'm only gonna bolus on certain days, I'm gonna skip it entirely. And offering people that freedom to choose is super empowering as I know you know from your own work.
I try to remind myself, and I try to remind the audience too that, you know, even in my daughter my daughter's 22. She was diagnosed when she was two. There was a time when we were excited if they put out a new meter. It wasn't any more accurate. It didn't do anything that the old meter did.
It just looked different. We were like, oh, this is awesome. A new meter. And now we're sitting around going like, oh, so you made the the advancement of Omnipod five. When are you gonna make more to it?
When's Omnipod six coming? Have you thought about Omnipod seven, eight? Not you know? And and I know the world works that way now, but it's it's valuable to remember that there are people alive with type one diabetes right now who boiled needles in a in a pot of water to sterilize them. And I I get really excited about how quickly things are moving nowadays.
Inside Omnipod 633:14
With that in mind, if we're back here next year, what are we talking about? Are we talking about Omnipod six? And can you give me give people a little detail about it for those who haven't heard your announcements?
Yeah. When we're here next year, we're gonna be talking a lot about Omnipod six, and we'll be talking even more about the fully closed loop product for type two. Omnipod six is super exciting, Scott. Omnipod six is our next flagship Omnipod product. It's starts with a new algorithm back to better clinical outcomes, simplifying for people.
It's a big step on both of those from an AID perspective. Is it
a completely new stack? It's not Omnipod five zooshed up a little more? It's it is it a completely different like, is it a built a bottom up build, or is it in a is it iterating on top of Omnipod five? Or are you not allowed to say that out loud?
It's not so much about what I'm allowed to say. I'm actually just thinking about the question. I think one of things I've learned is we're all always standing on the shoulders of giants. And so even when one thinks you're doing something bottom up, one never is. Certainly, it builds on Omnipod five.
So we learned a lot from Omnipod five, and we saw some really powerful ways that we can improve outcomes for people when we pulled those levers in Omnipod six. In addition to the automation improvements, we're also improving wearability. So as, sensors have gotten smaller, the wear locations that people are wearing automated and delivery systems to keep connectivity high have become a little bit restricted. And, you know, we recognize that what people want from a wearable experience is they wanna wear it anywhere they can take an injection of insulin and still have great connectivity to a CGM. Yeah.
And so we're making pretty significant hardware changes in order to enable that for Omnipod six.
So next year, I won't have to say the words line of sight anymore. Is that what you're telling me?
That is our aspiration. Awesome. That yeah. I the gentleman I sat next to on the plane, on on the one hand, I was happy that when he reached to show me his body, he reached for the wrong arm, and I thought, oh, that's good. He forgot where it was.
And then he put it he reached for the other arm. Then he told me I had the two side by side. And and look. We as we aspire exactly as you just said to break the need for line of sight and let people have the freedom to enjoy the wearable experience where they want it. That's really awesome.
There is one more piece of Omnipod six, if I may.
Well, yeah. Tease me. Tell me what's happening. Let's go.
The the last piece of Omnipod six is it's it's an updatable pod. So in with Omnipod five, when we launch new innovation, we actually have to start it in our factories. Oh. And so and it's often a new physical skew that people have to pick up in the pharmacy, which takes six to nine months. We were making pods that were compatible with Freestyle Libre three plus in our factories at the end of twenty twenty five, and we're just announcing that launch this week because we have to make enough supply, get it into the wholesale channel, and get it in the hands of customers.
So, again, back to our principles with Omnipod six, we've got a fully updatable pod, which means it's easier for prescribers to prescribe because they've just one SKU to write. And it means we can accelerate innovation to customers because when we have an update, we can actually push updated pod software to the pod hardware through app updates, which is really cool.
Wait. Is what you're telling me is that some of it's gonna live on the pod, but some of it'll live on your phone? Or no. You're telling me that when I put the pod on, it's gonna update?
Yes. Get out
of here.
It's it's
very cool. Did that person get a raise? I don't I don't know the answer to that,
but I I think they probably did.
Yeah. That's a May so if I have a you make a pod and it's version a, and you guys have updated to version b. I put a on. And during the priming process, it updates that pod, and it's ready to go with the new the new brain.
You got it. You're good at this.
No. No. Stop. And and so we do you have to go back to the FDA as much then, or does that does that that doesn't stop that?
Yeah. It doesn't really change the regulatory requirements. There will be some things that, for various reasons, it takes us a couple generation to be able to update absolutely everything on the on the pod, but we'll be able to update a lot of the technology on the pod during priming exactly as you described.
That's exciting. And it brings people stuff quicker, probably eliminates waste, and a lot of other things. Right?
You got
it. Really appreciate you doing this with me. Thank you very much. Likewise. This was fun.
So I'm glad you think so. I thought so too. Yeah. It was. Thank you again.
Wrapping Up37:20
If this is your first time listening to the Juice Box podcast, I'd love it if you'd subscribe and follow in your favorite app, Apple Podcasts, Spotify, or wherever you get your audio. There's also a ton of free offerings on my website, juiceboxpodcast.com. And if you're looking for community, we have maybe the most active and lovely Facebook group wrapped around type one diabetes. It is called Juice Box Podcast type one diabetes. And as of this recording, I believe it has 85,000 active members in it.
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Again, really did enjoy being at ADA, meeting Eric and actually a ton of other people who are gonna be on the podcast because I was able to meet them in person and and have nice conversations. And we thought, oh, this is this is good. I wish somebody else was listening to this. We're gonna be talking about DIY algorithms with people I met there, a lady who's writing a book about diabetes that I found very interesting. Gosh.
The the person who makes glow gummies. And I think we're gonna be doing some stuff with other companies, and it's gonna be great. It was a it was a really good time, and it was definitely something that's gonna help the podcast to grow. So you guys are gonna get, gonna get more because of it. If your loved one is newly diagnosed with type one diabetes and you're seeking a clear practical perspective,
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Recorded live at the ADA Scientific Sessions, Scott Benner talks with Insulet COO Eric Benjamin about what's new for Omnipod 5: a 100 mg/dL glucose target, an algorithm update that keeps the system in automated mode longer, and Freestyle Libre 3+ support. They look ahead to Omnipod 6 (new algorithm, wearability, updatable pod) and a fully closed-loop system aimed first at type 2 diabetes.