Full Transcripts

Hello friends, and welcome to Episode 506 of the Juicebox Podcast. it finally happened. I received an email from an endocrinologist who wanted to come on the show. I've been waiting for this for so long. On today's show, I bring you Kathleen bolts, MD, pro medica, pediatric endocrinology, she's got a title and everything is like legit. I have been waiting so long for this day, to get an endocrinologist, someone who's been helping people with type one diabetes for years. And then they found the podcast and have some thoughts to share. I'm up for this, you know, this is what I'm looking for. I want to talk to more endocrinologist, you've come on, keep coming. I love this. I love this. Please remember, while you're listening, that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, please always consult a physician before making any changes to your health care plan are becoming bold with insulin. And while I'm at it, let me just say that Dr. molts is representing her own opinions right here. And not the opinions of any of her employers, past, present, or future. I edited this a week ago and I am still excited to do this right now. I'm just putting some ads on this thing and get it out to you guys. So excited. This episode of The Juicebox Podcast is sponsored by the Dexcom g six continuous glucose monitor. You can find out more and get started today. even@dexcom.com. forward slash juicebox. Do it just do it. Just listen to me. Just go do it. While you're out there doing things want to check out the Omni pod dash you may be eligible for a free 30 day trial of the Omni pod dash tubeless insulin pump. I don't know if you just heard what I said. But you could be pumping with insulin for free for 30 days. Find out if you're eligible. omnipod.com forward slash juice box. I'm getting right to this a long episode. I loved it. I was very emotional at points. I don't want to ruin it for you now. But dig in Kathleen's terrific. This is an insightful episode.

I'm Dr. Kathleen Moltz. I'm a pediatric endocrinologist and I'm really excited to talk to you, Scott,

I'm very excited to talk to you as well, I have been waiting for an email like yours for a very long time. So thank you very much sincerely. I'm genuinely saying that. Okay. So I guess Let me tell you why. I start this podcast. And I think to myself, everybody can benefit from good information. And I think that's counterintuitive to how people think about it. I think I think on some level quietly in spaces and corners, there's the idea that some people can understand this stuff better than others, and that some people just aren't going to do as well as others. And maybe that's maybe that's it, maybe that's just how it has to be. And I always thought, like no, like, we could boil it down to these simple, simple ideas that I think almost anybody could understand. And then once it started to prove itself out on the podcast, I started thinking like, maybe doctors will hear it one day. That was really like, like my thought. And I do get notes from people who tell me that they found the podcast through their physician, which I think is amazing. But if you listen, you know that every once in a while I throw it out there. I'm like, Hey, if you're a CDE or an endo like and you find this helpful, and you're the one that said hello, so thank you so much.

That's exactly why I actually sent the note. I actually didn't start listening to your podcast until maybe a month before I sent the note. Okay, just maybe two three months ago, um, I had heard about it before. I mostly listened to other kinds of podcasts, science fictiony types of podcasts on my 70 minute one way drive to and from work. And I got caught up on all my other podcasts. And then I was looking for something so I searched for a bunch of different diabetes podcasts, listened to one super boring listened to another really not focused on type one focused on type two. So I'm like well, I've heard of juicebox before I'll try this and I listen to one of yours and I enjoy So I listened to another one. And I enjoyed that. So then you mentioned the pro tips podcast. And I started at the beginning, just like you recommend. And I listened to the pro tips podcast, and I almost quit listening to you. Because Because I'm excited. Go ahead. Why? You bash doctor?

Do you feel that? Is that how it feels?

That's how the first time that wasn't just me because I turned to everybody in my group. And I said, after I listened to a few more, I didn't give up. I listened to a few more. And after I listened to a few more, I told the rest of my group I said, Hey, guys, you have to listen to these protests. But you've got to get past the first one because the first one seems to medical bash, I call it doctor bashing because I'm a doctor, but like, it bashes the medical community a little bit. Not. I don't think you intended it to come across that way. To be honest, having heard now Oh, gosh, how many of your podcasts have I heard? I don't even know. I'm 130 140 out of the 50 150 500. Right. Um, but it definitely is harsh. And one of my nurse practitioners who listen to the first one came to me and said, Dr. maltz, I don't know if I can keep listening to this. Does he continue on like this? And I said, No, no, he doesn't, you have to listen, the concepts are really awesome. And it got me thinking about a lot of things. And that's how I binge through all of the pro tips, and then all of the defining diabetes, and then I listened backwards through 2021. And then I started in 2015. And I'm July or August of 2015, at this point, and still keeping up to date on 2021. And moving backwards through 2020. Wow, that's amazing.

First of all, everyone should listen like that. Thank you very much for saying it that way.

You're welcome. I agree. That's how I tell people to listen, when I recommend your podcasts, I can't

wait till you get to the first handful of them. That's gonna be super interesting to hear how you feel about those. So okay, so now I want to say that if I was letting you take this out of our space for a second, if I was a garbage guy, and I every week, I rode by your house, and I grabbed the garbage. And I did a really good job of grabbing the garbage for some people. And for some people, I did a medium job. And for some people, I left trash strewn on their front yard. And, and I was going to make a podcast to talk to all people who are serviced by garbage men, I might start by saying, Hey, I know some of you get great service. And I know some of you get what you think is great service. But some of you aren't getting good service at all. And so I imagine if I'm a, if I'm now the garbage man, and I'm the guy that does a great job. I'm like, Hey, what's this about garbage men do great jobs, but they do a great job, not everybody. And so I get that. No, but I'm super. So is that actually a term like is Doctor bashing like a, like a term that exists in this like ice that I'm just not aware of?

It really is. Um, so I belong to a number of Facebook groups. I don't spend a lot of time on Facebook, but I do find I get a good amount of support. And there's great forums for asking questions. Some of the groups I belong to are women physician, some of them are endocrinologists, both adult and pediatric. Some are just pediatric. Some are just like, people who are interested in the same things are going through the same life experiences. And doctor bashing is a real thing. We often I'm not going to speak for we I'm going to say I have come across a number of situations where people will express their disappointment in their interactions with their group of physicians, nurse practitioners, physician assistants, not always being able to tell the difference between us. And many people in the same conversation will agree with them. And then they'll turn and look at me and they'll say, Oh, I'm sure you're different. With very little sincerity. So there is a little bit of what's the right word. defensiveness that many of us come into conversations with when we hear others making critical statements that don't seem to recognize what at least I feel like most pediatric endocrinologists basic motivation is Yeah,

well, I would imagine Everyone's so I want to say this. I imagine everyone's Basic motivation is good. Like, I think it would be a weird, a weird profession to take up if you weren't interested in helping people. But I don't know that that makes a difference. For this, maybe maybe I do sound harsh. I don't know if that makes a difference. Ready? Here we go. I don't know if that makes somebody if you're not good at your job. Like intentions not helpful at that point. If, if, if a person comes into a medical practice, and says, Hey, I learned how to Pre-Bolus my meals, and I fixed my basil rate and look, my a one sees 5.8. And then you spend 10 minutes yelling at that person. I don't care whose feelings it hurts. You're not a good doctor. Right? Okay. That is correct. That happened. I agree. A lot, a lot. Actually, two people. That's really sad. Yeah. But now I think I see the other side of it, though. Because if I'm a doctor, who doesn't have great up to date information for people, and I think to be fair, the advent of continuous glucose monitors, pumps faster acting insulin could leave a lot of people who have been teaching people how to manage type one, since the ad is at a loss. And so if they're used to seeing an A one, C, that's 5.6. And thinking, this means these people are having frightening lows, because no one knows how to get an A one c like this, I even get the initial reaction of like, Oh my god, you're gonna kill yourself. But how do you, I don't know how to take that person and teach that old dog a new trick. And so I have to put myself in the position of speaking to the people who are going to end up getting yelled at and empower them. So I'm not bashing the doctor as much as I'm telling the person to expect better and that some doctors might not have better to give. Does that seem fair?

That is fair. Yeah. And again, as I continue to listen to the pro tips, and has now become a serious fan of the podcast, in general, I agree. And I think the way you get to physicians and the rest of the world, is by having exactly what you're putting out a really enjoyable, easy to listen to friendly podcast, that goes over information, not just in a dry academic way. But also in a way that's conversational, that brings in real life experiences, that talks to people who are living the diabetes, and not just people who are practicing the medicine for whatever, 10 or 12 hour shifts that each of us does.

Well, I appreciate that it struck you that way. Because that was surely my intention. Which because I think it's funny, because I'm sort of I don't think I'm growth Personally, I have a very low threshold for bullsh, I guess. Right. And so I know that I know, people, like I know, that's gonna sound strange. But I think one of the reasons I'm good at communicating with people is because I, there are times where I know what people need, not just what they think they want, and you need good information. But you also need it to be delivered in a way that you can take it and and you need to be able to take it up and it can't be thrown at you all at once. Listen, I've spoken at so many live events, I have lost count of them. And I will stand at the back of rooms when doctors present. And I think to myself, I understand this. And I can't make myself Listen to this. And it's not because it's boring. It's because it's so academic, that it's not even usable. Right. And so you're sitting Yes, it's a failure of people not to understand their audience. And to understand, you know, I'm gonna say something that feels committed to saying I think outside of the box, and I hate that, but you have to meet people where they are.

Absolutely, absolutely true. completely true. I think too many professionals of all fields, when they're talking to people outside of their fields, don't do a great job of remembering how little they knew, because before they became a professional in their own field. And

let me see what's hard. You may not be able to answer for your own personal safety and 42. Well, I'm 35 that if that's where we're going with this? No, no, no, no, the answer to everything. Oh is 42. Okay, you know, the most commonly guessed number between one and 137. If you ask people for a number between one and 100, they will most randomly come up with 37. Don't worry about that. Let's move on. So I'm going to ask you a question. You might not Feel comfortable answering? Am I better at being an endocrinologist and some people's endocrinologist in regard in regards to giving people information that's usable?

you actually are okay. And I think I can go on record by saying that you also have the ability to make endocrinologists better endocrinologists, if they take what you're saying, and think about it, and turn it around in their own heads and their own experiences. And I say that coming from I actually, before we had this conversation, I sat down and did like a little Google document my career and diabetes tab. And there has I sort of, I sort of want to like, share it with you. And that's

okay, I would love you to,

um, I graduate, I'm going to date myself now. I graduated from college undergrad in 1986.

Oh, bedrock University.

Um, and the first insulin pen didn't come out till 1985 was the novo patent. When I graduated from medical school, we were using regular and NPH human and pork, two shots a day, nobody did more than that. And a standard new patient stay in the hospital was six to seven days, right? And so the first day or so you're on IV insulin, and then you went on every six hour regular. And then from the regular, we calculated your regular and mph doses and gave you your meal plan. And that's that's the cut and dry. You have to

Can I ask you a question before you go on? What was the medical intention of that? keeping people who otherwise would die alive as long as possible? Sorry, I have a phone ringing and you're not allowed to have a personal life while you're making this podcast. It isn't a personal life. It's a landline I want to get rid of. I think you know, it's somebody right now seeing if you have solar panels on your house, or if you'd like to get an extended car warranty.

I may have the liberty to update my market.

100% Yeah. So so and so. So that's not a judgment. That's no, no, no,

I understand. It was truly, this is the best window that will help people live a reasonable life with low risks of having hypoglycemic seizures and dying. And probably higher than we want risks of having high blood sugars and complications. Yeah. But But as much as we thought that high blood sugars weren't good, the dcct started in 1982. It didn't stop until 1993. And that's the year I finished residency. Wow. So we didn't have all of the stuff that you and your daughter benefited from, which was even checking your blood sugar more than once a day was actually important right now, in those first date, years when I was in residency, like having a patient come in, and having a handwritten logbook, because nobody had download programs, and looking at the logbook to see how many days of numbers were written in the same color ink or pencil. So you could guess how many of the numbers were accurate and how many of the numbers weren't? That was kind of the standard we worked from. And you manually calculated averages for breakfast, lunch, dinner, bedtime, based upon, you know, the three glucose numbers a week in each category that someone might get you, you made a guess about which regular and NPH doses might need to be changed. So wasn't malicious. It was truly what we had to work with. So So tell me as a person who came up through that, how do Is it just not? What's the question? Why is it so difficult to learn something new when you've been taught a certain way? So you gotta listen to the rest of my story? I'm listening. Go ahead. Okay. So, I graduate from residency, I go into fellowship, humalog is approved at the end of my fellowship, and I have, I think, a really excellent fellowship. Um, I feel like I got excellent training from people who are thought leaders and research leaders. I didn't even through the entire training, have the opportunity to teach another patient how to give an insulin injection. And I joined a practice that was a private, mostly outpatient specialty only practice in the greater Boston area. And the practice model was no one is admitted to the hospital unless they're in moderate to severe decay. A, we teach everybody in our office, the doctor stays after work and does all the teaching. And so I found like my second day of work, I'm like, Okay, I have to teach somebody how to give insulin. And I've never done this before. The practice, I think was really instrumental in my being encouraged and supported and being more assertive. I'm not going to say aggressive with insulin. So we use humor log on almost everybody, we would mix humor log regular and mph or humor log regular and ultra latte. We would do two or three shots a day, we expected our patients to check blood sugar's four to six times a day, we tried to we beta tested a bunch of the original one touch glucose meters, the old clunky ones. And by the time I finished at that first job, I felt like my practice of diabetes was pretty aggressive. There were no CGM still, right. They were just the blinded occasional patients who got the blinded professional CGM, which were really impossible to use. They were painful to put in. It's really hard for somebody to gather enough information that you can look at the less accurate old CGM and make any sense out of it. And it was three days. Yeah. So I moved on to my second job. It was a more academic job. And at that point, when I changed jobs, the mini med Guardian CGM was just released. Um, we were still sometimes using pork insulin. And the Omni pod hadn't come out yet. By now, I understand. So through the next few years, I was kind of the lead in the diabetes section. And I tried to encourage continued proactive, let's give shots at lunch. Let's do insulin multiple times a day, let's I'm a very big pump proponent. So I've never had artificial durations of diabetes you have to have before starting on an insulin pump. And that, by the way, drives me that's loony. I hate sorry for the swearing. I hate I hate when people say you have to have diabetes, for a certain length of time before you can benefit from a pump because it's artificial, right? There's zero common sense or science. Do you think that go ahead, I'm gonna jump in for a second is that just end up being like the pot roast story then? Like, I know, you guys, I love your pot roast story? Yes, it's the pot recipe. It's just that this is how we do it. And it might stem from that's what we've learned through insurance problems, or that's what we've learned through the company. So you just give people this artificial number, so that they're not, it's almost, it's almost the idea of you should under promise and over deliver. Right? Like it is it is a and there's a surprising number of people that back in the 90s and early 2000s thought that that was very, very reasonable. I, I never did that. I had people argue with me. Um, why are you giving this person a pump? So soon? You know, we need to have X months of data first. And I'm like, why? How is that? How is that going to affect what we do at the time we set up the pump or any of the changes that we make? And nobody could ever give me a good answer. And I've never believed that. Okay. Okay. So, I'm going to kind of skip ahead,

go ahead. I'm making it next. I don't want to forget to ask me something,

no problem. Dexcom. Seven comes out. The mini med rebel comes out the Dexcom four plus g four comes out. things move forward. And there's more and more pushback from institutions to follow evidence based medicine and national guidelines. And in retrospect, it I didn't even think about this till I started listening to your podcast in retrospect, my my interest in being assertive and pushing that squashed it frankly did. I was criticized for not following national guidelines. I was put in a position of having to defend why I thought a toddler's target range should be 90 to 200 instead of 100 to 200 which is still a ridiculous range to you.

It's not really that big of a difference and an odd range. Well, but so my eyes fit it into the rules. Right?

Right. So you're trying to fit it into the rules. But also, I, over the years have found a lot of patients, or rather parents whose kids were diagnosed as toddlers, who never got over their fear of double digit numbers. So if the target range is 100 to 200, and you spend the first x years of your child's diabetes, thinking that a 99 is scary and dangerous, double digit numbers are always scary. And I found that if I gave a family a target range of 90 to something, then they would less scared and then I could move it down to 80. Or I could move it down to 70. Yeah, and I was through that barrier of double digit numbers are scary, we can't see them.

You needed that 90, just so you could keep the the moving. Yeah, it's a bait and switch, eventually, you're just gonna keep kind of moving the carrot on the stick, you're just gonna keep moving them a little closer and moving them a little closer, but you needed them to see a non triple digit number so that the anxiety in their mind could slowly dissipate. Exactly. So you're brilliant.

I'm not brilliant. Because I let I let my interest and I let my enthusiasm get squashed. And there were a lot of reasons for that for profit medicine is part of it. I'm very happy in my current position, which is my third position after fellowship. I will insert interject here and say that nothing I say, is reflective of my current or previous employers that everything I say is my own opinions in my own work.

I don't know about you, but when somebody makes a disclaimer, I'm super excited to find out what they're going to say next. So let me get through these ads quickly and get you back to Dr. molts. Let me think this is off the top of my head. Nothing written down in front of me. I can't see anything. The Dexcom g six continuous glucose monitor. What does it do for my daughter? Oh, it lets her sleep easier. lets her go out with her friends. It lets her find out what her blood sugar is, and what it's on its way to being. That's pretty crazy, right? Not only seeing that your blood sugar is I don't know what my daughter's blood sugar is right now. I'm gonna open up my phone and tell you how's that sound? phones open 81 her blood sugar's 81 aren't his blood sugar is 81. It is one o'clock in the afternoon. And it is steady and stable. I can tell that by what the arrows on my Dexcom follow up are indicating. You see, Arden has an app on her phone, you could do this for Android or iPhone, but Arden has an app on her phone. And right now it's showing her her blood sugar. And should she leave the range that we've preset on her phone, it will indicate to her that she's gone below 70 or above 130. You could make your range whatever you want. on my phone, actually, the range is 70 to 120. Nonetheless, nevertheless, whatever that saying is, you will get an alert if you leave the range that you have set. So if you want to know when you're over 150, it'll tell you if you want to know when it's rising quickly or falling quickly, it'll tell you and it'll tell up to 10 followers of your choosing. Now you can share this with somebody if you want to like your husband or wife or stockbroker, I guess if you have a stockbroker and you want to know what your blood sugar is, doesn't matter, you could as long as I guess if your husband was a stockbroker, to for one there, but not the point, right? You can share it with up to 10 followers. That's astonishing. Other people could be looking out for you to think about that, that can be a school nurse even. Right? Are you listen, are you putting it all together with me. And when you know what your blood sugar's doing, and where it's heading, you can make better decisions with insulin, at least that's how I think of it. I think of it as being able to make great decisions that stop rises and stop falls, you'll find out what you want to do with Dexcom when you get it in your hot little hands. And you'll do that@dexcom.com forward slash juicebox head over today and get started. While you're out changing your life on the internet. Get yourself a free no obligation. 30 day trial of the Omni pod dash is for those who are eligible, so you have to go find out if you are the eligible ones. But there's a pretty good chance you will be 30 days my friend 30 days is swimming and playing and jumping and involved in your sports activities. And if you're an adult like stuff you do with other adults, all kinds of stuff the way you live your life cooking in the kitchen, wandering out in the backyard pulling some weeds. I don't know what your life's like, but am I got a crystal ball. I have no idea but whatever you're doing, you can do it with the Omni pod dash on and decide for yourself if this is the way you want to go. If it is you keep going and if it's not what else Right, they're not like holding me up, you can do whatever you want. But a free 30 days to try an insulin pump is a pretty crazy offer. On the pod.com Ford slash juice box, head over and find out if you're eligible or just pick around or you know what, maybe you're already pre sold. Maybe you're in then get started. Get started today, being unencumbered. It's summertime and on most of the planet, which I don't know if that's true or not, it's summertime around that, like you right now might be in Australia, like, Dude, it's winter, but just go with it. Okay. omnipod.com forward slash juicebox dexcom.com, forward slash fuse box, links in the show notes, links at Juicebox Podcast Comm. Let's find out why Kathleen thought she had to make a disclaimer before she kept talking. People that was one take four minutes straight talking top of my head, I'm legit proud of myself, I don't know if you are or not. But just trust me, that's not easy to do, you should try it sometime. Now here's caffeine,

you really get into the habit. And if you are used to looking at things a certain way. Unless you're challenged by patients, or by society guidelines, or by, by articles that you read or conferences you go to, unless you're challenged in some way. After 25 years of doing this, there's certain habits that you form, just like you would if you were a car mechanic, and you had to then take care of a newer car that had a newer system, it would be a little bit of a switch.

Can I ask a tough question? Absolutely. Was I bashing? Or did it just make you uncomfortable to look at yourself like that?

I think both. Okay. I think both because if it was just me, that said, this is this is the problem with doctors, I would absolutely accept that it was my own issues. And I do in fact, thank you for the wake up call. Um, but it wasn't just me. Other people that I had listened to the podcast came and said, I don't know if I want to listen to the second prototypes, right. And I said, I have to insist you listen to the second pro tips.

I like that there's a person that can force people to listen to the podcast. That's very lovely. I wish everyone had that power. Well, okay, so follow up question to that is,

absolutely. And that's that kind of catches me up. I'm sorry, that catches me up to the President, which is like, I find I'm using more of your words, I find I'm listening to my patients who are telling me things that I now can recognize as coming from whether from your podcast or similar concepts, I can recognize what they're saying to me. Yeah, so we're speaking the same language again. And that's, that's really why I wrote it,

I have to ask you how that makes you feel like on a personal level,

it makes me feel awesome. It makes me feel just as excited about practicing pediatric diabetes and endocrinology as I did the day I

graduate. That's excellent. I'm so happy for you that I had any little part in that makes me feel very warm inside. And I'm grateful that you're telling me about this. And, and moreover, that you're willing to tell it to other people? Is there is a God complex among doctors a real thing?

I think more so in the generation that came before mine. Okay. So I get I graduated medical school in 1990. I think there was more of that in the people who graduated before that. Um, I don't think it fails to exist today. I think people who have that personality are more likely to be choosing non pediatrics and non pediatric endocrine careers. Because

Do you think it's ego? Or do you think it's the protection? Or do you think it's both and provide protection? What I mean is, if I'm the General and I'm telling you where to shoot the missiles, I don't need seven people yelling in my ear while I'm trying to figure it out. It's already enough pressure. And it's on me. Is that is that part of it? Or is that is is there a part of it? Hey, I'm a smart person. I went to a lot of school, you are not as smart as me. You did not go to as much school as me and shut up like it is or is there a black? Go ahead, Tommy,

there's a black, there's a black. So I think again, before, kind of the time period I graduated medicine was taught as you are in charge of the health care, you are the leader of the team. And whether it was my medical school, which was very avant garde, or whether it was the time that I was in residency and fellowship. Things have really switched to you are a leading member of the team, but you are not the only member of the team and team based care works better than solo practitioners sitting on their doorstep handing out prescriptions. Without instruction,

does it? Does the podcast become more difficult? Because it's a faceless, nameless person who, by the way missed 53 days of his senior year of high school and never went to college? No, okay. It just it just, it's just difficult. Is it difficult to I'm imagining there are some doctors that just probably out of practice, or, again, out of comfort or or maybe security, say, if the system doesn't tell me that these are the rules we're following? I don't want to hear about it. Right?

That is correct. Okay. Um, I think my viewpoint has always been, I know a lot about diabetes, you know a lot about your kid, we have to work together to figure out a system that's going to work. And where I fell behind was in recognizing how many internet based resources there are, like podcasts, like blogs, um, that

I'm not aware of other resources for anybody, I mean, you have those resources podcast, and then I don't know, Danny, Jenny, Jenny's different. Jenny's a deity. She's a diabetes goddess, right? That's where she is.

But she is another resource, and you can contact

me, I just don't want people to listen to their pockets.

But that is a part that people now have available that wasn't available when I graduated. You got information from textbooks that were already obsolete by the time they came out? Yeah. And whatever Jocelyn published about take care of your diabetes, I actually have a really old Joslin Diabetes book from the 1950s, with glass syringes and a picture black and white picture of a girl at diabetes camp smiling.

Well, I think this format is amazing. I'll tell you three is the official number of book deals to write about diabetes, I've turned down. And always for the same reason, because by the time I write it down and hand it to somebody, it's too static, and it's going to change and, and then one day, someone's going to pick it up and make bad decisions with it. I agree. That's why I like this, this way of talking to people.

I agree. But go ahead. And I haven't thought I will. I will preface this by saying I haven't looked at your blog. I really haven't. You don't have I don't have a lot of time to read stuff. So I find the podcast to be perfect for me. Yeah. Um, but do you have like, cheat sheets that go along with the topics? know people who want something? Want to hear my

theory on? Why not? Okay, yeah, I don't have time. I am literally I am the podcast. I know that guy. There's no one else. So you have that group of volunteers that are like cataloging, they show off a little bit. If I had the ability to yell at them, I might yell at them. So But no, anybody who else is generally nice and amazing. But here's my theory. It has to come in slowly. And it has to come in organically to your brain. Because that's how you'll understand it. So I mass market talking. And you can listen to other people who say like, Oh, I read a lot of people read my blog, or a lot of people listen to my podcast. I know how many people listen to his podcast. Based on numbers, no one's listening to them. Okay. So when you're, when you are talking to hundreds of 1000s of people at a time, you have to come from a different perspective. So I can't speak to everyone. I can't meet people where they are. So I have to start with slow matriculation ideas that are get repeated in different ways. They need to be able to listen at their own pace. They need to be able to go back and listen again, if they don't understand they do need a place to go ask questions if they don't, if they can't get something together. But I think that there are some people you can bring up to speed too quickly. And there are some people who are readily available to the information and can just absorb it. In three seconds. I think there's an episode called diabetes fast forward, where I had a woman on who found the podcast, in the hospital during diagnosis. I heard it and never once experienced any of the problems that you associate with people who live with Type One Diabetes. Now I heard that's amazing to me. All that tells me is that's possible for some people. Right? And for other people, for other people. Like I'm following a kid right now, who's I think had diabetes for four or five years and the mother reached out just said, Look, I'm lost. I listen. It's not hitting me, right. I'm always chasing the insulin around. I don't know what I'm doing. So for her I said you call me on the phone. And I can't do that for everybody. But the process of me speaking to her for an hour, and then getting to watch how she figures it out, helps me talk about it so that other people in her situation can maybe benefit. And I think that's it, I think there's something to do with the way it's disseminated my theory about how it should be disseminated and my understanding of how to speak to people and that I'm speaking to a varied audience, but do not want to leave anyone behind. I've said here all the time, I do not understand when we take a classroom full of people, choose the five that are, you know, need the most help and then abandon the other 15. Because we want to make sure no one falls behind, I think there's a way to teach everybody where they are, without letting anybody fall behind anybody who's interested. So if you, I find that when I speak to people, the one, the one factor that ties them all together, the one reason I can tell they're going to be successful one day for whatever they want success to be, is because they're genuinely interested. And they're trying, that's the, that's what you need more than anything. Now, if you try really hard with the wrong tools, or the wrong information, then you're screwed. And then diabetes will make you insane, you know, because you're going to be like, I don't understand, they said to Pre-Bolus. But if your Pre-Bolus in 10 minutes too long, or five minutes too short, it's not gonna matter if you're Pre-Bolus, he's just gonna create a different problem that you don't understand down the road. Will everybody get to where I am? Where to where Jenny is? I hope so. But I don't imagine they will. But I do think that a lot of people can, can roll around with six a one C's without getting low all the time, and get to keep all their fingers and toes and vision for their whole life and live into their 80s that I think is possible and very humbly, or maybe not. So humbly. I believe that information lies within the episodes of this podcast. So I agree, but I have a question for you. How to phrase this, okay, it's hard, isn't it? Good?

It is hard. You're this? I'm not. So, um, I agree with everything that you have just said, I think that having the right tools, and having the information at a pace that you can accept, and understand and implement, and then reassess. And move forward is super important. And so I'm interested in hearing your, your opinion on how new onset education with a family that has no background or information about diabetes can be better?

That's easy. See, yes, made easy question. And remember earlier, when I said I wrote something down to ask you, it says, How do you fix the system? I will just erase that. And we'll just start right now.

And I'll share with you my ideas after

I am. I'm very excited to hear your ideas. I'm excited to hear anybody's ideas about this for me what I've seen work. And I want to say something I'm going to preface this by saying that I came up through a community of bloggers about diabetes, I have been podcasting about diabetes for this is the I'm halfway through the seventh season. So seven full years, no no BS 20, you know, episode seasons, like, you know, every week, seven and a half years, I have still not caught up to podcasting for as long as I blogged. Okay. And I came up through a system where those people no matter what they would say public facing, would say to each other privately. I am not teaching anybody about how to use insulin, because I'm not getting sued by somebody. Okay, so they there were people who knew and would not say, and there were people who didn't know. And those people who don't know, and still want to say exist today. I'm fascinated by you, people. If you're listening Shame on you. I know what your a one C is stop acting like you should be telling other people what to do. Okay. That's, that's very scary to me. But the idea of not giving people information is even more frightening to me. So you can't say there's no one that gets to decide who gets the information and who doesn't get the information. There. There are some honest truths about the world. And some of us don't know how to do algebra. I'm one of them. Okay, but you don't not teach algebra because I don't understand it. So everybody gets to hear it. Hopefully they'll all respond to it well, if they don't, protecting them is not protecting everyone. So you can Not, should not, in my opinion, hold back information for the fear that someone's not going to react well to it. So what do you tell people when they're newly diagnosed, you say, Listen, this sucks. This was this is a bad turn, I am sorry, I'm not going to lie to you, this ain't going to be fun for a while. But on the other side of this feeling, and you will go through a number of the of the impacts that you would associate with any kind of loss, right, this is a loss of health, you're going to feel that way, it's going to be overwhelming sometimes. But there are some empirical truths about using insulin, I'm going to teach them to you. And then with any luck, they'll start making sense to you over time, and you will find a rhythm. And one day, it won't feel like this anymore. That is the first thing I would tell them. And then I would say the word basil about 1000 times until they believed it. Because people ignore basil. In a way that is frightening. It is absolutely the basis of the entire thing. If your basil is not well tuned, if you are not flexible, about about your basil growing as your honeymoon ends, if you're not flexible about using your basil, when you have your period, or when you go from being active to inactive or whatever, nothing else works. And basil is spoken about, like you inject it, and you never think about it again. And that's that that is a travesty to not teach people how to use Basal insulin, they should be the most important thing in the world. I agree. Okay, after that. If they're honeymooning, and that makes you uncomfortable telling them the Pre-Bolus. Fair enough. But you have to tell them in a normal situation, we're going to need to Pre-Bolus your meals, we can't right now, because your pancreas is still working a little bit. But moving forward, that should be your expectation, you don't leave that bit out, and then get them used to doing it one way so that when it's time to do it the other way, they can't make the leap, right, you got to show them the 90 so they they believe in the 90. After that, you have to find better words for glycemic index and glycemic load, because they're boring and they feel like school. And and because of that doctors see people glaze over. And don't go over it enough. Understanding the difference between 10 carbs of white rice 10 carbs of basmati rice, 10 carbs of banana and 10 carbs of mashed potatoes is the whole thing. You have to be able to like stand there and kind of groove with it and go, alright, my insulin to carb ratio says this, but I got a ripe banana here instead of an unripe banana. So I'm going to go out and a little harder, you have to be able to do that. From there. You have to tell them that they're always going to need to be flexible. And there is some vigilance involved. But that over time, these things become so Matter of fact in your life, so obvious to you that you won't be thinking about it the way you're thinking about it. Now, it won't, it won't take up so much space in your brain one day. And the faster we get to that, the more quickly that you have experiences to learn from the less often that you have one of those experiences, and then run around crying and screaming and full of drama. I almost killed somebody. Isn't it crazy that a cookie saved my life? Like it's crazy to cookie save your life? like okay, like, let's let's keep going now, right? Like, why did you need the cookie? What happened here? Don't waste this experience, right? The more more experiences you waste, the more experiences you're going to have to have go wrong before you figure it out. You tell people that and then trust them. And some people are going to want to do well, some people aren't some people are going to struggle, some people are going to thrive. And then you figure out who those people are and reorder them and go over it with them again. But I have I have about 90% confidence that there is no one you could find that I couldn't speak to for an hour and stabilize their blood sugar's in less than 48 hours after that. And if I can do that, then everybody listening should be able to do that if you're a doctor and endo and if you can't, you got to look at yourself and ask why. Like, why is this my job if I can't do that, it would be like saying I change people's tires. But I can't do the cars was six lug nuts. It's just beyond me. I can't figure it out. You can figure it out like and if you don't want to figure it out. have the nerve to tell the people that say look, I'm going to do a good job for you. I'm never going to do a great job for you. We're going to get your a one c two, seven. And if that's okay with you, I'm the right man for your job. But if it's not stop looking at me like I have the answers because while you're not and I'm directly speaking to doctors, while you're in helping those people, those people believe you are helping them. And then they go home and have experiences that counter that feeling. And you are making them crazy. You're telling them It's okay. And then they go home. It's not okay. They don't know what to do. They can't trust how they feel. They want to trust you. And there's a mental conflict that happens that I've seen burden people to the point of wanting to end their own lives. So you can't just you have to at least be honest with them. there that was way more than your answer to your question. I'm so sorry. I talked forever. I'm going to talk

to a lot. So thank you, first of all, um, I think I've worked with a lot of different doctors, nurse practitioners, diabetes, educators, dieticians, social workers, psychologists over the years. And there's definitely something that some people do well, and some people don't do well. And that setting up the fact that what someone needs to know, in the crisis moment of learning that your kid has diabetes isn't all there is to know.

I'm

my entry into a room for years has been Hi, I'm Dr. Kathleen Moulton, I'm sorry to meet you. Your kid has diabetes, none of us wanted that. But I'm glad I'm here to help you. And what we're going to teach you for the next couple of days in the hospital is going to be the beginning of what you need to know. And I think giving people all the information at once, when they're struggling with figuring out the beginning stuff doesn't necessarily work. But making sure everybody knows all of the stuff exists and has access to it, right? I think is important. So like to give the to give the off off label example, you're not going to have somebody read Shakespeare if they can't identify the letters of the alphabet.

know for certain, I mean, if you ask me more directly, I'd say the defining diabetes series is huge, because it takes weird terms that you don't know, it puts them into some context, and gives you an example that you'll probably bump into along the way of it. That's huge. I, I have to say that at the end of all that I would probably tell them, everything I just said to you is probably going to fall out of your head in the next 30 seconds. And I don't expect you to hold on to it. But here's where we're going to start, I'm going to try to help you get your Basal insulin, right, we're going to figure out your own son to carb ratio. And then we're going to move forward. But I think what you need to leave with them is the idea that this is going to change, these ratios are going to change, right? That because the amount of time that I see people who can't take their basil rates from point 252, point three, five, because they think it's an exhaustive amount of insulin that's going to kill everyone, right? You know, like, they they like no, no, it's point two, five, I use my personal example all the time, someone handed me novolog in a hospital. And for five years, I just believe that's what insulin was. I didn't know there were other brands of insulin, I had no clue. Because the guy in the white coat was said, Hey, here's your insulin. I was like, Oh, this is insulin. I never once could have questioned that. And when someone told me, You should try a Piedra. I was like, oh, like I remember the moment I said, how would I be able to do that this is insulin novalogic insulin, I wouldn't be able to try another instance, the doctor didn't say another insulin, you get caught in that loop so quickly about trying to get somebody to Pre-Bolus trying to get them. So you can't My point is Yes, I understand. They can't know too much. They can't run before they walk. That's obvious. But you can't tell them walking is the only thing that exists in the world. Because then they get scared and screwed over and they get stuck walking, then

agreed? Yeah, agreed. Yeah, no, I think we're I think we're saying the same thing. I think I think a lot of people, really, a lot of doctors, a lot of educators don't do that second part. I think we're all pretty good at doing the first part, which is this is what you need to know to survive and get your kid home from the hospital. Or if they're not in the hospital. This is what you need to do to survive. And the part that a lot of people miss is and everything is going to change, right? And 90% of what we thought was true 10 years ago is now not true. And that's going to be the same thing. 10 years from now.

Two questions about the same sentence. Do you I agree with the sentiment that that's do not die advice. And do you hate that? That's the way I say it. Yes and no. Oh, thank you. The more you agree with me, the happier I get just so everyone can understand my psyche.

No, no, no, that's very. You like you like being right? I do. Most of us do.

I don't, I don't like being right. Because I Well, I like everyone likes being right. I'm just stunned when I'm right. Sometimes like, and because the podcast is completely off the cuff. So the first time I said that's do not die advice. Those are just the words that popped into my head. While I was saying it. That pro tip series that you that you listened to was not in any way scripted. And many of the episodes started with me going, Hey, Jenny, you want to talk about Pre-Bolus thing today? And she'd go, okay, because I didn't even tell her what we were going to talk about until we got on the call. So those are real, legitimate conversations that were not pre planned in any way. That's why this works. Yeah, I think so too. That's why this word Yeah. You start writing down bullet points. I just know how my brain works. If I started, if I started some jackass came on a podcast and started reading to me from the Pink Panther book, I'd be like, whoo, I'm out of here. You know, like, pretty quickly, even even if, and here's where I'll talk to you. Forget diabetes for a second. As a communicator. I always say, I don't think I've ever said, Maybe I've never said it out loud on the podcast, but I've learned something about people. Okay. If you put dog crap in a bag, and offer it to somebody, they don't want it. But if you call it free dog crap, they'll be like, cool. I didn't know it was free. Like so there's a there's a, there's a psychological thing that people people will take a free thing. I learned that in a marketing job I had when I was little. Here's what I learned about podcasting. If it sounds forced, or fake, or it's noisy, or people click when they talk or breathe heavy after they talk, people will not listen, it turns them off. Even if you told them 45 minutes into this conversation, you have to listen to all 45 minutes, but 45 minutes into this conversation exists the secret to life 65% of the people would shut off, if you just clicked your words, if I popped my piece, they would just they'd leave. You have to give people they don't even realize it about themselves. But you have to give it to them in a way that they're happy to take it in so that when that information comes out, they're having a good experience already. And so everything that gets said, gets absorbed, you're actually doing a great kindness for people in the future right now. You don't even realize it. But by giving me kind of your quote unquote seal of approval, anybody who hears that, the next time they hear me say something that that rubs them wrong. They'll take an extra second to listen. And so that's where the trust piece comes in. It's super important. I just told a woman this morning, she told me her 14 year old daughter is difficult and won't listen about diabetes. I responded, You're hilarious that you think it's your 14 year old daughter. That's difficult. I also said that. I also said, by the way, for anyone listening, I like I like girls who who ask a lot of questions and aren't pushed around. I think they end up being amazing adults. And it's a little difficult when you're parenting them. But it's a great sign for the future. But she said Why won't she listened to me? And I said, my best guess is you've been wrong about this a lot. And she said I have been I said, so you've come to her with a bunch of stuff about let's try this. Let's try that it's not worked out. And now you're saying I found a podcast, we should try this thing. I was like in the back of her head. She's like, lady, you don't know what the hell you're talking about. And then what is the kids say all the time, I've got this. Every parent listening has heard their kids say, I've got this and then they go do it. And I mean, honestly, most of the time, they ain't got it, you know, but they they're tired of you being wrong about it. And so, that's another thing for doctors to know, every time you say something in that room. And then some parent goes home and tries to assert with that child this thing, and then your thing doesn't work. That kid gets farther and farther away from being able to believe their parents. And lastly, being able to believe you. So you're hurting your own Cause if you're not giving them good information up front. That's correct. Thank you. I'm so worried I'm gonna stop talking you're gonna be like that's completely wrong it

Yeah. I'm gonna circle back to the don't die advice. Go ahead, please. Don't die advice is still important.

Yeah, not dying is hugely important.

I mean, I mean, so and this is a bummer and a downer but like i Last two patients in the past year. And there were horrible tragedies. And I spend a little bit of time every day thinking about what could I teach? What could I do differently? So that doesn't happen again.

Can I ask these people and I'm sorry for your loss? Did these people die from uncontrollable high blood sugars or from low blood sugars?

fees? Well, the two this year in the past 12 months, were related to high blood sugar's a couple years ago, it was related to low blood sugars. I don't think there's a single pediatric endocrinologist working, that doesn't have memories and scars on their heart from the people we've lost. And the do not die advice isn't something to be just thrown away, and it's just not enough. Like you have to start with a please don't die. And then you have to go to the end. You I want you to thrive. I want you to have a good life. I want you to enjoy yourself, I want you to have appropriate developmental stages, both in your regular life and in your diabetes life. And then you have to move from the thrive to the really excel

when you hear me say do not die? Do you take it the way I mean it? Meaning Do you hear me say there's more to this than that? I do now. Okay. You did? I didn't at first, because you have a different perspective than I do. And and the people listening, none of us have had to shepherd along a person who doesn't who's not with us anymore.

And to be frank, I don't imagine anyone listening to your podcast, or it would be a very rare person listening to your podcast, who has lost a family member from what I can only list as a diabetes error. Yeah, and whether that error was in action in understanding and technology in what they were taught in what they took in insurance coverage of what they needed, in the Postal Service, in parenting.

So when you get back to the beginning, you're gonna you're gonna bump up on a, on an episode, I think just called Matthew haulover. Oh, so

so you forget that I went back to the beginning that I'm listening. From beginning forward and backward. I'm

doing both. So my experience speaking with Lindell about her son who passed away in college. I took I can't remember any of that conversation except the part where she said that she would have rather her son have 21 exceptional years, over having 40 scared years. And that really, really stuck with me. And so I have, I'm money where my mouth is because my daughter could pass away. Like there's nothing to say that she couldn't. And I just kind of, I believe right now, in this moment, that if that were to happen, I think I could say what Lindell said, at that moment. I believe that academically right now, I also want to point out that one of the things doctors lack through no fault of their own, but I get to have, and it's an amazing benefit of the podcast, is that I get to, and the more the more popular the podcast gets, the more of the world that it covers, the more far reaching it becomes, and the different stories I get to have. So you guys get to listen to them, which is one experience. I listen to podcasts that I don't produce, and it's one experience. But having a conversation like this with a person, every time I do it, the one we're having now, but when I had yesterday, the one I'm gonna have on Tuesday, they changed me and informed me differently every time. And then, and this is gonna sound really high minded, please don't take it that way, then I become a conduit for that information. So then it's my privilege to stay here and have these conversations, and then say something off the top of my head. That just occurs to me, but it doesn't just occur. To me, it comes from this amalgam of conversations that I've had. And so there's something about having like a sphere of information that can listen to you, and then spit back out the best guess it has based on everything that it's heard, that I think is really valuable. So that makes sense.

It does, does and to some extent, like as a physician we hear over years 1000s of stories, and as a pediatric endocrinologist, I have the privilege of helping and watching kids grow up And getting information from them and learning and then kind of letting it stew and transforming it into something that someone else can use is the same thing I feel like I get from listening to your podcast and I feel like other medical professionals, if they listen can get from listening to your podcast is very cool.

I will tell you to you're at a disadvantage because I imagine that the stories you hear are probably fairly similar from person to person, and never the good parts. It's probably always Moreover, the struggles what's not working. And then once in a while, like, Hey, thank you get this happen, like, Look, I'm gonna tell you right now one of the best memories of my life is the first time I got Arden's a one seater really move after we got to Dexcom. And I left the room. And we were going out to fill out paperwork at the at the end, and I happened to look up and see the the nurse practitioner there. And she looked me in the face. And we did not have the agency yet, because we actually got through the whole visit without it coming out of the machine. And she goes, Oh, I was just coming back to see you. And she told me Arden say one se and then I broke down uncontrollably sobbing in front of her. And then this tiny little woman hugged me. And she's like, you're doing a good job. And I was like, thank you, like an all I could think was like, I've been trying for years for this to happen. Like, like, I really didn't think I could do this. I never, I never thought this was gonna happen. I always thought I was killing my daughter, like constantly felt like that 24 hours a day, seven days a week, in the middle of the night, I opened my eyes. And my first thought was, is Arden alive. I'd put her in her bed. And the last thing I think when I left the room was please don't die tonight. Like Like, that's just like, my whole life was like that. And no matter how hard I worked, or no matter what I tried, or how much I cared he once he just sat in the eights. I didn't know what I was doing. I had no idea. And I go to what I think you would consider to be a really good Children's Hospital on the east coast. Yes, right. I know which one yeah. And it didn't matter. It just didn't matter. I didn't have the tools, I didn't have the understanding. I'm a pretty bright person. And I couldn't figure it out. And I could see my whole life was going to be like this. And then I could see her whole life was going to be terrible. And I have the perspective of my friend Mike having type one when we were in high school. And Mike in the last two years has passed away. And I can tell you right now, Mike passed away because he didn't understand what he was doing. And when technology got better, he did not move along with it. So I'm never going to make that mistake. I think that as much as what we do right now for Arden's care probably will work better than any retail available algorithm that's going to be available in the future coming up right now that most people living with diabetes will benefit significantly from being on one of those algorithms. And it's so exciting to me, that that exists in such a short time, right? Like, what it's 2021, the Omnipod five is gonna come out soon. That thing's gonna learn and make changes, right? That's insane. In 1988, my buddy was diagnosed with diabetes, he couldn't even make it to see that technology. That's how different the care is from the late 80s. Till right now, that's mind numbing. Everyone needs to know that who has type one, everyone who uses insulin needs to know that. And I'm going to take the last 10 years of my professional life trying to make sure people understand it. If sometimes I talk in a way that makes a doctor uncomfortable, you have to see the bigger picture of what it is I'm trying to accomplish. And you being here is such a fulfilling thing for me. And a note that I got the other day that said someone just changed their major because they want to be a CD now because of the podcast. Like I this is gonna sound crazy, because I'm too direct. Like if I spoke more flour early around this, it would probably sound better. But I'm going to change the next generation of how people talk about diabetes. Like that's my goal. I want my if my daughter has a kid with type one, she better never go to a doctor's appointment, where they're like, Oh, you got a seven, five, you're doing great. Get out of there because somebody ever I'm gonna come back from the dead and find somebody if they say that to my grandchild one day. Okay, so I just, I want to make a bigger impact. And I want there to be people who talk about it this way. And I think if I just keep talking about it, then other people will learn how to talk about it like this too. My goal is that one day I meet people who are so much better If this than I am, who tell me Hey, I figured this out through your podcast, that that's that's my very overarching high minded idea about diabetes. So I don't even remember what we were talking about, but

it's okay. Because I have a couple responses, please. And the first one is I think your legacy is changing the way people talk and think about diabetes. Hope so not that you have to end that now.

Yeah, don't make me cry either. It's sad.

No. Okay, but I'm gonna now. So the other thing I really feel like I need to say to you, is that even though you spent all of those years every single day, thinking, am I killing Arden? Is she gonna wake up? You every day saved her life. And you learned from what you did. And you were flexible enough to take advantage of technology, even when it wasn't what was recommended by your professionals, like the Omni pod. And if people can start from a place of, I'm saving my kid's life, and I have to get better at doing that. How much easier would it be to accept your own faults and your own advantage advances? You saved Arden's life all those years, and now you know how to do it better. And now you're sharing it with other people. But you didn't fail her? You didn't fail this child. You succeeded. You saved her.

I think, um, um, I don't know how to answer that. But I think that we all if this podcast means anything to anybody listening, like you really have to. Sound sounds crazy, but you have to be grateful for how poorly Mike's life went with diabetes. Because I have to tell you that it was such a part of our existence. And he was absolutely my best friend in the whole world, that when Arden was diagnosed with type one, it took me weeks to realize that Mike had Type One Diabetes to it didn't even occur to me. His care was so in the background, and almost an afterthought, that when my daughter was diagnosed with Type One Diabetes, my first thought wasn't my best friend has type one diabetes. I didn't think of him that way. And that care model? It it led to it. I mean, that led to his demise. It really did. Yeah, and, and so I can't sit here and know that there are still people giving that advice. And it happens.

It does. It does. And that's wrong. Right. I have to not the same but similar to Mike's that I think about when I was in kindergarten, there was a little boy, I still remember his name, if you're out there. And I remember you, um, and he was diagnosed with diabetes between kindergarten and first grade. And I remember I remember, as a six year old as a five year old thinking, what is diabetes? What does that mean? And I can't remember ever seeing him do anything for his diabetes. He disappeared from the school I went to after first grade, I have no idea what became of him. But I always wondered like, how was his life. One of the first patients I took care of, in my first job out of fellowship is another person who was probably a victim of what we didn't know and what didn't change. I picked her up as a young adult patient, because in that practice, I also saw young adults, and she already had retinopathy and neuropathy in her early 20s. And she passed away. I believe, a month before her nephew was diagnosed with Type One Diabetes. And her brother brought his son to see me and said I don't ever want what my siddhart my sister went through to happen to my son, you have to we have to do better. You have to do better. Tell me what to do.

Well, I'm going to tell you something that I think is going to make you kind of shocked and happy. You said you started listening to podcasts a handful of months ago. Yeah. Okay. Do you believe that the way you're doing your job is better than it was prior to that? Different more enthused, I

think that's a, that's a that's a correct statement, I feel better about how I'm doing my job. And I think I'm doing my job better.

So do you know I have a website called juicebox, Doc's calm, where listeners, I've heard of it. They're sending their doctors that they think do amazing jobs for them. And three days ago, someone sent you in. So you're up there now to think did a gentleman sent you in and the stuff he said about you was really very wonderful. So I think you'd be thrilled. Okay, now you're gonna make now you're gonna make me cry? Well, I've been saving that for the whole hour. You mean, me? Okay. But you know what, thank you. Thank you for telling me No, but what made me think to say it just now was that you said hello to the kid in from kindergarten. And you said, if you're listening, and I thought he might be listening. Because that's crazy to me, like, I get an email and it says, Hey, this is an entry for Juicebox Podcast, a really like thoughtful thing about why the doctor should be in here. And then I looked down it and it was you. And I thought, that's so full circle crazy. It's it's like there's a story, that from the Facebook page, a couple weeks ago, a woman walks into a Costco with a Juicebox Podcast t shirt on. And she intersects a woman who points at her shirt and goes, I listened to the Juicebox Podcast, and they have a quick back and forth, and they go on their way. The woman with the shirt comes to the Facebook group and says, You'll never believe what happened today. I was at Costco, and blah, blah, blah, blah, blah. And in a half an hour, someone else comes in and goes, that was me. And I'm like, Oh, I'm building an empire. Like, that's all like, I know, I thought it was such a lovely thing. But but the Joking aside of that, I thought, I started a podcast about type one diabetes, not even about diabetes. And a lady just walked into a Costco in New York, and walked past another listener of the show. And I was fascinated by that, just that piece of it. But then that they both are in that other space. I was like, wow, maybe this is the model that helps people. Like because of like this distribution. I mean, the joking aside, and it is cool that I have a podcast that people recognize and etc. And I'm not saying that like, but that the distribution works that well, was very heartwarming to me. I thought, I think I'm onto something like I think this works, whatever this is right now works. So if you're a doctor listening, and you've listened to something and thought that guy's bashing me, I want you to please just know that I have never sat down in front of this microphone, and consciously started talking about anything. I've never once thought today I'm going to talk about this or that. I've never taken a note the people I speak to, I don't even let them talk to me before we do it. So we start Truth Truth. Yes. Okay. So I don't like that actually, everyone. And sometimes I leave it in because it fits. But mostly what happens is people get on I say, Hello, we get the tech set up. And I tell them in a moment, introduce yourself any way you want to be known. And then I'll ask you a question. And then in an hour, we'll be done talking. And that is as much consideration that I've given any of these recordings so far. So because I like I like what comes out of this, like this thing, whatever this is we're doing like you and I are making an amazing episode of this podcast. I understand that on one level. But personally, we're just having a really great conversation. And then on another level, we're helping people with diabetes. And on another level, we're helping physicians that help people with diabetes, like there's so much happening within these minutes. And I'm not aware of them in totality, while it's happening, and just I'm just answering the questions the best way I can. And I think there's something to be said for that for people who don't try to make everything seem so professional and clean that it doesn't work for most people. So I don't know where I got that from. But anyway, it's cool that somebody bought a T shirt even that freaks me out caffeine that somebody was like, like I being serious to to see how growth works. I have never in my life thought to myself, I'm gonna sell t shirts. I don't want to sell t shirts. I don't like that. It makes my life more complicated. It doesn't make me very much money. You know, but people said, When enough people come to you and say I want a T shirt. You think this isn't about shirts. Make them a T shirt. When very recently, it's gonna sound weird the wording, but I had to put up a buy me a coffee campaign, because that's how many people said to me, I want to give you a couple of dollars, and there's no way for me to do it. And I just thought like, That can't be right. Like when the first time that gets said to you, you think, Oh, this is an outlier. It's a crazy person. That's so nice. I'll thank them. And, but when the 50th person tells you, I'd like to give you three bucks a month, because it'll make me feel better. It's an odd feeling. But you have to it's sort of the same thing with a T shirt, you think this is something they really want to do. I know that I'm going to end up with $3 when it's over. But I think I have to let them do this. I don't know if that makes sense or not.

It makes sense. And you do have to let them do this. You are providing something. You're doing it for free. People have ads, it's not free. Well, okay, yeah. But for the people, it's free.

I understand,

okay, there's no fight, you've said it, and I will repeat it. There's no firewall. There's no content hidden that you have to put in your, you know, password to get to. This is just all out there. It's available. It's waiting for people, for doctors, for nurse practitioners, for anybody who wants to have another way of thinking about this. Have your perspective and all of the people that you've talked to. And if somebody wants to give back to you for the hat, accepting the gift honors the giver,

that's I, it took me a while to get to that because it just felt wrong to me the whole time. There's one person whose name I won't say who Badger's me more than anyone else. And I finally was like, Okay, I'll do this, no one's gonna do this. She's like, Yes, they are. And I'm like, No, they're not like I, it's not necessary. I do make money from the ads. It's not about money. But then I started having this other thought, as crazy as it sounds, the more I could make from this, the more I could do with it as well. And I'm not telling you, I wouldn't pay for my cable bill or send my kids to college or anything like that with any of the money people would send. But there is like bigger ideas, like I have stuff going now, that takes money I'll tell you about afterwards that I think you'll be excited about. But there's no doubt that more money would help that. Like there's no no doubt that it would be nice if I could pay somebody to, you know, prep the shows for me, because we're up to, I don't know where the listeners are up to like 498, maybe. But I already have the next seven prepped and up, I've already recorded the next 60 or so they all need to be edited, put together, like there's a lot that goes into like an hour of listening for you is probably eight or nine hours of my life, I would guess. And so at least at least it's a lot and, and this is 100% a full time job. Now I work on the podcast six days a week now. And there are times where I have to stop myself, and I have to walk away from it. And I'm gonna get a big fat. But if I keep sitting here, so I got to get up and move around a little more, although I have a fairly flat, but I don't think I could make it. The fat will just go somewhere else probably Catholic. But I don't think it's an item, I think I'd end up being a big balloon with a flat but if that happened to me, but but but joking aside, I do see the value of it. And and I don't in any way disregard people's ideas that they would like to do that I understand it. I am a person who not on purpose. And not by design receives about 10 emails a day that at some point, say you saved my life. And that's heavy and it's it's hard to absorb sometimes, you know? So

it wasn't what you set out to do you set out to share ideas. You have Episode 497 posted. And somehow my pod player says there's 507 episodes that I've listened to 126 of them. Yeah,

there's probably some extra ones in there before I knew how to really number them and do all that stuff, probably.

But 497 is what's up right now. That's what I'm listening to before I go back to 2015. Yeah, we're actually interesting. It's interesting to hear your different style to just for reference, like I would say to people who are hearing this or who have been told to listen to juicebox. Scott is right. You got to listen to the pro tips. You've got to listen to the defining diabetes, and then listen to whatever strikes your fancy. Yeah, do what in whatever order you want, because there isn't a perfect order for anything. They're all good episodes and they're All, providing different information,

I have never put up an episode and thought that is crap. But I need something today. So I'm putting this up, I've never had that feeling there, there's, there's some, like, I know, there's so much if you're listening, I know there are so many episodes and it feels overwhelming and promotive, you're not gonna be able to listen to them all. And I get all that. But I think that to be a good content provider, you have to provide content. And if I put up one episode a month, or one episode a week, I would never get to all the stuff that I've recorded. So I have to do exactly what Kathleen just said, I have to put it out there, and you have to pick through it, and nobody can hold your hand you're gonna have to fit. And I know I don't help you. I know that some of the I know some of the titles don't have anything to do with anything. And I mean, there's one up now called monkey's eyebrow. So good luck figuring out what that's about. And but I can tell you this about it. I couldn't give you a synopsis of that episode right now to save my life. But what I know about it is I spoke to an adult female type one who moved around the country a lot, has a really heavy job is super smart, talked about what it's like to live with diabetes, had a really funny father with a lot of great stories. And I had a wonderful time talking to her. Will you take something different away from that? That I will probably, but I can't tell you what that's going to be I have no idea. You know, it's a very strange art form. Because I don't think it's the same thing to other people. I also think, am I getting better at it as I go? Yes, yes, absolutely. Makes sense. But I don't know like talking to you right now. I can't academically tell you. I speak more slowly. I listen better. I don't feel as forced to be funny. Like that. I know, I've learned over time. So I definitely have gotten better at it. But then that just makes me feel like I'm such a competitive person with myself. That that sentence just makes me wonder like how much better I can be at it next year. It doesn't make me feel happy about this space. It's like the downloads. I get so many downloads every day. Every time I see the number, I just think about how to make it into more downloads. I never think, Wow, a month and a half ago, it was 30% less than this. I never think that I'm always like, well, if we hit this, I wonder what we could do here. And yes, that's about distribution. Because the more people that listen to show, the more likely somebody is to want to find out more about a free 30 day supply the Omni pod dash, which makes people continue to buy ads, but and I do take money. Like Don't get me wrong, but what it really gives me a side of the money is the ability to keep making the podcast and to keep putting effort into it the way it deserves. And the way everybody listening deserves it should this should not be a fly by night thing. Like I might sound unprepared. But I actually have a kind of a fabric woven concept of what this all should be like, as by mistake is this all seems it's incredibly on purpose. But I try to hide that because I don't want you to feel like you're being talked to, if that makes sense. Talk that I guess I mean, anyway, now you know something about making a podcast? Never gonna do it. Yeah. Yeah. And no one else should either, by the way, dammit. I don't need the competition. Just shut up and listen to mine. Dammit. You're here. Yeah. Thank you, Kathleen, is there anything that we have not spoken about that you wanted to talk about?

I think we covered almost all of it. Okay, I think the only thing I can say is I would really encourage people to tell their physicians, nurse practitioners, diabetes educators, what they like about the podcast, what they've learned from the podcast, so that it's not seen by some medical people, as this guy talking. Because there's so much value that I've I mean, just me I feel like I've received so much value from listening. And I feel like there's so many other people that can receive that value. Also, if they have time to listen,

can I ask a question based on I'm assuming, you know, a lot of doctors. What would it feel like if I'm a doctor, and the best time doing lead somebody to a 8.1 a one c? And then they come in three months later, with a five nine and I start to freak out and they stop and go No, no, don't worry. I'm not having frequent or extended lows. And I'm not spiking Look, look at my data. And when the doctor says Where did you learn that? And they say, from a podcast. Do you think that's hard for a doctor to hear? What do you think they're just happy for you?

I think the number one thing is happy, right? I actually don't think most doctors freak out at a 5.9 anymore if we have CGM data to look at. And I, truly I think truly, it doesn't hurt that somebody got information somewhere that helped them. In the end, every pediatric endocrinologist wants every kid with diabetes, to have a long, healthy, fulfilling childhood, and a long, healthy, fulfilling life.

I'm lazy,

we want to be we want to be extraneous. We want to be like, how can I add value to this person's life? Because they're already doing great.

That's what I was thinking, yeah, that's what I want. I'm lazy. I would, I would tell everybody out the podcast and be like, Oh, my God, I'm gonna look like a genius. If everybody comes back with a nine, nothing to be amazing. I see if I'm the doctor. I'm like, I'll just keep getting the checks. I'll probably play golf a little bit. Maybe I'll learn to fly a plane. Maybe then like, I'll just be like, all mine have five nines. I don't know what your problem is. And I'm glad to hear that you think that's the case? Can I ask you? Your thoughts on why? adult endos don't seem to be like, Why do people say the best care I ever got was from my pediatric endo. What's the disconnect?

I think there's a few things. So and again, this is my opinion, it doesn't reflect that everybody I've currently or in the past worked with.

Um, but bill, now I'm just getting good. Excuse don't die before we're done, I need this.

I have this, I have this thing where if I could laugh, I sometimes cough, so I can't make me laugh anymore. Um, I think so much of training for adult endocrinology is type two diabetes, which doesn't mean, they shouldn't also be aiming for a 5.9. But there's a lot of emphasis placed on the comorbidities and 40% of people who already have nephropathy, when they're diagnosed with type two diabetes, and the heart disease and the feeble little old lady who can fall and break her hip and we can't let her have a low blood sugar. I think it's difficult for a lot of adult endocrinologists to individualize what they're telling to fit the person that they're actually seeing in front of them. And not the fear that they've experienced over and over again, when something bad happens.

What does it say to you that the most well controlled, I know people don't like that word, but it paints a picture, person with Type One Diabetes that I meet, all see their doctors as the nice people with the prescription pads, and the a one c test. What does that does that I

think they should see them as the nice people with the prescriptions and a one sees, and they get to talk about, you know, the kids play or what the dog is doing? Or, Hey, did you know that there's this new product? You know, you're in Europe, and I watching to see when it gets to the United States that I think is really good. I hope you like there should be more that we can offer, then correcting or incorrectly correcting things that somebody is doing right?

What does it feel like when you take someone's pump and make a change? And you I because you have to know I'm inferring this on you. But you have to know that this is a crapshoot that you're about to involve yourself in right. I'm going to turn a couple of dials, push a couple of buttons and hope this thing gets better. I'll see them again in three months. Does that feel bad?

So I don't, in my practice, see them again in three months? I say look, I kind of reviewing the data, you told me what's happening here. What do you think about making this change? Right? I could do this, I could do this. What are you more comfortable with? Is there something else that you would like to try it? They put it in the pump. I teach kids to program their pumps with their adults watching. And then I say, Look, do you have a computer at home that you can upload two in three days a week? If you do, I would be happy to look at this. Even once a week. I probably can't look at it as often as Scott would look at his own daughters. But I'd be happy to look at this once a week if you want to shoot me an email and say hey, we upload it. Can you go look? So in my practice, it's not three months, it's never like unless somebody on their end doesn't want to think about it for Three months. That's not what I offer.

Well, that's excellent. I bet it's but it's a common thing that I've described, right?

Oh, absolutely, absolutely. And that is a crapshoot. And in the end, like, there are things that I don't get finished in my job, then there are things I don't get to do with my family. Because I've got stuff I've got to take care of. If they ask you, if a family wants to reach out and say, Hey, can you look at this, right? I'm never going to tell them no. And it doesn't matter whether I can build for it or not. Like that's just that's what I'm here for.

If I picked you up and dropped you in a setting where there was a person with uncontrolled blood sugar's 250, managed is that the words we use,

manage, we don't say controlled, you can't control diabetes, it's a wild animal. You can tie it out, I

do a pretty good job over here caffeine,

you can tie it up you test insulin, he you can tie it up, okay? I can't control it. Because you know, something is going to change, I'm

gonna give you your my respect on your feelings around the world. But if I, okay, a person who's having that experience, I drop you in their home, give you full control? How long until you've got their blood sugar low and stable?

I see. You're asking me a question that I've never experienced. And I've thought about

you should try it. kidnap one of those kids just take them home.

I have people asking me to take their kids home, right? Um, my family is not at that point at the moment. Um, how long would it take me? It was a it would take me longer than you. Because you've been doing this for a long time with people remotely. I think being able to see what's happening, being able to make adjustments continuously. I think I would have things in a healthy, stable place. I'm going to give myself five days, yeah. So five to seven days,

I'm gonna make a suggestion to you. And I don't know if this is possible, you should do it. You should pick a person and do it because the experience will be invaluable to you. It puts you in the mindset of Do you remember before people could remotely take control of your computer, you'd have to call them on the phone to find out like my computer is broken. Here's how I need you to fix it for me. On the other side of that phone call was a person who could imagine your computer without looking at it. It's a great, great skill to have around diabetes. It's very cool to be able to know the parts, the variables that you can ignore for the moment to make the bigger changes. Right. Like I this morning. The woman I spoke to this morning, her kid had a waffle. And I sent her a text and I said you need to Bolus more this is about to go wrong. No, no, no, no, no, he's doing an activity right now. It's going to be fine. Well, now the kids blood sugar's to 40. And guess who was right? You were right. You were right. And but but she just doesn't have the experience to know she will one day, but I could see it across the country. Just looking at the Dexcom graph. And knowing this, the kid got up at this time got this much insulin ate this. And then I can look at the time, I can start inferring from the graph. And I'm like, No, no, the insulin is gone. The food still there. This is about to be a problem. Do it now. That came from talking to all these people. And and I can I use it for my daughter all the time. Like last night Arden's blood sugar has been trying to go up at like 11 o'clock the last few nights. I don't know why. I don't even care why. I just know that's happening. So around 1030 I looked at her blood sugar last night, and I start saying things like, let's, you know, we basically she's looping we jacked up her intensity, like 50% lowered the targets a little bit. So it would be more aggressive, put some insulin and like all that stuff, blood sugar went to like 145 and came back down again. If that doesn't happen tonight, cool. If it happens one more night, whatever. Like that flexibility comes from knowing how to react in the moment. Because while it is true for most people, and I'm interested in what you think about this, like when I tell people that what you do now with insulin is for later, but it's more appropriate to think about it as what you've done in the past with insulin is for now. Do you understand what I mean when I say that?

I do. I do. I think what I'm trying to teach residents or newly hired people about how do you figure out what to do with the pump. And somebody comes to me with a graph and says Look, they're having all these lows at this time I was going to change this Basal rate. I'm like now No, no, you have to go back a few hours, right? That isn't happening because of what's going on now that's happening because of what happened before

his blood sugar goes up every night at 11 o'clock makes me think you're bad at dinner. That's the first thing. I think when it happened.

No, it makes me ask the question, when was dinner? Okay, and how much did he have to eat between dinner and night time? And did he get bonuses for anything? Right snack time between dinner and

latency. Now, you're 100%? Right. I would agree with you in spades in court. But what you just heard me say is the leap that I've learned to make from having been asked the question by so many different people, and that's where the shortcuts come in, to teach it to people. Because your, your questions are all right, in my opinion there. But if you said that, to me, as a person who's had a kid for diabetes for two years, I'd start going like, Oh, hold on a second. That's a lot. Right? Right. Where I were, what I'm saying is, dinner is getting messed up some way and you're drifting highlighter. Let's go back, make sure we're Pre-Bolus and dinner that we're using enough insulin for that we're thinking about fat and protein that might cause a rise two hours after you eat. Let's let's simplify like, I'm all about turning diabetes into t shirt slogans. Right? Because I think that's how they're actionable in the moment. Not that you're you're 100%. Right. But I think you and I just said the same thing. You use more words than I did.

Well, I said, No, use more words. And I think I get one of the things I'm working on improving myself as I get lost in the Why did this happen? When it doesn't always matter? why it happened? It happened.

It happened. Yeah. I never was like,

that's part of that's part of what I've learned about myself. Yeah, is that I can get sidetracked wondering, why did this happen? And, like, in the end, good. Just got to take care of it.

Do you have a type A personality? Um, my family would say so. Yeah. Well, they're probably right. There's times you need to listen to other people. That's one of them. I know, because you would never know. But so to me, that's one of the things that I've spoken about on the podcast for years. It's super important that I think that I can't infer to you in a moment. Because if I just say to you Don't worry about what happens. You're gonna mess everything up. That's a vibe. Not an idea. Right, that's the like, Arden's been getting hired. 11 o'clock, I don't really care why it's happening. It's gonna stop happening soon. I just need to get ahead of it. Like, I'm all about staying ahead of problems. It's so interesting to listen to somebody, with your perspective, talk about all this.

So like, one of the things that frustrates me that I'm trying to wrap my head around is the attitude I get from a lot of patients. Oh, your blood sugar's were high on last week, but that's because they had a cold, so I didn't change anything. And it drives me crazy.

I'm like, No, no,

there's nothing wrong, you should have changed something, the cold is gonna go away faster. If the blood sugars are high, the white blood cells are going to work better. If the blood sugars are Ty could have always changed it back.

I mean, what you just said made me think that people would probably really enjoy hearing the five minutes of Jenny and I talked before we start recording. Because it because the way I see my job, and I guess this is my job now it's self appointed. But yes, it's my No, it's your job, right? is that there are confusing things that people think that that mess them up, and they don't even know it. And being cognizant of that, and being able to stand back and see it happen, it's super easy to feel like that like, like, how could you ask this question like, but the truth is, it's everybody's first day having this thought somewhere, right? And what builds a really strong community is never, like, you can think that stuff. And I think it's sometimes too, but it's it's never saying it out loud. So that the next person feels free to ask that question. Again. It's, it's the idea of there's never a dumb question. Right? Exactly. And you have to see how cyclical The space is. I hope I use that word, right? Where people I really should have went to a couple of those days in high school, probably where new people come in there. It's very interesting. In my, in my current day, there are any number of 1000s of people who interact with me, who all feel like I'm a very good friend of them. And I'm aware of their little avatars like I see them. They make sense to me, but those people are constantly getting the information they need and dropping off, which to me seems like a huge success. I don't want you living your life in a Facebook group. Right, right. I don't want you living your life worried about what happens if my daughter's blood sugar goes up at 11 o'clock at night. I just want you to be in this kind of like loose mode, where something happens. You recognize it, you jump all over it. It stops being a problem. You move on you go to the next thing I wish For everybody, and I have not figured out a way to teach it to them yet. But I wish for everybody that you could look at a graph on a Dexcom and have the thoughts that I have when I look at them, because I just see them immediately as basil issues Pre-Bolus Singh issues, insulin to carb ratio issues. And it's just they're incredibly obvious to me. But I don't know how to teach that to you, other than to say, you should talk about diabetes every day, until it starts making sense. And of course, I

would just to back up, I would never say, why don't you change things to a patient? Like, that's a teachable moment? I'm glad you told me, right. Um, I. So in all of your non existent free time, maybe if the world provides you with more assistance, it would be lovely to offer insight into inside the mind of Scott voiceovers as you look at things. Yeah,

I wait, definitely. It's on the left people to see it's on the list. Teaching graph reading is definitely on the list. It really is, I let me finish by telling you this and asking you your opinion. So it's possible and I have my fingers crossed, that I'm about to go to a hospital, and sit down with the staff of an endocrine chronology department and explain to them how I talked to people about diabetes, and what I think they should be saying to them. So I'm gonna sign you up, oh, I would definitely do that. I'm dying to do that. It almost happened last year at a really big institution. And then that fell apart. And now it's happening again, it's a smaller hospital, but it's in a big healthcare system, which is exciting for me, because I think, I think that I could spend two hours talking to people, and then they could go do a better job talking to people. And is there anything obvious about the set the setting that I'll walk into? That knowing me from listening to the podcast, I will be ignorant of? And how do I not make enemies walking in the door? Is my question, let me think for a sec, I want everybody to be open minded.

I think the first thing you should be aware of is probably that a number of the people working in the environment are going to be people with diabetes. Okay. And they may or may not enjoy following your podcast. Yeah,

it's hard to hear from somebody who doesn't have diabetes, it doesn't have a degree, right. Um, I hear that.

But then the other thing I think is, I would emphasize that this is a process that what you want to explain to people, and what you want to share with them, is a process that took you years to figure out, you've kind of distilled it down to this little bit. And that no one is going to walk out the door with a certificate of excellence in a better diabetes. Like, that's just not going to happen. But that if people practice using some of the ideas and tools that you give, that better is better. Yeah. And that things will be better for a lot of people.

Okay, I would definitely come out and do it at your hospital, I would enjoy the first five minutes where they threw rotten fruit and vegetables that make the tomato maybe in the side of the head, but as long as it's soft, I'd be fine. No, I listen, I'm not gonna just put a banana under your foot. I'm not gonna front as the kids would say, this is one of my end of life goals is to do this. So I've been on a plane since COVID. And I'm not afraid. So give me a call.

I one of the things I wanted to ask you and I actually put it on the after the broadcast was, do you have any plans for teaching the teachers for teaching the physician to the professionals, I really thought

it was going to happen at a huge institution last year, and then my conduit to the idea switched jobs. And I now have a new conduit, which is just a listener who wrote me a nice note and said something to the effect of If I hear someone say 15 carbs 15 minutes one more time, I'm gonna go off in this place. And so and then we started talking about it and I made the offer and it actually looks like it's moving forward. So I have my fingers crossed for that. I think it's well, let's talk offline. Yeah, of course. I think it's amazing idea. I have to let me wrap up by saying this. You do not come off like you know how brave this was. So let me tell you that I thought this was really astounding if you to do and I appreciate it very much. I think it will mean more coming from a doctor to other doctors that it will ever mean coming from me. And that you were open enough to hear something that made you think differently and feel poorly first. And that you stuck with it and got to it again is really astonishing. You must be an incredible person privately as well as professionally. And that's not for agreeing with me. That's for being open minded. Oh, it's a little bit for agree for agreeing with me. There's other things that are great about.

Thank you. Thank you very much. I don't I guess I don't see it this brave. I'm not I'm not a particularly brave person. I'm rather risk averse.

But don't many people are gonna hear this, maybe you'll start feeling more brave after that.

No, I don't want to think about that. Okay, I'm just talking to you. I'm sitting in my like home office, and you're sitting in your home office, and we're having a conversation and I need to remember that's part

of my superpower. It feels very personal. This conversation we're having that everyone's gonna listen to you later. Excellent.

But I have to say thank you, because having the opportunity to chat with you is is really meant a lot to me too. And I would be ecstatic to like, circle back with you at some point

I talked I told you before we recorded and I mean, it right now that this is the most excited, I've been to record the podcast in like a year and a half. So I I think that the far reaching implications of what you share today are incredibly important for people living with diabetes, people who are helping people living with diabetes, and people who may get diabetes in the future. So I think this is really cool. Thank you very much. Thank you. Appreciate it. We have to have Hold on. Where's my little button that I need?

participants?

Jessica, come back on. I'm still recording. Yes, I'm unmuted now. So for everybody listening the PR person at the hospital that Kathleen works that has been listening the whole time. And I am dying. You're being recorded. Are you okay with that? I'm fine with that. Yeah, how they do give a list of notes. Speaker 1 1:52:06 I don't have a list of notes per se. But I think this is great. I have a lot of respect for Dr. motes. I've heard from other patients. And she when she told me about the podcast, I listened to several of your episodes and thought they were real. And I wish this kind of access existed for other diseases, other conditions that were patients could access in this way. I think it's really important. I appreciate both of your advocacy.

That was so professional. Jessica, I was hoping you would I am professional like that. Be like buddy, 18 minutes and 17 seconds, we're gonna have to talk about what was said here, but uh, Speaker 1 1:52:49 no, all right, really, I just like to listen in to kind of pull out you know, we're gonna want to help share this and get the word out to more people too.

So, Jessica, I have one last question. And then I'm gonna I'm gonna stop the recording and we can keep talking if you want to after that, but I'm okay with this work as a live event. Yes, okay, that was all I had. I'm gonna stop the recording now so you can start cursing and saying your weird stuff just right. That's it. That's what I'm gonna do. I know dirty you get. Well, I hope you enjoyed that. I had a great time making that episode for you. And I really appreciate kathlyn coming on. Thank you also to Dexcom makers of the G six continuous glucose monitor. And of course, on the pod the bestest tube listen until in this this pump ever. By there's no words there at all. I love on the pod. It's a tubeless insulin pump. You might love it to find out on the pod.com Ford slash juicebox, bestest, and tubeless in this list is not a word, either. Those are words or not words I, I got confused. If you're a child listening, try to forget these last couple of moments. But if you're an adult, why don't you go see if you're eligible for a free 30 day trial of the Omni pod dash. And seriously, if you're an endocrinologist, and you want to come on the show, send me an email. Don't forget, we're putting out some extra episodes this week. So be subscribed in your podcast app so that you get a notification that lets you know they're coming out. There'll be episodes on days you're not expecting. They're going to be the diabetes variables episodes, in case you're wondering. But I just need to catch up a little bit over here. So help me out if you can, and subscribe in a podcast app. Also, thank you so much for listening. Tell a friend, share the show with someone it grows when you share. I know you hear me say this all the time, but it's incredibly important. And it's really true if you need anything. And the advertisers that I have on the show are up your alley are what you're looking for just using my link to check them out is a big deal to the show as well. Thank you so much for listening. Kathleen. Again, thank you so much for coming on. I look forward to talking with you again. Soon

Hello friends, and welcome to episode 1080 of the Juicebox Podcast. I'm incredibly excited to give you a preview of a brand new series that's coming in January Grand Rounds. These episodes are aimed at practitioners, but are also going to be very valuable for people living with diabetes. Our goal is to let doctors know what they should know. I've taken feedback from the Juicebox Podcast listeners to develop this series, we're going to use your words to describe to doctors what they need to know to help you. But moreover, this information is going to let you know what you should be expecting from your physicians and frankly, what you deserve. While you're listening. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan, or becoming bold with insulin. This series is going to help physicians be the kind of people you want to consult. If you're enjoying this series, please share it with your health care provider, doctors that you know in your life or other people living with diabetes. This episode of The Juicebox Podcast is sponsored by touched by type one touched by type one is an organization that is dedicated to helping people with type one diabetes. They're asking if you'd be willing to go check them out on Facebook and give them a follow on Instagram and do the same or at their website touched by type one.org. Head over to that website now to see all of the amazing things that touched by type one does for people living with type one diabetes. The podcast is also sponsored today by us med. US med is the place where Arden gets her diabetes supplies from she gets her Dexcom G sevens and her Omni pod dashes. But they have so much more. And I'll tell you about it a little later. For now, here's what you need to know, you can get a free benefits check at my phone number 888-721-1514. Or by going to us med.com/juicebox.

Hopefully, none of that was recorded. I

did not record any of that. But I'm recording you saying hopefully none of that was recorded. Jenny and I are having a day together. And we're gonna use that energy to build the next series of the podcast. So yeah, let's go. I'm pretty settled on calling this episode Grand Rounds, actually the series Grand Rounds. That is really only from my knowledge of the medical profession as far as I've watched Grey's Anatomy. And because I am old, I've also seen the entire run of er, that's what I know about hospitals, I realized that might not be accurate. But I do remember people saying Grand Rounds, like where all the students would get together and go around with an older more wisdom teacher and they would go from case to case and talk about things. And my idea here, Jenny is this. I feel like we can put a series of of episodes together that would simultaneously teach patients what to expect from their doctors, while teaching doctors what their patients deserve. Because that makes them how to interact, yes, and how to actually feed that information to them. Taking into account that diabetes is probably three pages in a book at medical school and 20 minutes somewhere while you're going through things. And that a lot of people are going to intersect emergency room people, doctors in what like urgent cares in their primary care offices, right? Yep. People who don't aren't schooled on diabetes, the way people who live with it and are correct, what we've done is gone out to the population that listens to the podcast, and so that people know who are listening. I'm talking about 40,000 people on a Facebook group and millions of downloads of the podcast. And we've asked these people, you know, to give their feedback about what would have been helpful, helpful, and what was not helpful. And then we've broken that down. And today, you and I, as we've come to do with the beginning of a series are going to talk through how we're going to build the series. We're going to take this information, put it in some reasonable order. Let people know what to expect. And that's what we're going to do. And you are Yeah, you're incredibly passionate about this. So if you could talk for a minute about why you think this is important. I'd appreciate it.

Yeah, I'm, I'm passionate, that's a great word. Because I think that, as you've already stated, general medicine practitioners who haven't had the extra schooling, right, when you complete medical school, then you can specialize, right? Specializing in endocrine, you go on to a fellowship, you complete a fellowship. And so you have that more in depth. In general, a first step, anytime you're sick is going to be a primary care doctor, they're going to be a first step, whether there's symptoms for something or whatnot, you're going to go to primary care, or in the case that really urgent symptoms come up, you're going to go urgent care emergency department or whatnot. And in those cases, they're knowledgeable people. I mean, that's one big thing I want is people to hear that they're schooled. They're schooled in medicine, but they are not schooled in a specialty. And we can't expect them to be either, right. But in order for them to understand what to do, I think it's a it's a two way but right,

I want to say right at the onset, that I am almost positive that through this series somewhere, if you're a physician, you're going to feel like there's Doctor bashing going on. And there, there is not we have both have the utmost respect for you, and what you do, and how difficult it is. We just know that the only doctors are the first people to say this, usually, they'll tell people with diabetes all the time, look, you're gonna have this for six months or a year, and then you're gonna know more about it than I am. Right there living with it really is the only way. But the reason that this is so important, even from minute one, is because I mean, Jenny, you know, I'll tell you a little more about what Jenny does as we're going along, but she intersects people with diabetes all day long. I do as well, I have long form conversations with them. And I can tell you that sometimes things that are said to them in the first five minutes, haunt them, sometimes forever. And so when a doctor says something offhanded, it literally it could change their life significantly good or bad. And so why not move it in the right direction is what we were thinking about making this series.

Correct. And I think in general, when we're talking about overall medical personnel, clinicians, we're not doing any bashing. That's not the idea here at all. So that's, that's great to clear up. The idea, though, is for a communication piece, to be more in the forefront of the mind, both on the person maybe with diabetes, and how they can communicate better, but also from the physician knowing that I think a forgotten part of healthcare is that, like, health care is it's it's human care. Yeah. So we're not looking at just talking in a very flat manner to somebody, we're looking at talking to somebody about something that's going to affect their life. And with diabetes, it impacts the life on a 24 24/7 note, right, there's no shut off to it. And so as you said, you may make a statement, as a clinician, that's a statement you think may need to be in the conversation. And maybe at some point, it does need to be there. But in a, in a different way, different context, at a different point, you have to learn, you have to learn what somebody is coming in with the need for at that moment. And that takes talking, right.

And there are also I think you have to build more than just a spreadsheet in your mind evolve. First of all, tell him about this. And then the next time I see them all mentioned this, like, you need to know where they are like you might deliver the information, like Jenny said too soon or too late, you might deliver it the wrong way. And I know that you could also be listening and think well, how am I supposed to know where they're at? You could talk to them. Now, that'd be a really great way. Right? And you really have to understand that no matter how much you think you can put yourself in the shoes of a person who needs manmade insulin, or the shoes of a person who is charged with caring for someone who needs manmade insulin. You can't. It's far more impactful, and potentially destructive, and difficult and time consuming and exhausting than you'll ever be able to imagine. And the only thing that will help those people not live like that is the stuff we're going to talk about in these episodes. And you can listen to these and pick it up and apply it to what you're doing. I really think you can help and that's not just me saying I make a podcast. So here's my next topic. We've been doing this a long time. We have a lot of feed back, we know what works. So I hope you guys listen. And if we sound like we're bashing you, at some point, I promise you we're not. We just feel really strongly. And we've also heard from a number of people whose lives have been, I mean, honestly, sometimes derailed by by bad medical advice.

Right. And I think something to go along with that is bad medical advice, or misguided even really understood, right? When you are a when you're a practitioner, and someone is coming to you, that's out of your wheelhouse of being able to answer than your best ability is to say, You know what, I can't answer that the way that you need the answer to come or I don't know enough about it. My job is to direct you to the right person. So it goes along with saying the right thing are saying it at the right time. And in this instance, if you don't know enough, the better thing is to not pretend that you know, and it's to direct somebody to the right person in your healthcare system. So that the answer can be given in the right way and in the right time frame around the right context, you know, to not scare people,

and I think don't just think of that as like, I said something to them that was incorrect. Like, here's an easy one, right? If I went up to your general practitioner, and I said, I use insulin, will chicken make my blood sugar rise? I think most general practitioners would say no, if there's no carbs in that, you'll be fine. Right? Like, I think that would be the answer. And it's what most people get, except proteins broken down, it's stored as glucose makes your blood sugar rise? Is it a significant rise for some people, for some people, not depending on variables, too great to even go into right now. But if you tell that person, no chicken won't make your blood sugar rise, you're the deity in this situation, you got the white coat on, they believe you, they'll never think again, is my blood sugar high because of chicken, you've told them that won't happen. And then that that's gone from their mind forever now. And then if someone comes along 10 years from now, and tries to tell them, they'll fight to defend you and what you told them 10 years prior it You mean that much to them? Right in their life. So it could be that and it could just be you have no idea could just be Miss speaking or saying something. Without enough description. I for years. For years, I only thought Novolog was insulin, you didn't know that there were other No, because

they gave us dialogue was insulin and that insulin, this

is insulin, and I went alright, and I took it now this is insulin, right. So I now now when my daughter has struggles, I don't know that I could look into other kinds of insulin, I had no idea. It just would have never occurred to me, because I've already been predisposed to believe that what I was handed is insulin. And there shouldn't be any questions after that. Right? That's all right. And again, this could seem like nitpicking, but I've interviewed over 1000 people with diabetes. And I'm sure Jenny's talked to way more people than that with type one and type two. And it's got an impact on their lives that you, you can appreciate till you have those conversations with them.

And even the simplest statement could be misunderstood. And so that's why really unless you have a good enough idea how to give a simple but correct answer, the better idea so you know what? I don't I don't know, either. Let's look that up. Let's take the time to gather to understand it in office, I think that goes a long way with actually trust from a person with diabetes to the clinician, because the clinician is willing to take that step with somebody or say, You know what, we can set up another visit and or I'm going to have another clinician who knows all about this be the one to present you with the right information, and timely visits, I think within that are an important thing to consider when you're the clinician scheduling somebody out. It's somebody has a question. Oh, it looks like three months from now you can see this person who can answer I know, no, having worked clinically how scheduling works, I get it, but a question needs an answer. And it doesn't need a delay to it.

So you know, I think it might be important to dimension here before we go through what we think are going to be the topics the topics in this in this series. Everybody who has diabetes has diabetes supplies, but not everybody gets them from us med the way we do us med.com forward slash juicebox or call 888721151 for us med is the number one distributor for FreeStyle Libre systems nationwide. They are the number one specialty distributor For Omnipod dash, the number one fastest growing tandem distributor nationwide. And they always provide 90 days worth of supplies, and fast and free shipping. That's right us med carries everything from insulin pumps to diabetes testing supplies, right up to your latest CGM, like the FreeStyle Libre two, n three, and the Dexcom, G six and seven. They even have Omni pod dash and Omni pod five, they have an A plus rating with the Better Business Bureau and you can reach them at 888-721-1514 or by going to my link us med.com forward slash juicebox. When you contact them, you get your free benefits check. And then if they take your insurance, you're often going and US med takes over 800 private insurers and Medicare nationwide. better service and better care is what US med wants to provide for you. Us med.com forward slash juicebox get your diabetes supplies the same way Arden does from us med links in the show notes links at juicebox podcast.com. To us Med and all the sponsors, when you use my links, you're supporting the show. You know what I'm gonna let it go. I'm gonna let it go. And I'm gonna bring it back up in a second. So let me let me jump forward to the time has to make a note for myself here maybe doesn't fit right here. Okay, so what we've got here is a fairly, a fairly big list of of ideas and thoughts. But I wouldn't want a physician or even a person listening who's like, what am I going to what should I be expecting from my doctor? I wouldn't want you to think, how am I going to put all this to memory? What am I going to carry bullet points around with you make sure he asked me about this, make sure I've talked about that. To me, that's not how this works. To me the way it works as these conversations you listen to them. And you sort of just fold the information into your understanding of diabetes, so that when these things do come up, your natural inclination will lead you towards answers and ideas that will be helpful for you. So don't think of this as like a study guide. And don't think of it as a list. Think of it is it broadening your understanding so that you can ask or, or give the right information? Correct. That's what I was thinking so. So we have a broken down diagnosis, hospitals, insulin food, CGM, and bgmc, insulin pumps, the humanity and mentality, communication, management and pregnancy at the end. And I actually, as we started talking, wandered out loud and wandered on my notepad to myself, do we do want at the end for school nurses too? So let's make a good

one as well, I do we have, you know, one that came to mind since you had insulin in there, right? is safety. I think safety would go right along with that insulin topic.

You're hearing Jenny and I morphing the list as we go. So the reason

is, because I've I've seen too many things that circulate around insulin, and the topic of safety. It's not discussed the right way and or the tools that are there for safe measures aren't talked about at

all. And you might, as an example, oh, everyone knows that. But I quite literally spoke to a woman two weeks ago, who is in her 30s and has had diabetes for 20 years, who until two years ago, did not know that insulin could be dangerous to her. Right? That's it. So that is a thing that I think a doctor wouldn't expect. Right? You know, and so you so you don't say also, here's a good example, and we'll go over that episode. You don't give them the insulin and say, Hey, this is really dangerous, it could kill you. Because if you use too much of it, it can kill you. You don't tell them that. That way you. You want them to know the truth about how it works. You don't want them to be scared to use it. Because all that's going to do is drive people to have higher blood sugars and complications one day, and it's just these are the things we're talking about. So yeah, I

think within that insulin and that safety is tactics of discussion, honestly, because I think too often you brought up, you know, just the word scare. Too often, the strategy that's used, it's not a direct thing, but I think too often scare tactics are used. That shouldn't be the way that people are educated.

You can't lump everybody together into one mindset. Like there are going to be some people who don't do a good job taking care of themselves. That might be because they don't understand it. That might be because they're afraid aid, it might because they're apathetic, on and online. But what you what you see happen, the stories you get back from people are that the doctor just assumed I didn't care. But that wasn't the case. And often people have, you know, psychological reasons why they can't do the things you're asking them to do. There's plenty of times and plenty of stories where you as the doctor, you think you're giving great advice, and you're not. And that person is at home, breaking their ass trying to make this work. And they come back to you, and you say, Well, you're not trying hard enough. That's how much you believe in information that is not actually very valuable to them, or you haven't done a good job of, of giving it to them in a way that that they can pick up and use. And

that's the reason that, you know, you have to with each person, that human piece to it again, you have to bring, like your whole wealth of knowledge into those visits, and your your understanding of being human and all the variables that impact your life up to that visit time, because people are going to lean in and respond and ask questions. And that gives you who they are. And it leads you the route of simplified information, more extensive information, this type of technology to discuss Nope, we're not there yet. I mean, it leads you down the path to help this person on an individual level. But you have to be willing to listen. And I know in today's world, I don't think that doctors don't want to listen, I know that there is a time constraint, I 100%. Understand that. But I think even the first couple of minutes of of a discussion could be enough to be able to feel out the avenue, you're gonna go down for that visits.

I think if you heard that, and you think, Well, look, I told them what to do if they don't do it too bad. Like, if that's your feeling, I'll say this to Jenny and I both from different perspectives have an incredible amount of experience, helping people who we are not sitting in front of. Right, and Jenny does it one on one through a video chat, right. And that's a special skill. That's why she's talking so much about getting to know people because that's what she knows, works. And for me, I have a different skill. I help people without knowing who they are. Right, I can't see them. I don't know their circumstances. And, and I'm left to give information in a way that I imagined that the most amount of people can pick up and use. And you need to be able to deliver information in a very digestible way when you do that, because I don't know who I'm talking to right now. Like I could be. And I know I There are doctors, physicians learned people whose kids get diabetes, and they can't figure it out. And they listen to this podcast to figure it out. And I have spoken to people who have not graduated from high school, and who struggle financially, who have mental disorders, like all like all different kinds of people have written to me to say, I'm better off now for listening to the podcast. And that, to me, at its core, is about delivery of the information. Absolutely, because if I said to any doctor, right now, I want you to explain diabetes to a faceless person, I can't tell you if they're male or female, if they get a period, if they don't, if they're an adult, or a child, or if they're 100 years old, or 50. And you can't give them bad information. But it needs to work for as many of them as possible. I think it would freeze them in their tracks. I find it kind of simple to do. And so it's just I don't know why. I don't know why I'm good at this. I don't know why you're good at the thing you're good at but people should, should pay a little bit of attention to this.

Yeah, I think one of the biggest pieces that is not it's not personality based that you you start from and it's very directed to insulin, right. Your your big emphasis is all around understanding insulin. And that insulin understanding can get very precise person to person and variable to variable in lifestyle. But in general, if you have an idea of how insulin works, it doesn't matter whether you're male, female with hormone action, a child a 90 year old, you know, whatever. Insulin is meant to work a certain way and if you start to understand that, then the person becomes important because then the action and the use of insulin can be a Just based on the person, I started

this podcast almost a decade ago, based on the idea that if you understood how insulin worked, that was the starting point, like I looked at all of the different things that people are told about their diabetes. And there's so many. And I looked at each one of them. And I thought, is this the core idea? No. Is this the core idea? No. What's the core idea? Like, what do I have to know on day one moment one, and it's how insulin reacts in your body. That's it, you need to have some starting point, so that you can begin to have experiences, and then witness those experiences, hold them up against your knowledge, and decide what happened there. And how do I make it do what I want? How do I bend this thing to my will, instead of sitting here waiting for diabetes to happen to me, I'm going to try to happen to it. And because

that's where individualizing your use of insulin comes into the picture. Right?

Yeah. And I think what ends up happening in a, I mean, we'll talk about it through the the episodes, but you know, you're diagnosed, there's a lot of fear right away, okay, like and good reason to be good reason to be scared, it's a scary thing. And then terms start flying around, and rules. And this could kill, you don't use too much don't use too little shoot for this range. Like they start saying things like that. It's overwhelming. It's incredibly overwhelming. And your brain picks and chooses what it's going to remember. I think most people's brains work, the way they talk about astronauts making decisions, the only problem in front of them is the next thing that can kill them. And then once they once they get that one, then they go to the next thing that can kill them, because everything in space is trying to kill you. So you don't worry about everything you worry about the next thing coming for you. And I think you can get put into that situation when you're diagnosed with type one, or type two honestly, like like, like, quite honestly, this is where at diagnosis, not saying the wrong thing is almost more important than saying the right thing. Correct. So Jenny, the next thing after being diagnosed is for a lot of people, they end up in the hospital. And for a lot of people, just as many actually sometimes I think more they end up like just being sent home adults are sent home at to me what seems like an alarming rate when they're diagnosed with diabetes very quickly. Yeah. So that's going to be we think, right, that's the next episode. So we're gonna start with diagnosis have a big conversation about being diagnosed. Correct. And then we're gonna talk about hospitals. And that first setting that you're in, because that's the next opportunity for a different group of clinicians to be in contact with you. Correct lot of nursing staff is going to be in contact with you. A lot of roving doctors are going to be in and out. I'm not saying you guys send them in just so you can build. But you know, there's a lot of people coming in and out. And they all have to say something to you, if they want insurance to cover it. So we want them to know what they're saying. There might be nothing more disheartening, when you're dealing with a doctor than when you're sitting there. And you realize they don't know what they're talking about. And they know they don't know, we're just talking at each other. Because boy, does that take the air out of you. Because you don't know what you're doing. You're looking to this person, and they're just glad handing you or just talking around things like oh, they're not saying anything. And

sometimes that's a process. I mean, having worked, you know, enough hospital time, it's almost an intermediate step of sorts of not that you've given a diagnosis, it's diagnosis, that is something maybe nobody has ever heard of the heard of it, they don't know anything about it. And it's a you know, 100% brand new as diabetes diagnosis typically is. And I think from the clinical standpoint, that is where they don't just want to leave you with this diagnosis. And even if they don't know enough about it, because they're not specialized in it. There's a sense of not leaving somebody just with that new information. And so there's, you know, I need to stay here and talk but I really don't have anything to talk about because I don't know enough to give you answers to all the questions that you have. So I can they kind of skirt around answering things in a direct way because they don't want to miss inform. I don't think any any clinician really wants to give the wrong information at all. But I do think that that time between really talking to the knowledgeable Viet an educator or nurse practitioner or the endocrine team that's going to come in and really give you the in depth right. There's also a time segment where they may not be in the hospital yet, right? If you take your cell For a child, or a teen or a loved one in at two o'clock in the morning, you're likely not going to see a knowledgeable, true condition, physician or team until the normal hours of the day.

But again, I think that's why this will be important, because you could listen through this one time, in a few hours in your car while you're working or whatever, and then actually have something valuable to say, even if you are the one at 2am. You know, like, even if you're the one at 2am, who just says, Listen, this is going to seem very overwhelming at first, and I don't want to lie to you it is, but it's doable. You and your team, you know, your family, you're gonna find your way through this, I guarantee, I'll tell you that nicest thing you can say to a person with diabetes a year from now, it's not going to feel like this. Right? It's just just going to be learning some new stuff. And it's not a test. It's not learning like that. It's just having experiences and learning from them and moving on and applying. It's gonna take a little time, but you'll see it'll be okay. Not don't promise them it'll magically be okay. Like you don't I mean, don't don't don't do the thing. That's been happening for decades. Jenny has no idea what I'm going to say right now. But what does everybody told when they're diagnosed? Oh, that

it's going to be cured in seven years? Where did you come up with the magic number of seven to begin with? Right? Five years,

seven years? 10 years? It's happening. I read an article in Forbes, he didn't say it. It's almost over like that. Don't do that to people don't do that. Right. Cuz then they don't take care of themselves. Yeah, I think it's almost over. Right. Right. So I mean,

you asked, you know that what's the biggest thing that I really want? I want? If I if I had like my full 100% wish, this whole, like Grand Rounds, it would be part of like medical school education? It really would. It would be because I think regardless of what specialty somebody ends up going into, it may very well not be diabetes, because diabetes is it's on the rise. Yeah, you're honest, you are going to touch somebody or be touched by somebody with diabetes, whether it's type one or type two, or maybe even gestational diabetes, you know, whatnot, the more you have than the basic of the one class you took in an hour's worth of your medical schooling, you will find somebody that it's valuable for you to know just a little bit more. So that's my goal.

Yeah. Because the better chance you'll have not to frustrate that person and make another person who doesn't believe you are listening to you. You know, don't be the dentist that says you shouldn't use candy to stop a low blood sugar to a woman whose four year old will only take candy when they're when their blood sugar is falling, and she's afraid the kid is gonna die. Like that's not a good time to tell her that Skittles are bad, right? I'm gonna curse for a second. She knows Skittles are bad, Jenny. He's in a situation here. The space capsule is breaking open, and she's trying to stay alive and you're telling her Hey, you probably shouldn't eat Skittles. That's what's wrong. Yeah. Like have Don't be the eye doctor who asks if you've tested your blood sugar today, you have type one diabetes, you have tested at 53 times.

You are my one of my favorite questions at the eye doctor is Do you know what your blood sugar is? Nope. Right this?

No, no,

I was up. I was supposed to check. What No, I

never look. It's crazy. It's a certainty that they don't know what the hell they're talking about.

It's because it's on a questionnaire. It's part of the checkoff. Yes, you've asked this Yes, you've asked this. And I know Yeah, even listen,

if you're a doctor, just for self preservation, you want to billable person to show back up every couple of months, I wouldn't leave them with the idea that you don't understand their diabetes, because they're gonna bolt from you very quickly if you do that. So there, let's break it down to money, if that makes it better. Like you need to understand this. So you can do good for them. But so that you can also be a viable option for other people. And if you don't think people will go online and tell them don't go see this one that's happening constantly. So, you know, that's how these people stay alive by finding each other and making a community and telling them you know, where the good information is, this is good, don't go there. Just get it you could get a reputation as just being somebody who gets that they don't know and is willing to be in a partnership with someone with it correct? Right. There's a lot of ways to think about so. So anyway, that stuff in the hospital. So those are wanting to to me, but I'd still put insulin one except I'm not asking the person the nurse in the hospital to tell you about insulin, but you're gonna get to endocrinology general practitioner Next type two type one depends on what you are, I guess, adult or child, you're gonna end up in that scenario. This is it. This is when you start explaining insulin to them. And we Jenny and I are gonna have a long conversation about how when Some work so that when you're done listening, you can really understand it too. And I know you think you do, but you don't. So I mean, if you have diabetes and you're listening, then you're just giggling along, like,

I know you think you know, insulin, you really

are not using insulin, you don't understand how it works, and not for nothing. thyroid medication, right? autoimmune issues kind of run together. So I happen to know a lot about thyroid. Most doctors are terrible at prescribing thyroid medication, they're not good at it. They don't know how it works. And I don't just mean, take it in the morning before you eat. I know you think that that's the whole thing. But it's not and you don't know. And maybe it's not your fault, you don't know. But that little decision, not understanding how to medicate someone's thyroid problem causes them problems with how their insulin works long term and how their weight reacts. And if they're heavier, then they need more insulin. And now you already didn't teach them how to use insulin. And now you're putting them in a situation where they know they need more of it. And you don't know that, you know, because you don't have a thyroid problem and diabetes, and it's cool. Like not to know, we'll explain it to you. So we're gonna go all through insulin, not just how it works, but just any brought up all your safety now. Food is next on our list, huh? Okay,

can I say

please go? Also tell them you got letters behind your name? This makes this even more impressive. What are you that

which is the reason? Yes, so I'm a registered dietitian and certified diabetes care and education specialist. And to be quite honest, as a registered dietitian, you go through a lot of schooling specific to human nutrition. I did many years of education in human nutrition, and an internship program and application in clinical needs, etc. By no means should clinical staff that hasn't had the education be giving out nutrition information. You just really I mean, and this goes, as far as you know, years ago, when I started as an educator, so many people brought up well, my doctor told me not to eat white food. What does that mean? So I can't eat apples, because they're white. And so in general, my statement is, I would never try to tell somebody what to do for a brain tumor. I would say I'm not a specialist. Sounds like you got a problem. You need somebody specialized, though. Please don't tell people about nutrition, because I guarantee that the majority of them don't have nutrition degrees.

Well, also, if I'm being told about nutrition from somebody who does not personally appear like they understand it, I have a hard time taking you seriously. Yeah,

yes, yes, if you're the doctor who smokes and then tells people not to smoke, I guarantee with your

yellow fingers, you know what you're doing, that's really hurting you smoking, I heard about it. It's bad. I think Jenny's point is and you know, it's funny when I think of you and where your value lies, for people with diabetes, obviously, being a nutritionist, and a CD is important. But I Brank. Just as importantly, you've had diabetes for over 35 years. So that's a long time and a lot of lessons. And then you, you couple in that education on top of those lessons, then you couple in the experiences you're having talking to people every day, on top of those lessons. Jenny knows what she's talking about. She's not here by mistake. And I

I also think within the topic of food, I do think that it's under discussed in the right way. So and I find this both for kiddos, and like all ages, let's just say, you know, the whole idea around food, as you said before, you know, something nice to say is that a year from now, this will look different. And it will be it will be better than it feels right now. Right? Something around food that often gets said is that you really don't have to change anything at all about what you're doing. And I think as an in a nice way. The clinician is trying to just say, hey, it's it's not that bad, right. But in general, there is a lot to understand about food there is and it's not just as cut and dry as take your insulin and eat your food. And the other consideration there is each person again, going on the individual, very personalized basis. Each person needs to know how much they should have. It's not just a well gosh, if you just take your insulin and your time at the right way you can eat whatever you want to eat. And I think that that's that's a widespread problem. Whether you have diabetes or not is just the intake of food is not managed well because we don't understand what our real needs are.

Understand food most Have it's processed, yeah, they don't have access to good food to begin with. All these are different problems. And then you just say to them, nothing has to change if you're trying to be kind. It's the same kindness, by the way, that's meant by Oh, I heard there's going to be a cure. It's the same. They're trying to alleviate your your sorrow, I get that. Don't worry, nothing's gonna have to change. Well, yeah, that's true. Unless you unless you eat like, horribly, and you know, like, and then you send them home, go, don't worry, it's gonna be fine. Then they get up in the morning and have a bowl of Captain Crunch and their blood sugar's 350. And you didn't teach them how to use enzyme anyway, by the way, I get both bucket bowls for Captain Crunch. But that's not the point. Like the point is, it's going to impact them hard. And then they roll into lunch, and it's frozen pizza. And then they roll into dinner. And it's processed chicken nuggets, and a friend and oil and all this stuff. They don't know they think they're eating well, right. I promise you. I've talked to a lot of people. I think the majority of people who are eating poorly don't know they are. Right. I honestly believe that. I don't think it's I don't think it's apathy. I don't think it's ignorance. I think they just don't know. And now you're telling them Don't worry about it's not a problem. You don't know what they're eating? How could you possibly say that? Right, right. So yeah, and how does food impact insulin? How does insulin impact food? We're going to talk all about that. Because if you don't understand that, I don't know how you're possibly directing people I am going to share with you that online the other day in the in the private Facebook group, I watched somebody tell a story, where they were in a doctor's office and said to the doctor, look, you're giving me this information. But the truth is, is that 10 grams of this food and 10 grams of that food impact my kid completely differently. Right? And they said the doctor looked at them crazy, like just sideways. And and he's like what he does? Well, there's there's obviously a personal as to the podcast, we're like, well, the glycemic impact of this food is not the same as that, right, and the loads different with this one because it's more complex. And therefore one of these needs a different amount of insulin, actually, it also needs kind of an extended Bolus, and all that and this other ones are simpler. And they're having this conversation and the doctor stopped them and said, This burned in my head when I watched when I read it, you are completely wrong about that. A carb is a carb is a carb. That's what they were told. So now this lady was, you know, educated enough that she could fight back. And by the way, she didn't fight back. You want to know what she did to look for another doctor? Yeah. So but there she was in a room that how many people? Is he saying that to? Correct, right? Yes. And that's not right. And if you heard that just now and thought, oh, wait, a card is not a card is the card for a person with diabetes, you might want to start wondering what else you don't know? Because that's a pretty basic one. And it's huge.

Right? Right. Absolutely. Okay. And I think in today's in today's technology use that has become much more visible years and years ago, not so much, right. But in today's world, which we've had technology long enough, now, it's very visible that you can, you know, know the difference between food versus food, even though they technically fall within the same macro.

And that's why the next piece of this is going to be glucose monitors, continuous glucose monitors and blood glucose monitors. Yes, because again, it's they're more than I think they're more than what most people think when they prescribe them, and the value that they have, and how you can interpret that value. And the information is huge. So that's going to be the next step. Then we're going to talk about insulin pumping. And I'm probably going to rail against all of you who think that you have to have diabetes for a prescribed amount of time before you get an insulin pump. And we're gonna talk about how they work and how you can support people with them. Then the next piece that Jenny keeps bringing up over and over again, when she and I talked about this, before we got together today is just the mentality and the humanity behind everything. You know, and how important it is to, you know, like we said earlier to treat people, not like a patient and not like a customer, but not

like a checklist of things that you have to get through because they're necessary to ask about, while they may be important, you have to remember the person coming in is it's got a life, full of a lot of things beyond just the diabetes, which may very well be part of the part of the communication or the conversation that you have if you take the time to listen. Right.

And that takes us to the next part, which is communication. We're going to talk a lot about how we have found the talking part of it to be so important. And the tactics I hate to say that word but the tactics that that Jenny and I both use it In what we do separately and together, when we're talking to people together, we're doing it now, by the way, you don't realize it, if Jenny and I were talking about this privately, it wouldn't exactly sound like this. We're delivering this in a way that we think that would interest doctors without making the mad. So they'll keep listening in a way that will let patients hear it. So they know what to go like advocate for. But without making them mad at the doctors, right, like, right, that's what you're hearing for the last 45 minutes is being given to you purposefully. And there's a way to do that. By the way, both ways, doctor to patient, patient to doctor, because, you know, if you just walk in there as the patient, and you're a big pain in the ass, the doctor still a person, and they're going to put up a wall, you know? Namie, right? Absolutely. You're gonna be like, Oh, this one is how they're gonna think when you come in. Right? Yeah, that's not how you want to get your your doctor in get any mean, you want them to be excited to see you. And, you know, and there's responsibility on both sides for that, then we have management Jenny, and I have to scroll down a little bit. To be perfectly honest with you. To see what that is a long list. We put this together a couple of weeks ago. Okay. So this is going to be kind of a big, a big kind of overview about education, you know, kind of don't just teach a man to fish. You know, right, you know, teach them how to fish kind of a situation more about ratios, like real kind of more nuts and bolts stuff that I think that isn't that difficult if you're a physician that you could understand. Right? And then Jenny added pregnancy at the end, because it's one of the things that she does, and she can be really valuable. And that I will probably not say as much during that episode, but we'll talk about that. And then I don't know, Jenny, do we? Do we like adding school nurses to

this? I like adding school nurses? Absolutely. All right.

I'm gonna tell you why. Now, just briefly, and then I'll remember when we make the episode to tell you the whole story, but I'm going to tell you in the nursing, the school nurse part, the story that a guy named Joe literally just called me last night and told me about, and just remind me when we get to that episode to tell you Joe's story about school. Okay. Okay, thank you. I really appreciate this. I'm super excited. Yes, that you're willing to do this with me. And and I can't. I'm excited. It was a great idea. Well, so that's my idea. But thank you. It was everybody's idea. I'll tell you what, being serious. It was a thought I had just out of nowhere, I think I was in the shower. And I was like, What are Jenny and I going to do next? And it popped into my head. But it's only an idea that popped in my head because of the countless hours of conversations I've had with you. And on this podcast and hearing back from people, all of that stuff together. Like it's not some stroke of brilliance? You know what I mean?

No. And I think that at one point, I said to you, I wish, I don't know, maybe it was after a particularly frustrating conversation with somebody who was really just, they were frustrated with their, their clinician, and what they were not necessarily getting, or what they had gotten and forced them to kind of change physicians. But I think I had said to you, I was like, I wish that we could just like package the prototypes and send it out to all clinicians that are out there. I wish we could just do this so that they could understand it from this

level. Right? So we have this series called diabetes pro tip. And it's this 26 part series that I mean, if you're you know, if doctors are listening right now, I can tell you that most people report back in a one seeing the low sixes the high fives just from listening to these these podcast episodes. It's with Jenny and I. And she's just like, why can't we just like, like, how do you do that? And I kept thinking, I'm like, I don't wouldn't begin to put them on thumb drives and mail them to doctors offices, like, like, yeah, that's not going to work. And, you know, and, you know, how do you talk somebody into getting information that they don't know they need? So my thought was, there are plenty of doctors that listen to this podcast that are that like the podcast. So maybe we'll put this series together and maybe they'll start sharing it amongst colleagues. This is kind of how we were hoping so anyway, I appreciate it very much. Hope you have a good weekend. You

as well. Thanks. Thanks.

I want to thank you all for listening. And I want to thank you us med for sponsoring the episode us med.com/juice box or call 888-721-1514 To get your free benefits check and to get started today, getting your diabetes supplies the same way we do from us but I want to thank Jenny and remind you that she works at integrated diabetes.com If you'd like to hire her and I'd also like to let you know that this series starts off properly in the first week of January 2024. If you're not subscribed or following the podcast right now on Apple podcast, Spotify or another audio app, do that right now, to get the very first episode of the Grand Rounds series, this series will run for my gosh, I think it's going to probably be 910 10 or so weeks. Once a week, you'll get a grand rounds episode. But there's going to be more than that in the first quarter, maybe the first half of the season of the Juicebox Podcast, which by the way, 2024 will be the 10th season of the Juicebox Podcast and thank you very much for being a longtime listeners and supporting the entire show. But we're not just going to get grand rounds, we're also going to get something called cold wind. That's a healthcare whistleblower series. Wait till you hear the whistleblower episodes. These are professionals working in healthcare, from emergency room nurses to human resources, professionals, doctors, everybody in between. They're going to be on the show, anonymously, with their voices electronically changed so that they can feel free to talk about the business they work in. I don't want to give it away, but you're going to be well, it's going to be chilling. So cold wind, healthcare whistleblowers coming in January to the Juicebox Podcast. In the meantime, you're invited to join the private Facebook group for the Juicebox Podcast. That's if you're a physician, other health care provider or someone living with type one. It's called Juicebox. Podcast type one diabetes, it's a private group. It has over 44,000 members in it, it gets over 100 posts a day of people living with diabetes. If you're a physician, if you're a nurse practitioner, or if you're just somebody helping someone with diabetes, you've heard this and you think, maybe I don't really understand this enough. Just being in that group. You don't even have to participate. But just being there will help you learn more than you can imagine. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

Hello friends, and welcome to episode 1097 of the Juicebox Podcast. Welcome back to the 10th season of the Juicebox Podcast we are starting strong in 2024. With a brand new series called Grand Rounds, these episodes will be myself and Jenny Smith. And Jenny and I are going to be talking to two distinct audiences in these episodes. On one hand, these conversations are directed to clinicians. But on the other hand, they're also directed to patients. People living with type one diabetes deserve good care, and they need to know what to expect and demand from their physicians and physicians. It feels like sometimes some of you don't know you're from a hole in the ground. So with good humor, and much love, this is the Grand Rounds series, where we're going to try to explain to doctors what they don't know about diabetes. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan, or becoming bold with insulin. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show. This episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. Learn more and get started today at contour next one.com/juicebox. This episode of The Juicebox Podcast is sponsored by touched by type one touched by type one.org. And find them on Facebook and Instagram touched by type one is an organization dedicated to helping people living with type one diabetes. And they have so many different programs that are doing just that. Check them out at touched by type one.org. Hey, Jenny, welcome back. Hi, how are you? I'm good. Thank you. How are you? I'm fine. Look at us on a Monday again. We've been doing so many Fridays lately. And now today, beginning of the week energy you're getting from us? Yay. I don't know what that means.

Like, I don't know, weekend into Monday. I don't know if there's energy there. Maybe Yeah,

well, we're about to find out. It's funny. We did the first Grand Rounds episode, which is like an overview of what we're going to talk about. And I think I vacillated a little bit I said I like it's hospitals. First, it's diagnosis first. And then as I really thought about today, like most people are going to end up in some sort of an urgent care hospital care scenario first, right? It's it's very few and far between where people figure out they have diabetes, and, you know, go right into a hospital like, right into a diagnosis. I mean, like, you don't end up at your physician going, Hey, I'm here I have diabetes, like you manage me from here. Like I think a lot of people end up in some sort of an emergent situation initially, do you think that's fair?

I think it's fair in the majority of like a diagnosis setting, I think for adults, who may be a little bit more in tune with what their body has been feeling like, and they've just paid enough attention recently to say, This isn't me, like I, I feel horrible, or I've noticed, you know, I clearly can eat like the whole entire refrigerator. And I'm still like losing weight, or I, you know what I mean? That might prompt them to make an appointment with a primary care doctor to actually just go in and go over. And that obviously isn't an emergent, especially unless they call and they get a really good sort of intake nurse who's like, I don't know these symptoms, maybe you should just go to the emergency department instead of coming in here most often they're going to be and sometimes they're also caught, like, you know, you go in for a new job, and they might have you do a physical and you get a fasting glucose or even just a random glucose that kind of sparks up. Hey, we should do more testing here because this glucose number is out of range. But in general, yes, it's more emergent.

I'm thinking then that these these two topics are kind of one one a there, you know, I don't know if I can, for sure say but I'm just going to start with hospitals. Because I think hospitals, urgent care, those sorts of things. These are the people who are probably least prepared to give you information and most likely to say something, it's just gonna say, Look at me starting right off most likely to say something that puts you on a bad path.

Correct? Not in not because they're meaning to but because again, as we said in the you know, initial sort of discussion, it's because they Really, that's not a specialty for them? Sure they have, they have broad knowledge of a lot of different conditions. And a lot of honestly, I mean, emergency departments are a lot of like test results, right? And what do you do? What specialty do we knew now call it and because of this test result, or this type of trauma or this type of thing that the person came in with, so they have a lot of information. But they're like snippets, right? It's just the tip of the iceberg of information.

And I think through that their professional experiences, especially if you're in an emergency room, or, you know, urgent care, any emergency situation, when you see people who have diabetes, they're not coming there, because things are going great normally. So these are people whose blood sugars could be wildly swinging around, they might be having a ton of low blood sugars, they might be having so many highs that they're having other kinds of concerns. And so that when that's your experience with people with diabetes, I think it's then when you meet a new person, newly diagnosed person, whether you mean to or not, you're colored in that direction, right? Like, you lean into, oh, this is bad. Or you want to make sure about like this, because all when I see the people they can't feel their feet and like like, and then does, it may not become a self fulfilling prophecy, then when you bring a newly diagnosed person who is going to be in shock, once you tell them what's going on, their blood sugar's are probably very high. So they're altered to begin with. And now you're saying all these things to them that they did not expect in their life. And if you're coming from the, oh, this is really bad. Then you predispose somebody to believe they now have a thing that's really bad. And you know what I mean by that? Yeah, I

do. And I think something that also goes along with it, I mean, my husband would be the first to say that I clearly should never be a poker player, I have no poker face, I just don't like I, if something's up with me, like it's, I have a different expression for a lot of things. And so I think that's another piece in this. That's not verbal. But you know, if you're walking in with lab information, or a urinalysis or something, as the first point of contact of this new information for the family, or for the adult, or whoever it is, you're going to say, hey, you have diabetes, you know, I know you shouldn't be like looking like a happy, happy person. But really, you should also look like this isn't like the Grim Reaper expression on your face, right?

I don't mean to say that people should be disingenuous. As a matter of fact, one of my favorite restaurants, there's a teacher, a school teacher that works there as a as a weight as waitstaff. And she teaches very young children. And so she comes at you with that energy. And the entire time you're talking to her you're like, I don't feel like this is real. But I actually think it's who she is. But it's still like, it makes you feel like is she pretending? And so you don't want to come to somebody with this happy energy? Like, oh, don't you have diabetes? No big deal. Because Correct. That's also like a lot about what we're going to talk about here is the path you're sending someone on. So you don't want to send them down a doom and gloom path, because if they think there's no hope they might live, like there's no hope. And they might educate themselves as if it doesn't matter what I learned, because I'm gonna end up back in that hospital one day, right? You also don't want to let them think like, everything is just amazing. And this is super easy. And you know, or that, you know, we talked about earlier to, you don't start telling them about a cure that you heard about an even yet, right? Because Because I know where that comes from, it comes from a, I want to make you feel happier, we're better about this. Correct. But what you might not know if you're in an emergency room is when you tell somebody something's going to be cured. Soon, you predispose them to not learning about it and not taking care of it because they think it's a temporary issue. Right?

Yeah, absolutely. And I think that's another piece that temporary, it's a good, it's a good word, because I think something also that gets laid down early on not every time but many times is just do these simple steps. And it will, it will work right. And or, here's your here's your dose, you know, let's say this is a new diagnosis of type one diabetes, obviously and here are your doses. The explanation beyond that, even though you may not know what that transition may look like, should never lead the person to believe that these start these starting doses or this starting is where it is going to be that there will be movement you will follow up with a care team the care team will direct this your doses may change they will change you know all these all these points to have them understand that this is a like a moving picture. All right,

if you put me in this position, I would tell people, listen, this is scary, I understand, it's going to get easier over time. But that's only going to come if you learn a few things. And really, at its core, you're gonna have to learn how insulin works. Now we're setting you up best we can, with some settings, and some ideas, just like you said, These things are going to morph and change. As a matter of fact, it's possible. Don't say things to them, like you might be in a honeymoon period, say it's possible, you may still be getting some assistance from your pancreas that will over time, and I can't tell you how much time will dwindle to nothing. And that could be a week, it could be a month, it could be a year, I don't know. But I can tell you that that's going to keep changing as that changes the how you use manmade insulin, the amounts. And I think, you know, a lot of the strategies are going to change as you move forward, leaving them with the idea that it's not going to stay static is super important in a society where people think about pills fixing things, correct? Yeah, right, exactly.

Because most of the medications, honestly outside of insulin, and maybe a couple of other things, other medications, oral or even injected Ra, I take it in the morning. And that's it, I don't have to think about what I'm doing the rest of the day, because the medication just does what it's supposed to do. The understanding that you're giving them of this medicine, I hate calling insulin medicine, because it is something that your body does naturally make, right, just in the case of diabetes, it doesn't. But this insulin that you're taking essentially, will need to be adjusted, we are just at a starting place. And to understand, again, we're not your specialty team, we're setting you up with a place to be able to get out of the hospital, essentially, and then move forward into a team that can provide you with that detailed information. We are just covering the basic,

I think when you're doing triage work, which is what that is, right? It's triage and initial, and then you move people on to something else. For most things that happen in an emergency room, the thing that's happening now goes away, when you get to the next step, I broke my leg, you know, hey, broke your leg, it looks good, it looks bad, I just shouldn't be a problem, we're gonna get you to somebody, boom, you leave. Right? A day or two later, what was said to you in the emergency room is no longer impactful to you. It's over. Now, this is a situation where the least knowledgeable person in your care plan and I mean care plan from day one being diagnosed, the day you die. The least knowledgeable person is the first person you see. And they imprint ideas on you. And they don't know like, I'm talking to the doctors. Now I know you don't know you're doing it. It's because you don't have diabetes, like and I get it. But you start saying things like, Don't worry, it'll be fine makes people not pay attention. When you tell people to worry, you ruin their lives. Like they, some people will go home and be burdened in ways you can't imagine. You need to say, I don't know a lot about this. But what I know for sure is all of management, at its core is how insulin works. You need to get to an endocrinologist and learn about insulin. And if your endocrinologist doesn't teach you go out into the world, do your best to find that information. Otherwise, you get lost in a direction you either get lost in over management direction, which causes significant psychological issues for people. Right, I was just talking to a girl the other day on the pocket. She's 21 diabetes, and she was five years old. And still, when she got to her adult endocrinologist who would just tell her you're a one sees too high. Just say that to her a couple times. Then one day, he said, Eat Fewer carbs. Well, then it got in her head. And that's all she could think about. Right? I'm not gonna eat more than 20 carbs today. And then she started having a disordered eating pattern. And if somebody else in her life hadn't come around to her and said, Hey, you're not eating well at all. This is what she would have done out of that fear. Because she said once she started using such a small amount of insulin, even though she wasn't nourishing herself. After she started using such a small amount of insulin, she saw more stability. And that's the building made her ignore that she wasn't eating anymore. Of course, yeah. And then when somebody finally came along and said, I don't think you're even nourishing yourself, and it was time to inject more insulin for her her meals. She was frightened and she couldn't do it. Right. I tell you that like quick story that people were listening, because that all came from a someone who just didn't know how to help her with her insulin and said once you just need fewer carbs, that throwaway idea caused that landslide of problems for that lasted two years. contour next.com/juicebox. That's the link you'll use. To find out more about the contour next gen blood glucose meter, when you get there, there's a little bit at the top, you can click right on blood glucose monitoring, I'll do it with you go to meters, click on any of the meters, I'll click on the Next Gen, and you're gonna get more information, it's easy to use, and highly accurate. smartlight provides a simple understanding of your blood glucose levels. And of course, with Second Chance sampling technology, you can save money with fewer wasted test strips, as if all that wasn't enough, the contour, next gen also has a compatible app for an easy way to share and see your blood glucose results. Contour next one.com/juicebox. And if you scroll down at that link, you're gonna see things like a Buy Now button, you could register your meter after you purchase it, or what is this, download a coupon, oh, receive a free contour, next gen blood glucose meter, do tell contour next one.com/juicebox head over there now get the same accurate and reliable meter that we use.

Right, and you're talking about somebody who had been speaking with what we would consider is a specialist within the diabetes, you know, community, right. And so back stepping to the baseline. And I don't say baseline in a very generic way or in a you know, a not not educated way. But it's a baseline of information that those who don't have a specialty outside of this specialty of navigating so many different types of things that come in to an emergent situation, I mean, that that takes a special type of clinical mind, right to be able to navigate between, you know, this type of wound versus this type of vomiting versus that type of headache, there's a lot of consideration there to figure out and know what tests to do. It's a very quick paced environment. So nobody would expect them to be specialists in just one thing. But I do believe that from a general place. diabetes in and of itself is a hate thing easy, but it is, if you understand the baseline of type one versus type two diabetes, then in an emergency situation, test results are something that should be easy to interpret, right? And then what you provide with the family or the person who is going to be newly diagnosed, it should come from at least that baseline of this is what type one diabetes is. This is what it means. And I think those those basics for the person who this is very new four, are really important. Because again, I mean, we've talked in other things about, you know, blame or feeling guilty, and from the person who now has this diagnosis. And I think that even keel of you know what, we found out why you're feeling the way that you do you have type one diabetes, this is what that means. And, you know, I think that's at least a way for someone to accept the information, as well as for you to give them none of these like gray areas of like the unknown what to do with it.

You know, it's funny, you said that we don't, we wouldn't, and shouldn't expect a person in an emergency room, for example, to know the ins and outs of diabetes. That's great. And you and I sitting here philosophizing about it is exactly right. But the person who's just been diagnosed five seconds ago, you're the most learned person in the world to them. Correct. And so if you don't know, the best thing you can say, is I don't know a lot about this, you know, and I'd be afraid to tell you something that would lead you in the wrong direction. But I hear I listen to this podcast, I probably don't tell them that you but but but you know, here's what I do know, it's a lot about how insulin works. When you get to the next step. If you feel like you're not getting good information about how insulin works. Don't accept that as a baseline. Everything's about how insulin works. You know, it's not difficult. Once you understand it, it takes a while to understand it. Be patient, be kind to yourself, I mean, that's the thing. I always feel dopey saying stuff like that, but it's absolutely true. Like you gotta give yourself a break. It's gonna take some time. This is the kind of stuff you can lead them with. You know, you're gonna learn as you go, right? I know plenty of people who live well with this by the way, if you don't, it's okay still lie and say you do. Okay. Like you know, like you don't say Nick Jonas to them, apparently that's one of the feedback things from the people that are like, without telling me about Nick Jonas when I'm diagnosed. But But ironically enough, down the road, there are some people who are very comforted to know that people who they they see as they know, functioning well in the world and that they're aware of have Diabetes. But yeah, it's funny how many people said like, Please don't tell me about Nick Jonas? Well, my kids being tagged

with that is what? And again, that's, it's almost a, like you said before, oh, there'll be a cure kind of comment. It's not that bad. Yeah, when really, you're the one living this new thing. It is it's, it's

ever happened to you the worst

thing that's ever happened to you, right? I mean, in general, to when someone comes in emergent lead with this diagnosis, nine times out of 10, especially for kiddos are going to be admitted, there is going to be at least a day or two, depending on the status, when you come in with this type of diagnosis, depending on the status of the child, the teen, the young adult or the adult, there's going to be an admission, which means that you're again, you're the first explanation of this new diagnosis as the clinician who's there. But expanding on that, being able to say you know what, we're going to admit you, if that's what's going to happen, and there will be there will be specialists who will come and explain this further. I don't know all the answers, I'm not going to pretend to know all of the answers, you will have specialists who come in and explain and sit down and talk with you and answer all of the many questions that I know are probably sort of circulating in your head right now. And I think that's important to explain, because like you said, You're the first know all like, you're like everything right now in terms of delivering this new diagnosis to somebody, but also explaining, I know, I know what you have, but I can't do much more. That's why we're going to get you to the people who do

it's an awesome responsibility to have one of those jobs that people just blindly trust teachers, police officers, doctors, you know, you don't realize that what gets said is it's gospel. It just it right away is and you know, if you're listening right now, and you're a nurse that's in working in an ER or a doctor that works in some sort of intake, and you think I've I went through this in school, I know, you don't know anything about diabetes, if that's all you know, and I will offer as a personal anecdote about that, that this podcast is strewn with doctors and nurses whose children or selves have been diagnosed with diabetes. And when they were diagnosed, they thought, oh, this will be easy. I know about this. I learned about this in school. And then five minutes into it, they realize, oh, they only told us enough. So we don't kill somebody. Right. Right. And, and bringing up that kind of language. There's this phrase I used in the podcast a number of years ago. I swear to you, I wasn't trying to start a catchphrase. I said, I think some doctors not all by the way, by the way, there's plenty of doctors listening right now and nurses and doctors who are very good with diabetes and insulin management who are just saying Hallelujah, like preach to people, right, but, but for the ones that aren't, I used to say, I haven't said in a while. Often you get what I call don't die advice. Like it's enough management, that you'll you'll be alive today. And you're not going to have a seizure. But there's no no view of long term health or long term stability mentally, physically. It's just enough that you won't die today. Oh, yeah. Yeah, once the seven, that's pretty good. You know, like that kind of stuff. Your blood sugar went up to 300. But it came back down. Yeah, yeah.

And in an emergent situation, I think that you're not going to die right now information. I don't think that that's, that's very important. It's really, really important. This is a baseline, this is what's going to get us through to the next point, right. And that next point, again, is specialty. It's someone who's going to teach you not just how not to die, but is going to teach you how to live honestly, with this and strive and do all the things that you want to do in life that comes from a good specialist that that's not don't and as the person with diabetes, you know, newly diagnosed, shouldn't expect to get that either. Yeah, but as the clinician addressing them for the first time there, you should explain that to them. I am I am your baseline of information. This is what I know from the test results that we have. This is what it means. This is the basic definition of what you have. And we are going to get you people who can really explain this at a much higher level for you and I think that's really important for to not try to be the No at all. In that situation. Right? to not try to explain beyond what you truly don't grab it points. Essentially stick

to what you know, and check into what you think you know, before you start spreading it around As if it's true, because there was two pages in your book in college. And, you know, even when you think about managing diabetes in a long term setting in a hospital, I mean, honestly, Jenny, they, you know, if your blood sugar's under 300, while you're in the hospital, they're going to be thrilled. They're going to be focused on not making you low, and they're gonna have you eat, and then they'll shoot your insulin later, even when sometimes people who really understand their care will say, I, you know, I can't let my budget or up to 200 and sit here all day. Oh, no, we're okay with that. Whose way? Like, I'm not okay with that. But once you say it's okay, now a person goes out into their life, and it's okay. You know, 200 is fine. Like, because that's what happens in the beginning, you're giving good you're giving don't die advice, which is very, very important. But if you don't say the rest, like over time, we need to tighten these tolerances, right? They'll just live like that forever, right? Some feedback from people, even a small pamphlet with resources and basic information would have been amazing to get to the hospital. Please, somebody educate the hospitals, I want doctors to understand that a diagnosis also causes mental trauma. And not just a mental trauma. But it's, I went through it having my daughter diagnosed, I didn't know which way was up. Like I've said it a million times in this podcast, it feels like someone ran up to me, hit me in the head with a shovel and started yelling math at me. And if I didn't remember it, my daughter was gonna die. That's exactly how it felt. And it went on for days. If you think the third day I was better off than I was on the first day. I wasn't every conscious moment you sit there thinking, Oh, my God, Everything's ruined. Like it's over. Like everything I thought is gone. Like because you don't know. Right? You don't you don't know that. It's, it's incredibly doable. And that millions of people live with it well, and like all that stuff. So you're just sitting there in a panic. And you're like, Oh, it's my problem to take care of the kid. But if you're an adult, it's almost worse, because it's on you. And you're the one who's going to get a low blood sugar and not be able to think at the same time. And you're going to end up with an adult endocrinologist who has you point out all the time very likely, mostly helps people with type two diabetes, at least when you're a kid you get at Children's Hospital? It's a little more. Yeah, yeah. Right.

You know, right. I, you know, I think too with that, because of the constraints of hospital stays, that are dictated by essentially diagnosis status within that diagnosis, and honestly, insurance that covers all of that, right. I think that many times from a clinician standpoint, they're trying to pack as much as they possibly can to send you out the door with more than just the This Is How Not to Die. Right? And what gets lost in that it's great that you bring in the mouth mental component to that because what gets lost is the consideration for how much in of traumatic type of setting the human brain can actually retain.

Very little from my experience. Yeah, well, and you're,

I mean, you're not a dumb person by any means. So you know, I know it just in the many discussions we've had you grab on to information very easily and very quickly and you get it and you can dig deeper and you can understand much more so I think it was it not your daughter I would have been alright probably would have been okay, you would have gotten it you know if it is a nephew, okay, you have to care for him over the weekend, I got this, I got this, like I can do it, you know, but for somebody that you like your, your arm, right? It's like a piece of your body is your child, honestly, as a parent, and so you, you have this mental piece of not only do I have to keep them alive, but oh my gosh, I have to keep them alive with this new stuff that

I'm supposed to do. And they'll say to you look too much is gonna kill them too. And you're like, wait, what, and then it's not enough is gonna cause long term complications. And too much is gonna cause a lot of it's about how it's said. It's the delivery, it's your communication and your delivery and listen, and to Jenny's point. I'm pretty good at diabetes. But on day four. On day four, I was crying in a room because someone was trying to teach me how to add fractions a thing that by the way, I knew how to do. I was beside myself. And it wasn't because I was learning how to like figure out a dose based off of carbs. That was easy. It was because of the pressure that came with it. Like what do you mean? Like she's like, when her doses were i My daughter was two years old when her doses are a half a unit and you make a math mistake and now you're at a unit and a half. Well, geez, right? I might just we'll just toss her out the window right? Like let's get it over with because I'm like, I'm gonna screw this up and I'm gonna kill her and then that fear turns into while just let her blood sugar boil little high. And then all the sudden it's, the doctor will say to you like, well, you know what? Let's make your let's make it I don't know 70 to 200, but we're going to treat 90 is low, but two hundreds, okay? Well, once somebody tells you two hundreds, okay, 220 doesn't seem that far over 200 Correct. And then you start, like, getting farther and farther away from healthy. And no one tells you on day one that a high blood sugar makes someone altered. I don't know that my daughter's not the person she's supposed to be because their blood sugar's 250. No one says that the mean, if they said it to me would have freaked me out more. So you're in this like paradox where you need the information, but you need it correctly. And that means time, it means a thoughtful explanation. And again, if you can't give it, I think it's better not to say anything. Right?

That's, that's where understanding that those beginning pieces of information need to come with the explanation that this is a start, we will adjust. And you will, again, have some specialists who are going to help navigate the adjustments. Right now, the safe target range may be this to this and it may be very broad. This, again, is a starting place. So everything as the as the first person that this person who's newly diagnosed, is going to encounter, the baseline you give them should be this is just the start, this is going to be an OK place. And we're going to move further beyond this. So that you can really, again, live the life or have your kid live the life that they want.

The number of people pointed out that as a an adult diagnosis. They're like I needed an endo console in the hospital, and didn't get one because the hospital so don't worry, like leave here, call this number, we'll get you set up with an endocrinologist. And then the endocrinologist sometimes will tell you, they don't have an opening for three months. So now you're holding insulin, you know that. And somebody told you it's dangerous, be careful, or worse, they didn't tell you it was dangerous. And they make it off you like loosey goosey and fancy free. And then there's so much feedback from here from people like I gave myself way too much insulin almost killed myself. And you know, and because who knew it was? Because if you take two Advils or three Advils, you're kind of okay. And that's how and until you've had a tea, you've had a serious medical issue, like a day to day thing that's always with you, right? You don't ever think about your health that much. And people just don't think about it, it's a thing you take for granted, you know? Correct, right.

And as the adult level, which is great to bring in, because as I mentioned initially, many, many adults are actually not diagnosed in an emergency room scenario, right? They're actually, as an adult, they're like, I just don't feel good, or I just have not felt great i or I'm doing this and I didn't used to do this or whatever it is, and then they it's a primary care. And then like you said, the primary care may say, hey, let's get you to see a specialist, especially if that primary care, did a great job and actually did enough testing to diagnose type one versus type two diabetes, hey, you know, I'm not your specialist, let's get you to the specialist. But again, there is there's a problem in that we don't have enough specialty, with enough time on their schedule, to be able to get that newly diagnosed person in within two days or even three weeks, it many times is much delayed, and what does that leave the person who now has to take medicine, they now have to take, you know, their blood sugar, they have to understand a little bit about food and about, you know, activity and maybe their job is a heavily active kind of lifestyle in all of these things that in no way can primary or general medicine really expand on to the degree that's needed. I think there's a very big deficiency in our healthcare system in terms of the ability to get what you need when you need it. There just is and that's not, that's not a knowledge component from the clinical staff. That's, that's just the way that healthcare is set up. And it's

unfair to talk to people who are working in emergency and, and to put this on them. But I think it's incredibly true. You're whether you know it or not, you're in charge of what happens to those people 30 years from now. And and it's you might say, Well, how is that possible? But I mean, I've done my best to say it here over and over again. If you put someone on the wrong path, they might never get off of

it. Especially if they never get to see somebody who can clear it up for them

right or the next person they get to is inept, or whatever. And you know, and now you have a doctor telling you Oh, you're a onesie aid. I mean, ADA says seven. So that's not too bad. Right? Right. Right. Yeah. And it's gonna be a problem. And so I think some people also go to scare tactics. I can't believe how often I hear from people that they've been scare tactic than a hospital before, but telling them trying to relate to people by telling them your dog has diabetes, your cat has diabetes. That's not good. Don't do that. Now, right? Telling them Oh, my grandmother lost her foot. I know all about diabetes. Don't do that either. Don't do that either. Right? There are some things that feel confident. It's funny, isn't it? When you see a conversational thought, hit someone's head, and then they speak it out loud? And you think, why would you say that? And even I think a moment later, the person might even think like, oh, I shouldn't have brought that up. But it's too late, then. Like it's too late. So you're sitting with a person who thinks their life, they either think their life is doomed, or they have so little understanding of it, they don't know, to put the effort into it to stop their life from being doomed. Right? Right, they need, they need a good launch from you. And that launch might just hopefully be to across the street tomorrow for another appointment. But you don't want to put a thought in their head that they can't get rid of that that sticks with them. And, and especially in that scenario, like you have to treat them like they were just in a car accident, and that they aren't following what's happening. Right? Because the other thing here, I this is also, I think very important. If the people are healthcare professionals who are being diagnosed, the parents or the adult, do not assume they don't need your help, or they don't need someone's help. And they've got it because they're doctors, because the amount of conversations I've had with doctors who said I was not educated properly, because they looked at me and thought, Oh, well, you're a doctor, you know. And that was it. That's incredibly dangerous. Those people then have to go home, by the way, and fight with their own ego for a minute where they're like, I should know this, then they feel defeated. That's a big one. Don't do that to health care professionals. I don't know like there's I feel like I could just talk about this forever. But I don't want to muddle it.

Yeah, well, I think, you know, from my previous hospital and clinic based sort of experience, I had the unique advantage to work with a really wonderful endocrine team, within a big hospital system. And within this hospital, the emergency department actually came to the endocrine team and said, you know, we actually know that we don't, we want to navigate managing those with diabetes, both type one and type two and newly diagnosed, especially who come in better. But we also are a big city emergency department, right. And so from a staffing standpoint, we don't have time to walk through somebody's medication, exactly other than take it once a day or take at this time of day, and some of the education and so they worked really, really intensively with our endocrine team to develop actually a protocol of education specific to diabetes. And in stackable hours, not that we were there at two o'clock in the morning. But within hours of normal daytime operation, when people with diabetes were diagnosed, we got a page to come to the emergency department and actually provide the education as well as the medication dictation about how to start something and how to dose it, et cetera. So I think, you know, system to system if they adapted or adopted something similar to this. And if you have any, say within your, you know, for kind of talking to emergency or urgent care kind of staff, if you have any ability to have some poll about what could be done, you may actually be able to make more of a difference for those who are diagnosed with diabetes in that emergent situation, by just pulling somebody in, even if they're not going to be admitted for additional information that especially for the adults, if there's somebody on staff that could come, that would be a huge advantage for

that big deal. Right. Now, of course, I don't want to overwhelm the person who's in that position who probably doesn't have enough information. I don't want them to and I don't want them to. But But I think again, saying things you don't know, is maybe the worst thing you can do. Like really and assuming too, that the next person they get to is going to fix the whole thing is also like so there is some responsibility there for you to give them some basic information and education. Or tell them there are places online you could go to, like meet other people who have diabetes, because unlike if I come into the emergency room in heart failure, I'm going to go to a cardiologist who is now going to manage my heart. I will just do what that person says and this thing will go as well as it could if I come in there with cancer, I'm going to go to an oncologist and they're going to take care of everything a broken leg, someone's going to fix it, they're going to teach me and then they're going to send me to physical therapy afterwards, you get diabetes, you go talk to somebody, they go, here's insulin, good luck. And then you go home, and now you're in charge. And that is just what happens type two or type one. That's what happens to diabetes, it's not a thing that the doctor is helping you with, or putting you on a path. And then you don't really have to do anything except take this thing on an empty stomach or like that. It's so different than that. And I know it's a misunderstood thing within the population, and that part of the population are nurses, and doctors and everything else. And I know it's misunderstood by them as well. But it's why we're doing this. And also, the opposite side of this, which I'm going to at the end of every one of these episodes bring up. This episode is not just for somebody who's a physician, or in a position to help somebody, you should be listening to this and saying, This is what I should be expecting. You know what I mean? Because maybe you're listening now. And yes, you already have diabetes, but you're gonna end up back in the emergency room one day for something if your mount but odds are, and you get there, and those people are going to still not know anything about your diabetes, you know, and they're, but they're gonna say they do and, etc.

No, that's a great point to bring up. Because I, I was gonna bring up similar that as the person with diabetes or the family with diabetes, you have to know how to be an advocate for yourself, honestly, you have to be the one to say, You know what, I don't expect you to know all the answers here. I know that you can help me with this emergent situation, or maybe not. So let's can we get the specialty? Right? Is it within hours that a specialist would be here? Let's get them in here. Because I don't know what to do. I've clearly not done something right. Or I've been sick enough to bring myself to the emergency department with diabetes. I want to make sure that this gets, you know, figured out the right way.

There's also a way to not I mean, it's hard, but you got to not flip out a little bit. These people. It's not their fault. They don't know about this. Like it's no, no, not not a little bit. It's not negligence, it's not apathy. It's just It's the system and the way it works, right. So it's a number of years ago, but Arden and I take her to the emergency room once for stomach pain. And we're there for a couple of minutes, and the nurse comes in and she goes, we're gonna get that insulin pump off of her. And I went, No, we're not. No, we're definitely not doing that. She has no, we'll get her some Basal insulin. I'm like, Whoa, no, no, you want to inject. I'm like, I haven't done that in 10 years. I don't even know how to do that right now, like, because you see that that's what the pump is doing. The pumps already doing that. And then at one point, her blood sugar as they gave her an IV, I guess that dilutes your blood a little bit. And her blood sugar started to go lower and lower. And she says, I'm gonna give her dextrose through the IV, maybe? I don't know, exactly, she was gonna get extra hit or something, you know? So I said, Listen, she's on an algorithm. As soon as her blood sugar jumps up, it's gonna, like start giving her instantly and we don't want that either. So tell me what you're doing. And I'll adjust the algorithms so that that doesn't happen. And then she's like, Oh, what's that? And then I explained it to her a little bit, then she became interested. And then she was a lovely person, and a thoughtful person. And in 10 minutes, she knew what we were doing. And then we were partners, you know, and now I had taught her a little something. And now she wasn't saying things like, let's take the pump off of her. Correct, trust me an hour into it. No one was more thrilled in that room than that nurse. sure that we had come to an understanding and educate each other.

Because you had stepped up and been an advocate for your daughter, right? And or the person who has diabetes, as long as you come in. I mean, this is a piece in the education that I typically do with like, either preparing for a hospital stay or a surgery or planning for an emergency, right? Is the idea that if you come in and urgently know that they're one not going to have any extra supplies to help you, right? Right. And so you do everything you can, as long as you are verbally, okay, you can address and talk to them and you're not out of it. Then great 100% You're keeping your pump on you or 100% You're talking to them about these are the doses that I take this is this has nothing to do with the sore on my toe right now. Don't worry about

it at all you want. I'm not taking the CGM off if I have one ether, like it's alright. We don't trust that thing. I'm like, Okay, I've been living my whole life trust in that thing, and it's working out pretty well for me, right? It really is. I don't know it's to dance. It's a little bit of a dance and you have to be a good community to cater to you can't just start ranting and because the minute you rant, it's over. You know, like they're gonna be like that lady's yelling at me and I don't want to be involved in this and then you're never getting anywhere. Correct. It's just a very it's incumbent on both sides to, to want to, you need to want to work together, I think. And it's it's hard because they're in and out of the room. They're tired, they probably overworked, they're probably underpaid. They've probably been eaten in six hours. And you're trying to explain your, you know, your, I don't know, your algorithm to and they're probably like, well, I don't even know what you're talking about. Right. Right. I was lucky once as Arden went into medical procedure, that one of the nurses in the room was like, my friend has diabetes. And all that happened was I used a word that she recognized. And that was enough to make her look, amigo tell me more about that. Yeah, that was it. And I said, Okay, here's how this is working. And she goes, Oh, that's great. We would probably love to use that. Let me get the doctor and find out doctor comes in and re explain it. He goes, Yeah, let's keep that on her. And I was like, great, but five minutes before that people were pulling at it. Because they don't know why it's just what they do. You know, and, and to feel, then that puts you in a position where you feel attacked. And and then you lash out. And it's tough to because you know, I have this note for myself in this in this document that we're working from for this series. It struck me a couple of weeks ago, while I was thinking about this, we always tell people, you have to advocate for yourself. But it has two different meanings. If you don't know what you're talking about advocate means please teach me you have to I need to know more. I don't have enough information, blah, blah. But if you know what you're talking about, what advocate really kind of means is you have to make them do a thing, right? They don't want to do

advocating for yourself as explaining what you know, it's almost like proving yourself essentially proving that, like you did, hey, we've got this thing it does this, it will really help beyond what you think your protocol says. Yeah, this is above that. And this way, and again, from advocating sometimes you have to simplify it right? You don't want to tell them all the bells and whistles because quite honestly, they don't need that. And it's going to be confusing. Do

what I did when I was dating my wife tell her the good stuff. Okay, no, yeah, she can find out the rest after it's too late. Way too late. Arden had a surgery once. But it was a quick one was like a 30 minute like laparoscopic thing where they were just kind of going in and looking around for something. I said, Look, she's wearing an algorithm. It's run from her cell phone, you have to keep the phone with her. And they said, Okay, that's fine. But I want you to turn off the auto Bolus thing. And I was like, Okay. And then I just didn't do that. I just picked the phone up. I was like, oh, yeah, I got it. There you go. And then I just go ahead, because she was gonna go in there, and very likely not eat insulin. Like she's sedated. Like I thought her and by the way, I thought that's what was going to happen too. But the minute she woke up, and she was like, you know, at her adrenaline kicked in everything, and her blood sugar started to go up, that thing started to Bolus in the recovery room, and I couldn't get into that recovery room for like, 30 minutes, right. And we stopped a blood sugar that was easily gonna go to 300 by just letting her algorithm run. And I never told anybody about that. And if they know me, this is when they're finding out right now. So and I don't believe they'll ever hear if you know, best then say, is really is what I'm thinking. And I think listen to this conversation, recognize that these poor people, they're not trying to screw you. And they just don't know. And it's not their fault, you know? Correct.

They've got a protocol, they're not picking weird stuff from the air, right? They have a protocol. And the protocol is a safety based protocol. And it's based on a line of here is okay for the majority of people, or here is okay for the majority of peds. Right. And that's what they're going to use. Is it going to keep you from having a low blood sugar? It is absolutely, but it will not, you know, prevent you from having a high

blood sugar. It's not a way to live long term. No, it's perfect for that set and setting in the moment. That's all the problem is again, and to end is you do not want to leave thinking this is how it works. Because you when you get into your regular life that is it's not going to fly. Right anyway. Okay, great. This is a good start. Awesome. Thank you very much. Excellent, thank you. I'm excited. Having an easy to use and accurate blood glucose meter is just one click away. Contour next one.com/juice box. That's right. Today's episode is sponsored by the contour next gen blood glucose meter. A huge thanks to a longtime sponsor touch by type one, please check them out on Facebook, Instagram, and at touched by type one.org. If you're looking to support an organization that supporting people with type one diabetes, check out touched by type one. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome type one type two gestational loved ones, it doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community, check out Juicebox Podcast type one diabetes on Facebook. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

Hello friends, welcome to episode 1102 of the Juicebox Podcast Welcome back everybody today Jenny and I are going to do another grand rounds episode we're going to talk about being diagnosed with your regular old doctor. We'll talk about symptoms that could easily be misdiagnosed. misinformation about diabetes, and a little bit about doctors egos. Nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. Don't forget to save 40% off of your entire order at cozy earth.com. All you have to do is use the offer code juice box at checkout that's juice box at checkout to save 40% at cosy earth.com. When you place your first order for ag one with my link, you'll get five free travel packs and a free year supply of vitamin D. Drink ag one.com/juice box. If you're a physician listening to this and you'd like to make a rebuttal or add to the conversation, you can find me at juicebox podcast.com and send me an email I'd love to have you on the show this episode of The Juicebox Podcast is sponsored by touched by type one touched by type one.org. And find them on Facebook and Instagram touched by type one is an organization dedicated to helping people living with type one diabetes. And they have so many different programs that are doing just that check them out at touched by type one.org. This episode of The Juicebox Podcast is sponsored by the continuous glucose monitor that my daughter wears the Dexcom G seven dexcom.com/juice box Get started today using this link. And you'll not only be doing something great for yourself, you'll be supporting the Juicebox Podcast. This show is sponsored today by the glucagon that my daughter carries. G voc hypo Penn. Find out more at G voc glucagon.com. Forward slash juicebox. Jenny, welcome back to the Grand Rounds series. Yeah, are you?

I'm fine. Oh, so

far, so good. Today, we did our opening intro episode, we've done emergent care. So if you're diagnosed and in such trouble that you're in urgent care and emergency rooms, something like that. But today we're going to talk about, you know, what might happen if you have symptoms that come on and you end up in your regular doctor's office, nothing that makes you go to the hospital, but still lands you in medical attention. So yes, yeah, well,

that's an interesting place to kind of start to because most people who have some symptoms that are concerning, are typically going to call their primary care. Yeah. Right. And or talk to the intake nurse or whoever. And depending on what you say, when you call, you may or may not get in today, tomorrow or a week, right from now. So I think it's important to think about how you present the symptoms and the fact that, you know, these are very irregular, this isn't what normally happens to you or your child or you know, the person that you're caring for. And to be really specific in what you say in that call. Because again, it may be a more emergent type of setting. And in those cases, I think what I've mostly seen is that parents especially they don't wait, they just off to the emergency room, you go call

this go kid seems sick. I don't want to make another one. Let's do this. Now. I think this is an interesting conversation, because if you have it specifically from the perspective of people who have diabetes, or have been through this, they'll tell you things like I don't understand why doctors offices just don't do a finger stick when you present with the symptoms. And and that's because you know, that's why you think that right? Like I'm not saying if we couldn't snap our fingers and have everybody who had flu like symptoms, get a finger stick, that wouldn't be a great thing. It would I'm sure it would catch a lot of issues. But doctors offices until they see it happen, aren't going to think that way. You know, the problem could be you call your doctor and say I feel rundown. Right? I'm losing weight. Like you're describing how Bringing the flu, and then they'd be right and but who you're talking to, you're talking to the person at the desk at the doctor's office who maybe as a medical assistant, probably, maybe not, maybe you're lucky to get to a nurse, and you start describing flu like symptoms during flu season. And they're gonna say, you've got the flu, because in medicine, and you're trained, so this is just something I know colloquially. But if it walks like a duck, and it quacks like a duck, it's not a lot of reason to think it's a tiger. And so, you know, I think that's how that works. Also, if you know, physicians, especially like general practitioner, people, you'll know that they see themselves more as sometimes just reflecting what's going on in the community, if you come in with symptoms that people have been coming in with for two weeks. That's where the assumption gets made. So it's not it's not even anyone's fault. Honestly, that it gets missed,

especially seasonally, and or, you know, we've just had now a month ish, or maybe a little bit more, depending on where you live, of school starting. And so the influx of kids coming in or being called about, you know, my child was sent home from school with such and such, or, I've noticed this, you know, in Frankie, because, you know, this wasn't normal, but school just started. So there's a lot of consideration that's like gray area, when you present with symptoms that they do need a good evaluation, but how it gets evaluated? Is the question.

I think that it's important if you're the doctor to hear this. I know. I mean, what what is the number Jenny? How many Americans have type one diabetes? Is it like getting close to 2 million now or something like 1.8 or something? Look up

this, I think it was about a year ago that I looked, I usually look in January, when more statistical kinds of things

might point out. There's a lot more people than that. And so you're already being diagnosed with something that I think would be considered rare, right? I mean, type one diabetes is considered rare, isn't it?

I think when you consider the or compare to type two diabetes, type one is the lesser right. Yeah.

Well, I mean, I kind of mean, compared to everything else. They're seeing, like more than that, like quacks like a duck situation again, sure, like colds,

you're going to have many more colds coming in than a child who comes in or an adult or anybody who comes in with symptoms, then oh, gosh, this must be type one. So yes, it's, it's more you're looking for something that's more frequently seen. Yeah, then looking for something that I guess rare would be the right word in this context to use

Mayo Clinic. This year, it's estimated that about 1.2 5 million Americans live with type one diabetes. So you know, I'm just gonna do a real quick how many Americans are there? Yeah, there's 340 million. So that's not a lot. Can if that makes that makes it rare. And so I guess my point is, is that if this is the first time for you, as a doctor seeing this, I can see it getting right past you. What I don't understand is after you've seen it once, or twice, why we don't adjust why you could miss it. Yeah, yeah. Like, let's start like remembering what what happened learn from learn from the past. Because here's something is from a listener, right? I wish our regular pediatrician would have known that it was okay to just do some blood work. So the pediatrician was so scared to just draw blood because they thought it was going to scare the kid sure that they just kept throwing different medications and different things that the kid try this do that. And meanwhile, further and further into DKA. Sure. I think that what to me, what that points out, is that you can't allow yourself to be dismissed. And on the physician side, dismissing people, I think is, is dangerous, like, you know, like it, you have to assume that people know what's going on with them better than you do, even if they're not,

even if they can't give you a diagnosis that you can't they can't name a diet diagnosis, right? They know what they've been seeing or feeling or they know that, you know, little Johnny has looked and acted this way for the past eight years, and is no longer doing that, right. Things have changed, doesn't want to play is now wetting the bed again, and wasn't before all of these things. Are there red lights in our world of knowledgeable like diabetes, because we've been living with it. But for the newbie, again, and or the new Doctor Who, like you said, maybe it's somebody who's fresh into their first job, you know, in a pediatric office or in a general practice or whatever. And then it might look rare. Yeah.

So yeah, it happens to adults just the same way it happens to kids, by the way, and so there's this balance if you're the physician, and I can See where it would be difficult? I need to listen to what they're saying. But what if what they're saying doesn't make any sense at all? If I said I've been urinating a lot, right? That would be me indicating that I think I'm urinating more than I normally do. Correct. But But if the doctor says, Hey, how much do you urinate? And they tell you a number that seems high to you, but it's not high to them. You have to push back and say, That doesn't seem right. We should look into that. Like there's a balancing act within every question. Dexcom g7 offers an easier way to manage diabetes without finger sticks. It is a simple CGM system that delivers real time glucose numbers to your smartphone, your smartwatch. And it effortlessly allows you to see your glucose levels and where they're headed. My daughter is wearing a Dexcom g7 Right now, and I can't recommend it enough. Whether you have commercial insurance, Medicare coverage, or no CGM coverage at all Dexcom can help you go to my link dexcom.com/juicebox. And look for that button that says Get a free benefits check. That'll get you going with Dexcom. When you're there, check out the Dexcom clarity app, where the follow Did you know that people can follow your Dexcom up to 10 people can follow you. Right now I'm following my daughter, but my wife is also following her. Her roommates at school are following her. So I guess Arden is being followed right now by five people who are concerned for her health and welfare. And you can do the same thing. School Nurses, your neighbor, people in your family, everyone can have access to that information, if you want them to have it. Or if you're an adult, and you don't want anyone to know, you don't have to share with anybody, it's completely up to you. dexcom.com/juice box links in the show notes links at juicebox podcast.com. And when you use my link to learn about Dexcom you're supporting the podcast. Because there's, there's what's going on, there's what the person believes is going on, it's what they don't understand is going on, uh, you know, it's there's a lot happening, and it's your job to dig through it. But the real concern here is emergent, really, if you don't figure it out quickly enough. Now we're DKA. Correct. And that puts you down a different path. Right? You know, like, again, I've spoken to so many people, people who catch something early, where they're just like, I don't know, if something didn't seem right, I went to the doctor, and he was a great doctor, and he figured it out. And I went home and I didn't have to go to the hospital. That whole path changes their life. And I know that's hard to imagine, but it really does.

And it makes it I mean, what you're kind of alluding to is a very emergent scary scenario of diagnosis, versus a scenario of, hey, I had these symptoms, it seems kind of weird, I'm feeling kind of off but not like terrible at this point. Again, at that point, your ability to provide a little bit more in depth, searching for them. And in depth asking of what what they feel like has changed. Again, this is where addressing the person as a person, not just as a case to evaluate becomes really important. Because as you said, if you're going to the bathroom a lot, you have to say, this is really a lot for me. Like I don't I don't get up overnight. I don't you know, have to get up in between meetings at work. I you know, all these things are very different from the clinical side, then they have to, they have to remember to take that the step further and say, Well, you know what, I don't know. But we could easily do this test this test in this test. And I think that's where when people say things who are already in the group of people who have diabetes, they say, Well, why didn't they just do? Why didn't they just do this? And you the new person is like, I don't know what to ask for? Clearly, I'm coming to the doctor, they should know what to do for me. Why didn't they do it? Yeah. And, again, that's where from the clinical standpoint, I think, in general, there maybe need to be some guidelines that are changed a bit. That's, you know,

I don't know what that's supposed to be. But I think that from practice, to practice and doctor to doctor, you should be able to figure it out on your own. You know, like, have a meeting, sit down and say, hey, the last couple of times we've diagnosed a person with type one, it's not gone well, and here's why and right, you know, what could we have done? So many people get sent home with insulin, and told to go find an endocrinologist. But now they have this insulin, they don't know how to use it. And it's, they're scared of it. And then the doctor will say something like, you know, listen, high blood sugars are the leading cause of blah, blah, blah. So now you're you've just been diagnosed with something, someone who says something very scary to you. Then they've given you insulin. If you're lucky. They've told you the insulin is dangerous. Some of them don't do that. I don't know if it's because they don't know or they don't want to scare You, but now you've given them these competing problems. Insulin makes your blood sugar low, and could kill you right now. And high blood sugar is gonna kill you later. And then you get sent home with that paradox. And what are you supposed to do with that with no knowledge? It's, you know, it's, if you're doing that to somebody, that's terrible. And it happens, every single I think it happens every hour of every day, from the people I talked to. And this woman asks me, how did my general practitioner not see how upsetting it was to tell me for 15 minutes? How bad high blood sugars are for me, and then they handed me insulin and said, keep your blood sugar high until you can see an endo. Right? Yeah, right. I mean, what, what is she supposed to do with that? Exactly, except go home and be out of her mind word.

Right? Yeah. And Or try to. And hopefully, the goal is with a diagnosis that you do get a new, essentially, kind of introduction, kind of a nice handoff, if you will, to the knowledgeable clinician, who will be your next go to in the dive into the education. But, again, a very good baseline of each and every practitioner, who is just a general medicine practitioner, should have the same guideline of if these symptoms, you know, are presented to you. And I mean, the symptoms aren't weird symptoms, no peeing a lot, you're losing weight, you can't get enough to drink. I mean, those I mean, as classic symptoms, the grand majority of people who come in complaining of something, those are going to be the top three, I think, classic symptoms. So you would think that in learning about all the different types of disorders or you know, diseases in the body in general school, you would think that he would remember some of that and be like, Oh, well, an easy thing that we could do is, we could do you know, a urinalysis, you can look for glucose, we could look for all these things, we can look for ketones, we could also do a finger stick. Those are some pretty simple things that should be I think, on a broader scale of this, they should be something that is done when you present with symptoms that could possibly be diabetes. And if you

don't, if I think is a regular practitioner, if you if you're not aware of this, could you not reach out to a local organization, hospital endocrinologist and say, Look, we'd like to have, you know, a checklist for ourselves. Yes, could you help us put that together, and we'd like to have something to send people home with because we know it can be difficult to get an end dose appointment, like just some learning materials that they could go home with or a link that we could actually, it makes more sense than handing them a learning material, you should hand them a link, you know, whatever your practice name is slash type one, and that you could actually keep updated and you know, turn it into a resource for them and explain the questions that they're obviously going to have in the beginning. Because all this all this does, by the way, is you send people to the internet, and then it's luck of the draw if they find good or bad information, correct. And then you yell at them later for getting their information from the internet so you don't help them they go to the internet, then you tell them you know you're not a doctor. You shouldn't be on that line. Well who was going to help me if you take insulin or sulfonylureas you are at risk for your blood sugar going too low. You need a safety net when it matters most. Be ready with G voc hypo pen. My daughter carries G voc hypo pen everywhere she goes because it's a ready to use rescue pen for treating very low blood sugar and people with diabetes ages two and above that I trust. Low blood sugar emergencies can happen unexpectedly and they demand quick action. Luckily, G vo Capo pen can be administered in two simple steps even by yourself in certain situations. Show those around you where you store G vo Capo pen and how to use it. They need to know how to use G vo Capo pen before an emergency situation happens. Learn more about why G vo Capo pen is in Ardens diabetes toolkit at G voc glucagon.com/juicebox. G voc shouldn't be used if you have a tumor in the gland on the top of your kidneys caught a pheochromocytoma. Or if you have a tumor in your pancreas called an insulinoma visit G voc glucagon.com/risk For safety information.

You sent me home with this information about and or maybe they even as especially as an adult maybe got sent home without any insulin right because the doctor wasn't sure. And while the test results were more conclusive towards this being diabetic. Eat is the idea that they could get in the next day with someone who could educate them. And give them a little bit more. I mean, I've seen so many different diagnosis stories go so many different ways. Yeah,

no, but isn't there, there has to be a fairly centralized way to keep most people from being in a bad situation, we're not going to stop everybody from having a problem, right? But it can't be that crazy of a problem. I feel like if I put you in I and a couple of other people in a room for four hours, we could come up with that list, and a way to implement it, it just it. But I can't do that for you. And if we sat here and did it, by the way, you wouldn't listen to it, you'd be like I heard on a podcast ridiculous. But you know, you have to go do that yourself. Because, again, the problem you're not seeing as the practitioner is the thing that only people like Jenny and I and people have lived through it can see that there are these multitude of paths that you can lead people down. And I'm not kidding, you can destroy their lives, like psychologically, medically, with their relationships with their, like their mental health, it's not an overblown thing to say that what happens to them in the beginning, goes a long way into how they live their life after that, and you're, you're the ground zero for this, you know,

depending on who they get connected with, after their visit with you, after their diagnosis with you. It could completely turn around if they find somebody who is really good in is a great educator or has a great, you know, diabetes practice, and they get in sooner than later to clear up. I don't want to say it's misinformation, I think it's misguided information about what to do. And I think, as you said before, the initial diagnosis in a general practice is going to be to some degree, it seems often to be fear based. Right? It's, well, this is your diagnosis, this is what we've figured out. These are why you're having these symptoms, and you're going to have to start injecting insulin, and insulin is going to do this. And if you don't take it, your blood sugars are going to be high, like you said, or if you do take it, you have to be concerned that you don't take too much, or you're going to end up with low blood sugars. And they may or may not tell you about symptoms, honestly, yeah. Right. They may or may not tell you what you might feel like when that happens. There's a cascade effect from that initial diagnosis. And you can send somebody home in just a whirl of,

there's a difference between throwing me in a giant, never ending warehouse with no lights on and telling me the answers in here somewhere. And giving me a flashlight. Like, I'm not telling you, you have to show me exactly where it is. I'm saying, you know, say the rest of the sentence, which is a phrase, I think about all the time, like don't just say, hey, low blood sugars are dangerous, like keep talking, complete it, why are they dangerous? In what scenarios might I find myself in this situation. And if you as the practitioner, don't know the answers to the rest of the sentence, you need to educate yourself. Because that's just you don't know enough to give this information to somebody, you know, you were just talking about, like a low blood sugar. And I think about all the time, how many people are probably told, for instance, chickens free, like there's no carbs in it chickens free, right? But protein gets broken down it gets, it gets stored as glucose that can make your blood sugar rise, sometimes 90 minutes after your meal. In the beginning, these people are probably honeymooning, it's probably not that much of an impact. It's possible that you don't have their insulin right. And so you're not noticing it because their Basal is too strong or something like that. Or by the way, you don't have their insulin too strong. You have a two week and they're seeing these weird spikes all over the place. And then you start turning knobs, you don't know what the hell you're doing. And that right there. That's it. That's the beginning of the end. Like once you start chasing blood sugars around it, you don't know why the variables do what they do. When that happens, you are on an hour, day, week, month, year, lifetime long struggle. And that's it

from the practitioner standpoint. If that's the road of navigation that you're leading people with, they will be the ones who are always tied to coming in and asking you to make the adjustments. Right. And if you don't know as you said, if you don't know the knobs to turn or which one to turn to impact what you see happening, nor do you likely know how to interpret the data. That should teach you how to turn the knobs one way or another. Then they are there seeing your adjustments. One way or or another, and those adjustments are likely not teaching them the right things to do when they go home. Because while their visits with you might be every three months, four months, every six months or whatnot, in between that person at home has diabetes every second of every single day. And they need to know how to turn the knobs. So if you're turning them one way, and adjusting in a way, that's not good for them to learn, then it's gonna get more fuddled up in between, as they think that they will, I can adjust it that that I saw the doctor do this, yeah, I should try to adjust it this way. Or I saw the doctor do this or told me to that it looks like this is what we need to do. So in between those visits, where they may not be connecting with you via you know, electronic record or even via phone, they may try, I will tell you firsthand that people with diabetes, want to try to navigate? Well, they want to try to do the best. And if the best is the knowledge that you've given them, and it may not be 100%. Correct, then you can expect their management to be I

mean, in honesty, kind of your whole like career is getting people after they've been funneled up, which I've never heard, but let's just keep going. I like that. I love it. I'm going with I'm using it again. And so you see this every day? And and be honest, how busy are you? I am very busy. If there were 10 of you, would you still be this busy?

If there were 10 of me, I would still be this busy. I mean, our office has a number of clinicians who all have the knowledge base that I do. And we are all very busy. So

yeah, my point is, is that too many people get put on the wrong path. Correct. And the people who are reaching you or are, you know, more upwardly mobile people that can that can afford this, like, can even afford the time to sit down and think I don't know what I'm doing. I gotta go find somebody who knows what I'm doing. You know, I gotta not worry if it's an insurance thing. Now I'm I know I'm in I'm in real trouble. Everyone's in that situation. The minute they're diagnosed with diabetes? Yes, they just are. I don't know how often I say it. I was so bad at taking care of my daughter. In the beginning. I didn't know what I was doing. All I had and we went to a and I hate saying this. But we went to a prominent Children's Hospital in the East Coast, that I think most people would say this is amazing. And again, it was it was 18. I don't know how long it was, like 15 years ago, I guess. But it was before all this technology and everything. But it doesn't seem to matter now, because the technology is here. And still nobody tells anybody how to use anything. Right? And I can't tell if it's because you don't know, where you don't want to be involved. Like, like, I can't figure out what it is like, is it liability? Or is it you just don't understand.

So what was it from your, from your perspective of diagnosis again, being years ago? And yes, things are very, they're very different technology wise right now. But when Arden was diagnosed, what was the difference between that initial diagnostic information that you are given? And how soon after, were you handed off to a team that up to the level of understanding so that you felt like you could take her home and at least have an idea?

I mean, keeping in mind that Arden was two and right? We were young girls. I mean we were given syringes and insulin vials and a freestyle meter and test strips. And they taught us how to do the math for insulin to carb ratio for MDI. And that was it.

And that was with though a specialist right, that was with a peds Endo? Yeah, we

were on vacation. And we were lucky enough to find a children's hospital on vacation that had a dedicated peds, endo diabetes wing, like a real another great place that as far as you know, people would say, I didn't know what I was doing at all. Like, like not at all. I mean, I think Arden had a seizure in the first six months, because we counted the carbs and gave her the insulin. And it was a slower, it was a slower digesting, like like food. So the blood sugar the the insulin meter really low. There was an initial spike, but the initial spike went away. It was like simple sugar and then I'll hit later with a with a different glycemic impact. And she, you know, we got her out of it with glucose gel, but looking back on the person I was then I did not know what happened. Right? I had no idea what happened. I thought, Oh, my daughter's gonna have seizures all her whole life. Like this is the way that it goes. This is what this is right? and you go to the doctor doesn't say anything. No, listen, I'm just going to be honest with you. I have figured this out myself, right? That's why the podcast is so colloquial a blue collar or like simplistic, because I don't have any big words for the things I learned. Like no one told me about, like, no one ever said glycemic index to me. And if they did, I was like, that seems like too much. And I didn't listen. Right? Like, it's like, that's a lot of words. What I need you to tell me is that some foods hit harder than other foods and some foods that quicker than other foods like that, I would have been able to wrap my head around, right? Yeah, honestly, it was depressing, and scary, and overwhelming. And I started to write a blog about it. And I got to the point where I thought, Oh, I'm just writing what everyone else is writing. And so because there were a lot of diabetes blogs back in the day, like 1000s of them, and I thought, I'm wasting my time saying what everybody else is saying. And then I thought, I'm just going to, like, dig deeper into this. And I started off by asking, Arden CDE, I know I've said this before, but here I asked her, I said, if I give you a magic wand, what would you make people with diabetes do if you can make them do one thing. And she said, I'd make them not be afraid of insulin. And at the time, I didn't think what I'm thinking now, which is, oh, well, you probably should have explained it to them then. And maybe they wouldn't be so afraid of it. But I took her thought that she sees a lot of people afraid of insulin. And I just started doing the work on that. And I dug through that made myself not afraid of insulin, it took me a year of like writing about it and talking to people about it and having conversations with people. And then I think the next thing that happened was Dexcom became available. And that opened up my understanding of what was happening. And then I was able to sort of apply my feelings, that information. And then we started having good experiences. And I'm like, Oh, this worked. And then I just started chasing things that worked. Yeah. And then you'd go back to the doctor, and her agency would be coming down. And they'd say, What are you doing? Is she having a lot of lows? And I'm like, wait, what, that's when I realized they expected her a one C to be eight. And that it was now seven, going into the sixes. They thought I was crashing her blood sugar all over the place, because they can't even imagine that someone could manage a blood sugar in the sexes. Sure. That was 15 years ago, right? You know, like so. And I understand how old thoughts impact now. But now it's not then anymore,

right? Because we have the amount of technology that we have, right? We should aim for better. And we should teach, we should be able to teach people that better is possible in a safe way, right? And we're not aiming for blood sugars to sit at 60 all the time, just to enable a blood sugar and an average that looks you know, like you're in the range of those without diabetes. I think you're right about the old school thought still really being a piece of it. I mean, if you being who you are now, and looking back on who you were without the knowledge level that you had,

what did I need? Right? What

did you need? What did the doctors like? If I Was Your clinician? At that point? What would you have been like, Hey, I don't get this, or what should I have told you that would have made you I mean, and also what if you hadn't been on vacation? Great that you had access to a facility that actually had good people who were trying to give you more information? But what if not, I mean, what if you would have just been sent home with? Right? Yeah.

Oh, please, I don't know that I would have been that much different. Also, the internet wasn't really a thing, then. No, the way it is now. We have the ability to communicate better now. True, and to get information to people quickly, digest doubly. I mean, listen, if they handed it was that pink panther book? Is that what that was? I

have one, I still have mine. Sure. I

think we just think we just are hours away. So I get if I'm a doctor, I hand somebody this big book. My first thought is they're not going to read this. And you know, like so then you can easily write them off. Well, they don't want to take responsibility for their care. I mean, come on, no one wants to read that stupid book. Like it. Just it. I get that that's what there was back then. But it's not like that now, and we still treat people like it is like that's the thing I never understand.

And I think there's something important in there to remember, if you are the clinician, what, what you say? And even just the base diagnosis, you have type one diabetes, right? The good majority of people as I hear so many times when I talk to somebody who's new, is right away upon diagnosis. The caregiver or they themselves are online right away. What is this? What's type one diabetes, and you're brought into this gigantic room of information with so many different files that you could pull to get the information from. So as as the clinical person diagnosing, I think it's really important to provide some good guidelines of the right places for education, because people will search online. Dr. Google is

Yeah, so really how it works. Now, also, I will tell you this. I've given a lot of thought to this. You can't dumb things down. No, you can communicate them in a way that a lot of people can understand. But you can't dumb things down. Everyone deserves the knowledge. Right? Correct. You shouldn't assess someone because if you would have assessed me on the first day, I was crying in Arden's room, while they were trying to teach me how to do the math for her insulin to carb ratio. Like I was like, it hit me all at once. Oh, I'm a stay at home dad. My wife is gonna go back to work this two year old kid. Oh, my God, this is me. I'm in charge. Overwhelming, right? Yeah. So I cried. The nurse left because Kelly said, I think maybe he needs a minute. They never came back and tried to teach it to me again. I guarantee you, they wrote me off. They're like, alright, that one doesn't get it. It was probably that simple. You can't write people off, you have to give them the information enough that at least it sparks their mind later when they aren't crying. And they can think a little bit that this person here says I wish they didn't dumb things down. I need support, you should show me where there's community around this. I'd like a brief explanation of type one diabetes, it was very overwhelming. It sent me home to watch video after video and I got drugged down a rabbit hole. Right? I needed Quickstart information. That I think is the big deal. Right? I wish they would have told us. So there's this phrase that gets used in the podcast? I don't know if I say it as much anymore. But I refer to what a lot of doctors do is they give you don't die advice. It's enough. You know what I mean? Yeah, it's enough that you won't die, but you're not necessarily going to live healthy with it. Right.

And that's more general to it is it's more, I'm going to send you home with this. It is it's it's don't die advice. It's take this do this at this time, and then connect with this person, because they're going to they're going to dig into this for you. But again, when that ends up happening, or between that happening, and seeing somebody who can really help you understand. And at a time when you're not crying anymore about this, yeah. In between that time, you're not. You're not sitting at home not looking up information. So what happens between diagnosis and formal education, if we call it that, that educator now has a load of stuff to clean up from wherever that person went home and looked up information? Which may not be correct, right?

I can tell you Look, I know at this point, everybody's pretty like internet savvy at this point. So I think doctors can understand this next point. My Facebook group adds 150 new people. Do you know how long it takes to put 150 new people in the group? A couple of days, four days? Yeah. Every day. It's a three. But you heard in 50 new people show up. I have my 10,000 hours that watching them. Okay, I know the storm that they're living in, right. And they are so confused. And by now they've been online, they have absolutely found somebody who's telling them don't eat a carbohydrate ever. There's absolutely they found somebody that tells them that insulin is bad for them. They've absolutely found somebody that told them that they can reverse this whole thing. This is the myriad of different information they're getting over and over and over again. I see this happening. Please listen to me. Not once in a while. All the constantly. So you're sending people out into the world. Like, look, not even everyone's going to agree this podcast is valuable. Right now I see how it helps people and at the at the scope and scale that it does. So I know. But you can't even get everyone to agree about that. So they're out in the world looking for what ever has a good like, return like when they Google something. And now they've got 16 different perspectives. They are twisting in the wind at this point. They're scared they think they're going to kill themselves. They think they're going to kill their kid. And I want to read with this woman said she I wish they told us more than don't die advice. That advice that we got a diagnosis from them. We haven't gotten any new information since that quick class we had at the hospital discharge. I've never had any advice about improving time and range. Nothing about Pre-Bolus Sing no one has ever mentioned Pre-Bolus seem to me nothing about how fat and protein affect blood sugar, no guidance on how to exercise or play sports. No guidance on how to adjust insulin to carb ratios, how to adjust long acting insulin. Honestly, I am fairly sure that this don't die plan is the standard of care. And this is forever how they want it to be. And

the unfortunate thing about that is what this person is getting to is the in depth what should be being covered in education, This by no means should be coming from a primary care, right? It should not because they don't, there's not a bandwidth there for it at all, unless you found a general practitioner, you know, who is a specialty in diabetes? And then many times it's even just a specialty in type two management, likely not type one. But

yeah, but my point is, this is what happened to her. Correct, right. So she went to the hospital even and didn't get anything. This is your responsibility, if you're the doctor like this lady situation, is because of the lack of guidance that she got at the beginning. That's it. So you can say, Oh, this is her endos problem, or the hospital failed her. You can say whatever you want. This is still who she is now. So you know, and she's raising a child with diabetes, that kid is going to his? Well, by the way, nothing bad's gonna happen to this kid, because he found a podcast, like his Mommy found a podcast. So now she understands all these things. But you could. I don't want to out myself here, Jenny. The podcast isn't really that in depth. Like it's it's understanding how to use insulin, understanding the impacts of foods. That's it. Right? You could explain that to somebody, listen, I can explain it to them. Use, you must be smarter than me, you're a doctor, you absolutely could do it. I trust me, I couldn't even barely graduate from high school. So like, I know, you can do this, I figured it out. I figured that out. Because I had to. You need to put yourself in a situation where you feel like you have to, like I have to learn how to talk to these people about these things. Because if I don't, here's what happens next.

And especially because you've decided to specialize, you've decided to specialize in something that does encompass diabetes, unless you really are only a thyroid endocrinologist, you're really only a hormone based right then great, you're probably not even taking patients who have diabetes, right? But if you have gone that route, then you're 100% Correct. These are the pieces that should be being discussed. And there should be there should be, I guess, some things that are asked of each person with diabetes in terms of their understanding that then you can dig in with them and say, Okay, well, we need to start here, you want to get here. Let's start here, so that I can get you to playing three hours of soccer on a Saturday, right? The way that you want. I

mean, I'll take it further. If you're a GP, type two diabetes is everywhere. You don't when an adult is diagnosed, please, this person asks, please check them for anybody's before telling them they have type two diabetes, you have any idea how many type ones you're sending home on Metformin. And they're not dying through good luck, because they're still in their honeymoon yet, and we're getting very sick because you're like, oh, diabetes, that can't be that's type two, cuz you're fat, or cuz you're old, or whatever the health thing you think that isn't accurate? And, you know, type ones, have this happens to them constantly. Go pick through the podcast, find people living with that with type one diabetes, for years, on the brink of death. And it's because somebody told him they had type two never checked, or who have

literally done every single one of the lifestyle changes that you've told them to do. Type Two often gets, you know, I'm gonna give you this medication and oral medication. Let's say you mentioned Metformin. Sure, it might be Metformin, then you're, let's try to get some exercise every day. And let's try to watch what you're eating. Some people will especially again, with the information now online, they will take that to the level of they're now eating lettuce and their blood sugar on you know, they're doing their finger sticks. And it might still be 200 or 300. In the thinking, I can't eat less. I can't walk anymore. My dog doesn't want to walk with me because I walk him eight times a day, right? I mean, and then they go back and they say, I'm doing what you asked me to do. And it's not, it's not better. So at that point, you look and you say, Well, gosh, maybe we should do some testing.

And if you think Jenny's just making that up as an example out of her head, I've been told that story 50 times. It's incredibly common. This person here says please do not let patients leave your office with insulin and zero education regarding lows Because managing lows without causing fear is really important and it requires a playbook like you don't Just get to do it on like, oh, 15 carbs, 15 minutes. Like, if you're still saying that shame on you, first of all, here's what I think there are, however many people being diagnosed today with type one or type two diabetes, even I mean, we can lump them together to be perfectly honest with you. Each one of those people, if you don't help them has to learn it all by themselves, millions of people having to learn this thing that if you just learned, you could explain to them, right.

And if you come back at them, and you say they bring you some results, they bring you some information. And they say, Well, I went online, and I looked up this information, and now look what I've achieved. And then the turnaround ends up being where did you get that information? You got it online? Or what kind of, you know, they're not looking at even what the person actually achieved? They're just looking at the fact that well, this person got it out of like, you know, the back end of somebody's blog about something, something diabetes related. And this person has no information about where that information came from. So they blame you, instead of just saying, Well, gosh, where did you get this? And this looks like you're really what what has made the difference? Because you know what, you as a clinician, you might actually learn something.

This by the way, you don't know because you all don't know Jenny as well, as I do in public. This is as angry as Jenny gets, but she's mad. I'll just be mad for her. Yeah, I'll be mad for her. They just made me laugh. They're so mad.

Because my my angry doesn't. I don't know that you've ever seen. I tell my kids when I'm angry about something. I'm like, you don't want the dragon lady. And then they're like, Okay, Mom, you're right, we don't

make your point one more time very succinctly in one sentence. My

point is to take the success of somebody that has come to you and look at where and what they've done. Don't just blame them for getting their information from someplace else. You didn't supply it, they went looking, yep, they have found some success. Help them keep that going.

Right. And the reason why that creates anger in genuine in me as well as because I get those people's emails. And those people come to me to tell me, I listened to the podcast, I got my time and range down, my agency started to fall, I was so excited. And then I went to the doctor, they yelled at me for 15 minutes and changed all my settings so that my blood sugars would be higher. And these are not people who walked in there with like 70 blood sugars all day long. And they were walking all precipice between life and death. Like it wasn't it's not that it's just they learned how to Bolus for their food. Right? And then they they understood, I don't know, like simple things that you could understand, too. I mean, you're a freaking doctor, like, learn it or, or leave them alone. Like, you know what I mean? Like, if they're doing well, don't get in their way, for God's sakes, you've gotten in their way twice already now. Like, like, you can do it again, you know, or

with their success, say, Well, what are we working on next? And your your job as the person that they're coming to, to share this really awesome, exciting success with is great. How can we move on? Or hey, ask, what did you get this information from? Yeah, maybe I should take a listen. Maybe I should, you know, check into the clinician that you talked with outside of my practice, or whatever, so that you now have more to work with other people who are going to come in, you could get them started in a really good place to begin with.

It occurs to me that you have to put your ego aside in that moment. Yeah. And just want to you need to want better for them. Because what's gonna happen next, when someone tells you, I don't know, I listen to this guy. He's got a podcast. Sometimes there's this lady that comes on, she seems like she's from Canada, I can't tell whether accent and like, you know, like, and now they were talking about this thing. Because Jenny, you and I think that people hear every word and remember it like the Torah, which is not how it works, right? Like we have these conversations, and they pick things out of them. Correct. You might have to go listen to that conversation to and trust me, if you feel like well, I'm a doctor, I don't need to do that, then you're never going to help those people. Then I'm telling you that I've spoken to them over and over and over again. So as Jenny, and they are all they're struggling significantly in their lives, and you're not helping them. So

and I think that from a clinical perspective, too, you have to you have to find a comfort level and working as a team. I mean, there's a saying that's been there forever, right? It takes a village to raise a child, right? It takes a really significant good care team to navigate managing life with diabetes. A lot of the people that come in to our practice, you know that work with me or one of the other clinicians in the practice. We are very happy in fact When there are other clinical participants in that, you know, some people come to us and they're like, We have a phenomenal endocrine team. We love them. But this is the piece that I'm missing. And they haven't gotten as in depth about it, as I think that you can, can you help me with this? Can you help me understand, but I'm getting this, this and this from my tear team. So I don't need that from you. Fantastic. From a clinical perspective, you have to be able to say, You know what, I don't know everything, because I'm very happy myself to say, you know, what, I don't know anything, everything. If there's somebody that comes to us and is like, hey, I want to work with Jenny. And I'm like, that's not my wheelhouse, though, you would be much better working with this person. That's the same approach that I have with other clinicians. I'm like, You know what, you take care of this, and I've got this.

So I had to make this leap. I'm just gonna be completely honest. I know. I've always known that community around diabetes was important. I never knew exactly how important it was. I heard other people say that it was important. One day, I got so much pressure from listeners to the podcast about making a Facebook group that I just did it. And I want you to know, it was not a thing I was excited about at the time. I thought, Oh, God, I'm gonna have to moderate a Facebook group. I pull Jesus, that sounds terrible. But here I am. They asked for it. I did it right. Now, that's, I think three years ago, now, maybe a little less. There are now over 42,000 people in the Facebook group. In the beginning, I it was me going, that sounds like this. Show me your graph, I think. I think that like, you know, because doctors frequently mess things up. Even graph reading. Here's the thing you guys do all the time, people come in with a low, and you take away their Basal. Like that somehow is the fix for a low blood sugar instead of looking and saying, Hey, you had a meal here, right? And then you spiked up and crashed down? When did you give yourself the insulin. And if you by the way, if I'm now talking, and you don't understand what I'm saying, You have no chance of helping people with diabetes, okay? Because where you time that meal, insulin stops that spike from happening. And more importantly, it uses up the meal insulin to combat the carbohydrates. So the meal insulins not leftover to cause a low later, if you don't know that you are doing people a disservice. So anyway, I used to have to go through over and over and over again, like I said, I learned once like so I could tell other people. At some point, I thought I can't do this. Like I cannot keep up with us. And then I realized I didn't have to. Because so many other people heard me say it. They were helping other people. And before I knew it, I was watching people respond thinking, holy, they're using my words, like they're talking to that person the way I spoke to them. It's a beautiful moment, a beautiful moment, when you see that you you put something out into the world. And it's it's being redistributed by other people. So I understand if you're the doctor, you can't say these things a million times a day, there's not even enough time. But you can't just make that be the the end of it. Like you have to find a place to send them off to I'm not saying your doctor's office should start a Facebook group because the truth is mine only accomplished this level of proficiency for people because it's so big and far reaching. Because when someone asks a question, there's at least three or four or five people in there to answer,

you know, and what do you have backing it up? There are episodes backing it up, to be able to point people to for a broader understanding or like you said, maybe some people take one snippet out of one whole episode. And that's what really made the difference for them. And in that same episode, there might be one or two other snippets that really hit or resonate with another person. They're both improving, but because they heard the information that they needed, right about the same topic.

Yeah. So what Jenny's kind of alluding to in the first part there is that if someone asks a specific question, at some point, I have moderators or I will jump in and say, here's a link to an episode you should listen to to get more information about this. Now you think, Oh, I'm only helping one person. You're helping everybody who read that thread. And it's way more people than likes and hearts would indicate to you. So that's another thing you don't know is that you think oh, only one person asked this question and only five people got attracted to answering it. This is a six person situation. Now what you can see is that this thing's been through 1000s and 1000s of people's like feeds and they're taking time to look at it, which means a lot of people have those questions. They're too scared to even ask them out loud, right? So if they won't ask them online, what do you think they're going to do when they get in the doctor's office

or they don't know how to ask ask them. They don't exactly quite know what the issue is. They have have maybe like a subconscious level of considering, but they don't know how to voice it. They don't know how to bring it up and they need somebody to sit down. And as you said before that one example of, oh, now you're low, I think what I've seen so many times over and over is that you go into a visit, all prepared as the person with diabetes, you brought in all of your documentation, you brought in all of your logs, and, you know, the printouts from let's say, you're using a continuous monitor, whatever it is. And clinically, you may sit down as, as, you know, the doctor, and you might say, Oh, what happened here? You can you pinpoint one, most often it's lows, or it's the extreme highs, what happened here, and the person with diabetes is honestly thinking, Well, I don't know. I was like, four weeks ago, and I've got three kids, and I truck them all over the sick. I don't know what happened at that point in time as a clinician, it's the bigger picture of a trend. You're not looking to pick apart the data, and picking it apart also makes the person with diabetes feel judged.

don't frustrate them and judge them. Like that's correct. What what happened here means What did you do wrong? Right. And by the way, if I knew I would stop doing it, because so like, now you're asking me the question, like you said, bring all these logs in, I did it. It's a pain in the ass. I brought you all this stuff. I handed it to you. And you sit. And instead of telling me, here's an answer, you said, what happened here? Are you kidding me? Like that's your plan. And by the way, if people come in the office and don't ask any questions, do not sit there smugly thinking, Oh, I'm so good at this. They don't have any questions. They don't know how to ask their question. They're embarrassed. They don't want to be judged again, you're an asshole. And you don't realize it, which happens. Sometimes some of you are assholes, and you yell at people and talk down to them, and then they don't come back. And then you think, Oh, they're non compliant. They're not non compliant. They don't want to be near you. Right. You know, like, that happens. I'm not saying everybody. But if you're wondering, does, it happens, you know? Yeah, it's, I

mean, from the that standpoint, too, you know, remembering that the person coming into your office is, they're a human, they're a person, they are just like you when you go home, you've got a life right outside of your office, when they come in. The first things should really be more personal questions, you know, how are you doing? How are things going? You know, what are your concerns today? What? What is on your list of what's working really well, please tell me or what's not? What What can I help you with today? Yeah, right, because it opens a door of personal connection. That isn't white coat.

This is just very important. And, you know, I watched my mom live with cancer for a couple of years. And the truth is, every day of her life was about that cancer, like a lot of other things get swept under the rug, right? diabetes isn't like that. Like those, these people are not at home, like 24/7, like mired down, like they're trying to continue living, they think they either believe there's a way out of this. And they're looking for it in the time they have available to them, or the situation and the lack of information has beaten them into believing that they get a lesser life than everybody else. And they're just going to push on. Right? And I'm just going to live my lesser life now. That's not true. Right? Like, I just, I mean, take it from me. You can. Jenny, I know you could do this too. And I know you're probably getting low on time. But if you put me in a room for one hour with a person who is newly diagnosed, I can put them on a good path. And then I could speak to them again a couple of times over the next six months, and they'd be okay. Right? If I could do that, and you can do that, then doctors can do that. Yeah. Don't tell me the system's wrong or you don't understand how many people I have to see or the insurance figure out something. Don't just say don't wash your hands up and go Oh, this isn't my fault that this is happening right? You might not be your fault but you're the last year what we have so

right trying to get a connection and yeah, yeah,

try harder. It would be nice anyway, I didn't expect to get upset but here we go. Thank you for doing this with me here welcome. Any doctor still listening to this episode right now that like those people yelled at me for a while.

So well, they you know, I think in in a really big way. It's It's hard because you don't want to call out like as a listener if I was a doctor and I was hearing it I'd feel very like singled out but you have to have a wider view. It's not have to have a wide view and say, you know, but I'm not doing that you have to remember and say but you know what, I learned something. I could do this better. I could pass this on better, I could hand them off like a gentle handoff to another, another practitioner that can get them to help. The other thing I think I wish could be heard here is behind the scenes. What it really calls for is a very specific medical protocol of when you come in, this is the checkoff of what you do flu symptoms. You do a urinalysis, you do a finger stick, that's the protocol, you will do it whether the person is two minutes old, or you're they're 98 years old. This is the protocol that you will do. I think it begs a broader change to our medical system, for sure. It really does. Yeah,

I mean, hearts and minds is only going to take you so far like the system has to, here's a good example, when the system gets in the way, not overblowing this a half a dozen times a year, I get contacted to come to a facility and explain how I talk to people about diabetes, to hospitals, to doctors offices to big practices, you know how many times I've actually done it? None? Never. Because by the time it goes up the chain, somebody squashes it.

Somebody says no, yeah. And do you know, do you know why? I know, you know, I'm not a doctor. So they don't want me to have you have no initials behind your name. Right. So my

point is, is that even? Yeah, and sometimes people get good ideas, and they are motivated, and they want to help people. And then the system squashes that, I understand that, I guess I don't know what to do with that. And that's why I'm hoping that just this conversation leaks into people's minds. So that at least what they have control over. Right, they can maybe make more purposeful decisions with

Well, I think even if they wanted truly just the educational pieces that you've put together, I think, again, from a protocol standpoint, I mean, my like end all would be that they all just get a little handout pamphlet in every single medical practice that's like, hey, you know what, this is your new diagnosis. If you want the right place to look for information to begin with, because I know you're gonna go on whatever internet doctor visit, you know, a site you're looking at, this is the right place to find this, this and this bit of information. So

when people come into that Facebook group, they answer a few questions. One of them is Where did you hear about this 40% of them from my doctor. So it is good. I mean, it is getting better, but it's just the ones that slipped through the cracks. I can't I can't state firmly enough, that the ones that slipped through the initial cracks very frequently don't get back out. Like that's, that's the part that I'm upset by. Like, if somebody's got to struggle for six months to figure out the truth. That's, I mean, not preferable, but okay. But like, there are so many people who just never leave or never look again, or they're disoriented or they're, they're overmatched or whatever. They don't have the time all the things we've mentioned, they never get out their whole life like this. So it doesn't need to be that way is my only point. No, I completely agree. Okay, thank you. I appreciate it. Absolutely. Talk to you next time. We'll try to have a more upbeat one next time. Thanks, bye if you're enjoying the Grand Rounds series, good news, there's much more to come. Don't forget to share it with somebody who you think might also enjoy it. Even a doctor. A huge thank you to one of today's sponsors, G Vogue glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com Ford slash juicebox. You spell that? G VOKEGLUC. Ag o n.com. Forward slash juice box. A huge thanks to Dexcom for supporting the podcast and for sponsoring this episode dexcom.com/juice box go get yourself a Dexcom g7 right now using my link. A huge thanks to a longtime sponsor touched by type one please check them out on Facebook, Instagram, and at touched by type one.org. If you're looking to support an organization that's supporting people with type one diabetes, check out touched by type one. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome. Type one type two gestational loved ones. It doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community check out Juicebox Podcast type one diabetes on Facebook. The episode you just heard was professionally edited by wrong way recording. Wrong way record korting.com Thank you so much for listening I'll be back soon with another episode of The Juicebox Podcast

Hello friends and welcome to episode 1107 of the Juicebox Podcast Hello everyone, welcome back to the third installment of the Grand Rounds series. In the first episode, which was episode 1097. We did hospitals urgent care and initial contact the second episode, Episode 1102 Grand Rounds, diagnosing diabetes, and today we're going to do insulin and safety. My grand rounds series has two objectives, one to let doctors know what you need and deserve and to to let you know what to ask for. Nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome type one type two gestational loved ones. It doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community check out Juicebox Podcast type one diabetes on Facebook if you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. This episode of The Juicebox Podcast is sponsored by cozy Earth cozy earth.com use the offer code juicebox at checkout to save 40% off of the clothing, towels sheets off of everything they have at cozy earth.com. This episode of The Juicebox Podcast is sponsored by ag one drink ag one.com/juice box. head there now to learn more about ag one. It's vegan friendly, gluten free, dairy free, non GMO, no sugar added no artificial sweeteners. And when you make your first order with my link, you're going to get a G one and a welcome kit that includes a shaker scoop and canister. You're also going to get five free travel packs in a year supply of vitamin D with that first order at drink a G one.com/juice. Box. Jennifer, we are back for the Grand Rounds series. Yay. Yes. Today we're going to talk about insulin and safety. Kind of these two things are gonna kind of go hand in hand in this conversation. They do. Yeah. So if you present Yeah, so far, we've talked about hospitals and diagnosis today, insulin and safety. And we're just going to start with what people sent us and then let the conversation unfold. Fantastic. The first bit of information that came back from a listener just said, we were terrified of stacking insulin. I think this goes to show that immediately on day one, you get told counting carbs, but in your insulin, you know, at the next meal, let's keep it maybe three hours from now. Do it again, right. And then inevitably, what happens is you either didn't Bolus well for the meal miscounted your carbs, maybe that ratio wasn't right, you get a high blood sugar. And that first thought comes into your head. Do I want to put more insulin in here? Right? But I can't because the doctor told me not to not to because it would be stalking. Yeah. So what that really points out to me, like if this was a management conversation, we would talk about, you know, when to Bolus again, or different impacts of foods. But in the context of this series, what it points out is you've sent people home with a misunderstanding of how insulin works on day one.

Correct? Yeah, in fact, I've, you know, nobody reads the little insert in the insulin box, like Out goes the box or out goes that little insert that falls out all the time and nobody looks at what the profile of and we're talking right now rapid acting insulin right, the stuff that goes in out within a couple of hours. And it's got to finish to its action time. And I think it's a piece that's missing in initial education is the profile of your rapid acting insulin looks like this. I mean, if you're already teaching somebody how to inject a medication that will impact their blood sugar significantly, if they don't get it. Couldn't you also talk about that action profile? Because it would take away a fear factor? Yeah, it would give them something to visually be able to consider and so that you can explain stacking or the concept of stacking a little further right. I mean, in no way would be at advocate for well Bolus and if your fingerstick or your CGM looks like it's doing this within 30 minutes. Probably not a great Gordonsville. And Right, right. But there is there is that window of explanation that I think should be done up front. Because you're sending somebody home with something that this is 100% brand new to them. And

here, this next statement, you know, if you're a physician, and you're listening, this person leads by saying, I wish my doctor would have told me to not be absolutely afraid to eat. This is a person who says that I've already lost a ton of weight because of my diagnosis. So they're in decay, they're losing weight, right, they're wasting away, they get lucky, and somebody tells them, they have type one. So they prior to diagnosis, they've already lost weight. Now, she says, I couldn't get enough calories or carbs, because I was afraid to eat. I was afraid that my blood sugar would rock it and cause blindness, the need for an amputation, a heart attack, or my demise. Wow. So that's what they went home with. So they got afraid to eat. So they saw one blood sugar jump up after what they were told, they don't know how to use insulin. And so you see this a lot. This is what drives people to like, like Uber low carb diets at some point to a lot of the time, right. And

I think there's something to be said about, you know, we're talking from the perspective of newly diagnosed, right, from a clinician standpoint of explanation to that person. We're not talking about somebody who has had diabetes, and been using insulin for an extended period of time, there's a difference in explanation. And so I think initially, there is going to be a little bit of caution to dosing strategy. In fact, that's something that it's kind of like a marathon, you learn, and you learn, and you experiment and you learn along the way. But again, along with that should be a caretaker or caregiver, that actually is also getting good information and feedback from a clinician. And so from a starting point, decreasing that fear piece, when you're talking about insulin, having them understand some of the very basic concepts so that they don't fear eating, or they don't fear taking insulin at all. And they don't also fear correcting a high blood sugar, right? You know, if your blood sugar is sitting elevated, and they've not given you any, any information as to how and what to do about that other than just a set dose. That's your job to give that to them to begin with.

So this never ending cycle that happens. And I obviously I record other stuff. While you know, sure. I've already recorded another episode today. So I have a lot of different conversations happening in my head right now. And I'm also making a series that I think I'm going to call whistleblower, which Jenny doesn't know about but it's clinicians, like doctors, nurses, pharmacists, people in health care, we're going to come on and speak anonymously, I'm actually even gonna change their voice so that they can talk about Jenny's like, Yeah, let's do it. So I had a conversation this morning with a pharmacist who works in an urban hospital, like an 800 bed hospital, pretty big hospital. Right. Yeah. And, you know, through that conversation, I almost got to the point where I said to myself, Okay, well, doctor, see a lot of mismanaged people with diabetes, yes, this becomes their expectation for what it is. And so that when someone comes into the hospital for an emergent reason, and has diabetes, they slot them almost automatically automatically into that space, right? Oh, you have diabetes, you must be unwell. You must not understand your blood sugar's probably high all the time, like all that, yes. But you just said something. Now, that brought this whole thought full circle to me, okay, which is, and it goes along with the statement that this other person wrote. So let me walk through it a little bit. She says, I wish no one would have said anything about a three hour rule or stalking or anything like that. I wish they would have just what Jenny just said, taught me how to use insulin. Right. And the note I made under that was that scaring somebody from stalking, which I understand why you would want to do that I would understand why you wouldn't want them to use, you know, uncovered insulin, sure, but it leads to their mismanagement. And it just hit me as this all comes together, I get diagnosed, and a doctor out of an abundance of concern scares me into not using my insulin correctly. And 20 years later, I end up in a hospital with high blood sugar's high one see I don't know how to manage my stuff and the doctor says up that's how people with diabetes are. But no, not if on day one. You want to help them understand and so maybe they never become that person and maybe that's how the system fixes itself. Right. Like right from from step one, not from you know what I mean? Like what I

do. Yeah, I also think it's really important to, if you are a clinician, I think it's important to see the person and where they are. And expect that this might be your first interaction. And if they're in with a history of diabetes, as you're alluding to somebody coming in mismanaged for many years are not given proper information. This is your opportunity to start educating them. Every interaction with somebody who has diabetes, whether newly diagnosed or meeting have that information is your first point of ability to say, Hey, how can I help you understand this better?

Yeah. And I think that based on this other conversation I just had today, the expectation is going to be that that's not going to happen, and that the doctor is going to have a reason in their head, why it's not okay. Why it's not their job, or they don't have time, and they probably they're probably right. But that's where I think, sure, we need to have a thing that you hand to somebody, and you go, hey, you know what it seems to me, you might not know how to use your insulin. And that's the core of this whole thing, just two sentences. Go listen to this, go read this, go see your doctor and tell them I said, XYZ, right. I think we can get you on a better path and keep you from being in this situation in the future. But that's, I think the problem is, is that we all are just waiting for the system to fix itself. And it's not that easy. It's not just a doctor, not wanting to do a good job. I think they all want to do a good job.

Correct. Or they wouldn't have gone. Yeah, absolutely. If you're going into healthcare, I think 99% of healthcare employees are there in it to help.

Right. All right. Yeah. I do think that based on some things that have been said to me recently, that maybe a certain personality drifts towards emergency medicine. Yeah. And that maybe a certain personality drift towards specialty, and that you might be getting a little more comfort and compassionate specialty than you are, you know, in the ER, absolutely,

there is a certain personality that works the best in the emergency room. It's somebody who can compartmentalize a situation and then move on. And there's another new situation completely different, and they have to attack it. And they have to look at many different pieces that brought that situation in, and then they have to move on yet again.

Right, right. So so it might be unfair to say I hope an ER nurse sees that my one C is nine and fixes it for me, that's not going to happen, right? Like no, top down there. They're trying to stop the thing is trying to kill you. Most importantly, you know, they also don't tell you to take vitamin D if you don't take it like they're not they're not there for your generalized. No. But when you get into a into a hospital setting, the expectation is, oh, this person must know a lot about this. But in the end, I don't think that's mostly ever true. You know, and if you don't know anything about your diabetes, and they don't know anything about it, then nobody's gonna do anything about it.

Yeah, right. Absolutely. And acute care to, you know, in, in a hospital setting, not necessarily emergent. But in hospital is also it can be a tip of starting some information to bring to somebody but that person, you know, if you are the prescribing doctor or you're the doctor who's following the case or whatnot, it's not an educational environment. I worked in patient education for a long enough to learn one that that's not where I wanted to be. And to that you can only really give a little bit. And those little tidbits should be enough to send somebody out safely with some new information. But you have to be the one to set up the follow up. Yeah, you have to be the one to be able to provide them with the next step. I gave you this I taught you the basics of safely using insulin. Your next step is this person has been set up for an outpatient Yeah.

This episode of The Juicebox Podcast is sponsored by cozy Earth and right now I'm looking at cozy earth.com to see what's going on. I got oh look at this bamboo pajama set for ladies. That jogger pants for ladies looks like plush lounge socks. That's one of Oprah's Favorite Things. There's the bath collection. We love the waffle towels but there's also premium plush bath towels. Everything that you see here can be had for 40% off with the offer code juice box at checkout. Even the sheets now we use the bamboo sheets, you may choose different linens I don't know what you're going to love when you get to cozy earth.com But we sleep on bamboo sheets from cozy Earth. They are incredibly comfortable, and I bought them myself with my own money using my own offer code, juice box at checkout 40% off is what I saved, you can as well at cozy earth.com. I partnered with ag one because I needed a daily foundational nutritional supplement that supported my whole body health. I continue to drink as you want every day because it works for me. Ag one is my foundational nutritional supplement. It gives me comprehensive nutrition, and it supports my whole body health, drink, ag one.com/juice box, when you use my link to place your first order, here's what you're gonna get a free welcome kit that includes a shaker scoop and canister, five free travel packs, a free year supply of vitamin D, and of course, your ag one. So if you want to take ownership of your health, it starts with ag one, try ag one and get a free one year supply of vitamin D and five free ag one travel packs with your first purchase. Go to drink, ag one.com/juice box that's drink ag one.com/juice box, check it out. Right, I'm not a Pollyanna person, I don't think that everybody who's doing poorly is doing poorly because someone just didn't tell them what to do. I know there are plenty of people who correct or a myriad of reasons don't take good care of themselves in a lot of different ways, what they eat, how they exercise, what they take in their body other than food. Like I understand all that. But when you initially set like, let's just say, you know, you see, I don't know, 500 new patients a year with diabetes, which is probably an astonishing low number, I would imagine. Yeah. And you don't give any of them a good direction, well, then they're left on their own to maybe find it or maybe not. But if you give them good direction, and a third of them take it, that's a win, you know, like, that's better than not anybody Correct? You know, this person says, Look, if you would have just told me that fat protein and adrenaline, for example, would have changed my insulin needs, it would have saved about three years of me banging my head against the law. Like, that's a long part of your life, to every day, every meal be going like I don't understand what's happening here. You know, and then you get that fear. Explaining why you're suggesting these changes would be great. This person says, also listen, when I tell you that they don't work and why I think they won't work, you know, so it's not enough to just say something blanket to them. Because your blanket idea may not be the answer. I'm just gonna go out and say that I've been doing this a very, very long time, speaking to people about diabetes, and seeing what leads them to success, right? And the answer, I think the only answer is information that they can access at their leisure. I think that's very important. Because you can't force somebody to care about it, just because it's day one, or because it's been a year, because you're a once they hit a certain number, they have to be able to intersect this information, when it's comfortable for them when they're ready to take it in. And I think that's what gives them the best chance at success and moving forward. Right,

I think what you're talking about is kind of stepping stones, right? You give them a baseline, again, from a safety standpoint, this is safe, this will lead you to blood sugars that are more optimized, but then we're going to move on from here. And you have to look at it again, like a long duration of little pieces of inflammation information that collectively at some point, they'll start to fit together like a puzzle, they'll start to make a lot more sense. And it's, it's also from the person with diabetes standpoint, it's a lived experience, you know, if somebody tells them their diabetes educator, or their endocrinology doctor or whatever, says, why don't we start here and do this, and then you come back as the person with diabetes as the next visit. And the doctor should say, Well, hey, we talked about this last time, did you try this, you know, and did it work. And I think that that's the piece that often kind of gets missed, it gets missed in the jumble of there's lab work to look at and what they think they need to check off in terms of discussion, but what it needs to be is almost like a review, it's like, go back to what was talked about, did it work, and that's the person with diabetes that needs to bring in when you told me to do this. I tried it for a couple of days. And it didn't really seem to work. Right. Okay, then let's take another look. And let's see what else we can make a change to Yeah,

and reasons why most likely doesn't work when it doesn't work. It's just settings, right? You know, if you don't have their Basal, right if you don't have their insulin to carb ratio, right, their correction factor, right. Like it doesn't even if you tell them the correct thing to do. doing the correct thing with the wrong amount of insulin is not getting you anywhere, right. And it points to this feedback here. A person that says that if the doctor would have just admitted to me that they were just starting me off that this wasn't the end all be all conversation, that would have been great. But at some point it felt to them, like, ego. Oh, almost like the doctor didn't want to admit, like the thing I told you in the beginning wasn't all of it, or they didn't know one or the other. But I'm telling you, if you're listening, if Basal should be a unit, and it's point eight, you're already screwed, right? It's that easy. You know, if you know your insulin to carb ratio is one to eight, but you've got it set at one to 10, you're going to lose, right? And that stuff, snowballs on top of people, and leads to the statements and leads to long term health. And you can't just say, well, that's diabetes, they're gonna have to figure it out on their own, right? Because, Jenny, I don't know, maybe that is true, on some level, that you are going to have to figure it out on your own. But you don't need to start me 10 miles deep in a hole, and then tell me to figure it out on my own. You don't I mean,

right. And on your own, it implies that you don't have follow up or someone to check in with, right, what you're kind of seeing in a roundabout way to is that at that initial diagnosis time, or an initial re education time, but especially at initial diagnosis, it's the understanding that when you're talking about insulin use, and the safety of it, I think a safe piece to tell people is that we're starting here at a new diagnosis, this will change. And these are some of the reasons that as your child grows, or as you change your lifestyle as an adult, or as we see how things are moving and changing. This will get adjusted this 110 20 unit of insulin that we're taking now, it's going to change. So don't expect it to be this way for the next 20. I think if you're just told that right now, you are less likely to feel irritated when it does change. And you know,

to look for it. Right? So my daughter was diagnosed at two, I mean, 15 years ago, and we struggled for years. I'll never, ever forget the time that I realized her correction factor was like one to one unit moved to 350 points or something like that. But that's because she was diagnosed when she was two, right? Yeah. And so like, now she's four. And I'm like, I don't know, why is there anyone seeing the eights? Like I can't figure this out? I'm trying to move her blood sugar with not nearly enough insulin. Right. And she went to a good children's hospital. They never change that. Yeah, even they weren't thinking about it, like so. I mean, I don't want to say like, it's, it's not, it's not, it's not hopeless. Okay. But, but I think it is important to remember if you're the person listening who has diabetes, that it could go this way. And if you're a doctor, and you're hearing it, I hope what you're hearing is that with tiny little adjustments, that what I say to these people, and how I say it to them, we could avoid a lot of these issues, I get a ton of them. And Jenny brought up such a good example, that she just kind of cruised over I think, but at the end of your notes, it should say, this is what we talked about. So that the next time you open it up, yes. Next time, we're together, you start with Okay, the last time we were together, we discussed this. And let's move from that point, instead of like you said, Oh, we're going to check your agency today. Let me check your sites. Don't put it here anymore. Move it over here. Great, thanks. How are you feeling? How school how school, shut up. told me how to make my blood sugar to be lower and stable. It's not asking me how math is for God's sakes, like like, you assessing my psychological well being, I tell you what, it would be better for me once he wasn't nine. What do you think of that?

I could actually think when I was doing my test,

I'd be doing great in math. If my head wasn't foggy all the time. And I wasn't constantly low and jam and a bunch of food in my mouth I didn't want while my mom's crying on the phone. Like I bet you all that would make it better

or being pulled out a class because I mean, for kids, especially kids are consistently being pulled out of class because their blood sugar is too high for something or it's too low for something and they don't have enough, you know, authorized ability to treat it in the classrooms. They have to get pulled out and they go three hallways down to the nurse and they sit there for 20 minutes. Well that's 20 minutes of math class or 20 minutes of learning where to put the commas in your sentence. And

while you're sitting here listening is a physician thinking that's not my fault. Yes, it is. I've told this story on the podcast before my daughter leaving second grade going into third grade. We thought she was like, stupid, but I'm not even gonna like idea. Like we were like, that kid can't do math, you know? But luckily for her, her second grade teacher did that leap thing with her class to the whole. She had the same teacher next year. And the woman just had an epiphany. And she said, oh my god Arden's struggles with math. If Arden goes to the nurse every day while I'm explaining the math section, and that's why it took her a whole year to get back on course with it by the way Arden's very good at math now, yeah, but why was that happening? It was happening because in Arden's insulin to carb ratio was wrong. So she had to go to the nurse because we were afraid of how high your blood sugar was going to be. And we were setting up the certain times of day to try to check them, no lie. If art in settings were better, she wouldn't have struggled in math. And that is a direct correlation. And you should be aware of that if you're a doctor. Because

that's, that's where as a physician, again, you know, I understand time constraints and everything I really, truly do. But as I said before, that's a, you have to also have an idea, especially when you're working with kids and teens. Their schedules are crazy, honestly, and you have to have an idea of what is their life, like, if you're going to try to navigate, helping them manage with their insulin doses, and strategizing, adjust this way, one day and adjust this day, because this is the recess B and it comes right after lunchtime. You have to know that type of thing about your patient,

you have to have that conversation with them. Right and ask them what are the struggles you're having? Like, where are you having these problems? Not just like what happened here at two o'clock? By the way people hate that question. Because it was three months ago at two o'clock. I don't know what happened. I have a low blood sugar, right? I don't know. And by the way, in case you're wondering, I know that you have to ask about the lows for insurance reasons or whatever. Like I get it like I know what's happening. But the people don't understand that they think this is like your high level, like deducing like you're trying to figure things out. Not that you're just trying to get them to say something that looks good on the form. Because I see what's happening when I'm in there. This this one person says, if you just would have explained Pre-Bolus thing to me, that one concept, oh my gosh, what things would have changed. I tell people all the time, if you're not Pre-Bolus thing, you might knock a point off, you're a one c by Pre-Bolus. And and that's not even like purposeful direction. It's just something that I've noticed. So Right.

Yeah, absolutely. And I think it it boils down to, there's an there's an also an age appropriate component to that Pre-Bolus. Right, especially with a new diagnosis where you're not quite sure where, where the doses are gonna go in the next week or two, as the body sort of responds to getting insulin and having more normalized blood sugars and insulin, you know, maybe honeymooning comes into the picture. And so all of this as an explanation of this time period, it's going to look a little bit up and down, we're going to have real close conversation. Here's our office number. And many pediatric practices actually do that they provide enough hand holding. But if you're not doing that, that's really important. And it's even important for what I think is like the Forgotten crowd of people with type one diagnosis, which is adults. Honestly, if there's an under education that Speaker 1 28:01 no one's followed up with adults, nobody fought like they're given.

If anything, this baseline of this is how to do an injection, take this amount of insulin, and make sure you take it with your food, no reference to Pre-Bolus. And if they're at their insulin needs, and the type of food that they're probably eating and the load that they're probably eating. Most adults even at early diagnosis, need some kind of a Pre-Bolus They're not three years old, where you're questioning whether they're going to eat the 10 grams on their plate or better for

my brothers that type two. And his last day once he just came back five, five down from seven, eight. Awesome in that crazy? Do you know who led him to the information that got his a one c into the mid fives? It was me. Yeah. A guy with a podcast pointing out you know, nobody can see that is Doctor Who, by the way had been doctoring him for three years to a mid seven a one C and tell him you're doing great. So yeah, but

without also and I don't know whether he was using a CGM, but a mid seven could have been with a very considerable variance. So it may not have you even if seven was, quote unquote, healthy and where they felt like it should be fine at if his variance was excessive. Yeah. Well, that's not

healthy. He was sick a lot. He was tired a lot. Like he just couldn't like get anything done. And finally listened. This has happened to me. And it's interesting because the people in my life, it's harder for me to tell a person in my life, I think you should do this than it is for me to tell a stranger on the podcast, which is interesting. We had this situation last night in the Facebook group. It's not really a situation like I sort of got irritated about something and I made a post and somebody was talking crap about me on the internet somewhere and I just kind of It's okay, don't worry, it happens sometimes.

It's never kind of do I don't care who you are very nice. It comes with.

I don't feel right saying this, but it comes with popularity. The more popular the podcast is the more people kind of take shots and stuff like that, so it's fine. So I put this post up that I guess led everybody to think that I was in a bad way. And to help me what they did was they came in and they told their stories about what the podcast has done for them. And if I spent the next two hours on this recording, I could probably record everything that was said. But suffice it to say, the podcast helps people. They say that that's me helping them, which okay, it is, but all I did was told them how insulin works, right? That's all I did. I know that everybody like, it's nice. And I appreciate the credit and all the good wishes. But all I did was teach you how insulin works. If doctors would do the thing I was asking them to do, I put myself out of business. And, and by the way, I'm getting older. So let's go. You know what I mean? Like, like, let's get to it. Now, I can't do this forever. You know, I wish my doctor would have told me about the balancing act of insulin to carbs and how insulin actually works. Over and over. These are different responses from different people all telling you the same thing. Now that I've had it for a while, now that I found the podcast. Now that my agency is low and stable, and I understand diabetes, I wish you would have told me how insulin works. It's what everyone is saying in here. Just everybody.

And there is you know, as this is insulin and safety. There's a safety component to explaining that from the get go. Yeah, I mean, it's like it's like thyroid, for example. Right? That's a medication that is for everybody I've ever worked with who takes meds, Synthroid, for example, or the other, you know, options. They're given that information from their doctor or from the pharmacist who they get the medication from, about timing it away from food away from certain supplements away from other things. And this is a simplified example, in comparison to insulin, but they're told why y with insulin can cause such extremes in blood sugar,

don't take Synthroid with this vitamin, don't take it on a full stomach don't like here are a couple of things to do. We'd like you to take it in the morning be consistent every 24 hours, actual direction about how to take the pill. Now, if you don't do it that way, then it's your problem. Like but at least,

you're also not going to end up with a blood sugar. That's 42. Yes, right.

Right. And so they do the thing of, instead of telling you what to really do, we'll just err on the side of caution, which is a way of making it sound like you're doing them a favor, but you're not doing them a favor, you're turning them into a person that 20 years from now in an ER is going to be treated like a scumbag for not understanding their diabetes, but your initial meeting with them put them 20 years later in that position, and maybe not 20 years, maybe much sooner. 510.

Right, almost a blame for maybe they are coming in with some complications or something in the picture already. And I think it's an an unfortunate thing that happens, because your expectation about what you know about somebody just based on now seeing their diagnosis. Yeah. You don't know what's gone into their life up to that point. Yeah, or

what their initial meeting with health care is put, listen, here's a here's an example that I think is pretty dead on. If an 18 year old kids caught with three joints in 1970, and thrown in jail for 20 years, and then murders two people in jail 15 years later, you say, Oh, look, we were lucky. We got him off the street, he was a murderer, I say, maybe if you would have just taken the weed from them and been like, hey, go home, you wouldn't have sent them on this path. Right. And that's what this I swear that it's going to sound harsh to a doctor. But that's what this is, when you intersect people early with diabetes and don't do the right things for them. And I'm telling you the right things are explaining how insulin works. Like when you don't do that. every bad thing that happens to them afterwards is likely avoidable. Or you'll never know. Maybe Maybe the guy was gonna murder somebody in 15 years, but you're never going to know because you didn't give them the right chance. In the beginning. I

meant that could have encouraged the behavior for what happened 15 years later. Yeah. Versus like you said, Oh, slap on the hand, send them home, hey, probably don't sell those or give those are yours.

We're not going to for you to for 20 years, which by the way, 20 years later, society generally accepts that that was the wrong thing to do. I mean, this, like, if you live your whole life as a physician doing this, and you go retire somewhere, and then you're just sitting around enjoying your life. And you see that health care has jumped forward and proves out that the thing you were doing now wasn't the right way to go. It's going to eat at your gut. So just like listen now like because Jenny mentioned thyroid a little while ago, we're talking about diabetes, but all of these disease states that require the user, the patient to understand it and to help manage themselves. We always say it right. I guarantee every doctor listening has said this, you know more about your diabetes than I do. First of all, why? Like, it's not that hard to figure out. And secondly, okay, well, if they know more, why aren't you listening to them? And why does it happen? A generation again, like, Okay, well, we figured out doctors don't know, but the users know the patients now, let's go ask them what they know. And we'll make that the standard of care. It's all I'm saying right now. That's all I'm saying. No, yeah,

I think I think I mean, thyroid was my example. But I can think of another one that I was, as a dietitian, gave education on was the Coumadin diet, people get more education about using Coumadin, which is a blood thinner, essentially, and a specific, right, Vitamin K kind of type of diet, and what do you have to they get more education, you think that medication using insulin? So there you go.

So what is really happening is, I'm left to look back on this and say to myself, you either don't know what you're talking about, or you are willfully not explaining it to people, those are the only two options and neither option is okay. So either educate yourself about it, I have a, I have a series of episodes you could listen to while you were driving, and a week and a half from now, you'd go Oh, I understand how insulin works. Now, that would be that easy. Or just admit you don't know. Right? But stop being punitive to these people and sending them down a path that leads to things you can't even imagine poor health psychologically and physically. relationship problems, you know, like because they can't write their blood sugar's are bouncing around, they can't even communicate with people well, and we hold the

job well enough for absolutely, yeah, chronic

pain comes and then they start doing things where they're like, oh, all start managing this. But this next thing, you know, they're taking 16 different meds, and they're smoking weed and stuff to try to get through their day. And I know that all sounds like that's not our fault. But yes, it is. In this specific scenario, every person you let leave who doesn't understand. This is what your basil is for. This is what your insulin to carb ratio is. This is what your correction factor is. Here's how these foods impact versus these foods. Don't just say glycemic index and glycemic load to them. And if they don't listen, it's their fault. Like because that's like Chinese. Yeah, I don't understand. I've said on this podcast a million times. Somebody said to me one day, hey, glycemic index, glycemic load, it's really important. And my kid had just been diagnosed with diabetes. I was like, what? And then I never thought about it again. I started making this podcast and I said to Jenny, one day, I'm like, Oh, my God, the biggest problem is people don't understand the impacts of their foods. Speaker 2 37:55 So did someone try to tell me years before? I don't know, not really. They pulled me into an office, they set a thing. They checked a box, and they kicked me out again. That's what they did. Seriously. That's what they did to me.

I'm sorry, you got to boot. They were able to say, hey, we

told him, Hey, that kid drops that it's not our fault. Like that. That can't be the way you do this. No, it just Yeah. You know,

can't I think I think it also brings up from a component of this conversation being safety. There's an elephant in the room that honestly needs to be brought up. And it's, if you prescribe insulin, Scott, what else should you prescribe?

Oh, glucagon, yes. Because you're right, it is dangerous. And they might pass out and freaking try to die. And it would be cool if they had a thing where they could just jam it in them and stop that from happening. So Correct. And how do you get in that position? You don't tell them how it works. And then they start sniffing around it, and they kind of figure it out. But they don't have a lot of directions, they start doing these like crazy. Like, I'm just gonna give myself a bunch of insulin and see what happens ideas. And sometimes that doesn't go well. So it's not just use more insulin, or it's understand how to thoughtfully use things. How does the insulin work? How do I thoughtfully apply what I know about the insulin to my specific situation, diet, etc. Yeah. And by the way, poor women who are already told so many times, like, that'll go away after you have a baby, or I hear that happens to a lot of you like like that, like that's your level of care you get sometimes. How about no one tells you that you might be three different kinds of people with diabetes every 30 days. Right? You might be the nice stable one. Maybe during your period, you might be the one that has troubled prior to your period after. Yes, I know. It seems like Oh, they'll figure it out. A lot of people never put two and two together. As

far as the person with diabetes. You You may not put it together, because it's never been defined to you as a difference from female hormones impacting a certain way. And impacting a certain way, depending on where you are in your life cycle of those hormones, creating a different type of impact compared to male hormones, which absolutely are very different than female hormones. And we, I feel like, you know, I work with a lot of women and women's health has become much more important to me to provide the right type of information for the females I work with. Because they've been left in the dark, they may have been given information about insulin reaction, and what to do and what their Basal and their Bolus do, they may have been given that but you ask the majority of women about whether they were told what to watch for once they start having a monthly cycle, or early like the preteen not even having a cycle yet, but the potential that there's a pattern that's starting to emerge, and you feel like a crazy parent that brings something up, and they're like, Well, I don't know, it's just, you know, we'll just adjust this way. And then the next time they come in, it's a different time of the month and the poor kid is like, well, let's adjust down this way. Instead, give them the reason that this is happening, right? And how to fix it. Yeah.

Listen, I sometimes I even get frustrated because people give they bring you these very specific situations. What's happening right here? And I always answer the same way, you're not using your insulin correctly, right? There are different variables, there are things that are happening to you. Maybe they're hormonal, maybe they're food related, maybe they're exercise related, hydration related, there are a couple of like big ones, right? That it could possibly be. And, you know, setting setting settings settings have to be right, you need to know when to use the insulin. And I say all the time, like if I had five seconds to make this podcast, I would tell you that it's using the right amount of insulin at the right time. It's timing and amount, dependent on variables. So when someone comes to you and says, I don't understand, you know, I'm good at this except when I'm swimming. Okay, well, then swimming is the variable, right? And we'll figure out like, where do we put the insulin? How much of it and where, you know, so when do we put this so that you can swim without a low blood sugar? It's infinitely doable, right? It really is. And yes, your doctor's probably not going to explain that to you, the day you're diagnosed, or even in the first couple of years of you going into that office. But if you knew its timing and amount, it settings, it's understanding the impacts of food, the impacts of hormones, the impacts of those sorts of things. Hydration, if you're not well hydrated, your insulin doesn't move around. Well, it doesn't work the same way. This person here says, hey, it might have been nice to tell me that my insulin sensitivity would act differently if my blood sugar was higher, because you gave me settings and directions that drove my blood sugar up. And now not only were those settings not okay, when I had a stable lower blood sugar, they're really not okay, now. And all that gets boiled down to a doctor by like, oh, yeah, when your blood sugar is high, you need more insulin. Okay. valuable, but not not nearly the whole story. That's all. I got upset during this one. I apologize.

No, it's all 100%. Correct. And I think you know, the point being that in general, you have to give the right information in the right timeframe. But starting out somebody with information that is lacking enough definition, that is going to set them up for going down a path of I don't understand, I don't understand I don't understand. So I'm just going to do the basic that I was told to do, because I don't know what else to do. And nobody's helping me. And then they also don't know what questions to ask to make it better. Even if it's with a, you know, a health care practitioner that's trying to do something for them. That person might be so in the dark that they don't even know where to start to ask.

Yeah, I just I'm stunned that with the prevalence of diabetes, such as that is that the simple ideas aren't better understood, and communicated. Like Jenny, I'm not going to like I hope this doesn't sound different than how I mean it. This podcast is insanely popular. I know. It's not a podcast made by like a big company or like a, you know, 20 people. It's like, I make it I have you on and a couple of people and I have guests on and like I you know, I pay an editor to like, make sure it sounds good. Like, it's not a big operation, right. The fact that so many people listen to it should be an indication to physicians. We are not doing a good job with this. Like that's that's, it should because if people understood it, it wouldn't be needed. It's not a comedy podcast. It isn't fun to watch Listen about talk people talking about diabetes, like their list. They're trying to save their lives, you know?

No, you're right. And in a broader sense, I think if there was, like a lot of the way that many people might even often come to the podcast is actually just by doing a search for more in depth education about diabetes, or type one diabetes, or support for diabetes, or whatever it might be. And obviously, it probably comes up pretty much first on a Google search, along with maybe a couple of other options, right? But right, the baseline here is that without the right information, people are left wanting almost with a almost with a subconscious idea that they haven't been given everything they need. And then they go searching. Yeah, wouldn't you rather that they get the right information from you to begin with, so that you don't have to repair all the misinformation, they may have gone down a rabbit hole of information online, perhaps they didn't find the podcast, but they found somebody else's. This is how I manage my diabetes and the like eating lettuce leaves all day or? Right? You know, if they're coming back to you like that, you're like, oh, oh, okay. All right.

That's not right. Yeah. I didn't mean for you to just eat cabbage. Sorry, right. You haven't led them in a good direction,

right? They're doing a search because you haven't given them the information they need to begin. Isn't it

funny, too, that a doctor will tell you don't go online to find out stuff? You know, like, Why do you think I was looking? I was looking, because I completely understood it. And I just wanted to see if there was more. Like, I don't know what I'm doing. I'm dying, physically and mentally. And I'm trying to save myself. And by the way, those are the people who are lucky enough to take that extra step. Correct. Most people just sit down and go, This is my lot in life, and they take it.

And this must be the way that it is because the doctor and I don't mean that rudely. But the doctor told me to do it this way. I do it this way. And as you said, this must be the way that this just works. Yeah, they don't go down the road of search.

I guess this is what living with diabetes means. I have an eight a one C and I feel cloudy all the time. And I guess if I get lucky, maybe I'll just get frozen shoulder and I'll get to keep my toes like that's literally what's going through their head. And none of that's necessary timing and amount. I don't know, Jenny, the Pro Tip series is 26 long. It's maybe 20. You know, 20 hours worth of listening. Everybody listens to it and comes back and says Am I even seasonal oh six is now. I just understand now, Jenny and I did a talk. Let's finish with this. Because I know you have to go. Jenny and I did a talk in front of some people in Austin, Texas recently. And we were invited to talk. And we said, we'll do that. But we're not going to put a slideshow behind us. We're not going to do this the way we normally do it. We did two solid hours of conversation. Just you and I to the audience. We went on a lunch break. And we came back and did three hours of q&a. No one left. Right. Everybody came back. Yeah. My my ego made sure No, I checked hard. Okay, like everyone was there. Okay. Well, my point is, is that if I said to a doctor, hey, we're going to offer this thing of five hours worth of education about diabetes. They'd go, nobody wants that. But they do. They want it desperately. You know. And so we go down there, and we just have conversation. We're not talking at them. It's not bullet points. We have this big conversation. Jenny said you saw someone online who said what after that about pizza?

Yeah, it was a The question had been raised about how to navigate pizza with a specific algorithm driven insulin pumping system. And I gave some baseline direction with some things to pay attention to. And when to put insulin in again, timing of insulin is the baseline here. So when to put it in and what to watch for. And from what I remember, the comment online was just back, hey, I did do a GT sat and look at what we got. I was I was very excited about that. I was like, thank good. Yeah. And

I heard back from a family whose daughter went out into the world afterwards, they were going all over the place eating a bunch of stuff that you know, generally speaking is not easy to Bolus for, right. And the person said, like look at this graph and showed showed a nice, like graph of stability over the next day. But their indication was not that we even said something so specific, like they didn't go like put, you know, Peg a and hole B, just having the conversation led to her making decisions that lead to better outcomes, just hearing people talking about it. And I'm not asking a doctor to do that. But I am asking, if you don't think you're providing that to somebody, then you have to lead them somewhere where they can get that it's very, very important for diabetes. So like, if you can't figure this out, or you don't have time, or your system doesn't allow for it or whatever your reasoning is, that's fine. But don't just shoo them away, like, give them somewhere else to go. It's really valuable for people. So

and I, you know, something valuable, I think I don't think I know that I see when I work with those that I get the opportunity to privately is when there are questions that come up that are their questions to me, too. I'm more than happy to say, You know what, I don't know, I'll have to look or I'll have to ask my colleagues, you know, I may have great resources with the other educators that I work with. And we all have wide ranges that we have good information in. We don't, each of us doesn't know everything. Sure. And so we use these each other as resources. And as a clinician, you have to be willing to say, I don't know. Yeah, it's okay. But I'll find the answer for you. I'll help you.

I don't remember that. I honestly don't remember the context. But while we were at that talk, I remember putting the microphone to myself pace and saying, Oh, wow, Jenny just said something. I don't remember what I said. I didn't know that. I just learned something here. And like, even that

was about honeymoon, something early morning. Basil needs.

Right, right. Oh, yeah, I don't remember the the exact I do remember that. I don't remember that. But it's not even important. What's important is that in front of in front of a few 100, people who kind of see me as a person who knows what I'm talking about, I was happy to go, Oh, I didn't know that. Right, like so that they can go, oh, well, he doesn't know it is stuff I don't know and feel comfortable about that. And then I turn to you. I say tell me more about that. Like, that's fine. You need to make people comfortable doing things like that because they're embarrassed to but that's the other part of it. I don't know if we'll get to talk about that in here. Yeah, we will. We're going to do like, kind of like mentality humanity stuff. I'll save it. Okay, I'm gonna let you go then. Awesome. Thank you so much, of course. This episode of The Juicebox Podcast is sponsored by ag one drink, ag one.com/juice box. When you use my link and place your first order, you're gonna get a welcome kit, a year supply of vitamin D and five free travel packs. This episode of The Juicebox Podcast is sponsored by cozy Earth cozy earth.com use the offer code juice box at checkout to save 40% off of the clothing, towels sheets off of everything they have at cozy earth.com The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

Hello friends, and welcome to episode 1112 of the Juicebox Podcast Welcome back everyone to the Grand Rounds series with myself and Jenny Smith. You know sometimes I just think everybody knows Jenny So I forget to introduce her properly, but Jennifer Smith has lived with type one diabetes since she was a child. She has first hand knowledge of the day to day events that affect diabetes management. Jenny holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She's a registered and licensed dietitian, a certified diabetes educator and a certified trainer and most make some models of insulin pumps, and continuous glucose monitoring systems. She is also all over this podcast from the Pro Tip series to defining diabetes, to ask Scott and Jenny. Also call her a friend. And I think she's one of the smartest people I know about managing type one diabetes, you can hire Jenny at integrated diabetes.com. Please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan are becoming bold with insulin. Don't forget to save 40% off of your entire order at cozy earth.com. All you have to do is use the offer code juice box at checkout that's juice box at checkout to save 40% at cosy earth.com This episode of The Juicebox Podcast is sponsored by ag one drink ag one.com/juice box. When you use my link and place your first order, you're gonna get a welcome kit, a year supply of vitamin D and five free travel packs. This episode of The Juicebox Podcast is sponsored by us med U S med.com/juice box or call 888721151. For us med is where my daughter gets her diabetes supplies from and you could to use the link or number to get your free benefit check and get started today with us met. Today we're going to talk about food to just briefly go over so far we've gone over hospitals diagnosis, insulin and safety today food should be a slightly shorter episode, although I expect you to go off on some sort of a tangent at some point. So maybe it'll take a little longer. The reason I thought that you'd have a lot to say about this is because obviously your background in nutrition. So we have a few pieces of feedback from the listeners about what they prefer, what they would have preferred to hear from doctors, we'll go through a little bit of that we'll talk about it from a couple different perspectives, and we'll we'll let people get back to their lives.

I really liked the feedback from people, especially in this because I think I think it offers a lot of perspective of knowing now what people know, and what would have been really helpful. And I think food is a big place. I mean, it's one of the three things that helps manage diabetes.

So I agree, I think for this episode for these episodes, specifically, having someone go through it not knowing what they should want or need. And then having them live long enough to think back and go, Oh, you know, what would have really helped back then. And sending in that information is great, right? This person says I wish I would have known in the initial phase with MDI that my toddler can have up to five grams of uncovered carbs for a snack. I came home from the hospital terrified to feed him anything, but meat and cheese. Wow. This is this is interesting, isn't it? Because a new diagnosis may assume some honeymooning and, but But telling somebody they don't need to Bolus for anything under over under five carbs is really giving it's really setting up the quiet expectation that we think you're going to get low. Or we're okay with you being higher one or the other. Right?

Correct. That's it's a good assumption. Yes. But it also creates a lot more confusion. Right, right. Because I guarantee that nobody said that as long as it's under five grams of carb. You don't have to Bolus for it. They didn't go on to say, but if you add up multiple things that are under five grams, and you eat them all at once, then you need to Bolus because the complete total is well more than five grams. And I guarantee that wasn't clarified.

Right? That's an assumption that doctor will make like, oh, that they'll understand that. I don't mean you know, if you have five grams at two o'clock and then five grams to 230 and etc. But there's no reason to think anybody would understand that. Correct? None. Yeah. And it sets up long term problems. Because now in their mind forever and ever anything under five carbs doesn't. It doesn't need insulin, and then they see a high blood sugar. I bet they don't even put two and two together at that point,

and they wonder unless they're paying enough attention to and have a continuous monitor, that they've really tried to pay attention to some trends or things that are, you know, happening over and over again, in those early days or weeks. Absolutely.

It's just a good example of if you can, outsmart yourself. So if you over I'm not saying every doctor does this, but we know what happens you over basil somebody because you don't believe that they're going to count their carbs correctly, or Bolus on time or whatever you whatever you're imagining isn't going to happen. And then you give them this piece on top of that, they now have to, I mean, two things that are gonna send them down the wrong path and create confusion for the rest of their lives. Right, and

some clarification there too. I mean, a lot of this is, if you're just clear upfront with some simple pieces, about insulin, about food about the variables, and even just a couple of the variables, especially for little kids, the explanation of what we might tell you right now, because sensitivity for your three year old child is going to be high, that maybe they can get away with a couple of grams of carb to nibble in between, you know, toddlers, I mean, they grab something, or they want something. I mean, they don't just sit down to a big meal three times a day, right? So you know, it brings in the idea that, well, if they want one cracker, and it's two grams, they can have that and you don't have to worry about having to give insulin for it. But then again, the understanding that that's going to change. Right now, they might not need insulin, they might be going through honeymoon. But eventually that five grams is meat, it needs to be counted.

The other thing here, I mean, no disrespect to the person who was kind enough to send in the question or the statement, but they now have a misgiving. They do like she now thinks like, listen to the words. I wish I would have been told that my toddler can have up to five grams of uncovered carbs. Yeah, not true. Like Like, yeah, it might be true in that situation. Maybe the kids honeymooning, but you need all the context of that. But now moving forward. This is how she speaks. He or she speaks about it when when she says it out loud. She's got a misgiving. I'm sorry. I'm just assuming moms are the ones listening to this podcast. Not that guy's dads are a lot of dads. I know. It's funny, like I'm a dad. And I just assumed no, there's no dads listening. But. But she's got this misgiving. And now when she goes out in the public, she's spreading it. Because she's telling us like, you need to let people know, your kid's gonna have five cards that are covering, like, okay, like, so here we are, we're spinning down a rabbit hole, and nobody's ever going to get back out of it.

And someone that may have read it and knows better already, at this point from what they've seen and dealt with thus far. can absolutely say, well, that's not the case. And may chime back in and say, Well, you know, especially, you know, with your group, they're really great about

going off each other. Oh, no, they're fantastic and helping each other. However, why did I set this up to tell you this one first, because here's the next one. It's a fantastic. Even three grams of a snack, like a small cheese puff package. We have to cover that. Even within days after diagnosis, we found out real quickly, there's no such thing as a free snack.

There you go. Absolutely. So good. Yeah, absolutely. And it just, it justifies the, the idea that individualization of the information that you give, which is really hard at initial diagnosis, you can't get to know somebody in that tiny amount of time where you're trying to give them some, save yourself or save your child kind of information. Because that's really what it is at initial diagnosis, right? They're setting you up to get you going to get you out the door to get you home. And then to be able to connect with somebody that can give you the broader scope of let's call it the correct information. Yeah, hopefully, yeah.

Hopefully, you'll find a next person who will go a little deeper with you. But again, a lot of this, a lot of these episodes to me are about what happens when you say these kinds of just offhanded things in the first days or weeks, and you leave people like, like the one person figured it out, and the other person didn't figure it out. And they're both listening to this podcast. So even that didn't help completely. No, this person says, I'd like my doctor to know that my son doesn't need to be on a low calorie diet to achieve a Grade A one say somebody was told to limit calories frequency.

That's where you said, you know, you'll wait for me to go off on a tangent. This might be my tangent, honestly. Because, depending on what facility You get diagnosed at and I'm, I'm speaking more toward the kid and teenage kind of facility, right? Because nobody anymore really pays attention to nutrition needs of a growing child or a growing teen. And I said nobody, that's not 100% Correct. But less and less I see that parents have an understanding when I get to work with somebody finally. And my question comes up, well, what parameters? Were you given for portions? Right? Because just because you can eat food and cover it with insulin, doesn't mean you need three packages of something. Right? And so initially, that's something that should be set up sooner than later, is the concept of containment of portion. Yeah. And it's not, it's a lot of just centered around carbohydrate thinking, centered around how to count the carbohydrates, with no idea that somebody needs this much, or the 13 year old needs this much in the 18 year old who plays you know, field hockey five days a week needs this much. There is a major variance, but no, just cover your carbohydrates, whatever you're choosing to eat.

I don't know that this would come to a shock to anybody. But Jenny and I talk privately. Fair, a fair amount. I think that what I saw in my life is the way I grew up. In the beginning, they tried, here's some chicken, here's some beans, like, have a salad boba. And the minute we push back as kids, they were like, Screw it. And then when money got tight, it all went to, like, processed prepackaged. And you can probably I don't know the dates, but I think in my childhood lifetime, you can look back to where processed foods became more and more prevalent, and ugly, and they were cheaper, and they were more convenient. And then my parents went to that before you knew it. Like you know, you weren't making something from scratch anymore. You were making it from a package or box. How amazing is this? Look, you just dumped this into water and add meat, Mike? Okay. Yeah. I want to say I've never liked Hamburger Helper, I will not eat it. But that is what um, but that is the thing that somebody was like, here, look dinner. It's got meat in it, like, you know. And so when that's all going on, and your body gets rewired to just like, I don't know, to crave those things. That that's tough then, because now these portion control problems are insane. And I only have perspective about it. 40 years later, because I'm taking a GLP one and my brain works differently now. Right? Right. Kelly and I were out last Saturday. It's Friday. Now last Saturday, we were out and we got this like we saw this chocolate cupcake. It was like chocolate cake with chocolate icing. And it was big. It was like four around and we were like we can split this. Sure. Three goddamn days later, we couldn't eat the damn thing. Like we were like taking a fork full out of it and being like, Oh, that was good. That's enough and putting it down. But if I'm not on this GLP we probably would have like, fought each other with the forks to get to the rest of the cupcake that we would have been gone in a couple of minutes. Correct. Then so you now you're giving this stuff to your kids. They're like, Let's go like and it's not them. It's their. It's their wiring. It's their, you know, it's the I hate to sound like a hippie, but it's the way it kind of restructures your gut to want these like carbs and all this stuff that goes with it. Absolutely Sugar,

Sugar. There is there is something to be said about sugar addiction. It's a real thing. 100% It is. And so again, if I were to go off on a tangent, it's it's definitely about the fact of today's life is busy. It's even busier than when these processed packaged all convenience, you know, you brought up a hamburger helper. And the reason it was there was because well we've got these dehydrated, like peas mixed in with noodles that you just have to pop in and Oh, then your ground beef. All you have to do is mix it together and you've got a complete meal. Yeah, we've got everything that you need within 15 minutes.

But that's not good for you. It's just not it's not good. And I think that more and more, we are eating food that is not it's not fueling us. It's not actually providing nutrition. And I'm not against saying that I think people are having other issues that are probably nutrition based that we're not even aware of at this point, correct? Yeah. Arden has been getting her diabetes supplies from us med for three years. You can as well, US med.com/juice box or call 888-721-1514 My thanks to us med for sponsoring this episode and for being longtime sponsors of the Juicebox Podcast. There are links in the show notes and links at juicebox podcast.com to us Med and all the sponsors.

Absolutely. But I think it compounds it then when you know URL In diagnosis, you've not been given the information about what your body actually needs, even on a caloric level. And by no means do I ever really recommend anybody count calories. It's tedious. It's it's just not purposeful, but understanding portions are visible. Your child needs this many portions of this in a day. Your child needs this many portions of this, making sure to emphasize that these foods should be real food.

Yeah, right. Yeah. So those are the words rattling in my head. While you're talking. I, you know, you do this long enough. And, you know, you know what you're gonna say next sometimes. And while you're speaking right there, I thought when she stops, I'm going to say real food. That's exactly what I was just thinking. So portions important, right? You can't just you don't want to be taking in 10s of 1000s of calories, when that's not what you need to get by, you are going to have an issue with your weight if you do that. But also, you're gonna end up using more insulin, that then very well may cause lows later that will cause you to need to eat again to like, bring it back up. But the problem we're trying to figure out here is what should doctors be saying to people? To a not? Because you don't want the people to hear? Oh, yeah, okay, I'll have four ounces of chicken and a salad and three beans. And I'll never drink soda again, like, because if the doctor leads with that, the people who don't want to hear that are gonna be like, Man, nevermind, not listen to that. The people who already eat that way are like, Yeah, cool. That's what we eat anyway, no big deal. Right? I really think that you should lead with real food, reasonable portions. I think that's enough to get people going. Right?

Correct. Absolutely. And I think within that, to the understanding that I think a lot of I know that a lot of parents also feel like all of a sudden there are these restrictions that are going to be in their child's life. And so they try to make up for these restrictions very early on, by not restricting in one of the places that there should be restricted.

I understand it, by the way, I'm not, I'm not, I would never come down. But I know you don't want there to be like these grand changes to your lifestyle, but I think it is worth mulling over privately, we were on a bad path, it just got shown to us earlier, because of the diagnosis, this path was going to lead you to a bad place eventually, but your body probably would have hammered through it for 10 or 15 years, then you might have got a couple of medications that got you a little farther. And then somebody would have been said, take our proton pump inhibitor, if you've got, you know, reflux and and maybe you would have got through it until finally one day in your 50s you would have been like I can't like it the medicines not helping. And I can't fight through this anymore. I've got pre maybe I'm working up on some type two diabetes, you know, or all the other things that come mobility and problems like that. You're just finding out earlier. So there's a way to think about that as a bonus. I know that's a weird thing. But you can say like, you know, I or my kid was diagnosed at least now I know, this food is like I think diabetes is just shining a light on the fact that you're eating things that aren't beneficial for you sometimes. And yes, you know what? I mean? Does that make sense? No,

it does. Absolutely. I've said that and thought that many times myself. I mean, if I wasn't diagnosed when I was with type one, I'm sure my career path would have been different. And would I have wanted to focus as much on overall like human health? I don't know, I originally wanted to be a veterinarian. So I don't know where that leaves nutrition information, right. But I'm very, I'm very happy for many reasons that I had to learn as much as I did. And obviously, where that led and how I can help people and everything. But I think that many people who live with some type of health condition, that lifestyle impact, you can start to learn a lot more about yourself and what, what makes a difference. And I mean, fortunate or unfortunate diabetes, it sure shows you a lot about the impact of food. Yeah,

and I mean, we've talked about this before, but it's worth bringing up you some luck for you, right? Your mom was a person who grew food she cooked she took it seriously when the doctor told her this was What's up, you didn't push back terribly. Like Like, there's a lot that went your way. But my point is, is that, okay, some people aren't going to have that that's not going to be their trajectory. It doesn't mean you shouldn't tell them. Correct. They still deserve to know, because maybe something will happen later in the future. And they'll just like, get smacked in the head and think, oh, that's what they meant. And, you know, maybe I could be doing that. Maybe not fair enough. Like we're not going to save it anybody and I understand all that. But as the doctor, I think it's incumbent upon you to tell them the truth, without scaring them or making it sound like you're stealing something from them. And that's not going to be easy to do. But again, from my perspective, listening to you listen to other people, if you just preach real food at a reasonable amount, I think that's most of it, really, you know, cook your food, you should be able to look at it and see what it is and actually go that's chicken. I know what that is. That's chicken, right? You know, you look at Hamburger Helper, and you go, that's noodles, and peas, and is it. Keep reading, there's more in there, like ever notice you don't flip the chicken over and it doesn't say chemicals. It's a chicken. And even now, like people are smart enough to know, like, look, organic might be better because or no antibiotics that have been used or grass fed for some reasons. Like these are all reasonable ways to avoid pesticides and chemicals and things that again, I feel like I'm just I feel like I sound like Joni Mitchell's like, like guru you hear or something, which is just a reference nobody's gonna get at this point. But like, these things are going to change the microbiome in your gut. And you're going to end up one day with a headache, or an achy joint, and you're going to think, Oh, my wrist is hurt. And somehow it's going to be that those billions of little things living in your stomach have gotten messed up by something, somebody sprayed on something. I partnered with ag one because I needed a daily foundational nutritional supplement that supported my whole body health. I continue to drink at one every day because it works for me. Ag one is my foundational nutritional supplement. It gives me comprehensive nutrition, and it supports my whole body health. Drink, ag one.com/juice box, when you use my link to place your first order, here's what you're gonna get a free welcome kit that includes a shaker scoop and canister, five free travel packs, a free year supply of vitamin D, and of course, your ag one. So if you want to take ownership of your health, it starts with ag one, try ag one and get a free one year supply of vitamin D and five free ag one travel packs with your first purchase. Go to drink ag one.com/juice box that's drink ag one.com/juice box, check it out.

You know, as I'm thinking about this, and where's the Introduction to Food started, it started at diagnosis. And majority of people with type one or younger people diagnosed with type one in a hospital setting are admitted. Right? What's your introduction to food? And what is possible to eat now that you have this new diagnosis that you're learning? Well, food has an impact on this. And now I have to pay attention to something called blood sugar or blood glucose. And we have to do these finger sticks and what the number pops up. Like, what is that? I mean, all of these thoughts are circulating around and then what comes in three times a day? Is the food from the cafeteria. Yeah, I know hospital food I worked in hospital cafeteria was when I was in college. And it's it's not

It's garbage. Yeah, no, it's terrible. And it's not good for you. And by the way, that diabetic menu is ridiculous. It just it just limits you from choosing from like one portion of men, it's, you could still get apple juice if you wanted to. You know, like we live in a world now where you could walk outside and ask anybody? Hey, do you think you should drink fruit juice? And most people would go no, I've heard that's not a good idea. Right? The hospital hasn't heard why they didn't get to them. And then you realize the hospital's a private company. It's not good. I mean, it's they're trying to make money too and etc.

Correct? Absolutely. But you know, I've, I've, I've had parents who've come to me and said, Well, you know, as we talked about this, like the process components and how to make things a little bit, you know, better overall. And, you know, I've heard it a couple of times will my child likes pancakes, and this is always happening. Okay, there's some alternatives. These are some ideas to still keep that in the picture. But they ate pancakes in the hospital. That's what they serve them after they were diagnosed now.

If you're a physician, maybe a good place to start is to go back to your the board of directors or however you report things. Okay, look, I don't know how you expect me to put these people on a good path. If this is the garbage we're sending into their room as we're diagnosing them. You know, how am I supposed to stand there and go real food reasonable portions while they're eating pretend food? So under a dome that makes everything moist? Has anyone been often in the hospital ever? Like, oh, I don't want I'm hungry, but you handled it. I don't want this now. I know when

we they actually looked at us like we had foreheads when we arrived for our first child to be born.

There's no way Jenny didn't bring food whether you He weighed

like three bags of groceries. And they looked at it like they looked at us, like, so weird, like these people who are these people? Where did they come from? What are they? Are they going to work in the food service and make their own?

Ladies got a hot plate? I I remember asking you one time, Jenny, what do you do on road trips? And you were like, I bring food and I was like, oh, okay, I'm like, you don't stop at a gas station ever and get a Milky Way bar? And she was like, No. I don't do that. So, listen, I am not the picture of health, right? Obviously, I've been on a lifelong, a bad path. Somebody put me on and my bodies crave things and move me in directions, etc. But I'm doing much better now with literally just because of a GLP one medication. There's no other reason I wanted to. And I, I searched it out and everything. But even now, I found myself Jenny and I spoke together recently at an event in Texas. And I was at the airport. And I was hungry. And I stood at that thing at that airport. And I thought there's no food here. That's what I kept thinking that I can't even get a drink. If it's not a bottle of water. Like there's nothing here for me to eat. I grabbed a banana and I left. I was like, That is the only real food I see sitting here. Yeah, that was it in a giant kiosk where people were just like, grabbing things and going in different directions and everything or, and so I eat reasonably clean now. Right? And not like it's not the way you think of it. Like I'm not like, I don't know, it's not like a bro science guy or something like that. I'm not like drinking amino acids and powders and stuff. Like I've just, I just I stick to things that I can recognize. The other night someone said, let's get Chinese food. I couldn't even eat that much of it. Because I'm on a medication that tells my stomach it's full. Right? Listen between me and you. It was maybe 45 minutes after I ate the Chinese food where I was like, Hey, I gotta Excuse me. I gotta go. Excuse me a second. Because my body was like, this ain't right. And that was it. I was and I don't even want to say second. I don't want to be dainty. Like, I just get rid of this right now. It fascinating, like, absolutely fascinating. So no nutrition. I was eating for sport when I had that Chinese food. Basically. Yeah, absolutely. Okay, yeah. But again, do not tell newly diagnosed, they can eat whatever they want and just Bolus for it. Nobody should eat whatever they want. Not in today's world of crappy food. And I made a note to this. I said it's the right message with the wrong wording. Because I do understand telling people, listen, you can eat whatever you want. You just have to cover it with insulin, not only do I understand that, I've made a podcast about it. Correct? Right. I want people to understand how to use insulin. But that's from a heavier perspective than you think. Doctors say it. I'm guessing because they want you to use your insulin, I'm guessing they know you're not going to eat well to begin with. That's probably their expectation. And they probably don't want you to feel limited. I'm guessing those are about the three reasons. The reason I say it is because I think if you know how to use insulin, for whatever you're eating, that means you'll know how to use it for other things as well. And hopefully one day, you'll figure out the rest of it. But in case you don't, I want you to be able to cover Hamburger Helper because I don't want you to have poor nutrition and poor diabetes management. Right. That's where I'm Yeah,

no, that's that's a good, very good clarification. I think from the doctor perspective of a new diagnosis, it's one of the thing it's sort of a feel good statement to hate it. It's yeah, they don't, you know, they don't want so much to change, because they know so much is going to change the fact that you don't have to change what you eat. Just make sure you take this medicine along with what you choose to eat. That's the blanket statement is you can eat whatever you want. Well, that's 100% True, as you're saying, but your level is learn to use insulin. So in the case of choosing something like Chinese food, or whatever, that you can actually manage the blood sugar, which has the impact on overall health.

Right to my expectation, just to be very clear, is that I don't think most people are going to eat well. That's I hope they do. I really do. I don't think they're going to and in that case, I don't want them to be again, like poorly fueled and poorly like managing their type one though, because they have now they have two different problems instead of one different problem. And now we're just spiraling out of life. By the way. I don't see any difference between this bit of conversation here about a physician saying oh, don't worry, you can eat whatever you want. I don't see any difference between that statement and oh, I've heard there's going to be a cure. I think those are both meant very passionately like and compassionately Excuse me. Yes. But again, you you run the risk of starting somebody on the wrong path, which is don't worry, eat whatever you want. Well, people do not understand nutrition to begin with. They're like, oh, let's go, you know. And the same thing when you tell somebody like, oh, you know, I heard there's a cure these algorithms work so great, now you barely have to do anything. What people hear is I don't really have to pay attention to my diabetes. And that's the unintended message. So find a way to talk to them about food, without scaring them about it, putting them on the right path, without giving them a hall pass to eat whatever they want. Like, you got to use better words. It's all communication, really. So yeah,

I always think, you know, at diagnosis, this, again, is, especially for kids and teens. I think a dietitian should be part of that. Team education, and in many cases it is. But I think what's left out still is the idea of, not only should it possibly be better food than maybe you're already eating, but also just how much does your kid need? Because if they go home with that, even if they are eating, you know, Doritos, or whatever it is, at least they know that the bag isn't the portion.

Right? That opened it, and we're gone. And that was it. Yeah, no, people don't listen, diabetes taught that to my daughter. She's like, there's 15 in here. I went No 15 to the serving, how many servings are in it? And she's like, Oh, yep, yeah, but she was young. But she got to figure it out that way. Again, another benefit of I can't believe I'm saying this is another benefit of her getting type one diabetes art is actually a fairly healthy like, fit person. So let's go over this last little bit of feedback. And then I'm going to say something banned. And and then I want to finish with you. This person says, please just find out how people eat before you start their meal plan. Our doctor had our son snacking five to six times a day, which was not just unsustainable, but we're not snackers to begin with. So this is not a thing we used to do. They were literally telling them like, eat more. And they're like, we don't do that. She also says he or she says that we're also not junk food people. And so like snacking, see what she's saying is you made a snack, we went and got bad food to snack with because he can't cook a meal six times a day, which is the way we usually eat. And she also said, please stop telling people protein is free food and doesn't need insulin. Yeah, because it's not. I'm gonna say this, even though there are probably some incredibly low carb people who think that I am pushing insulin on people because I say I think you should know how to use insulin. I am not. And I so I'm going to just ask Jenny here to dispel the the idea that you need carbohydrates to grow. Because fell it? Well, I think you need some carbohydrates, but from the right foods. And I think that some people hear that and think, oh, Doritos counts, you know what I mean? It's, it's another one of those mixed muddled messages. Correct?

Absolutely. Carbohydrates contain, especially the type of carbohydrates that should be being eaten, the vegetables and the fruits that should be being eaten in terms of carbohydrate content, they contain an enormous amount of antioxidants. The colors of the rainbow, are a phenomenal piece of the fruits and vegetables. And if you're aiming for lower carb, then you're aiming for the lower glycemic ones, you're not being carb free, or just being aware again, of how much of it are you eating, and you're eating those foods, not from an energy necessity standpoint, because the body can convert in a low carb environment, it can convert to using fat. And that's what many low carbers are doing. But you have to also talk with somebody who can really guide you in the right way for that, because you can really do it wrong, right?

And then not be getting a nutrition that way. Correct? Absolutely. So then when doctors say you need carbs to grow, their concern is that if you do keto wrong, you're not going to have the nutrition you need.

That would be my expectation, or that they really are just thinking that because the because the human body works very quickly and easily off of carbohydrate, but it's a quick burn, it goes in it goes out it goes in it goes out. And so if you have a really, really high carb intake above and beyond what you really honestly need, you're going to be on a constant roller coaster of hunger. And your brain is going to work off of carb and it's going to want want want want, right? Whereas if you moderate that, again, understanding what are your nutrition needs, what are your caloric needs, then your body can actually do very well. But you have to have balance, you have to know how to do that balance the right way.

I'm afraid that I don't know how to do it well, but I also wouldn't lie and I'd say there are days that I fairly low carb were all like I mean, I've said on here a million times like I'll I'll smoke a couple steaks and slice them up and pick at them for days, you know, or something or something like that. But I'll still Fruit during the day are you know, I've come to starting to eat like coconut milk, yogurts and things like that. And I also supplement pretty reasonably like I'm covering my supplemental needs if I don't think I'm getting them through food. Again, that's an expense. It's not a thing people know about. I think some people think vitamins are no bullsh. I think some people think they're everything. I don't think there either. You know what I mean, you still got to eat. You can't just take a vitamin. That would be the Jetsons, that'd be the opening to the Jetsons, which is another reference, no one will know. Yes. Jenny might be, Speaker 1 35:32 oh my gosh, I love the Jetsons. They were they were great. I used to be

jealous because they'd get that pill that would come out of the machine. And then they'd cut it in half with their knife and eat it and then go about their day. And I thought, Oh, I wish eating was like that. Right.

You know, what I always find funny about the Jetsons is that they had down what we do. All over, especially in the past five years, we've really come into zoom, and all of these online, like webcasts, and all of these, that was the Jetsons were like, they were well ahead in terms of our cartoon.

It is funny. I did a thing for World diabetes Day where I spoke to 100 people for two hours, like from sitting right here. Yeah, just everybody clicked on a thing. And we were all there together and had this nice conversation. That's awesome. Yeah, it's very cool. But

But yes, supplements were typing. Yeah,

yeah. So I mean, and that's, that's another part of this, that that I think people need to be aware of, especially with diabetes. There are supplements you you might need, like you know, your pancreas is part of your digestive process. Some of you might need like a digestive enzyme or something to help that along. I don't think it's something we're ready to talk about right now. But Jenny and I are looking into another supplement to try to like take to see how it goes. And by the way, I've ordered them. Oh, there's that piece of it. So just even just a good multivitamin, but even people go wrong there. They take their multivitamins as gummies or like, you know, it's just see Jenny's face, she would never take a gummy vitamin gummies are just like you brought her own food or birth.

Know that gummy vitamins are I mean, unfortunately, even from what looks like it's a good company. And you can find online very easily multiple reports about gummy vitamins not being consistent in content of the micronutrients and macro and things that they're that they

actually do people right. So in the gummy

I mean, even even that, you know, if you're gonna if you're gonna take a multivitamin, also look at where, where those vitamin sources are coming from? Are they actually quality? Are they synthetic? Do they have some type of spray applied to the homeless, they're supposed to be absorbed, the better. You know, I

think I was listening to something recently where someone said that one of the like, chewable vitamins has like something in it that at a certain parts per million would be deadly or something like that. And I was like, What the hell, they're more expensive, okay, but buying something cheaper, that's a waste of your time is a bigger waste of money. So I'll say that I stick to pure encapsulations or Thorne,

those are those are great brands.

Those are the two brands I stick to. So for things like vitamin D, zinc, I take an iron supplement from them, I mix it with a vitamin C from them, that kind of thing. multivitamin like that, that sort of stuff. So if you don't think you're getting it, I drink athletic greens, you can probably try to find a green drink that would you know, like help you with these things. But if your foods not giving it to you, I know nobody thinks of it this way. But if I found a random person around all day, I'm gonna guess that seven out of the 10 things they put in their mouth are not valuable to them. Nutritionally. I just think that I don't know how you could look at that stuff at that airport or in the grocery store and not come to the conclusion. Like there's a potato chip aisle. That is usually also the candy aisle. Literally nothing in there is helping your body stay alive, right, the soda aisle.

If we're if we're talking about carbohydrates, to get rid of the majority of them live in the aisles of your grocery store. Yeah, they do. 100%

and they're fun. I'm not gonna lie to you better than licking whatever that is off a Dorito. I don't know what it is. It's amazing. Jenny would know about it, but it's fantastic. And we all know it. Those are those things there. I mean, if you're going to eat those things, try to find a better way. I'm not saying like you should be sitting around growing carrots in your backyard. I know that's probably not reasonable for people. But I can tell you this, I can't eat potato chips. They make me nauseous because I don't really I don't, I don't consume oil. So like I only use either cold pressed olive oil, grass fed butter or coconut oil every once in a while. Those are the only three things that like I'll cook with or use. So if I have potato chips just out of a bag, I'll get nauseous from it. But if I were to make my own potato chips which is actually a thing I know how to do. I can, I'm okay. And not only that they hid Arden's blood sugar differently than a potato chip out of a bag. Yeah,

you'll you'll notice and a lot of it, you know, in terms of oils, I think what you're probably noticing digestive Lee yourself. And what you probably noticed in Arden's response blood sugar wise, is that I mean, the seed oils are horrible. Yeah, you're talking about canola oil. If you're talking about any of the like sunflower seed oil in the safflower oil, and all of those that are, they are cheap. They're fillers. And they are what is used in the majority of process package, right? Let's call it snack food. And

every restaurant is going to use it because it's cheaper. Yeah. So anytime you go to a restaurant, something's fried. It's basically machine lubricant, or whatever the hell that ends up being when you melted down. Listen, I think if you listen to the podcast long enough, you realize that I cut the oil thing out maybe three or four years ago. I've been making small adjustments to myself for years and actually making the podcast has helped me with that. Even watching my daughter's health and like, I think we should get rid of this or that like that kind of thing. But I was a person even as a child. If you took me out for pizza, I'd be sick to my stomach. And pee. And I know if you say that out loud, people would say, oh, that's celiac, right? Oh, that sounds like see, like, I do not have celiac. I don't have I don't have a gluten sensitivity. I've been tested. They've sucked things in both sides of me to look around. I don't have those things. Okay. But as a child, take me out to a pizza joint. You need to get me to a bathroom in about 90 minutes. I couldn't live like that. And I had a lot of moments in my life where I was like, Oh, I go to the bathroom. Like, like in an emergency situation. I have not gone to the restroom out of an emergent situation in years. years. I have never heard that Chinese food the other night notwithstanding. I have not. And even then I wasn't like, oh dear Lord, I need a bush. Like I was just like, oh, I don't feel good, you know. But yeah, that doesn't happen to me anymore. And so it's nothing wrong with my body. It was something wrong with what I was putting in it. Like my body was literally saying to me, this has to get out of here. Right? And doesn't work. Yeah, this doesn't work. And you we need it to go now. But

you can make your own pizza at home. Can you? Oh yeah, I

can eat forever. It doesn't matter. I make my own pizza, I use little double zero flour I haven't brought in from Italy or wherever they make that I don't know you overpay for it a little bit. You buy actual mozzarella cheese, not something that's wrapped in plastic, it looks like it was wrapped up nine years ago. And you open up an organic tomato paste and you're on your way. Like it's not. It's just not hard. And it doesn't even cost anything extra. Like I know people are like, Oh, it's more expensive. Yeah, I spent 10 extra dollars on the flour, and four extra dollars on the pound of cheese. And in return did not have diarrhea seems worth it to me. Like so like, you know, like, on and on didn't feel sick and nauseous and not good for days sometimes afterwards. And I know now, this it feels like it's devolving into like, seriously like something you'd hear online. And it's not it's just my experience. I've gone through it. And I've seen it. I think you're talking to Jenny who didn't go through it and doesn't experience this these things. So I just,

I mean, I I think the other, you know, piece to think about too is when I think about kids. And I think about what goes into their body, they've got a lot of growing to do, right. And you can facilitate healthy growing, and healthy movement through all the periods and stages of their life that they're going to get to. And a lot of times, I think the easiness of a lot of the process stuff with the busy life that we have, and the fact that you're trying to just have them feel like a kid like normal, right? But they've already adapted to either getting injections, having a CGM put on their body having a pump put on their body. If you tell them they can't have Doritos anymore, they're going to adapt. Right? They may be angry for you know at you for an entire week. But you know what? You're the parent.

Also just you get what you expect. Honestly, what I mean by that is Jenny has two little boys. They're like real classic little boys are big energy, like, you know, no need to look crazy. Like, right, they got the whole thing going on. Yeah, but I bet you they've never had a Dorito

unless they had them at friend's house that I did not know about I have never in I can't say that. I've never had a Dorito I mean, obviously in my childhood teen years, I know that I've had Doritos, but And I'm sorry that I'm picking on Doritos. Like there's so many other like, I

think what we're saying is that is like that every day when you pack your lunch is there a grab bag of chips in it? And for a lot of people there are and for you that's not a thing. Like I'm not saying you've never had a potato chip. I'm certainly not saying that. But I'm saying is your kids eat pretty clean. lifestyles and they're nice little well adjusted children. They're not like, like, I think it's possible people could like be like picturing. You know, like a homeschooled child that doesn't look like they've seen the sun. You know what I mean? Like, Oh,

not at all. It's really funny. As this year, my fifth grader came home, and he's like, Mom, this is so funny. And I was like, Okay, what? I made homemade pizza on Saturday evening, it's our movie and pizza night. And then they have leftover pizza for Monday's lunch at school, right? Because there's usually several slices left. And I mean, their pizza is mostly like veggie toppings and I will make the crust and whatever. But there's a lot of greens on there pizza. I fifth graders, like my friends keep telling me that I eat green pizza. Like it looks like I've got alien pizza. And I was like, are you okay with that? He's like, Yeah, aliens are cool. I can do to go

Yeah, well, that's a great, that's a great example of like, he's not being prepped, like, you said something earlier. I don't disagree with you, you want to be normal, you want to live your life like everyone else. But that in the end is a trade off. At some point, you're deciding to make a trade off. And so today, I've had a coconut milk yogurt, I've eaten two eggs. And I've had a bowl of chicken soup. This is what I've had to write. But I guarantee you when I go downstairs, I'm gonna have a couple of gummy bears, like saw them when I was coming up here. And I was like, I'm definitely having a couple of gummy bears later. Like, I'm not some person who's just like, you know, crazy lover side of it. I'm just saying there's, there's obvious things you can avoid that will really help you. And, you know, too many calories, too much processed oil. They are easy things to eliminate. Like it's a weird thing when you first go through your house. And like for us it was like, well, we make our own popcorn. What are we going to do? And it was always with canola oil. And so I said, Well, we're not gonna use canola oil anymore. We can make popcorn with olive oil tastes weird. And so like, my whole family was like, What are we like? There's just like a bone of contention. I spent six months buying different oils and making popcorn until one day I was like, I've got the answer. It's coconut oil. You can make popcorn. And it tastes good. Doesn't it? Like popcorn? Yes, I figured it out. Was fun. It was not fun. Did I throw away a lot of oil? I might have. Okay, but I figured it out. And I think you I think people could figure it out. Even I swear to you, this little girl came on. She has been on before her episodes called bugs in your belly. Oh came on first. Because she's talking about like, gut biome. She was like this, like 12 year old girl was like, Oh, my gut biome like, Oh my God, that's awesome. She's talking about all of it and everything I've had her back on since then. And she just turned me on to like organic grass fed butter. I think I spent $3 more on butter now than I used to. And I want to tell you, it's made a big difference. And I don't know another way to tell you like it's been it's made a difference in my life. So

you don't eat. So you say you know, it's $3 more, but you're not eating stick after stick every day. The cost of it actually, it evens out to your favor. Even though the cost is higher, you're doing something better, health wise, and you're not eating so much of it that that $3 really makes that much of a difference.

I could make the argument that I am saving in toilet paper what I'm spending in butter and I am not trying to be funny. So there you go, you're doing a good thing for yourself. And at the end. Listen if it's three extra dollars a week for butter, let's just say that okay, let's call it 10 Let's call it $150 A year for more butter 10 years from now when I'm not dying, all think that was worth it. And I think that's just sometimes the way you got to think about this stuff. Also, I know people can't afford everything and but there's still ways to do little things.

Yeah, I say pick, pick your battles, right? Pick your things that if you look at where what are the 80% of foods that you eat over and over and over again? Where can you start to either decrease processed or decrease the brand this brand is better this brand has less ingredients where can you start to pick some things to introduce better you know everybody I mean things are expensive today and the price of eggs when I look at that man really, I honestly we've considered like getting chickens because

they're expensive. It's weird to me you don't have chickens, but go ahead.

We can have them and we've thought about it for a number of years that already but you know there is there is a trade off the quality of nutrients that go into something that has yes a higher price but again when You portion things out, you may actually be doing better in many, in many ways by spending a little bit more. Again, not on everything. Maybe you pick and choose. Yeah.

So that's a great place to stop doctors, please put people on these paths. And I just wrote down that you and I should do a small series about how to remove processed foods from your life. Oh, I think that's a good idea. So hey, all right. I know you have to go. So I'll talk to you. Awesome. Thanks. If you're enjoying the grant, if you're enjoying the Grand Rounds series, please share it with someone else who you think might also enjoy it. As always, thanks to Jenny for coming on the show. And I'd like to thank ag one for sponsoring this episode of The Juicebox Podcast and remind you that with your first order, you're gonna get a free welcome kit. Five free travel packs in a year supply of vitamin D. That's at AG one.com/juice box. Arden has been getting her diabetes supplies from us med for three years. You can as well us med.com/juice box or call 888721151 for the episode you just heard was professionally edited by wrong way recording. Wrong way recording.com. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome type one type two gestational loved ones. It doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community. Check out Juicebox Podcast type one diabetes on Facebook. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

Hello friends, and welcome to episode 1118 of the Juicebox Podcast Welcome back to the fifth episode of the Grand Rounds series. Of course Grand Rounds is Jenny Smith and myself talking directly to doctors about what you need. And today's episode is about pregnancy. Nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome type one type two gestational loved ones. It doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community check out Juicebox Podcast type one diabetes on Facebook. When you place your first order for ag one with my link, you'll get five free travel packs and a free year supply of vitamin D. Drink ag one.com/juicebox If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show this episode of The Juicebox Podcast is sponsored by cozy Earth. use the offer code juice box at checkout at cozy earth.com. And you will save 40% off of your entire order. US Matt is sponsoring this episode of The Juicebox Podcast and we've been getting our diabetes supplies from us med for years. You can as well. Us med.com/juice box or call 888-721-1514 Use the link or the number get your free benefits. Check it get started today with us med Jenny Welcome back. How are you?

I'm great. How are you?

So good. Christmas is over. I hope your holiday was good.

It was really really nice. It was quiet. It didn't do a lot. We didn't go a lot of places. So there. It was just nice to be quiet and enjoy time. Yes,

I'm a fan of that as well. We sat around I think one of the best things we did this Christmas is we bought this big Lego thing that everybody could work on. And we like Oh, which fat? Oh, it's a 3d portrait that you hang on the wall. Oh, I see no. Spider Man. Okay, yeah. So we just saw like, it started off all four of us. Then I think Kelly and I got tired. And then Arden kept going for a while. And then the next day I saw Cole come back into it. Arden Arden was the one that was really focused on it, though. She sat down and she really hammered through it. And it's all done now. And now I'm like, Oh, we have to hang it up somewhere. So yeah,

they started bringing those out quite a while ago, I remember, my husband's my father in law really, really, really likes Marilyn Monroe, like, really likes her. And they had one of her quite a number of years ago. And we had looked at getting it and at the time, we were like, oh, we'll just wait until it's like a little bit last, like a holiday sale or something that'll get it for him. And then it was gone. anywhere anymore. So we missed it.

This was not inexpensive. But I did catch a sale. And I thought it's about the cost to take us all to a movie. And we'll kind of sit together and it was nice. So I'm glad you had a good holiday. Yeah, we

did. Thank you, of course. And it's almost the end of the year. This

is it. It's December 29. Yeah, we're making a grand rounds episode today instead of doing whatever it is we usually do at the end of the year. Usually we just sit around and chitchat. But this year, we're gonna we're gonna put some effort into these series, which I'm very excited about. Actually, as you and I are recording like the eighth or ninth episode of it today. The very first episode of it actually goes up in a couple days on December or January 2. So yay. I'm excited for people to hear it. Today. I thought we could talk about pregnancy. Well, now this is a topic that when we asked the audience about it, to be honest, not much came back from them. Oh, but of course you were very passionate about it when we were putting the list together. For people who don't know Jenny co wrote a book about pregnancy with type one diabetes called Yes,

it's called pregnancy with type one diabetes your month to month management. Your monitor my blood glucose management? Yes.

Can you put our sales voice on there? She's like, Well, hello. It's important because not only does it present a number of issues along the way trimester to trimester and after giving birth and through the postpartum time, but I think that from a human perspective, a lot of young women who are dying Most young women that I've spoken to who are diagnosed prior to the years where they want to have children spend a lot of time thinking that they can't have kids or that it's not going to work out well for them, or it won't be a healthy experience. It's a lot of fear leading up to that, right. And I'm wondering if doctors couldn't do a good job of being able to talk to them in those years. So they don't spend that time scared of what's coming. So maybe like, let's start there. Let's talk about what doctors should be saying to young type ones, or you know, anybody at all really, who might be thinking about having a baby one day, that can give them some comfort and guidance, and maybe start getting themselves together in their mind to think that this is doable? Because it is

it is absolutely. And I think you're considering it from the right starting point. You know, any young woman who has started monthly menstruation, right or monthly period, should be told what could potentially come from now having a monthly cycle, right? I Pregnancy is a potential. And if women don't understand from an early age on what that may mean, even though in the teen years, I would, I would expect that most women are not considering pregnancy, right? That's just not what their plan is at this time. In fact, it's much more about prevention. Yeah, at that point,

the way I hear my daughter talk about it, she just thinks about that if she believes it's going to hurt and she wants to avoid it. That's

great. But hopefully somebody teaches her that that's not really the truth. But But yeah, the teen years are when to start that discussion of even if it is in a preventative way it's know that if a pregnancy happens, whether it's unwanted or you know, unplanned, I should say not necessarily unwanted, unplanned or it's later on planned and something you definitely desire, your glucose management is going to shift, it's going to need to change your targets are going to change. Understanding how to navigate insulin management and everything else within that time period becomes tighter and kind of just much more controlled overall. And so from a non scary standpoint, starting out by saying you can absolutely have children, if that's your desire, someday, even though you don't want it now, Someday you may want kids and if that's the case, you can have them. I

used to hate ordering my daughter's diabetes supplies, and never had a good experience. And it was frustrating. But it hasn't been that way for a while actually for about three years now. Because that's how long we've been using us med us med.com/juice box or call 888721151 for us med is the number one distributor for FreeStyle Libre systems nationwide. They are the number one specialty distributor for Omni pod dash. The number one fastest growing tandem distributor nationwide, the number one rated distributor index com customer satisfaction surveys. They have served over 1 million people with diabetes since 1996. They always provide 90 days worth of supplies and fast and free shipping. US med carries everything from insulin pumps and diabetes testing supplies to the latest CGM like the libre three and Dexcom G seven. They accept Medicare nationwide and over 800 private insurers find out why us med has an A plus rating with the Better Business Bureau at us med.com/juice box or just call them at 888-721-1514 get started right now and you'll be getting your supplies the same way we do. This episode of The Juicebox Podcast is sponsored by cozy Earth and right now I'm looking at cozy earth.com to see what's going on. I got oh look at this bamboo pajama set for ladies. The jogger pants for ladies looks like plush lounge socks. That's one of Oprah's Favorite Things. There's the bath collection. We love the waffle towels but there's also premium plush bath towels. Everything that you see here can be had for 40% off with the offer code juice box at checkout. Even the sheets now we use the bamboo sheets, you may choose different linens I don't know what you're going to love when you get to cozy earth.com But we sleep on bamboo sheets from cozy Earth. They are incredibly comfortable. And I bought them myself with my own money using my own offer code. juice box at checkout. 40% off is what I saved. You can as well at cozy earth.com 100%

Nobody in this day and age He should be being told, Well, you have diabetes, and you should consider never having children. Or you should really think that you don't need children down the road, right? They shouldn't be told

that it's going to be so difficult that it that it makes them think, Oh, I can't do it or, you know, you put it off. Also, you know, this also impacts people's personal relationships. If you're, you know, getting serious with somebody, and that person one day mentioned, oh, I can't wait to have kids one day. And you know, you're secretly harboring inside of you, I can't have children, my a one C seven, I can't, the doctor said it needed to be six. And I don't I can't figure out how to do that. It just has a lot more impact on people than I think it meets the eye perhaps. Right. And from my perspective, I spend a lot of time like you have talking to people about their diabetes and how to help themselves. From my perspective, it all comes back to the basics, right? Because right now, what I hear from women who are just experiencing a cycle, just a monthly cycle, is I don't know what happens, you know, there's a week where everything goes nuts, I just accepted my blood sugar is going to be higher. And instead of teaching them how to handle that cycle, we tend to teach them that that's, that's the cost of doing business, you know, right. And that's just not right. But now, yes, that impact, which is significant, any woman with a period who has type one knows how significant it is the need for insulin, how it changes and fluctuates. But that's going to happen times a lot more during pregnancy. So if you know how to handle your cycle, prior, I think it gives you a better chance to handle your pregnancy, then it does, yeah,

absolutely. It also sets you up with the idea, you know, anybody who's going to a gynecologist for just, you know, the yearly checkups, and all those kinds of things. That's honestly, outside of endocrine, bringing up this topic, especially from a female perspective, your gynecologist should also be bringing this up seeing on your medical history that you have diabetes, it should be a piece of the discussion, you know, what are you doing for prevention? Or are you planning a pregnancy, if you are, this is the protocol, I'll stay with you for this portion, you may need to be handed off to a high risk doctor for this portion of it, or you're going to go right to a high risk doctor for this. And the idea of then how to navigate and what to expect should be part of that discussion. So that again, there's a fear factor that's removed, you can see that it's doable. But you can also see that having kind of your ducks in a line, if you will, is really, really important. Pre pregnancy, that preconception time is so valuable. Once you are pregnant. You know, I usually when I get to start with somebody, I hope that I get the preconception time so that we have, you know, one, two, even three months to work on, as you said, getting things all in order, getting Bolus timing, getting meals that are working really well understanding exercise, insulin dosing, and timing and all of that. Once you know that, yes, it will change in pregnancy. Yes, it'll change a lot in the early weeks of pregnancy, because hormones shift considerably, to keep that pregnancy viable. And if you know that ahead of time, you're not gonna be so surprised. Yeah, if you're planning a pregnancy, you also won't be surprised with what's happening. Because you know, to watch for it, right?

I think the diabetes tools are universal. Yes. And it's funny that Jenny and I were talking before we started recording, and it's about something different, but this came up managing insulin is, is a lot about Pre-Bolus, eating meals, having your settings right, knowing how to react if something goes wrong, not staring at a high blood sugar. Like these are just kind of basics that if you go through the Pro Tip series, you'll understand. And then after that, you apply them in different situations. And I really do think that one of the variables that exists for diabetes is pregnancy. Yes, not this, like separate thing off to the side. Like oh, you know, if you have type one diabetes, this is your life. But if you get pregnant, it's a new thing. It's the same thing with Swift are moving harder impacting variables. Like I think that's it, right. But if you have the tools to react, and the knowledge to say, oh my gosh, all of a sudden, my food seems to need more insulin or my I don't know, my, my, you know, my standing blood sugar. My my basil doesn't seem to be working anymore to hold me somewhere away from, you know, away from food, right? I need to react and do something correct. And it's going to, like Jenny said, with these hormonal impacts, it comes hard and sometimes it by the way, it takes it away as quickly as it gives it to you. Right? So this isn't all about more insulin. This can be at times where you have to back your insulin down. You can't be waiting three days or until the doctor calls back or whatnot. Like when you start having these impacts you need to react and Right, I mean, Jenny, to put an emphasis on the point, what's the increase, you can see in the amount of insulin that some women need during certain points of pregnancy, I'm trying to I'm trying to paint a picture of what the how much it can go up.

Yeah, it and an overall again, we kind of think about pregnancy, insulin management or insulin dose changes. It's kind of like a long duration variable. So that's a great kind of way to describe it. It's like a marathon, right? It's not this little sprint that you get through and you take care of it. And the next day is all better, right? Things shift and change, we look at variables, and then we say, okay, over the course of a whole pregnancy, women's need for insulin can double or even triple, depending on what their preconception dose looks like, and what variables that are healthy lifestyle variables that they keep in the place. If you remain active. If you know your insulin dose timing, if you pay attention to the changes that you're seeing, and we usually say in pregnancy, a trend over about two no more than three days suggests a shift that's needed in a setting. It's not a variable. It's a setting that needs to be changed. So we change much more swiftly than many, you know, many other times of life, maybe leave it a couple more days outside of pregnancy. But yeah, doubling tripling insulin needs, especially, you know, by third trimester, by about 30 plus weeks, up until about 36 weeks or so that's the heaviest amount of insulin that you're going to see changes in insulin dosing on about a weekly basis. You know, 10% more Basal adjustments to Bolus timing. I mean, by about 30 weeks, your Pre-Bolus time could be upwards of about 45 minutes, right. So we're thinking, you know, we're thinking, well, ahead of the meal, you're thinking, I have to Bolus and we're looking, of course, nowadays, we thankfully have technology that shows where things are and how they're drifting up, down stable. So we can use that to our advantage. But it's really, really intense third trimester

of pregnancy is a job in itself. But pregnancy with type one, it's a real job, like you have extra things to do now. And in a world where doctors don't often give autonomy to the patients, right? They will tell them things like well, next time you come in, we'll adjust that or call me first. That scares people, then people can't make adjustments. So in a world where they're not even able to turn a dial for 10%, more or 10% less, because they feel like they don't have the ability to seriously the wording that comes from people all the time is I'm afraid I'm going to get yelled at. I can't move my insulin because my doctor will be mad at me. Can you imagine? My doctor told me if I change my settings, they'll drop me. Right? Right. So you're taking away people's ability to like, read and react and see what's going on. A lot of them don't have that to begin with. Now you're putting them in a position that Jenny just described where their insulin needs are gonna go up maybe weekly. And then once it really hits in that third trimester, I've heard women tell me meals that took three units took nine units. Yeah, right. If you can't make the leap to go up 10% In your Basal without asking somebody? Where are you going to get the nerve to Bolus nine units for something you think, you know, historically? Three, three, you can't make that decision on your own. Right. So I think that it's more about I don't think we can't help people who have become pregnant, right? Like I know you can. I've heard plenty of stories of people like, Hey, I got pregnant, I didn't want I didn't mean to like it when she was eight. And I boom, I snap myself together. And I got it down. I did what I needed to do. But often those stories are followed by then the baby came, Mia once he went back up again. Right? Yes, she got through the pregnancy and good for the baby. But the baby's counting on the mom for a whole lifetime. So Correct. Why don't we do some things that help her throughout her life, not just for nine months. That's why I think that doctors need to hear this, so that they can be pre planning and laying this groundwork. And by the way, here's the big secret. We're not saying anything here. You shouldn't be saying to a man either, because all we're telling you is they need to understand their diabetes and how to react to it and how to make good decisions and how to see things and, and you know, and go, Oh, I know what that means. I need more. I need less, right. That's what they need. They need autonomy. And

on a broad scale, what they also need, kind of talking about here is really a care team. Again, when I work when I get the chance to work with somebody prior to conception. A big emphasis is who is your care team? Who do you know is in your corner? Is your endo on board? Or are they going to shuffle you off to mainly be managed by a maternal fetal man? venison, a high risk doctor is your OB GYN to manage along with a high risk is your team six people deep? You know, and everybody, it's like too many cooks in the kitchen and you don't know who to believe about what? Right. So I think planning again, goes a long way when we're talking about pregnancy, which is almost the course of a year, right? And a care team that doesn't slap hands, that you say, I've made these adjustments, you let them know, because that's also very important for you to tell them what you've done. So that they could acknowledge and say, Okay, I would have suggested that it looks like they did that already. Great. We'll go from here, right? So you have to be you have to be on a team. And you all have to have even jobs on the team. And you have to have that discussion to know who is going to do what part of this? Do you want my records every week? Do you want my CGM information? Do you have an online database that I can download and send information so you can send me weekly, you know, feedback that we can connect in between our visits that we're going to have more and more frequently, right? I mean, that's a piece that unfortunately, some women who have not planned the pregnancy did want it, but they weren't quite sure that it was going to happen so quickly. And now all of a sudden, oh, here we are. I don't know who I'm supposed to go and see, it makes that early, tiny, even a little bit more, I guess, worrisome or concerning, because they're not quite sure who they're supposed to be checking in with. And

you may see an increase in women with diabetes getting pregnant soon. This is a little extrapolation, but and very anecdotal, but I'm seeing on some GLP groups online, women who are just like, I don't even practice birth control. It's not necessarily I can't get pregnant, I've been trying for 20 years, they're magically getting pregnant on GLP medications. So sure, you know if maybe this is impacting PCOS, to some degree, which is allowing pregnancies and by the way, PCOS and type one can go hand in hand a little bit. So this could be the time, you know, like, you could see an inflation of people who are like, Hey, I'm pregnant. I never thought this was going to happen. I've never been planning for this. Right? You know, I'm not ready for this at all. I just think that it is so incumbent upon doctors to do more than just say, Oh, you had the baby. Now, your needs are going to change? Well, thanks. Yeah.

Like, what does that be? Yeah.

What am I supposed to do? I've lived my whole life, not knowing what I'm doing. And now I've have these crazy variables, these impacts are swaying back and forth. And the extent of your help is, look out. It's coming. You know, and if you don't know, it's so disheartening to look into a physician's eyes and say, Well, what do I do? And they got, I don't know. Yeah, just great, right.

And even if you did have some fairly good care during pregnancy are really phenomenal team during pregnancy. As you said, that postpartum time period is a very significant shift. And it after nine months of navigating and managing and understanding insulin resistance, and I have this Bolus timing, that's like 50 minutes long, and I, you know, I've, I've stayed away from these kinds of things, because I just can't navigate and I'm trying to control in these target ranges, and now postpartum, well, goodness, all those pregnancy hormones, they like, go and get washed out, they're gone, right? But now what do you have, most women are trying hard to nurse at least to some degree, that can have a major shift in terms of sensitivity to insulin. And if you're not ready for that, if you haven't been taught ahead of time, what to expect, and how to set up, let's say you're using an insulin pump or using injections with a certain amount of insulin. If you haven't been taught to set up a postpartum strategy, or a management plan with your insulin doses, you are going to be on a roller coaster, and it's going to be a roller coaster of a lot of scary lows, quite honestly. So again, those are all things to think about. And as a physician, or you know, a clinician who's taking care of women in the ages where they may be able to get pregnant or may want to get pregnant. These are discussion points that are really, really, really important. They should almost be check offs on that list of everything else you're checking off. They should be checkups have talked about and discussed pre pregnancy planning targets, et cetera, or, you know, prevention techniques, so that they don't have something that's unplanned happen. Yeah, it's just Well,

I guess a couple thoughts here. The first thing I'm thinking is, I get worried that doctors will hear Yeah, you're gonna give them information. They're not going to know what to do with it, and they're gonna make a decision that's going to hurt themselves. But I would tell them that it's like learning to drive when you put a 16 or 17 year old into a car, right? And you you say, Alright, here's the basics. You're not teaching them how to drive completely they haven't been through all the experiences and they're not going to react as well as a 25 year old or a 30 year old would in an emergency situation, right. But they're never going to get to that if you don't teach them that the brakes, you know, on the left three guests on the right. And this is how you turn and you don't over, you know, overcompensate when something happens, keep your eyes up, get to teach them all the basics, then send them out there in the world, and let them have experiences. And then one day something unexpected is gonna happen. And you'll see how those experiences aid them in that moment. Because I just I hear it too much like, well, they don't know how to do it. And I tell them to Bolus more they're going to make themselves well, if you don't, the other things can happen. Right. And the other thing is, is worse, in my opinion, right? So when we're talking about lifelong problems, life shortening issues, not I got a little low, I figured it out next time. I didn't use this much. You know, you have to give people the opportunity to to fend for themselves. Yes. You can't just act scared and tell them, they'll we can't tell them because they won't know what to do with it. That's not fair. No. Like you need a shot at taking care of yourself. And the other thing I wanted to bring up is, you were talking about the nursing and how it could lead to lows. Right? Hmm, I think that what you really need to understand as a physician is that if you don't prep somebody for that, and it happens, here's gonna be the decision tree. I'm holding a newborn baby, trying to nurse it, I got low, I'm never gonna let that happen again, right? You just put that person say once the up one or two points, because they're going to be fearful with their insulin from now on. In another situation where they didn't need to be if they knew how to use it correctly. Either that

or they're going to stop nursing. Oh, I didn't even think because yeah, if the nursing is what's causing the sensitivity to insulin, and every time they nurse, they put two and two together, and then why gosh, if I just stopped nursing, I clearly wouldn't be low all the time, or I wouldn't have all these issues. I guess I'll just switch to formula when quite honestly, it's better to breastfeed, it's better to provide breast milk, whether it's pumped or it's nursing or whatever it is, it's just better for many reasons. And if those if that's what you put together, then unfortunately, somebody has missed their job and teaching you how to avoid that as a problem not only being too high, and also not feeling great, it great. But on the opposite of that being able to continue doing what you wanted to do to begin with, for your infant, you're

just not putting people in the best possible scenario, like that point right there about them, maybe stopping breastfeeding, right. And the health implications of it aside, forget, like, put those aside for a second, you have no idea. Unless you've been a woman or been married to one for 25 years, like I have been their entire life. They'll never let go of it. I wanted to breastfeed that baby and I didn't. And it's gonna feel like a like, it's gonna be a mom guilt thing that will never leave them. And that is another opportunity to alleviate another problem from people. And with what are we talking about some pre planning some light knowledge of how insulin works, and some you know more? I don't know, laser focused knowledge about what's going to happen during your pregnancy and how to react to it. It's not undoable People do it all the time. Jenny shepherds people through it, I get notes all the time. What do you hear me jump out of the pockets all the time, one day, someone's gonna name a baby after me. It has not happened yet. But I did get a dog in something else. Not the point. The point is, is

that I do get a lot of great name for a dog. You

know, it's not, by the way, my name is terrible. Don't name your baby Scott. It's just very short and Curt, and it's not really very melodic. And I don't think you should do it. But my point is, is that I get a lot of notes from people who say that I just had a healthy baby because of this podcast. And it's just a podcast, you're a doctor, like you could you could do this for people all day long. Right? You know, right?

I mean, on the same note of what nursing can do, if someone is also not navigating, and they have a roller coaster, or they're just ending up writing higher blood sugars, from a safety standpoint, that's also going to have an impact on their breast milk production. Okay, right. So you know, hydration is really important. Hydration is a very under discussed, unless you're talking to the nurses in the hospital, postpartum, who are really awesome at bringing you water and making sure you're drinking, drinking when you go home. There's nobody who's going to bring you your water. There's nobody who's going to emphasize how important that is. There's nobody really who's going to re emphasize for you. How important not running consistently high blood sugars is for actually providing enough you know, quality breast milk, honestly. So

you're already asking a lot of your body before you're trying to make breast milk. And you see it with people living with diabetes all the time, just being the height graded slows down their insulin use the efficacy of the insulin that they have in them. Now they're pushing more insulin to get the same response. They don't know, all of a sudden they get hydrated or they, you know, they they find a better way and boom, they're dropped low they're eating, you turn the whole life into this, right, this chase that that's just you're always chasing diabetes instead of I don't know, like impacting it and bending it to their will to some degree, you know, right. Especially with CGM, you know, right. All of this is just so eminently possible. And if you're cheese, if you're kind of you're helping a person who's pregnant, you don't have them on a CGM. I mean, you've made a mistake, you know, so correct. Absolutely. We'll talk about the other side of it for a second, Jenny, because we're not horrible people who just think that doctors don't do a good job.

First of all, not at all, there are many amazing teams out there immensely.

Great, you know, just I've seen it over and over again. But it's not what everybody gets, right. And, you know, if you're in a position to help somebody, and you don't understand these things, I mean, this is gonna sound like I'm saying, just listen to my podcasts, but just trust me enough people listen to it already, that if you as a doctor, don't listen, I'll be okay. So I don't I'm not just asking you to listen. But you could take, I don't know, a couple of hours and listen through some of the Pro Tip series, or you could listen to we have like 16 episodes about pregnancy, from like pro tip episodes about pregnancy down to I think I did an interview with one woman after each of her trimesters, and then after she gave birth, right, like, yep, somebody said, it felt like my insulin needs changed as soon as I delivered the placenta. And I thought, Oh, that's so interesting. Who would think about that, you know, like, she's like that placenta came out, and I was turning down my Basal. And heading back home, I've heard other people say, it took days for my insulin needs to change, like, anywhere in between the least, you know, to look for it.

I mean, this whole honestly, this whole, like discussion here is really the reason that, you know, we're emphasizing to the clinicians benefit, to provide education provide information to provide a start, so that somebody doesn't feel so lost through what is a fairly long amount of time, you know, in terms of a developing baby, right? I mean, it's the reason that I put together the book that I did with, with my co author was quite honestly, there, there wasn't anything. I mean, I went through my two pregnancies, my first one, especially looking up researching, doing a lot of ahead of time work to know what I was getting into, and to know how I could expect, but where was that information coming from? Like, research articles? It wasn't like a pamphlet online that was like, This is what you should expect. Oh,

you're pregnant. Right? Right. Well, that's where I mean, that's how the podcast became what it is, right? I'm just one day thinking like, how do I help my daughter, and then you just pull information together, you put it into practice, it works, you keep what works, you get rid of what doesn't? And then from there, it's about how to communicate it, which is what this is about, like, I don't know something about diabetes, that you can't go read somewhere. I'm not a magic person who understands something that does the rest of you don't get to know. Right, I do understand this stuff. I do know how to implement it. But the thing I think I'm good at is describing it to other people. Right. And I think that is a thing that doctors could become good at, right? But you have to first become proficient at it as if you're trying to save your daughter, you know, like, we're as if you're Jenny, and you're pregnant, you're like, I don't know what to do, I need to figure this out. Right? Like, you have to put yourself in their position while you're collecting the data and feeling the importance of it. Right. And then you learn how to talk to people about it. And the only way you're going to learn is the same way those people are gonna learn how to use insulin, you got to start and you might maybe you'll screw it up at first, maybe you will, right? Like maybe the first time you try it, you may go, oh, I shouldn't have said it that way. And it might take you a couple of people before you really get good at it. But it doesn't take that long. And don't be scared, you know, like, just get out there and try to help somebody. Right? You'd be surprised what happens, you

know, and I think because the grand majority of general medicine practitioners are going to see women who potentially don't have pre existing diabetes, you know, before pregnancy. I think there's an unfortunate group of women who have gestational diabetes, right? With testing in that like late second trimester, a glucose tolerance test reveals that their body is not navigating glucose. It's not navigating food the way that it should, and that there is something that needs to be done in order to have a healthy baby. They're on out right. But what I've really seen is the aftermath delivery for women who have had gestational during pregnancy, while there is postpartum, further testing To evaluate that, yes, your glucose levels have gone back to normal your body is responding like it should. I think it's an underserved under educated in terms of lifestyle changes they made in pregnancy, and how important those changes are to keep, because there's a high risk of type two diabetes, if you have had gestational diabetes, right. And so it's an under followed.

Oh, yeah, it's treated like we got you. We got the baby. Right. It's over now. Right? Yeah, it's Yeah. Am I gonna get diabetes one day? Maybe? Good luck. Yeah. Yeah. Right. Like, right. Never think about it again. Oh, my gosh, the people with type two Oh, my God, like, you know, if you think people pregnant with type one aren't getting good, good information, people with type two are being just dropped left and right. Like we have somehow, as a society decided that there are some things that happened to you. And when they happen, you get pushed off onto another line, you know, like, oh, oh, they lose. Yeah.

And, and or it's not until something really significant is happening. You know, let's say pre pregnancy, a tight woman with type two is managing quite well, right? And is again, undereducated in what to expect to happen. And so they don't know how to keep up enough. And they end up coming in and now blood sugars are all over the place and their medications they were using, they're not working anymore, or medications maybe weren't discussed well enough to say here, you're likely going to need to change to using insulin. Are you ready for that? You know, this is what it would look like. And we're going to have you follow up with a high risk doctor, to ensure that you're being managed really, really well, again, it's a missing part of education. For that group,

it's become popular to say that, you know, it's not health care, you know, you're not really getting health care, right? It's not nothing's preventative. We just try to fix you after you're broken. Right, that that's how the system works. And it is how the system works. I'm not saying that. No, no, you're right. Maybe it's not that simple. Maybe it's more that we're not good at preventative. Not that we're not trying. But maybe people just don't know how to do it, or how to communicate it. Because you know what I mean? Like, I know, there's the business and the money side of it. And the money side is directed at what it's directed at. I understand all that I'm not being I'm not being Pollyanna about it. But I do think that part of the reason I wanted to make this podcast series is because I don't think that this doesn't happen just out of apathy. I think it doesn't happen because people don't think to do it like that. Everyone is like they see themselves as either working or broken. Do you don't I mean, and when you're working, you don't have to do anything about it. Like nobody does sit ups when they're thin. I mean, listen, after New Year's go outside, and everyone jogging, you're going to look at and think, oh, they should have started jogging like three years ago. Right? Like, right. But it's not till it hits you where you're like, I have to do something. It's not a very human thing to work on things that aren't obvious. But in this specific situation, if you know how to do it, you're saving a ton of problems. Right on the back end, just like you would with anything else. But here. It just seems more imminently important to me. Yeah,

no, absolutely. I think. I mean, you set it in a very nice way you said it, that there is that there is no preventative medicine. And you know, the reason like for that, right? I mean, no money in it. Yeah, there is no, I mean, I did not I there's no way to delicately say there's no money in preventative medicine. If you've got somebody coming in who is really healthy, because you've told them this, this and this in terms of lifestyle. And yes, these vitamins, no, you don't need this, eat carrots, you whatever it is, that's a one visit. And you know what, maybe they're gonna go off on healthy life for the next five years. Because we're come back, you're taught them to be healthy. That's awesome. That's an heart hook. Your system should work. But it doesn't make money. Yeah,

it's a shame. I mean, honestly, I understand how it happens and what the cycle is that brings us to that. And then once you get into that cycle, it holds us in that cycle, like that, I'll get ya get all that. So maybe this is the part of the conversation for the patients where I'm telling you, if you just go listen to the Pro Tip series, then when you get pregnant, you should probably be able to do this no trouble. Right? You know, and I do honestly believe that. I don't think that the podcast is magical. I don't think that the information is magical. I just think that it's being communicated in a way that is digestible for you understandable and will put you in a position to make good decisions, right. And I think that really is the key to this because as much as I'm hoping that doctors figure it out and that people listen to this and go I'm going to do that. I'm more certain that you're probably going to run into a doctor that helps you yes or no, it's going to be a coin flip. And you're not going to know the difference when it happens. That way really is the biggest trouble is that you're not going to know if you've got a good one OR, or NOT a good one until it's a little too late. By the way, marriage is like that too.

Well, it all starts with three.

Yeah, I could explain to you how not to do that too. But it just would take too much time. But listen, if you want a good life, you do the work first. Right? That's it, you do the work first. And then the rest is easy. And whether it's pregnancy or marriage or being a doctor, I mean, we're not really saying anything that difficult here.

It's not rocket science. And we've said, I don't know how many times we've said that is not rocket science,

effort upfront, everything else gets easier. That's all. So I know, not everybody is going to make a baby on purpose. Or, you know, and that doesn't make your pregnancy invalid, obviously, or that the love, you're going to have invalid. But if you're running around with an ad, one C, and you're a woman who could at any point be pregnant, I'm going to tell you that this podcast is full of stories from women who are in that situation. And when you hear them tell that story, what you're going to hear them say at some point is, I wish I would have learned how to do this sooner? Yes, I just don't want you all to be in the position where you're always saying, I wish I would have. Instead you could say you know what I did? You know, I learned about this thing that really impacts my life, and it made my whole life better. Right? That's what I'm hoping

for. And if you learn it the way that it's presented, and again, digestible, right bits and pieces that you can take, you can apply based on what you see happening long term in that post partum time period, you're going to stick with what you know, because of the fact that you have been applying it already. So it's not going to get all thrown out the window because Oh, it's all over now. And I can just go back to completely forgetting everything that I've learned, you're more likely to continue it, especially if you've planned to have another child someday, right? You don't want to start out from ground zero all over again. You might as well continue with what you know, and keep things in a range, that long term is going to keep you healthy, whether you have kids or not.

Yeah, that happens for some people. And then for other people, they fall into that trap where everything gets slotted above, it's the baby first, and then things that affect the baby. And then the next thing you know, you're not even thinking about yourself 20 steps down on your list, right? And when you have diabetes, that can't happen. No. So you if that's mom guilt, I don't know what does that right? What makes you although I was a stay at home dad for 20 years, I was the one like I'd make food and then like eat what was left

your family first and then you took the scraps, right?

And you think nothing of it while you're doing as a matter of fact, you feel kind of, I don't know what the word is, but you feel good about it, almost like I put people before me, it can't be like that with your diabetes, I tell my daughter all the time, all of the time. You are first. I don't care in what scenario in life. If you're out driving with your friends, if you're off to college, if you've met a boy, if you're just living your life sitting around the house, it's diabetes than anything else you want to put after that we cannot ignore the diabetes first, because it will ruin everything else if we ignore, right? Absolutely. It's diabetes first. And when you do that, it makes diabetes. This is gonna sound strange. But if you make it first, and you understand what to do, and you have the tools, which are very accessible here in the podcast, then everything else like I just said gets easy, like and then all of a sudden you don't think about I think people must believe that I'm constantly think or Jenny's constantly thinking about her diabetes. I mean, honestly, Jenny, you really think about it that often?

No, in fact, I don't. I mean, I know a lot of people who sit with like, you know, their apps open and whatever their tools and they look at it, unless my thing makes noises yet me

for some reason. It's three o'clock in the afternoon. I haven't looked at his blood sugar. Right,

unless it's making noises at me or, you know, my pod is like, decided to give the death toll. The you know, the, for some strange reason that I addressed something but yeah, yeah, I mean, I try really hard to because I know what I am doing. And most of the time, you know, 90% of the time I'm doing similar things over and over. I can let it take a backseat, but not in a way that I'm forgetting about it. It's just because things work because I know how to make them work.

It's the driving analogy again. Yes, you can get in a car and drive 100 miles. I just drove 700 miles one way and turn back around and drove 700 miles back again. I didn't hit anything. I didn't come close to dying. Like right like I just been driving a long time I have these tools that I don't even know I'm using that I'm using it doesn't weigh me down. I didn't get home ago. Oh my gosh, my life is ruined. I had to think about driving. Man I think diabetes the same way I just said, I haven't seen Arden's blood sugar today. So I opened up my phone, or blood sugar's 107. It hasn't been below 70 or over 110 in the last 12 hours, yay. But all that is, is Settings and Tools and insulin timing that I've already taught myself that happen almost automatically when we need them to happen, right. That's my point about all this. That's my point about the whole damn Podcast. I'm sick of telling people dammit, Jenny, I made myself upset. Go make a baby weight or throws up on you. It's gonna be a big ball of fun. Congratulations.

It is fun. Sure it is.

It's absolutely fantastic. Everyone should have a whole bunch of babies there. A lot of the big party. Good luck paying for college. Thank you for doing this with me. I

appreciate it. No, that's great. Thanks.

I'd like to thank cozy Earth for sponsoring this episode of The Juicebox Podcast and remind you that using my offer code juicebox at checkout will save you 40% off of your entire order at cozy earth.com. That's the sheets the towels, the clothing, anything available on the website. Arden has been getting her diabetes supplies from us med for three years, you can as well us med.com/juice box or call 888-721-1514 My thanks to us med for sponsoring this episode. And for being longtime sponsors of the Juicebox Podcast. There are links in the show notes and links at juicebox podcast.com. To us Med and all of the sponsors. The episode you just heard was professionally edited by wrong way recording. Wrong way. recording.com. Jenny Smith holds a bachelor's degree in Human Nutrition and biology from the University of Wisconsin. She is a registered and licensed dietitian, a certified diabetes educator and a certified trainer and most makes and models of insulin pumps and continuous glucose monitoring systems. She's also had type one diabetes for over 35 years, and she works at integrated diabetes.com. If you're interested in hiring Jenny, you can learn more about her at that link. BetterHelp is the world's largest therapy service and is 100% online. With better help, you can tap into a network of over 25,000 licensed and experienced therapist who can help you with a wide range of issues. Better help.com forward slash juicebox. To get started, you just answer a few questions about your needs and preferences in therapy. That way BetterHelp can match you with the right therapist from their network. And when you use my link, you'll save 10% On your first month of therapy. You can message your therapist at any time and schedule live sessions when it's convenient for you. Talk to them however you feel comfortable text chat phone or video call. If your therapist isn't the right fit. For any reason at all, you can switch to a new therapist at no additional charge. And the best part for me is that with better help you get the same professionalism and quality you expect from in office therapy. But with a therapist who is custom picked for you, and you're gonna get more scheduling flexibility, and a more affordable price betterhelp.com forward slash juicebox that's better help h e l p.com. Forward slash juicebox. Save 10% On your first month of therapy. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Hey, if you kept listening through all that, I really appreciate it. I just wanted you to know that. It's Saturday night at like nine o'clock and I'll make it a podcast and you never know who's gonna listen to it. But the fact that you listened this long, it really means a lot to me. Thank you so much.

Hello friends, welcome to episode 1125. This is part one of the Grand Rounds episode for technology part two is it episode 1126. Today Jenny Smith and I are continuing on with the Grand Rounds series, we're going to discuss technology in this two part episode and the first half general overview of CGM and pumps and in the second half different pumps technology and understanding the differences between them. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan or becoming bold with insulin. When you place your first order for ag one with my link, you'll get five free travel packs and a free year's supply of vitamin D. Drink ag one.com/juice box. Don't forget to save 40% off of your entire order at cozy earth.com. All you have to do is use the offer code juice box at checkout that's juice box at checkout to save 40% at cosy earth.com. If you're looking for the diabetes Pro Tip series, it runs between Episode 1001 1025. For subscribers to the podcast, those episodes are ad free. For everyone else. There's just a couple of ads episodes 1002 1025 diabetes Pro Tip series from the Juicebox Podcast. This episode of The Juicebox Podcast is sponsored by touched by type one touched by type one.org. And find them on Facebook and Instagram touched by type one is an organization dedicated to helping people living with type one diabetes. And they have so many different programs that are doing just that check them out at touched by type one.org. This episode of The Juicebox Podcast is sponsored by the insulin pump that my daughter wears Omni pod, learn more and get started today with the Omni pod dash or the Omni pod five at my link Omni pod.com/juice box. Alright, Jenny, we are back doing the Grand Rounds, which I guess is gonna get called by default, because I can't think of anything else.

I think it's a great name.

I love the name until one person online. It took one person to say to me, I don't think every hospital calls it that. And I was like, Oh, I pick the wrong. And but I think it makes the point, right?

It makes the point it does. Yes.

So today we're going to talk about continuous glucose monitors and blood glucose monitors in the same short conversation here. I guess we'll just start with BGMs blood glucose monitors and go over very quickly, that they're not all the same. And I'm beginning to wonder if doctors offices know that. That makes sense. These are not incredibly expensive items. Most people's insurance, if not all people's insurance are going to be covering a blood glucose meter. Yes, in a world where they're right. That's

some kind, it's fair. It's fair, I wouldn't say that they even good insurance companies have sort of a preferred glucose meter. Right. And you may pay more for one that you expect in reviewing is better in terms of accuracy. Insurance will typically cover up a meter. Yes,

I just think that it's worth mentioning that this meter that I'm giving you may not be as accurate as other meters, perhaps you should look into it or I don't understand why doctors offices don't begin with here are the top three, right? Because I think there's about three of them that kind of fall in similar space as far as accuracy goes, right? So here's the top three. If your insurance company doesn't cover the test strips for this, then you know, here's a declining list of accuracy. I just don't think that is a conversation that's ever had, I think you Gill, whatever the office leans towards maybe or I don't know how it even works to be honest, true.

Years ago, when I was working in office, the standard that would be is that you would get from different companies, you would get sent meters and the meters are not the expensive piece. The meters are actually more of like the freebie that kind of like we would give for newly diagnosed we would give them either Yeah, the prescription and the pay part comes with the test strips, right? So it then depends on what test strips are kind of covered at what cost they're being covered. But most of the offices like I said when I worked in the past would get a good supply from all of the brand name ones not the typical ones, that you're gonna find it like Walmart or any of the pharmacy places that might have the generic brands, but we would get all the way Any ones and we would essentially help to kind of figure out which one would work best for this person size, what other things that they might be working with, et cetera. For

my money, its accuracy and being able to read it. That's what I'm concerned with, and blood drops at this point. They're all pretty smaller, like requirements.

They are for the most part. I mean, you know, when I was first diagnosed, it had to be this hanging blood. Like this gigantic off your finger? Yeah, exactly. Yes, to get enough. But these days, pretty much they're all about the same tiny, you know, head of a pin sort of size that Yeah. And the other nice thing is that many of the good ones actually allow second drop applications so that if it didn't get enough to begin with, you have a certain number of seconds in order to reapply some additional blood to get enough of the sample.

Yeah, yeah. Are mucking it up. So it's not as accurate. Correct. So that to me, that's it just like, explain to them, here's the accuracy. I don't know what your insurance company is going to cover. I mean, even be clear and say, Look, from a purely business standpoint, the game is selling the test strips, like that's where they make money, right? So the meter is your, you know, caretaker meter, and then hopefully, you'll buy our test strips, because you like the meter afterwards. I would imagine there are people listening right now that are thinking, Wait, some of these meters are more accurate than other ones. I honestly 100% believe that that's not a thing everybody understands. And why would you think that? You know, why would you consider one to be less than the other or better. So I think have that conversation. And then on top of that, even if you're giving someone a CGM, which we're going to talk more about, you still give them a blood glucose meter. It's important. And you know, you test your blood sugar, if your blood sugar's really 110. And the the meter says, it's 150. That's a lot more insulin you're about to take, you know, right. And that's just not okay. So

all right, it's a safe place that you think that you're starting based on what you're planning to do after this test. And you may be aiming for that, when in fact, you might actually be lower. Or maybe you're actually higher than that. So yeah,

it's just important and I want to say to just because you're gonna give somebody a CGM doesn't mean, they don't need an accurate blood glucose meter. So right, you take five seconds to make sure they understand how to use it. Here, I'll ask you a question. You test your finger sometimes, right? Yes,

when's the last time more than sometimes,

sometimes, when's the last time you cleaned your hands with alcohol before you tested? In 2015, I needed support to start making this podcast and Omni pod was there. They bought my first ad, in a year when the entire podcast got as many downloads as it probably got today. Um, the pod was there to support the show. And they have been every year for nine seasons. I want to thank them very much. And I want to ask you to check them out at Omni pod.com/juice box. My daughter has been wearing an omni pod every day since she was four years old. And she turns 20 This summer, it's been a friend to us along the way. And I think you would enjoy it as well. Omni pod.com/juice box links in the show notes links at juicebox podcast.com to Omni pod and all the sponsors. I don't use

alcohol to wipe my finger. There may

not be alcohol in this house, actually. So I

do use it to clean sites. I do use it to clean the back you know those little ports. And again, we'll talk about CGM, but I do use it to clean that off. But in terms of it's really a degreaser, right? an alcohol swab is kind of a degreaser, you're better off honestly just washing your hands with warm, soapy water, sing the birthday song to make sure that you you know, get as much bacteria off as you're supposed to get off and then wipe your hands nice and dry. And then do the fingers.

So here's the question. That health aside, I don't mean like you don't want to open up a hole into your hand while there's bacteria and germs and everything in your hand that I know No, I don't want to do. But for the accuracy of the test. Dirty hands don't matter, right? Well, it depends what they're dirty with. Right? So glucose in your hand sugar on your hands that would interfere with the test. True, but if I was muddy, and I just rubbed my hands real quick and found a clean spot, would I get an accurate test? Jenny's like I don't want to say

that? It's a great question. It really is. I mean, I've I've never actually thought about it. Although I will have to say that so in I in college, I used to do Habitat for Humanity and we would do trips out of state for spring break. And there were many times on the worksite it's honestly that it wasn't easy to get to just like running water with soap. So I I would actually just dip it in like my water bottle. Wipe it off. I'm assuming it was clearly I never had any infections. I'm not by any means recommending this as a therapy or an option.

I just want to have the conversation. Jenny's not recommending it. Listen, I saw Mark Andrews get catch a touchdown pass a few weeks ago, and I'm telling apply somebody went on the sidelines tested his blood sugar didn't see him stop and wash his hands. So, right? Correct. The reason I bring it up is because I've seen newly diagnosed people kind of crippled by it. Like, oh, I have to test but I don't have a an alcohol swab, or somebody's like, I think I'm low, but I have to go get an alcohol. I'm like, Just test your blood sugar. You're like, yeah, let's get moving here. So anyway, that's my little bit for that. Why?

I think as far as accuracy, too, I think that that's something that, unfortunately, unless, as a, you know, we're speaking to, hopefully, practitioners here, too, right. And in terms of their understanding about accuracy, you really do have to read the fine print, this is where you might need to get your reading glasses out and read that tiny little print that comes inside each and every one of the meters that you may be recommending or handing out from your office space. Because if you haven't read that, right, all of the different blood glucose meters on the market, including continuous glucose monitors, they all have marred, right. It's an accuracy rating. And so you'll be able to tell by easily lining those papers up with the little graphs inside of them. Which ones are the better ones to be recommending to your patient? Why

do you care which one lives as long as it's the better one and their insurance covers it? Correct? Look, I'm not saying if you have no other options, or you're a cash payer, and it's hard for you, whatever, then take what you can get, you know, the best you can get. But while we're handing them out, it just it seems to me, it seems to me that you probably said that, and a number of physicians probably just in their mind with these meters are different. Like why would you think that their blood glucose meters? Seriously, you know, you would expect that

if they're on the market, they've been approved? And yes, they've met some type of accuracy rating in order to actually be on the market. Yes. But there are, as you said earlier, there are three that are pretty much the top tier and align with each other in terms of accuracy. I mean, I have two of the top three. And I will not often but probably, you know, once or twice a month, I'll actually pair them off of each other with the same drop of blood, just to see how they're still, you know, on par with each other

remarkably close every time you do it. They

are Yeah, very, I would say within about five milligrams per deciliter, honestly, they're very close to each other.

I just last night. So I mean, they're sponsors of the show. But you know, our news is a contour next meter, one of the content x meters, and there's a number of them, but she was bolusing for a blood sugar. And I was looking at her CGM. And I thought, that's not right. I know that's not right. Your blood sugar is not this high. From what she ate, and how much we Bolus. It just didn't make sense to me. I knew her site was working well. So I was like, you just gotta test real quick. And she tested and no kidding like her. I think her CGM had her at 190. And she was 150. So I was like, I knew it. And before we were gonna make another big Bolus. I was like, Don't do that. Again. I'm like, we have to check first. And I have to say I trust that meter pretty implicitly. So pretty great meter. Okay, so but CGM seems good, or do you have more to say on meters? No, I

wanted to make a point, though, about what you just brought up in terms of sensing or having a sense of where glucose should be. And as we move into talking about continuous glucose monitors, the accuracy of your blood glucose meter, where you're doing a finger stick and getting a number from, if at any point you need to calibrate that CGM, the accuracy of the blood glucose meter also makes them very big difference in terms of the CGM.

I left that out. But that was the last bit of what we did. As soon as that number came up. I was like, go ahead and calibrate the CGM it. Yep. Well said, I know that marketing wise. You know, all the CGM companies like to say like, you know, you don't have to calibrate you don't have to calibrate but you can, if you you know, so why can I if I don't need to sometimes. Right. And you know, and I'm down with that. I know, some people say it'll figure it out and we'll figure it out. But I mean, this is, is four or five days into this thing, her blood sugar. You know, it's she's got her period stuck a little higher using some extra insulin like stuff like that. But I was like, that's not right. And that's, by the way, we're not talking about management right now. But I don't mean that you can figure out what your blood sugar is by wandering out the space. It's a lot of years of experience and knowing what she ate what we Bolus and I think that can't be right. Also how the line moved on the CGM. It just wasn't acting the way I expected it to whichever Which made me think that something was up. Okay, but CGM. Give one to everybody. There. That's my advice. I mean, just everybody, if you've got type one diabetes, given the CGM, I would give type two CGM. I don't know if they're covered by insurance, I think they're incredibly helpful

depends on insulin use for type two diabetes. And other factors, obviously, but insulin use the big one. somebody with type two who is on insulin is going to have sort of priority, I guess, in terms of the ability to get one. So but I would 100% mean, if I was going to lobby for something, I would say everybody with diabetes should have a continuous glucose meter. Because that's the only way that you're actually going to see trends based on the variables in your life.

Right? I put up an episode today. It's an after dark with this 27 year old girl who said that when she was younger, they told her she was brittle, because her blood sugar's would bounce up and down, up and down. By the way, she's 27. She only had diabetes for 17 years. So it's in the last 20 years. Somebody told her she was brittle. So after I explained to her that that probably isn't really what was happening to her. All I could think was that she had a CGM. Maybe it would have like, struck a chord in or maybe she would have seen it, you know what I mean, instead of just guessing and testing when she wanted to. And by the way, all that led to and this is for the doctors. I mean, obviously timing wise CGM is didn't exist for this person. But not having one being told she was brutal, lead to an eating disorder. It led to manipulating her weight with insulin. It led to this anxiety about food she barely eats now, because of it, you know, all this stuff from just not being able to, like, witness what her blood sugar was doing and make some cogent decisions based on it. Right. So CGM, I mean, listen, Dexcom is a sponsor, but I still I just want to speak honestly here like, you know, I'm not trying to skirt anything. Big difference between g7 and libre three, like, no right

now, and that's it's a good point to bring up because I think all the sensors honestly have fair enough similarity and accuracy. What may be the difference person to person is how their body actually interacts with that sensor. Right? I mean, I've said before, I don't know anything about the new Medtronic sensor, the newest one with their seven ATG insulin pump system. I've had people have told me it's a lot better for them compared to previous models. The previous models never worked for me. But Dexcom has always worked very well for me. And prior to going off the market in 2010 ish. I think Abbott used to be called the Navigator. That one was phenomenal. It worked wonderful. I switched to Dexcom it works similar and accuracy now is quite great. The libre as well, I haven't used it in yours. But there are a lot of people that actually prefer that to Dexcom. Right. So there are I think, accuracy. They're similar. But then person to person, you may also have adhesive issues. So don't discard somebody's comments about one system. Because the other systems may work in terms of accuracy, but it may work for other things like adhesives, skin issues under the skin, you know, reactivity and all that kind of stuff.

I've seen people who can't wear a certain sensor just doesn't even give them a reasonable reading. And right, who knows, you know, they, I mean, you're not you're never there, but they say I'm hydrated. They say, you know, I did the right things when I put it on and they've tried sometimes for months and eventually abandoned them go to the other company or whatnot, is the sensor from Medtronic called a guardian still did they just keep that name? through it. It's just the newer one, or I wonder if they renamed it.

I think it's still the Guardian, I'd actually have to check. But it's it's the newest that works with their seven ATG system. So

there's Dexcom libre, Medtronic, there's the Sensi onyx, the implantable one, ever since ever since. Right, right. Yeah. And is that it at the moment?

here and I'm trying to think here in the United States. That is

it. Yeah. And those are the ones that are that are accurate enough for somebody to dose insulin from them. There's a crap ton of them now that are for like exercise and stuff like that. But yeah, those are not

right. Those are not what would be recommended to use for dosing. Oh,

Jenny, that was a big word out of you recommended. Okay.

Not usually use big words. No, no, I

mean it I thought it had a lot of implication when you said it. Maybe I was reading more into it. But no, you're not saying they work but they're not recommended.

They're not recommended mainly because they're not you know, There's no indication on them.

They haven't gone through the FDA process, right? That they're not going to pair with AI D systems or, you know any of that. Right? And really, you know, for doctors who are listening who might not know, I do think we should dig into it for a second, I'm just gonna let you speak from your own experience. But what is the difference between managing type one diabetes or insulin with diabetes with a CGM or without a CGM? Oh,

it's night and day. Really, I mean, as and I think I've said before, in other episodes about the number of times I was doing finger sticks to gather enough information in my day, to make enough decisions about things right, my doctor had written my prescription for 15 test trips a day, just so that insurance would give me enough test strips. And I wanted all of that information at my fingertips are now very happy since about 2005. That I don't have to do that. finger sticks every day. But there's a really good graphic that came out eons ago, when sensors really first sort of started to get a foot in the door. And it gave a graph a 24 hour graph of, I think it was four or six finger sticks on the graph at different times of the day. And then what brought in the visibility of the sensor, kind of what the sensor provides is an overlay behind all of that of the ups and downs from every five minutes of a sensor reading, compared to just the four to six finger sticks values. So I know you've said before, too, you thought you guys were doing really well. When Arden was little right, you'd put her to bed at a certain number. she'd wake up at this number. But then once you had to CGM, you could see that she was going hypo overnight, right? Yeah. And landing in a place that you thought was good. Without the sensor, you didn't know that was happening. I also didn't know where there were problems in the aftermath of my meals, despite doing what is a lot of finger sticks in a day. Yeah,

in the time, it took you to say that I with my pen in my hand, and my whiteboard in front of me, wrote down mental health, physical impacts, accuracy, being able to adjust your blood sugar. Well, being able to deal with difficult foods with insulin better being ready to pair with an algorithm. Those are just the reasons that I could think of in two minutes to have a seat salutely. So absolutely. It's not a fancy thing. It's not an extra it's not a nice to have like it really is. In my mind. It should be the first thing like you should get one in the hospital, when you're diagnosed. All these things that you hear people talk about years of diabetes, you know, the things old timers talk about the problems they have, I think many of them are completely alleviated with a with a CGM. Absolutely.

And I think in terms of where it should be prescribed in hospital would be great. Because if you've got it in the hospital, you would at least have an education component to what you're seeing, you know, sending somebody home with a prescription newly diagnosed and then they're supposed to slap on this device and make heads and tails out of what they're actually seeing, along with all of these other things that our new variables to pay attention to. That's an overload. It really is. Can it help if they get quick intervention of information after they get it? Yes, and it can make a big difference from the beginning. But it just goes to also demonstrate how important it is that follow up right after diagnosis with all of this stuff being valuable. It's it's just really,

even for people who are not like, dialed in super motivated about their diabetes, right? People who are just getting by not paying a ton of attention to it, let them see this number is when I don't feel good. Or this you know, I didn't know I started feeling dizzy at this number, but I still had time to do something about it before I got really low. Like those. I think that showing people those, those little guardrails maybe allows them to retrain their brain over time, to the point where they don't even know they're doing it. You know, until one day someone just says, Oh, I got a beeping it and wherever they ended up setting their, you know their CGM to beat that. I know when I'm 95 Diagonal down, I need like 10 carbs, that's another thing they would know before they would test their blood sugar See 95 And they Oh my god, this is perfect. And then you know, end up low a half an hour later. And that's when the mental part comes in the the instability is like, this is unknowable, and I'm never gonna figure this out. It doesn't make any sense because without that data, it doesn't make sense plus, it helps the doctor you know, it does

and the you know, we're talking about general medicine, primary care who may be working with more of the type two population. That also means that you now have to do a bit of homework and understanding and live Learning how to read reports, if you are going to prescribe these, being the primary person, this person with diabetes is coming back to, to relay information, you have to know what you're looking at and how to help them, you know, maybe you've talked to them before about not drinking two glasses of orange juice every single morning, hey, this isn't good for your blood, sugar, et cetera. Well, now that there's information and a view of what that actually does, that has to be brought back into the conversation, if that's the point you were trying to make. And sometimes it's just one point at a time, it's one point per visit,

it also helps people see the impacts of certain like foods to that they think are like Staples, like great stuff for them, but maybe they'll like, I don't know, maybe the third time they have mashed potatoes, they'll think I you know, that's not worth my blood sugar be in 250. For the next three hours, I'm gonna have, you know, a smaller amount or not eat this anymore, do something different to it, like all kinds of small things. We're always telling people to do the right thing. And then not giving them the tools to do it with, you know, or even the direction to do it with you just say you should eat better. exercise more, what does what does all that mean? You know, like, it's nice to say, but it's not actionable. Right? My brother is a type two, he got a hold of samples of a G six, get G six samples on time, enough to keep him going for like a month. And the significance was huge, like things that a doctor had been saying to him for years that he thought he understood, it turns out, he didn't understand that at all. And he was telling me, he understood, I get what they're saying, you know, and then he wears the CGM for three, three weeks, you know, a month and boom, he understands it.

He's like, Oh, that's what happened. That's what

they meant. I didn't get it. So anyway, I mean, again, back to insurance, everyone who can get it should get it. And even people who, you know, can't, Medicare, right covers Dexcom, I know, I'm pretty sure for Dexcom, these things are only going to get more and more popular and covered as time goes on, in my opinion, you should start at, we want you to have these things. Let's see if we can get your insurance to cover it. If not, you know what wouldn't be wrong to say to somebody, if your employer is self pay, maybe you should go talk to them. Because they might say okay to this for you, but you have no idea what you can work out. And as a doctor, I think that's the minimum you should understand to say to somebody, right, that's all that's what I got, there. We missing anything with this stuff, and what you want doctors to know about them. I

don't think I you know, I mentioned it before in terms of technology really takes some desire to learn about in order to be able to know what you're recommending to your patients. And so, you know, take some of your time, whether it's a class that you take, that you don't really think is purposeful for you that somebody is going to come in from Dexcom, or somebody is going to come in, you know, from Avid or whatever it might be. And you're like, whatever. But you know what you might grasp something from it. There are a lot of actual online tutorials. So you don't even have to go and sit in a class, though, do an online tutorial, but how does the system work? What type of information does it give, and they're all professional based tutorials. So it might take you 15 or 20 minutes, but you know what, now you can better serve your patients, you're actually more informed. And that goes across the board for the technology. Because not only do we have the continuous glucose monitors and the blood glucose meters, but we also have apps and things that sync with them. So from a clinical standpoint, the ability to get that information from somebody and be able to make sense of it and send them some thoughts back or in a visit, discuss that with them becomes even more for facilitating their well being.

There should be some continuing education for you. You know, diabetes, insulin, that the technology I mean, come on, like you have to understand how that works. And I don't know how you ever buy a car, and then had the person show you the car, but they didn't know how it works. And all you can do is sit there and think you work here. Shouldn't you know this? Did you know this? Yeah. What do you mean, you don't know what this switch does? You work here, you only sell for cars. You don't know what the switch is? That feeling that immediately removes your ability to trust the person you're talking to? Yes. Right. And, and what Jenny's saying about educating yourself about how these systems work, so you can speak about them is it's not just about that. It's not just about helping the person feel better and not going like Oh, they'll figure it out. You know, it's about them trusting you moving forward. Yes, it really is. You shoot yourself in the foot and it's hard to get back from it. I've had that experience where a physician has said something so bad bonkers, that I was like, Oh, now I know not to listen to them anymore, which isn't fair either. You don't mean like, but it is how it makes you feel. And

in today's world of, again, technology, technology being an online driven review system, honestly, shooting yourself in the foot is kind of a bottom of the barrel way of saying it. There's so much feedback that's given in online forums and everything in all different types of professions that you can make one little kind of misstep, and you're getting a bad review. And then it's bad review after nobody coming to you after somebody commenting. It's that it's sort of just snowball.

Yeah, you're in business to might be important for people to think that you're a value to them. Yeah. Especially in a world where by the way, people now can go to walk in clinics and get prescriptions if they needed. Even some people have, through their insurance through their employers have access to physicians now. Like, Yeah, everybody's not just going to come to you because you're there. But let's go through real quickly, Jenny, what everybody said, Oh, yes, for CGM, SB gems. My doctor didn't even tell me to watch even a YouTube video. He just prescribed it and left me on my own. So that's such a crazy idea. Here. Take this it does this good luck.

Right. Yeah, I know. I mean, when I and I don't know what you guys had when you first got the one because you only started with Dexcom. You never used anything else. Right? Correct. Yeah. So I'm assuming that you got some education given that Arden was a child? Yes.

But it felt like they were building the plane as they were flying it because it was so early on. You know, it's like you were learning together in the office with somebody which I appreciated. They, they were like, look, it's new. We don't really know. Right, which I thought that was great. Because we'd also had an experience in the past, where we were told not to use an omni pod. Because I forget, what did they tell us? Or they said Your daughter's to lean for that. And oh, and I was like, I don't know what that means. But we're getting this anyway. And so we got it. I mean, I went with Omni pod originally, because of the just the generally the tubeless nature of it seemed, for a number of reasons like the way to go. It took two years for the endocrinologist to pull me aside one day and say, We want you to know that because of RT and success on Omni pod. We're now writing prescriptions for Omni pod to younger kids that we weren't before. And I said, Why did you tell me all those years ago like not to use it, and in a very quiet tone, the person said to me, it was newer, and we weren't comfortable with it. So we didn't want you using a device we didn't understand. So it had nothing to do with how lean Arden was it had to do with they didn't understand it. They didn't want to take the time to learn it. And so they weren't going to they were going to just push me towards another device. And

or they had experience with what was already on the market. And in comparison, which wasn't a fair comparison. They were able to say she may be too lean, she may not do well with this or whatever. And again, their comfort level and I find this not as much now but years ago honestly, many offices had a comfort level weren't talking just about insulin pumps with one particular pump. Yeah, that's what they maneuvered everybody toward this pump. Because we know this pump Oh

yeah, that was a whole day of somebody saying to me animus ping animus ping, which by the way doesn't exist anymore?

No, it wasn't good pump.

I was on it. Everyone I've ever spoken to says they love it. Absolutely. But Arden is also used Omnipod for she started on a pump when she was four. She's 915 artists been using Omnipod for 15 years. So I think we did okay, but that point of understanding what you're talking about, so that you can actually talk about this person says they should know that CGM 's are extremely important at diagnosis, not knowing exactly how insulin affects you. And all of the other factors that go into managing sugars are very helpful in determining all of your personal factors. Yes. And I wrote a note after that, they just said, Look, patients shouldn't even have to ask for CGM. You shouldn't make a person. They don't know anything about diabetes. You don't I mean, now you're asking them to choose what they're supposed to be. You know, using they don't have any idea this person's like, You got to tell me, you know, she goes on to talk about, about catching loads how important it was, especially for their child. And then this other person says, I'm, uh, I was diagnosed at 29 I needed this the same for the same reasons, right? And then oh, this is interesting. This person had a libre back when back when they were scan only you had to hold the device up to the libre to get that number. And the physician told them that they were scanning it too frequently. You have you ever heard somebody say don't look at it so often.

Yes. Yeah. From a mental health standpoint. I think that there are there are some people obviously who they you Use it. Not quite to their health. But as almost an obsessive, I have to check, I have to check. I have to know where I am. Oh, it's going down. Oh, it's going up. And there's a difference in that versus I need to see where I am because I have this planned. And I need to see what my action is right now. For the coming, you know, plan? Yeah,

the best way I've ever found to make people comfortable there is to tell them, Look, let's set more reasonable alarms. And then don't look. Unless the alarm sounding. That's it, but we can't make your high alarm 250. Like, you know, we can't do that,

right? Because then you're gonna miss the mark. And that's going to make you hyper vigilant, again,

not gonna be the point. And for a doctor who says, Oh, if I don't make it to 50, the thing will be beeping all the time, I would say to you, you might want to go listen to the Pro Tip series, because it doesn't need to be beeping all the time. It doesn't need to be going high all the time. There's simple ways about using insulin that will help you right, so Okay, agreed. All right. Thank you very much. Yes, of course. Let's do this. Let's move into pumping. But if it doesn't fit here, I'll split it up into two different episodes. That way I have it here. But I can maybe put in its own if it needs to be is that okay? That's fine. I have about 15 minutes where you're going to go through the people's questions. And if we have to come back later and finish up we will. So cool. I wish they would have explained the difference in detail between t slim and Omni pod. Oh, isn't this interesting? In the new device world. This person doesn't even mention Medtronic. They were extremely vague and our toddler is on Omni pod. And so you made this point already in the CGM episode, but you need to understand what these things do. This is Omni pod, this is how it works. Here's why it might be better for you or you are here's what I'm even seeing from people who are using it. This is what the T Slim is. This is what control IQ is like. Do you think that it's possible that doctors just like tube, no tube, you think they're like, it's that simple.

Could be practice to practice, quite honestly, it could be that simple. It could also be, these are the pumps, they all deliver insulin. And I think they're trying to save people from some of the very little tidbits of information that make you different. But I also think that that's really important. From an individual need perspective, really good pediatric practices, I know often will have like pump exploration days, where they'll have you know, all of the different pump options come. And you can walk around almost like a fair, right, you can explore talk to the representative, you can feel it, pick it up push buttons, get kind of an idea of what it would look like feel like you know, you can even like clip it on and see what it would be like to kind of have it dangling on your pants or whatever. But those are all really important things when you as a clinician are recommending something, don't recommend based on your preference. That's the bottom line, you have to really consider what does the person need to know if they are a swimmer? And a competitive swimmer? Well, you might tell them a little bit more about why one may be more optimal than another. But it's still up to them to make the decision.

I think they should blend information to like I mean, the person who comes out to explain the device to you is the salesperson, right? So like, you know, okay, here's these are the highlights of the pump, that's great. But also go do some research on your own, and talk to users and get their feedback. And go online and hear what people are saying there. And then blend that together. When you're talking about don't just like you're not a salesman for T slim or for Omnipod you're you know, you can't just go by what the pamphlet says the pamphlets, its marketing, right? So right. I'm not saying that one of them is hiding something or something like that. But it's not going to give you a full understanding of it by just reading the brochure. I mean, that would be like making a decision based on my ad. Like if you hear an ad for something, these are the highlights. You should now go figure out the rest of it. Like you know, don't make a decision based on this. I think that's incredibly important. And it goes back to that thing you said during the CGM. It's like you have to educate yourself on how these things work. And especially with the algorithms now. It's not just the I mean, honestly, before the algorithms pumps were, they were just basic,

basic delivery that makes it easier than taking

injections. The idea behind going from MDI to pumping is that with pumping, you gain control over your Basal insulin. You know, you could set up extended boluses squarewave Bolus, things like that. You can vary basil Yeah, right. You know, you could temporary basil your insulin completely off if you wanted to, if you were in a situation these are things you can't do with MDI. But it wasn't some like insane leap. Like it was just here's the extra things you to me. It's amazing and it's incredibly helpful. But now you're gonna go from those Is to these algorithms, they all are aiming for the same thing, but doing those things differently. And you should know the differences. It just makes sense to me. Because when I stop and think about, where are doctors going to struggle in the coming years with algorithms? I think of it's like little things like fat and protein becomes really important. Right? Like, you know, because a doctor is gonna, like, say, oh, no, the thing does it. But it doesn't. It doesn't know, the thing doesn't know that there's a bunch of fat and the carbs that you told him about at one o'clock and 90 minutes later, your blood sugar's gonna start going up. And then people are like, Well, what should I do? Should I wait for the thing to do it? The thing is gonna take, I mean, honestly, hours to make another decision. And to

clarify, will the thing do it? It'll do it? Well, yeah. But as you just said, it'll take hours of time, because all the systems are based on with their algorithm are based on an sort of an extended time of action of our rapid acting influence, which are not rapid. It's a horrible word, whoever came up with that word for today's insulin, yes, it's faster than what I used originally, but it's not rapid, as fast

as the word makes it sounds correct. If the algorithm is thinking on a, I don't know, on a six hour timeframe, then your blood sugar shoots up an hour after you eat. And five hours later, the algorithms gonna be like, Oh, we should probably be more aggressive with this, you know, that happens to you at two meals, well, then this, I don't know what good the algorithm is to you at that point, like, you know, if your blood sugar in the 200. Now, if it's holding your blood sugar at 200, and eventually gets it back down, I see the doctors argument, this is way better than these people were doing before. And it is yeah, and I understand that, but a tiny bit of a tiny bit of understanding how insulin works. And a tiny bit of understanding how the algorithm works could lead you to tell them, here's a secondary Bolus maybe we could make that would help us, which the company isn't going to tell you about, because they're not legally allowed. That's not how that works. Like the FDA doesn't allow insulin pump manufacturers to direct you about how to use insulin. That's just the thing that they're not allowed to do. What you're

getting into is the idea that, and we've been talking about all along is that as a clinician, you have to educate yourself. Right? There are so many things that you learn as somebody with diabetes, because of the huge benefit of continuous glucose monitors. And when you fold that continuous information of what your glucose is doing, into a system that can now dose insulin, along with that, you have to know how to look at the data to help somebody best make decisions for their life. I mean, we started MDI, it is what it is you could Bolus 16 times a day and sort of mimic what you think you need to do. Sure, go ahead, but it's not going to have precision, conventional pumping. Next line, you've got some smart features, but who's the driver, the person, the person drives the the use of those precision parts of that technology. And then algorithms bring it even further. But not far enough. Our algorithms are not AI, right? They're not learning. They're not saying Oh, every Friday night pizza is coming in, you got to be ready for this. It's not there yet. So the smart driver is still the human. And the human needs the right information in order to be able to navigate blood sugars in a target range that's going to keep them healthy, long term,

we made a significant adjustment last night to get Arden's blood sugar down. We didn't wait for the algorithm to do it. We were like, No, I know what to do here like to get this down and did not cause a low or anything like that afterwards. I think maybe I'm just as you were talking, I thought maybe doctors should do ride alongs with people who have type one, right? Because you always hear my endo is terrific. They have type one diabetes, like people say that all the time. Like I hate to say it, but my endo is better because they have type one my nurse practitioner knows, I mean, listen, you have type one, right, like so. I do. Wonder if that's not doable. I wonder if doctors couldn't just like, live a day with a patient every once in a while. Just I mean, honestly, that's how you if you lived here for a week, you wouldn't, you'd know everything you needed to know.

But I wouldn't even say to go there. If you are a doctor who is prescribing these, an easier ride along really would be take the product, put it on your body and use it as if you were somebody with diabetes as if you were following the directions that you're giving people to walk out of your office with. Right? Yeah, you know, look up your carbs. Check what is happening before you go for a run, look at your data and know it's not going to reflect shifts like somebody with diabetes has, but it'll get you in the mindset of all of the considerations along with using this piece of technology that is delivering insulin, which is not a silly medication. Even

like, maybe this is the right along idea. Maybe it's Can't you just follow one of your patients for a week? Like, can you get somebody like get there? They say, Look, I'm trying to learn more about all this, would you help me? I'm gonna follow your CGM. I know that sounds crazy. But for a few days, just text me, I just ate this, it was this many carbs like that, like, here's how much insulin I put it, it wouldn't take you long to like, go, okay, I get this. And now you've had this, you take this thing you take time, one time. And now you can take what you learned and give it to everybody. It's just none of you are going to do that. I know when I said let me just tell you right now, that's the best idea I've ever heard. So if you're a doctor trying to help people with type one, following a type one, knowing what they when they ate it, and how much insulin they got, then watching their CGM, you would understand in no time at all what was happening. And you'd be able to not only just help that person, but you'd be able to transfer that knowledge on to other people. So anyway, you would I'm 100%. Right about that. I'm not I'm not backing down off of that, quickly, if this person says hey, if you're having issues with like a glucose monitor, or a pump or something, it would be lovely if the doctor would help us when we need help with our insurance, oh, writing letters of medical necessity, things like that, you know, don't just give people a script and then go, Oh, it didn't work out. That's tough. There are times they need you to step up. I would also say that giving somebody an arbitrary amount of time before they're allowed to have a device, I don't think makes a ton of sense,

is ridiculous. It needs to be individualized. Yes. Yeah, I

mean, I get that my assumption is, is that they've had this experience with insurance companies. And they know that the insurance companies deny in the beginning, but that's also you can get around that, and you know it. So you know, people are begging for insulin pumps, just telling them Oh, it has to be six months, or the practice has a rule. You have to be on MDI for a year, correct. You know, I mean, a year Jesus, you can't figure it out, you know,

yeah, I was gonna say that, that's often what it actually boils down to is a protocol that's within the practice, or within the department or whatever, that says, you have to meet all of these pieces. And typically, it takes six months. So we're gonna say, within about six months, then we can start working towards getting you a pump. Yeah, but again, that everybody is so different in their life, and has so many different variables and needs, that you really have to throw those protocols out. And you have to say, well, you know what, this person definitely needs a weight, there is a lot going on here, this person could definitely have it within the next month, because they need it and they, they get it, they're at a higher level of learning, or they've reached certain, you know, points of education that are already important. So individualize. Okay,

thank you, Jenny. I'm gonna leave a voice note here for both of us. So when we come back and re record again, we're going to talk about why insulin pumps are so important. What they do for people, they're not just replacements for injections, and what value they'd get out of pumping and what value they'd get out of an algorithm. And we're gonna actually like continue this conversation next time you're back. Fantastic. Thank you so much, of course. A huge thanks to Omni pod, not just my longest sponsor, but my first one Omni pod.com/juice box. If you love the podcast, and you love tubeless insulin pumps, this link is for you. Omni pod.com/juice box. A huge thanks to touched by type one for sponsoring this episode of The Juicebox Podcast. Check them out on their website touched by type one.org or on Facebook and Instagram. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome. Type one type two gestational loved ones. It doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community check out Juicebox Podcast type one diabetes on Facebook. To continue this conversation jump now to Episode 1126. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

Hello friends, welcome to episode 1126. This is part two of the Grand Rounds episode on technology. For part one, go to Episode 1125. Today Jenny Smith and I are continuing on with the Grand Rounds series, we're going to discuss technology in this two part episode and the first half general overview of CGM and pumps and in the second half different pumps technology and understanding the differences between them. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan or becoming bold with insulin. When you place your first order for ag one with my link, you'll get five free travel packs and a free year's supply of vitamin D. Drink ag one.com/juice box. Don't forget to save 40% off of your entire order at cozy earth.com. All you have to do is use the offer code juice box at checkout that's juice box at checkout to save 40% at cosy earth.com. If you're looking for the diabetes Pro Tip series, it runs between Episode 1001 1025. For subscribers to the podcast, those episodes are ad free. For everyone else. There's just a couple of ads episodes 1002 1025 diabetes Pro Tip series from the Juicebox Podcast. Today's episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. This is the meter that my daughter has on her person right now. It is incredibly accurate and waiting for you at contour next one.com/juice box. If you're interested in checking out the diabetes Pro Tip series, the bold beginning series or any of the series within the Juicebox Podcast, there's two quick ways to find them. First, go to juicebox podcast.com. Go up into the menu. And you'll see links for each of the different series, pro tips algorithm pumping, after dark etc. Click on them, there's a player in there to check them out. Or you can use that player to see which episodes correspond and go find them in your podcasts that the other quick way is to go to the private Facebook group, click on the feature tab. And there there are lists upon lists of all the series. Jenny has been a week and we're back. Yay. Last time we kind of stopped in the middle. Not really in the middle of the episode we'd already recorded quite a nice episode already. But we'd run out of time your schedule didn't allow. And you and I have just listened to the voice note that we that I left for us. So we're going to pick up by talking to doctors about why insulin pumps are so important for people. I think we should just start maybe at the misnomer that still exists that a pump is just a way to avoid injecting and nothing else.

Yeah, that's a great way to start. I'd certainly not it takes the place of injections. But it is not a one for one conversion. By any means. There is a major difference between injections even the smarter injection devices that we have today. 100% difference when you change to an insulin pump, it's a really strong way to assist somebody in improving management, just because of the much more I guess in general, just the much more precise dosing that you are offered with an insulin pump. Yeah, you

have fine control over Basal insulin, extending boluses creating, you know, patterns. Yeah, you can you can create a little here's the I think a great example is that, you know, if you experience a fat rise after a meal with fat in it, you push a button again to give yourself more insulin, or you tell it Hey, 90 minutes from now I'm expecting a rise, let's put some in here, you're not coming back at somebody with a with a needle again. And I know it feels like Oh, so you're just saying I'll avoid having to inject. But that's not it really, it's the psychological part of it, that people won't remember to do that. Or if it comes to, well, I have to do it to inject, they may just avoid it.

And in one of one of two ways of avoidance there, that's a good thing to bring in. It's either they'll avoid doing it kind of resulting in sustained high blood sugars because they're just avoiding taking 10 injections a day versus the four that they were told were necessary, despite them knowing better. Or secondly, they may actually go the route of just avoiding additional food that may be necessary. I

just interviewed a lady the other day that said that her newly diagnosed son changed his eating patterns and she couldn't figure out right away what was happening and then it hit her that she'd say Are you hungry and moments when she knew he was hungry and he's saying No, thank you. And then he kind of like soak away. But he was just trying to avoid injecting. Yeah,

absolutely. And it is a not only from the standpoint of injecting more, there are people absolutely, who that's their desire is just to manage with an injection and to do it multiple times a day in there, they're fine, and they do a wonderful job. But then there are the people who could do so much better. By having the precision instead of the smallest dose really is about a half a unit unless you really eyeball on a syringe and assume you're getting a quarter of a unit, which is again, not very precise. But you know, the precision of a pump to be able to deliver for somebody who is ultra sensitive to insulin. It's not there with injections.

Yeah, yeah. Where my concern comes is that if a doctor were to tell you, the contour, next gen blood glucose meter, is sponsoring this episode of The Juicebox Podcast. And it's entirely possible that it is less expensive in cash than you're paying right now, for your meter through your insurance company. That's right. If you go to my link contour next one.com/juicebox You're going to find links to Walmart, Amazon, Walgreens, CVS, Rite Aid, Kroger, and Meijer. You could be paying more right now through your insurance for your test strips and meter than you would pay through my link for the contour next gen and contour Next, test strips in cash. What am I saying my link may be cheaper out of your pocket than you're paying right now, even with your insurance. And I don't know what meter you have right now, I can't say that. But what I can say for sure is that the contour next gen meter is accurate. It is reliable. And it is the meter that we've been using for years contour next one.com/juicebox. And if you already have a contour meter, and you're buying test strips doing so through the Juicebox Podcast link will help to support the show. Even as they're handing you a pump, if they were to tell you this is great. Now you don't have to inject any more and make it feel like all we've done is take away like times you're getting poked, it takes your brain away from thinking that this thing could do other stuff for me. Like do you know what I mean by that? Yes, you neglect to mention that, if you get low every night at 2am, we could turn your Basal back at 12:30am to stop the low from happening at two, which if you're injecting Basal insulin is not a thing you could do even just correct. Think about that small idea, instead of messing with, oh, maybe we should, you know, shoot the Basal insulin an hour earlier, let's do it at night, instead of during the daytime, let's try 20 units instead of 21 units. Like instead of going through all that you just go I get low every night at 2am. I'll just take away some basil and see what that does. It's magical. But if the doctor puts in your head, oh, it's just a replacement to stop you from having to get poked so much. I think you don't wonder what else you could possibly do. Right? That's not me guessing that's me, having talked to so many people who've really told me that story. So

Right. And I think it also goes along with the lack of explanation of the pluses, or smart features, let's call them on today's pumps, even conventional versus the newer kind of algorithm and whatever that is out there. Myself example really is. Before I switched to a pump, I was taking a Basal insulin that required me to have a snack before I went to bed. If I did not, I was low by three o'clock in the morning. I was every and if I change every night, and if I changed my mind was worse with exercise and everything. If I changed my dose of the Basal insulin, it messed other things up that were not great. And so again, it brings in because food is such a center of diabetes management, it brings in the precision of a pump means that you're not feeding insulin that shouldn't be there. Yeah, yeah, right. I didn't want to have to have a snack at night. Most people don't want to have to nibble and snack when they don't want to or have to have very kind of timely meal intake to offset the action of a Bolus of insulin or their Basal action or whatever it is, as you said, if you can navigate those pump settings to accommodate for high need times are low need times you got something that can take care of that need to feed the insulin. Yeah.

I want to say to to empower somebody to make an adjustment or make adjustments to their insulin through their pump is would be huge. I can't possibly tell you how many people live months at a time waiting to get back to the office where let's be honest, if you're listening in your dock You're you're throwing darts at a wall going, I don't know, try this, you know, like, turn it this way, see what happens how you suppose. And that's no shade on the doctor how they're going to know, from a couple of graphs, what happens, you know, it's ridiculous. And then it puts the doctor in a position of trying to pretend they know what's happening, which then just makes you look bad in the long run. And it leaves the person in a in a position where they're never doing as well as they could be. And you could end up turning a knob in March, that's even worse. And they don't come back till April, May June, like you don't even talk till the spring. Correct. And these people don't feel like a thing I hear the most from people about the podcast is it gave me the courage to try something.

Yeah, people should try something specifically with the main control factor of diabetes, which is insulin. Yeah.

100%. And, and my point is, is that doctors should be encouraging that, like, you can't sit there and tell people like on one hand, wow, you're gonna know more about this than I do in six months. But don't do anything till you come see me. Right? You know, it's weird mixed messaging, and it freezes people and it leaves them with higher or lower blood sugar, either some people are eating, they're like crazy trying to keep their blood sugar up. You just made that example, like if I adjusted an injectable Basal insulin. Okay, I didn't get low anymore at 2am. But all day long, I'm 45 points higher than I want to be, you know, so it's not a fix. It's a anyway, and none of that's necessary. And if you're listening to this and thinking it is, it's not plenty of people live with lower stable blood sugars that don't create crazy lows and, and huge spikes all the time. Absolutely.

I think that is really, it kind of goes along with the fact of teaching people about their pump in the right way, right? If you're recommending a pump, you've got a patient, you've started on a pump, you're getting them going, their education needs to go beyond the basic of filling it with insulin, putting the tubing on or slapping on, you know, the pod device or whatever, and hitting go, and it just starts delivering insulin. That's not teaching. That's just learning how to use a device. Right there, there's so much more to learning because again, of the smart features, even the simplest smart features like a temporary Basal rate, when to use it, why to use it, how long to use it for before actually making true set adjustment. When you're using an extended Bolus, write a square wave or a dual wave type of Bolus. Those are advantages in the aftermath of food, or coverage for different types of, you know, different types of intake. And you can't do that as precisely with injections, unless you're willing to be the person to give multiple multiple injections to cover that type of intake. Right.

I want to say that plenty of people that I've met, manage amazingly on MDI, yes, but they understand how insulin works and when they need it. That's that, like, if you and I talked about this all the time, people would come to us and say, hey, the Pro Tip series is so like for people with pumping, can't you do more for people with MDI and I said, Oh, it's the same thing. I said, just when you hear me say, pump, think needle. And if you hear me say extended Bolus go, oh, I can't do that. I'll have to inject again. Like, that's the difference, really. But if you don't know that, Jenny, if you're the doctor, and you don't know that, and then someone comes in and says, Hey, every night at 3am, I get low, but I changed my basil, it didn't work. I'm still getting low at 3am. Now I'm getting high at, you know, 5am I don't know what's going on. The doctors gonna be like, Oh, they tried turn the basil down. That didn't work. They're gonna skip right over the idea about timing of insulin, which is why we talked about it so much in the other episode, because it's all about timing. And I don't regardless of the delivery method, no, right. It doesn't matter how you're putting it in the timing of the insulin. There's not much of a parallel about how basil works. When it's injected versus basil works through a pump. They're pretty different. They accomplish the same thing, but they're not manipulatable by the user at all. And that's it really like, and by the way, stop giving people Basal insulin that was invented 20 years ago, when there's stuff that works a lot better if they're going to be on MDI, at least give them modern basals that that have longer coverage and actually make it not just 20 more stable. Speaker 1 14:25 Yes, just stability. You know, I don't know how much time I spent. While Arden was on Leba mir wondering what the hell was happening when the truth was this 11 year wasn't lasting 24 hours.

It doesn't. I mean, a year and a half maybe of my life just staring at a wall and thinking about running my head through it trying to figure out what was going on. Then one day somebody said to me, oh, you should split that. I was like, why wouldn't somebody who said that to me sooner? I give her half now and half 12 hours now work, right? That was it, right? Yeah. So and that's timing. That's insulin time it is

it's insulin timing. And it's also based, you know, the kind of insulin I think that's another place to, to navigate within whether you're multiple daily injection, but definitely, if you're on a pump is we're talking about Basal insulin here, the understanding from a practitioner, that you still need to really recommend and have the person understand, they need to have a Basal insulin as a backup, right? Because we're talking about technology, technology can and at times will fail. And you have to have that backup as an injectable, in case. But I think it also is really important to explain that once you're on a pump, that Basal insulin gets put in the fridge with a label that says do not use unless pump fails. I've had a number of people over the years, who couldn't understand the concept that the pump was going to do the Basal and the Bolus delivery, but with one kind of insulin in the pump,

are you going to tell me they put two different insulins into the pump? They

did not. But they thought that they still needed to tow they were shooting? Oh, along with their pump? And then you know, I mean, clearly you clear that up very quickly, etcetera. I mean, it all goes into proper information and proper education from the get go. You know, there's a checklist of things that definitely, I told them this, I took care of this, this, this and this. They're all really important pieces that I think they sort of either get missed, but I don't think from I don't think it's a miss because they mean to miss it. Okay.

All right. Well, it's interesting. All right. So that would be just the conventional pump, what we would consider old school, instead of Basal rate, it gives it to you, you tell it how many carbs and you've preset your insulin to carb ratio, and it does the thing. But I mean, honestly, every company now, Omni pod has Omnipod five, tandem is control like you. Yeah, Medtronic, what is it? The mini med? was an ad G seven AG, that's the new one from them. Okay, I'm pretty new. So there now, I mean, those are the three major pump manufacturers, right? Like I'm not missing anything.

So you're in the States, those are the major rights.

So wherever you live them, there might be others that you're using. But these algorithms are prevalent. They're available. You know, they require you to wear a CGM at the same time. But correct. Let's say this. How do I put this? If I let you, Jenny, would you put an algorithm on everybody? You could? Or no, I'm interested in your feedback?

That's a really good question. I think, I think it depends on the algorithm. Okay. I think that an algorithm can improve the vast majority of people with diabetes, whether it's type one or insulin dependent type two diabetes, and insulin pump absolutely will be an advantage, and the algorithm within that will improve things. And I think the biggest group of people with diabetes that it improves are those who, for whatever reason, in life, they're just not navigating management, to the degree of effectively bringing glucose levels down to a place that long term is going to be healthy, right? And an algorithm again, depending on which one what system you're using, an algorithm can and will improve things. So for the majority of people, yes, I think it's a fantastic idea.

So let's stick with that for a minute. If you are, what do you think the cut off is in your head? If you're a one sees above, seven, seven and a half an algorithm is going to help you for almost for sure if the settings are right, and you're even reasonable about announcing carbs, is that fair? Correct? Yeah, yes. If you're rolling around with a five, five to a one C, you might not have that same outcome. If you just let the algorithm roll. As a matter of fact, they all target God, it's a What's the target for t? So obviously, it's something weird, like 100. And

technically, we just say 110. It's one 12.5, whatever you got, right? But yeah, one 12.5 or 110, Omnipod, five, the lowest adjustable is the 110. And then Medtronic, interestingly, with their 780 G, they have the lowest in an FDA approved product, which is 100.

Okay, but so those are still your targets, they're, they're a target. And if a doctor is probably listening, they're like, Oh, my God, you mean somebody could have 110 blood sugar most of the time, like, yes, like, I don't see that with anybody. But there are plenty of people who know how to use insulin in such a way and are are thoughtful about it in such a way that they're achieving lower agencies, but I remind myself constantly Jenny, I don't know if you run into this as well. Is it making the podcast your often talking to people who are either so lost, that they're just looking for information, or they're very. And maybe this is an end or so interested in doing better for themselves. It's a certain type of personality and you forget that you're, it's also a certain type of, sometimes it's a certain type of financial ability to write because these people have pumps they have you know, CGM is oftentimes, which means they have insurance. Yeah, I remind myself all the time, that that's not nearly most people, you know. And so, you say so easily, like, you know, I say so easily will put an algorithm on, it'll help them I don't even know if they have insurance, correct?

Yeah. Right. And those are, I think, from a provider standpoint, those are the pieces that many are trying to understand and trying to navigate. Because there are so many different carriers, right, when you get into the group of people are using Medicare, and the restrictions and the things that you have pay attention to, or Medicaid, or even the general insurance plans that are national plans. Each of them has different pieces that work in a certain way in terms of coverage. And so that may dictate product to product, what you may be able to tell somebody about, I think, in general, all products should be an offering. And then when you boil it down, what's available in terms of coverage? What can you use? Great, you can have your choice of all the products, fabulous, you know, we're looking at your lifestyle next, then what does your lifestyle dictate? Do you you know, swim six times a week? Well, great, you probably may not love a tube pump, then it's going to be a lot of on off, disconnect, reconnect, etc. Do you really want an algorithm that's a little bit, you know, less your work and more at work, or a little bit less input? You know, there are certain systems that work person to person, and that's where you individualize once you know, what is available to them.

Yeah, so Jenny's point is, if you don't understand how these different algorithms work, you can't just hand somebody out and say, like, here, you know, it's not like you're just handing them a lighter, and it makes a flame at the end. You're all good, right? Like it's, I guess, be more specific. Right. On the part five is a little more, we take care of it, you don't take care of it. Right, right. Yeah. Yes. And what do you think of the other ones to what is control IQ? Is it a little more?

Yeah, I think that one is the most unique of the three that are on the market, it's most unique, because for those people who have fairly good settings coming from maybe a conventional pump that isn't giving that assistive help, right, if they've got fairly good sis settings, are there willing to test some settings, the control IQ system from tandem allows the users Basal profile, insulin to carb ratio correction factors and everything to be used by the algorithm to adapt or Anatidae app to adjust up and down. Their algorithm is really simple. It takes your baseline, it adjusts up or down based on factors that are very simple. But the great thing is that it works off of a pattern that for the most part, you know, works well. You just need some help navigating cleaning up little ups and downs that you otherwise would have to do on your own. Yeah.

How about the new Medtronic, I'm starting to hear people speak really well about it?

Yeah, the new Medtronic actually has a I think of, of the three systems on the market. It's, it's auto micro boluses. Or it's micro corrections along the way, are the most aggressive quite honestly. And a lot I've heard the same thing I only have a handful of people that I've been able to use it with us far because it's again newest kind of but it really it quite honestly does a lovely job. It's adjustments in between its corrections for those climbs and whatnot makes it a lot less the person's job to try to navigate. So yeah, it's a they've done a really nice job with updating that Yeah. And then

there's the the newer eyelet pump, which I don't know how like readily available that is Yeah, but there's a pump that tells you you don't really need to do anything like you just tell it I'm having a what is it a normal large or extra large meal something like that and it's breakfast lunch or dinner normal? Yeah, small normal large This is breakfast lunch or dinner and it's going to dig make adjustments where you know your blood sugar's are going to maybe go up from that it's going to I don't even know what they're saying. Like, I think they're trying to promise in a onesie in the sevens. But still, for my opinion, if you're a doctor, and you've got somebody running around with an 11 a one see that you're just like, look, they're not going to take care of themselves. This is a this is a great idea. And I don't know where that pump is with Medicare. Yeah, I don't know where they're at with that. Like I know Dexcom is good with it, right, the CGM czar now Omni pod, I think has Medicare coverage. I think they all like probably do.

Definitely, yes, I've got a couple of people I work with on Medicare who are using tandem. But

then that's the next spot is that you can't just tell somebody, oh, you should get a pump. Right. Okay. Like, I don't know how to do that. Do you know how many people don't know how to? I'm not going to sit here and argue whether or not people should or shouldn't understand how to handle their lives. Okay, they should. But if they don't, that doesn't mean they don't get an insulin pump, or that they have to have an A one C and the elevens. I think it's got to be incumbent upon that the doctor to build an office staff that can help shepherd people through these things. No, absolutely

have an office staff that's knowledgeable in technology is really important. I think, you know, it's one of the it's one of the filters, that when you are searching out clinician who can help with your diabetes management. It's certainly one of the things that you can ask when you call to make a new appointment. How does your office navigate this? What technology do you understand? What's the especially if you're type one versus type two? How much of the clientele that you see is type one, right? The all those questions are a good way to filter when you're in the search for a new endocrine providers specifically. Because there may very well be some that are very tied to one pump, despite there being multiple options available. They have known and kind of gotten used to the one and they're very inclined to recommend that one versus the other ones being very likely just as good or maybe better for your personal need. Yeah,

at this point, too. There's, I mean, if you live in the Midwest, upper midwest, you're very likely are being told about a Medtronic pump, because the company's nearby there, and it's just sort of like a thing that's happened, right? I'm assuming back from Salesforce days where people were just probably working for the hub, you know, Omni pod is very sexy online. Like it has like a social media following Do you know what I mean? Like, yes, they have that. Like, you don't see people taking pictures of their tandem pump, as much as you see people taking pictures of their on the pod, which is interesting. You never see pictures of people with their Medtronic pumps. But I also assume that those are more like that slated and people who are like, well, I'll just take what the doctor tells me to get, and I'm not going to think about it again. But they're all different segments, I guess is what I mean, like in business, if that makes sense. Yeah,

absolutely. And I think sometimes to even in, you know, working with so many people, I've had people who were one pump for such a long time. And again, my job as a diabetes educator is to be able to help somebody with individualizing, their, what they need in their life. And we can say, well, you know, what, you've been using this, you're using it really, really well. But you know that this new product, think about these things in your life, this would fit you better, you're coming up for a new pump, you know, your end of warranty is coming. Research this, let's talk about this. And those are all steps that as again, a clinician, you need to have in the forefront of your mind whenever you're working with somebody. Because if you're not getting the results that you want, and they're complaining, because they're not getting the results that they want, but you're not changing anything, then you're kind of at a standstill. Something has to change. And it might be their technology. Yeah,

not very well could be also I think it's important to remember that moving from MDI, to pumping or pumping to algorithm pumping, feels like starting over to people, and they're going to be very, a certain kind of person is going to be incredibly resistant to that. And by the way, a certain kind of person is going to be like incredibly enthusiastic, maybe more so than they should be like, You know what, I mean, people, some people jumped around from devices all the time. But, you know, even if it's in your head, like, Hey, I think if you use the pump, like Jenny was just saying, we we'd see a difference here. And the person goes, No, thanks. I don't know. Like, I think he maybe should dig into that a little more. Because I know you're picking up the chart and going asked about a pump check. You know what I mean? Like, like, don't

don't do don't do don't just check a box. But there is your that's a great point. It's No, I don't think so. I mean, it begs the why, right. And if they offer some really good reasoning, I'm doing well here. I think I you know, I needed this there. Maybe there are some pieces that you could be more informative as to how could a pump actually improve some of the things that they're bringing in as concern? Right,

right. I'm also not talking about badgering people. I'm just saying that. I've just spoken to too many people who will eventually say my doctor asked me for years, and I finally broke down at Oh, I wish I would have done that sooner. Right. Absolutely. All the time. Yeah, not just about pumps, CGM EMS Paying attention to like the food I'm eating like like the Oh, I wish I would have paid attention sooner sentiment is wallpapered around diabetes, you know? And yes, what I'm saying is, is, is there not a way to say something, do something, ask a question that leads to people? You know, right, giving it harder consideration and moving. Exactly. Yeah,

absolutely. And I think your technology is, for those who are, who have grown in the years with diabetes, I think, if that hasn't been a discussion that's revisited recently, for somebody who's been using, as we said, more of a conventional pump, right? They've been on it. And they're, you know, they're doing baseline, they're doing pretty good. And they're kind of at this place of comfort. But there are some things that you can see could be better with some of the newer systems, sometimes, those are a little bit more in depth discussion of bringing in, hey, you know, I know you've probably seen this, I know, you've probably heard about this, let's have a discussion about how this could really be a benefit beyond what you're doing. Right. And sometimes that that's hard. The growth of technology is really, really, really moved in the past couple of years.

It's happening much more quickly now than it has in the past, which I think is also another reason why doctors are getting left behind and why I'm, I'm talking to people who are saying, at the end of my appointment the other day, the doctor asked me if I would stop and explain how am I pumped work to them? Which by the way, the person was not filled with, like confidence when that happened? No, there's there's a two headed argument there. At least the doctor asked, I maintain, they should have asked in a way that didn't leave the person going, Oh, my God, am I seeing the wrong physician? You know, yeah, because I can see the doctors perspective, by the way, like, you know, I don't know, I don't have diabetes. I don't know how this works. Can you show it to me? So Jenny, overall, we need the doctors to understand these devices, how they work, why they're important, how they can be helpful to help people get them, help them with their insurance, that stuff. And you know, make sure they have a choice. There's a lot of different options, those options work for other people for important reasons. Know what those reasons are, ask those probing questions, make sure you're getting them on a good device. And then I just want to add from the feedback that we got from people, Oh, yes. One person said that as an older type one, they equated a pump with being a bad diabetic, which is a term you hear a lot from people, you know what I mean? Like, and so, you know, that idea, like, cuz you know, what, from type two diabetes, oh, if you can't control it with food, then you didn't try hard enough. So now we're gonna give you a pill, oh, the pill didn't work? Well, you're gonna have to give you answered, you must have the really bad kind like that right? Progression or right

or failure, right? That really brings into the person with diabetes, I've clearly failed. And then you're on a slippery slope of getting them back up. And acknowledging this isn't a failure. This is progression. This is many times where things navigate and let's get you using what's going to be appropriate to improve and prevent further issues down the road. It's

another reason why the communication is so important. Because if you communicate failure to them, they might then start getting what they expect. And if they expect that they're failing, then they might let go of things, the amount of times that people just like throw their hands up, because they're so frustrated is true. So, you know, please let them know that getting these devices doesn't mean they're doing a poor job. This is going to help them experience something they didn't think existed, right? Not, you're doing a bad job, we need to do better. This is like, Hey, you should see what exists now, like, this is incredible, you know,

should be put out there as a step forward, not a step back. Yeah, it should be an example of, well, this hasn't been working the way that we wanted. But you know what, if we bring this into the picture, we're going to be moving forward with your health, overall quality of life, all these things that should be given examples as why it would be positive to include this type of technology. That's where you should be explaining things and coming from a clinician standpoint, so that you don't get that negative. Oh, well, I failed anyway, I guess I have to do what the doctor says. And then you do the baseline, right? You never go forward with asking for more information, because clearly, I've failed. I just have to deal with this new thing now and not learn any more about it. I'm gonna

leave this here at the end for anybody listening agenda. You can do this too, if you want to. I'm not pressuring you. I'm looking at my daughter's last 24 hours. She manages her diabetes the way I told her to she understands timing. She understands how insulin works. She understands how food impacts her. She's wearing a CGM and an algorithm. Her highest blood sugar in the last 24 hours was 154. That was a spike after a meal that lasted for no more than an hour and a half. And since Then her blood sugar has not been over 125 or under 72 For the last 24 hours. That's fabulous. That right there. That's an algorithm right there. Yay, no input, Jennifer, not like nobody's doing anything except announcing carbs and right. That's it, right. So please, if you're a doctor, and you don't know about this stuff, please learn about it. Because you could move an entire generation of people with diabetes, not forward, you can delete them. It's the difference between driving from New Jersey to Connecticut for vacation, and getting on a rocket ship and going to Mars. So,

you know, we talked to talk to clinicians about, you know, educate yourself, one one step of navigating education for yourself is get in touch with your area reps, get in touch with the clinical for all of the companies for these technology, you know, driven devices, and learn about them. Many times, they've got demos, they can pull, bring in for button pushing and whatever. There are even online resources like Dana tech for the clinical who, you know, if you look under their Panther services, essentially, you can look up all the devices you can play with simulated devices online. Yeah, I mean, they're wonderful resources for your reference,

whereas CGM, I mean, you can wear dummy, like, No, you can wear like a, like a Omni pod. That's not a real pump. That's just gonna give you the idea of what it's like to wear it. But you could actually wear a CGM and watch it work. Yes, that would be a big deal. And take a meter homes, you know, if you have to calibrate it,

and learn how the meter works. Yeah, learn how the

meter works. First, it really would be incredibly beneficial for people. Okay, gentlemen, thank you so much. Appreciate it.

Oh, course thank you.

Arden started using a contour meter because of its accuracy. But she continues to use it because it's adorable and trustworthy. If you have diabetes, you want the contour next gen blood glucose meter, there's already so many decisions. Let me take this one off your plate. Contour next one.com/juice box. If you know a health care professional that could use this series, send it to them, or anybody else for that matter. And if you're really enjoying it, please take the time in your favorite podcast app to leave a five star rating and a thoughtful review. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. Die diabetes Pro Tip series is available for you from Episode 1000 to 1025. And for subscribers in Apple podcasts. You'll get those same episodes ad free. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

Hello friends and welcome to episode 1130 of the Juicebox Podcast Welcome back to the Grand Rounds series today Jenny Smith and I are going to be discussing the humanity of type one diabetes, that healthcare is a human story. We don't want doctors to forget that part as they're helping us and treating us. Nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. When you place your first order for ag one with my link, you'll get five free travel packs and a free year supply of vitamin D. Drink ag one.com/juice box. Don't forget to save 40% off of your entire order at cozy earth.com. All you have to do is use the offer code juice box at checkout that's juice box at checkout to save 40% at cozy earth.com. If you're not already subscribed or following in your favorite audio app, please take the time now to do that it really helps the show this episode of The Juicebox Podcast is sponsored by the insulin pump that my daughter wears Omni pod, learn more and get started today with the Omni pod dash or the Omni pod five at my link Omni pod.com/juice box. This episode of The Juicebox Podcast is sponsored by touched by type one touched by type one.org. And find them on Facebook and Instagram touched by type one is an organization dedicated to helping people living with type one diabetes. And they have so many different programs that are doing just that check them out at touched by type one.org. So what are we doing today, Jenny? We are going to do? We're going to do a topic that I don't like, I don't like what I have typed above it is its moniker. So we have to like hammer this out. First, I just have the word humanity and mentality which, you know, aren't that descriptive. I think they're meant to lead us in a direction. But I don't know that they're a good title for an episode. So when you think about doctors needing to consider the humanity of the person that they're speaking with. And I think what did we mean by mentality when we wrote this down?

I don't know about mentality. But I do know, I remember sending you either an email or a text about us remembering to discuss that. Like healthcare is a human story. It's not just all about data, it's not just all about numbers and lab results and that kind of stuff. There's, there's a person behind all of this, and you have to remember that maybe in their you know, when you're talking to them, how their mental health is affected in the way that you discuss something with them,

right. And when you talk about that, it makes me want to expand on that. They're not just, they're not just the person that's in front of you. They have relationships and responsibilities and other problems and joys in their life and all these other things. And you're asking them to do this incredibly, a difficult and time consuming task that feels like of course, you know, the outcome is life and death, you know, to them, of course, and, and they need to go fold this in to the rest of their life when they get home. You know what I mean? You can't just I don't know how they how you, you know, I'm saying

and folded it in a way that's very, it's not like folding in a medication for your heart. Right, right. It's not like taking a pill every morning at six o'clock and be like, Oh, that's it for the day. Not until six o'clock tomorrow. Do I have to take another medication? Right. folding this in is really like it becomes a piece of you.

Yeah, yeah. You have to like Teach them that the routine is what makes it feel like take a pill at night am like so like What do you mean what I mean by that is sure it's simple to send someone home and say take one of these you know dinner, make sure you eat first. Great, right? Even by the way people have a hard enough time with that.

Right? Absolutely. Thus the pill minder apps and all

with the days Oh, by the way, the first time you get a pillbox is my experience, but you go ooh, I'm old. Damn. It happened. I have a box with my five Consider, but yeah, like people have a hard enough time remembering to take a pill with a meal. And then one miss day turns into two miss days. And then that thing happens. I watch it happen here in my own house sometimes. My daughter said to me the other day, she takes vitamin D, she needs to write she has to her vitamin D level drops without it. And she misses it for a couple of days. And she goes, I haven't taken this in a couple of days. And I feel fine. Right? Yeah. And I'm like, well, that's not how that works. But what happens when I don't Bolus for my meals, but my blood sugar goes up to 200. But it comes back down, but I feel fine. And I feel fine. Right? Yeah. So okay, so there's that part of it, why don't we go through some of the feedback, and we'll find out as we go. The first thing is from a listener that says, this can be very difficult, and mentally and physically exhausting. And you and I kind of translated that into like, you know, offer people grace, which I know is a is a hot thing to say nowadays, you know, to give someone grace, but what do you think that means for you? I mean, you're personally diabetes, what are you looking for from a doctor?

Right. So you know, from a doctor, the piece when I talked to my Endo, especially who's she's super great. And even her nurse practitioners really nice. Grace is not being nitpicky, from their angle of picking out just the one particular day, which was just your like, Crap show of a day, right? Well, what happened here, like, clearly, there's a wider picture. And as a clinician, you can see the scale of how things have been. So instead of picking things apart, you do have to give a little bit and if something is brought up, in that case, by the person to say, Hey, don't pay attention to this, or, you know, I was on vacation for these days or whatever. But you do have to have a little give and take back and forth in order to work together, you know, person with diabetes and care team. I mean, my doctor always asks me, What is it you know, we need to pick apart today, what is it that you really need from me today? And I think they are as a person with diabetes, you have to be ready to come to your clinician as well, with some thoughts

that they ask you. You're a person who people come to and ask that question of all day long, like help me, when you go to your doctor, you ask them for help. Today's episode of The Juicebox Podcast is sponsored by Omni pod. And before I tell you about Omni pod, the device, I'd like to tell you about Omni pod, the company I approached Omni pod in 2015 and asked them to buy an ad on a podcast that I hadn't even begun to make yet. Because the podcast didn't have any listeners, all I could promise them was that I was going to try to help people living with type one diabetes. And that was enough for Omni pod. They bought their first ad. And I use that money to support myself while I was growing the Juicebox Podcast. You might even say that Omni pod is the firm foundation of the Juicebox Podcast. And it's actually the firm foundation of how my daughter manages her type one diabetes every day. Omni pod.com/juice box whether you want the Omni pod five, or the Omni pod dash, using my link, lets Omni pod know what a good decision they made in 2015 and continue to make to this day. Omni pod is easy to use, easy to fill, easy to wear. And I know that because my daughter has been wearing one every day since she was four years old. And she will be 20 this year. There is not enough time in an ad for me to tell you everything that I know about Omni pod. But please take a look. Omni pod.com/juice box, I think Omni pod could be a good friend to you. Just like it has been to my daughter and my family.

Absolutely, there are things that I bring in as questions in my I've gotten to the point of knowing that my questions really have to be what I can't do myself or what I've got relevant, like questions about that I'm not able to take care of because my own diabetes management clinic. I don't really need my endo for that. But there are other pieces to that other considerations, especially as you get older, when to have these types of evaluations for like heart health, and this type of an evaluation for this firm, Women's Health kind of perspective. And those are all things that I expect them to have a good answer, not that I have no clue about them. But I want a little bit more direction. And so I can come to my doctor absolutely with questions. Do I send even though I look at my own reports, I send my reports to my doctor because if they don't have in between information to keep up with things, then it's kind of like a load that you're piling on their plate, three, six months worth of data and you expect them to figure something out about it. Right.

I'm glad to hear that that's your answer. But I also wanted to ask the question to point out that, you know, for all the people who you're like, Oh, they're a nurse, they understand it, or that person's a doctor, I don't need to explain this to them. That's not the case normally. So you know, you can't just disregard somebody because you think they might understand it's right. Yeah, I think that's important. Also, isn't it interesting. When you show somebody a report a graph with, I don't know, a one seat, it's in the low sixes and not a lot of variability and looks great. But there's a couple of bad days here. Why is it your thought to say, Oh, my God, what happened here? Instead of? Wow, so much of your time is so well managed? Congratulations. Like you don't I mean, like, you picked up the one problem. That's what the person remembers when they leave? That is, yeah. And it

is human nature to pick for the bad. Like, you see, I do it a lot with all the people that I work with to, you know, they come in either having emailed a bunch of things that they definitely are, we got to zone in on this, you know, and whatever. And I see those questions, and they're important to address. Absolutely. But I also really tried to look at the wider scope, and say, if we could filter out these, these incidents that you think are the majority of the time, you'd actually see that like, 80% of the time, you're doing a phenomenal job, like look at all of this, and these little, these little blips that you don't want, that have become what you're highlighting. They're not the big picture.

It is fascinating, isn't it? That as people it's not our inclination to, to gravitate to the things that are going well? Yeah. It's just really, it's not it's not the only place that happens. But it's one of the places where it's, it's really important. So if you're a doctor, and your mom always picked on you, like, don't do it other people. Oh, I mean, I wish all my doctors respected my desire to understand my disease. And there are treatment options. So this is a person telling me, I want to be included in this. And it's not enough for me to be even doing well, I need to understand how we got here. Right? Yeah, I need autonomy. I need. Because that's not just about management. I think that's about psychological comfort to it is

yeah, absolutely. And I think that all goes along with meeting the person where, where they are, as well as where, what are their goals? What are your targets? You know, I as a clinician may have targets and ranges and things that I want to help somebody get to. But you have to know where is the person starting? And what what are their immediate goals? And how can we bring things together so that they kind of both meet in the middle? In a way, right? And understanding is a big one, then, for people who have this particular goal, and you really would like to see them get a little bit further. What do they understand about how to get there?

I think that maybe far too often, a doctor or it doesn't have to be adultery, any personal interaction, right? between two people. I have an intention about what I'm saying. And you hear something else. And listen, here it is bare bones. It was pouring rain here last night, and it's trash tonight. And my wife had thrown a bag of garbage on the back step. And that's not the direction of where the garbage gets taken out. So it's raining, it's late. I'm like, I gotta take it. I waited all afternoon thinking it would just stop for a second. So I could just bet Okay, now I'm all bundled up and everything. And I say to my wife, I'm gonna get wet, and I am complaining. I'm like, I'm gonna get so wet. But anyway, I'm gonna go out to the trash. But I'm gonna walk around the back of the house to get this one bag of trash that she put out back. Instead of bringing it through the house. It's been outside, it's been raining, and she's mopping the floor in the kitchen. So in my mind, what I was thinking was, I don't want to bring the bag of trash to the house because she's just mopped it. I don't want to make a mess of it. But when I said, Oh, I gotta go all the way around the house to get the bag. I'm gonna get soaked. She thought I was complaining about the fact that I was going to get wet. And I was confused. I stopped and I was like, Wait, what's happening right now? Like, I'm seeing this nice thing. And she's taking it wrong. Or maybe I'm saying it wrong. So I stopped and I just said, Hey, I want to be clear. I'm not upset about getting wet in the rain. I'm trying to save the clean floor that you just made. And I'm gonna go back out. When I said I was gonna be all wet. I meant I didn't want to walk all wet through the house. I'm trying. I'm trying to respect what you're doing. But that simple little moment between two people who've known each other for like 30 years, there was that confusion. So when you look at a person and in a healthcare situation, they go Hello What happened here? Right? You might mean, hey, this graph looks terrific. We just got one little problem. Let's fix it. Let's fix. You didn't say that the way it's taken. Yeah, right. So you didn't say that, or they didn't hear that one way or the other. If you walk away from that conversation having not clarified, you now have a problem. And you'll never get you'll never get rid of it again. So

well, and I think what you really what you just sort of pulled all together, without probably thinking about it is the word communication, right. And that's what all of this, all of these that we've kind of put together. Now, they're all about the right type of communication. And communicate communication means that there is an understanding from both parties. And as the clinician, you have to make sure that what you're trying to either teach or discuss is not only being received the right way, but also that there's an understanding that's taking place so that there isn't miscommunication where somebody then gets irritated or angry or walks out. Thank you. Ah, I didn't get any of my questions.

Right. Here's the next thing on our list. Let me see if I'll say something, you tell me if you agree with it. Okay, if you're a type two, using insulin, or you have type one diabetes, your management is pretty much the same. take insulin, big picture, not very, like not granular big picture, you're gonna take insulin for food, you're gonna have a background insulin, pretty much the same. Yes, you and I talking about it here. We get what we're saying to each other, right? Yes. But if you say it like this to them, This person says, I was told by my endocrinologist that it didn't matter if I had type one or type two, my treatment would remain the same. He asked me why it mattered to me. Why does it matter to you, if you have type one, or type two diabetes? It's going to be the same either way? I wouldn't have said that to a person. But I was comfortable saying what I said to you. Right? You know, like, why would you add on that little thing? At the end? Why does it matter to you? I almost cursed who would say that to a person. It matters to me, because it's me. Because

it's me. And because I think that that clinician is also missing the grander picture of we know, in the diabetes community, despite many people not wanting lines being drawn, there are very hard lines drawn between I have type one, no, I have type two, and the community is learning to work or the communities are learning to work together, which is great. But there still are very drawn like, no, no, I have type one is not type two, and that clinician

is not seeing the picture. Yeah, well, you know, I'm probably gonna say something I don't mean to share with people. But whatever I'm trying to help. So to Jenny's point, I've tried very hard, I've had this podcast for like, 10 years now. And I've tried very hard to have a one tent mentality about diabetes. And I do it pretty well on Facebook. And I do it pretty well, here, I don't have a ton to share about type two. But you and I put together a really comprehensive Pro Tip series for people with type two diabetes, a great primer, something get you going if you don't understand that your doctor is not being very helpful. And Jenny knows this, and only a few other people in the world know this. But I knew when I was producing that material, that I was going to lose a certain percentage of my listeners for presenting type two material. And I did, I

put out a type as you've been seeing mainly as a type type one. And

but I think, moreover, that there are a number of people with either type one or type two diabetes, that do not want to be associated with the other side. And so most of 2023, I spent rebuilding the listeners I lost from just offering type two information. And by the way, don't get me wrong. It wasn't like, here's three weeks of type two information. It's in the course of a five day period, which I put out five episodes, for like eight weeks in a row, one of the five episodes had type two information. And it angered or annoyed people to the point where I lost, I think about 600 listeners, right, which is good. I think

it had started as you kind of mentioned with the comment from this clinician to this person, right? That's unfortunately that's where it kind of gets lost is how you're maybe how you're diagnosed or how you're told about it. And honestly, the lines in terms of the types of medications now are very blurry between type one and type two. Yes, there are some very well and very specifically defined meds that are really type two or the reason and the how they were in the body that you wouldn't use in type one diabetes, right. But now a lot of the meds that are available despite them being classified or whatever, you know, prescribed as a type two, they're finding an awful lot of benefit in type one. And so I think we've got this line that's getting blurred, that despite being two distinct conditions, for different reasons, management is kind of crossing over, honestly.

Yeah. And I think what Jenny's saying, like, without saying it is that you're gonna see GLP medications used more frequently with type ones in the future. Yes, I'm gonna have people on the show this year, handful of people who are type ones who, you know, maybe started for weight reasons, they got weak ova or something. And then they started seeing all the impacts on their, on their health. We're seeing people using it for like, PCOS symptoms, and they're having a significant reduction in their insulin. So yeah, it's possible that maybe this issue goes away moving forward. But for the moment, just look up, see sports, politics or anything else. People like being on a team? And yeah, you know, so and by the way, that part of the conversation aside, how about, he asked me why it mattered to me, that might not have nothing to do with that person wanting to be on Team type one or team type two? And maybe it's just I'd like to know what's happening to me, please. Right. You know,

and honestly, as we've said, there are now I just said, there's there is a distinction between the reason between type one and type two in the majority of cases, right? And so for somebody to say, Well, I just really want to be in one or the other. Because there is a different community aspect, as well, in either one or the other.

How about I'd like to look out for the rest of my family and see, you know, maybe I maybe I could be going back to my sister and saying, Hey, listen, you have a kid, like, look out for this, because I have type one diabetes now or, you know, who knows? Like, there's so many reasons why. I have some feedback here that says, I want the doctor to know that when I go in, in with a problem, it isn't always related to my diabetes. So that point is a good point. But for this specific conversation, I think what that means is Don't look at me and just see diabetes, please don't go, oh, that's a diabetic. If they're complaining about this, it must be because they have diabetes. Maybe it will be. But I think you make a mistake when you do that. And I can only relate a personal anecdote. But when my daughter was young, I taught myself. This was before CGM, so she'd come home from school, I didn't know where her blood sugar was. I was worried out of my mind, about the 20 minutes that was between when she texted me, I'm getting on the bus and my blood sugar is this. And when she actually got home, I first had to stop myself from standing at the door, like, oh, my god, are you okay? You know, and then I realized I can't ask her what her blood sugar is, when she comes home right away. It's dehumanizing. It really is. And you you might not think it to hear it out loud. But it is you are it's a dehumanizing thing to have someone look at you and say, What's your blood pressure? what's your what's your blood sugar? What's your but like, it's like, I'm a pull person here, you know, and so I take this person's point. But in that specific example, if someone comes to you and says, I'm having headaches, don't treat them like a diabetic having headaches. I mean, maybe you can in your mind and like be looking for things. But also they get real people sick too, which is a thing. People with diabetes, say because, right, it's so misunderstood, you know?

Well, and those are the cases that I think some people because they have gotten to have a relationship with their Endo, and maybe don't really use their primary care as often because they just don't get sick, or they don't have some of those minor things, sometimes a lot of endos or endocrine nurse practitioners or whatever, they may actually feel some of these questions that are, I've got a headache. And so they are in one particular field of care, you know, diabetes, and obviously the other kinds of things endocrine takes care of, but they have to think first is this relative to diabetes. So those questions may come out from the clinical side of consideration. But then their job is to also say, you know, what, everything looks really great, you know, in in your numbers in the data that you've given me, and I think that this is a consideration for your primary care. I'm going to refer you back here, or I'm going to refer you to ask for this type of, you know, clinician to seek out and get information from because you can't expect your endocrine team to manage all of your questions. Their job is to consider will this have impact on your diabetes? And if not, I'm going to refer you. Do you

know that there have been times We've taken my daughter to a specialist for something else. And I'll tell her when we go in, do not mention your diabetes. At first, like, let's explain what's happening, get their unbiased opinion of what you've said. And then we can layer that on afterwards. But that's just I've just found if you walk in and go, I have type one diabetes. And that's it, you're done. Like, they're going to just their brains gonna checklist down, find the thing that fits and not bother thinking about your issue. Now you tell them at some point, but I'm like, let's get it out first, and let them really consider it. Right, you know, they'll get a confirmation bias, and they won't even know what's happening. Right? This is something this person says, I wish that my doctor understood that shaming and judging me and other patients for not checking our blood sugar as frequently as they think we should, is absolutely not the way to get them to check their blood sugar more often. It makes me resent coming to the doctor.

And from an explanation standpoint, or a clinician, again, there you are, it's really important for you to explain more about why you're asking for this, right? Not the blame game of, well, why aren't you or I don't see enough information here. It's what's going on? That's a problem. Right? What else in your life is kind of deterring the ability, you know, to get this information, and from a clinical Is this the reason this would be really helpful, you've brought in these other questions and these other things that are bothering you. And if I had a little bit more information, I might be able to say whether or not diabetes is really a piece of this or not, right? So,

you know, it occurs to me while we're talking that if if you are listening to this, and you don't know you and I, it could almost seem like we're doing some Ultra woke like, be nice to me or like, you know, we're not, we're not, we're trying to sit, we're trying to say, the way you start is the way it finishes. And that people are going to be obviously unique and different and hear things in a ton of different ways. But there is a way for you to approach everyone, whether it's, you know, me or you or a little kid in a way that you can get the information you need from them, help them and not leave them in a situation where they're resenting you as they're walking out of the office. Like, even if you're right, like, I want to say that like even as a doctor, if what you're hearing right now is I need to know how often they're checking their blood sugar. This is very important. I think it is too. I'm not saying it isn't? Yeah, I'm saying that the way you get that information can go a long way towards building a good relationship. And by the way it you know, it might sound like I don't have time to figure out every person that comes into this office, I know exactly how they want to be talked to. But that's not really the case, there is a way to approach this, that covers everybody. And you don't have to have 1000 different statements to get you to your answer. There's there's ways to talk to people where you don't leave them feeling badly about your interaction. So that's what I'm talking about.

As a clinician myself, I always consider it from how do I want to be approached when I come in for my own visits, right? And, again, the reason that I like the team that I work with is because it always seems to start the way that I actually start a visit or a conversation with the people that I get to work with is like, how are things tell me about your family? And what's going on? And like, oftentimes, like the first five ish minutes or so is just how are we like, how are things going in the past month since we last talked or emailed or whatever. And that's what I expect when I come in, you know, I know clinician visits in office, they're limited in time. So there's only so much that you can expect them, you can't give their whole life story for three hours. And then finally get to what you need to get to. But there is that human side of connection, that may very likely open the door to them providing enough information for you to then give them what's really important.

Well, what you end up giving them eventually to is this autonomy to make decisions? Yes, which is what you want, you know, you want to give them confidence, and enough tools. And you know, like lead them in the right direction. Once they go do something and watch it go well, and then they get excited and do a better job. And then before you know it, it's commonplace, then they're just going to be in there asking you for their prescriptions, and hey, how are you? How are the kids and let's go, and everybody's healthy and happy and what you want. It's doable.

It is doable. And I think that those tools, you made a good like connection there and those tools that you may use to give somebody they change based on the person. And if you spend even five minutes in a visit, in which you start to get to know somebody's life, and what's going on the tools you pick out of your toolbox to help them they're going to be specific Add to that person's need, you're not going to tell them to do this when their time constraints are ridiculous in their day. And even though you want them to do something that's time consuming, you can now say, okay, they don't have time for this, I have to, I have to figure something else out, that's going to be relevant to get them to do what I think is important, but that they can do they

need a win, too. They do. They need a win to build on, everyone needs a win to build on. So you got to you have to find a way to give them one. It doesn't fit here. But I just had an experience with somebody yesterday. And that's what I figured out. I was like, she's just she's drowning. Like, she just needs to take four breasts in a row where she doesn't feel like she's drowning, and it's gonna get better. And I'll tell her this one little thing that will move her in a better direction. And sure enough, two days later, the content and tone of her message. This is by the way, I'm not even speaking to this person is just typing the content, the tone of this lady's message shifted in 48 hours, and now she feels empowered. That's it. Right? Not that hard. By the way, this one is written like it's from a listener, but I think this is huge Eddie. Oh, don't tell your newly diagnosed patient that you need to see them again in three months only for them to go out to the counter and find out you're booked out for five months. Yeah,

that's really annoying. Yeah, it is. And I think it's the reason that many offices, again, endocrinology, specifically, there are not enough endocrinologist, there are just not and when you break it down even to pediatric endocrinologist, they're even less, right. And then thankfully, we're now bringing in more nurse practitioners and PAs into endocrine practices. So that, you know, if it's six months until you can see the endo will maybe in three months, you can see the PA or the nurse practitioner and you do kind of a handoff back and forth every three months. But you're you're right. I mean, if you've been told to check in, and the check in point is going to be six months down the road, instead of two or three, you're left hanging in this in between void of, well, who is going to help me here? Am I even gonna get an answer back is somebody going to look at my information? This

is Jenny talking about it from like a maintenance, like a management perspective, I'm going to talk about it from a psychological perspective. You just told me, it's very important for me to come back in 90 days, then I walk outside and the girl that things like we can see you in June, I was like, June, it's December, she said for me to come back in three months, we can't do that, right? Is that important? Is something bad gonna happen. She said, 90 days. And you leave people in turmoil, always causing them turmoil and churning up their guts and then sending them on their way to be by themselves. It's confusing very much is, I wish my doctor would not have connected food with guilt, because that was a mistake that lasted a lifetime. Yeah. So it does suck. But as bad as that is to do to a person who doesn't have diabetes and isn't using insulin, it's maybe 50 times worse to do somebody using insomnia, you freeze them. And either cause I mean, you cause an eating disorder in one way or the other. They either restrict their food, or they just go woohoo, I'm not going to pay attention to this. Right? It's terrible. Like you can't do that. There's a

and a major, a major part of your diabetes management is tied to food. It's insulin. Right? So now that you've tied this piece that's necessary, I mean, two pieces that are necessary for human life, right? We've got food, it's a basic necessity, we have to have food, not too much, just enough. But you have to have the insulin to get the food in the right place in your body. And so now when you connect them in a negative way, they say, Well, you know this all about this food, and oh, there's too much here and oh, look at that. And all these blood sugar changes that we don't want to see. Oh, this must have been a really horrible meal. You see, though, oh, that was the bring in? Well, gosh, should I just eat lettuce or nothing at all? Yeah,

there's an entire movement right now of us identifying a problem. And then blaming the person that's happening to you could ask an eight year old at this point, what's the problem with food and American? They're gonna be like, Oh, it's processed and not good for me. Blah, blah, blah. And then you know, you go don't talk to my kids. Your kids don't know Jenny, raise those kids. They think a carrot is candy. And so but but you know, most people are gonna say, oh, yeah, I know there's a problem in the world processed food, fast food. It's troublesome. So much soda. You know it, our bodies can't handle it. Everybody understands it. But then when you get to the How to functionally help somebody, that's their problem. They're eating it. Have you ever driven around America and tried to stop and getting some deed? Good luck finding something I'm using we go V for weight loss. So now all of a sudden, I realized that in the past, if I was traveling, I would just eat what I could get my hands on. Even if it wasn't something I would Normally, but now I'm very careful not to eat like high, like anything that's fatty or greasy, even once in a while. And I have found myself going, there's nothing for me to eat here. And then going to another place and going, there's nothing for me to eat here, there's no food, I'm gonna have to go into a grocery store and get an apple. I can't physically walk it. We've set up a society, where this is how food has gotten restaurants, convenience stores, those sorts of things, and then fed people a ton of bad food, and then told them in the end, it's their fault for eating it. It's all they have. Right? You know, so I don't know how that happens. Like, how do you say to somebody, or you live in a volcano, your problem is your feet are hot. Thanks. Can I suppose to do with that? You got shoes that don't get hot? Can I? Can you hang me from the ceiling? Is there a like, don't tell me the problem. I know the problem. Give me an answer. Anyway, that's

no, that's 100%. Correct. And I think there are too many. I mean, this is a hot, this is a hot sort of piece in my mind that it bothers me when when clinicians who have no nutrition educational background, dole out blanket statements. Yeah. Right. Because one, you have to be blind to be completely or, you know, unaware of what's going on in our food society. The majority of the stuff that people call food, or that is readily easily available, is it's not hard, right? And I wish there was an easier way to define it. But it's also the reason when you go in a grocery store, the grand majority of that grocery store is not stuff. That's really great for anybody to eat. The tiny little natural food section.

That's the food. The rest is tastebud Playland there. Yes. Yeah. But but that's fine. But then don't as the doctor slip into bro science and be like, it's your fault. Right. Great. Thanks. Do you want me to do I make $250 a week? Could you help me? Yeah, hey, I don't know what to do it anyway, it's you're blaming people for a thing that you can say they're in control of, but if you look at the big picture, they don't have any. Yes, they're in control, but they don't have any choice. And so it doesn't matter. They're doing the thing that that's keeping them or at least they're eating, and they're staying alive. You know, and they probably were brought up thinking that it was good. Anyway, cheese. All right, now I'm all upset. Don't tell people they're non compliant, there's a free tip. You can think it if you want. And I know you probably have to chart it for, right, but you can't let them say it either.

Well, and that's the thing too, with today's you know, II charts and everything that are readily available, and even electronic medical records that now we have access to as the person who has the health condition, right? When I log in, I can absolutely read everything that was written in the doctor visit, right. So I think that word in an overall it should be totally removed. Because I think there are very, very, there's a very minimal amount of people who that truly would even apply to, and even that minimal amount, it's very likely the fact that they're not, they're not by choice, non compliant. It's there are things in their life, that are not allowing them to know enough about what to do, even in the simplest way that could make things better. And that's your job as a clinician again, to get to know them, and figure out how to help,

right. And also, by the way, there are going to be times where you give information to a person that knows better than you. And then you think they're non compliant for not listening. And if you think that's a crazy statement, then I'll introduce you to the 1000 people who've told me that they've lowered their a one C safely and in a healthy way and then go on to the doctor, the doctors tried to tell them to put it back up again. So you know, that actually happens to people as well. Caretaker burnout, you should include that conversation when you're talking to parents or people who are helping adults with diabetes that this and this kind of leads into the other part I want to I want to finish up here with is that I understand that the doctors might be burned out as well. Yes, you know that they have this compassion fatigue, maybe, you know, and that it's hard to like, I would imagine it's hard every 20 minutes to be like hey, how are you? What's going on with the family? You know, like I just did this with the last person being so needed like that being so needed from you not fake by the way if you fake happy people read that in two seconds, like Oh, absolutely, yeah, you can't fake the happy like you have to really mean it. And you have to have if there's good communication skills, and you know all For people real empathy, not like, right, you know, I know I'm supposed to say I feel bad for you. I know this is hard, but you know, and

something that I've found to within that realm is the ability, the ability of the clinician to connect as a person to. Right. A lot of times, we've heard that term like white coat syndrome, right? And to take that down a notch and bring a comfort level in, when you're asking about somebody, many times they'll ask, well, how are you? And that's not a well, how are you? I just want to know that you say, Well, I'm okay today. Most often, they're really they're interested, right? And if you, if you give yourself a personality, or if you give a little bit about you, and how your life has been and whatever, you don't have to give where you live and where your kids are going to school or anything, buy real, something, something real, something that's that's connectable, right? That makes you, I guess, and the information you want to provide a little bit more receivable.

Yeah, sure. You be a real person, although, yeah, some of us are going to run into doctors who are fantastic doctors, because their personality lends themselves to understand science and sit and study for years and everything. And maybe sometimes that doesn't lend to like, you know, personality, personality. Yeah, like, like, like a real life. Not that they're terrible people, but they just might not be like gregarious, and, and inviting sometimes and stuff like that. I mean, it can happen to anybody, but I'm just saying, I've met a couple of doctors who were brilliant doctors who, you know, you're in there, you're like, oh, was this heart? Yes. Great doctor, but hoof. I mean, what's the way to say that like, no bedside manner, what that really means is they lacking communication. But I don't come in and say, Hey, I fixed your toe, I put the ligament back on there. Let's do the exercises come back in six weeks, it's gonna be fine. You know what I mean? Like, this is a bigger thing. It's a lifelong thing that this last little bit here is this person says, sometimes it's like, they don't realize that I've been living in this body longer than they'll ever spend hurriedly glancing over people's notes while rushing into an office to talk for five or 10 minutes. Yeah, don't minimize my experience. You know, and I don't believe a physician rushes in and out, looks at your notes, tries to help you and thinks I'm minimizing this person's human experience. Right? They don't think that but no, this is how it's received. You just wouldn't know that. So in the end it Jenny, this is why you'll hear people say over and over again, if you can find an endo who has type one diabetes. Bolus? Yeah, yeah,

absolutely. Or, you know, a clinician in their office that they are using for their education piece, right, either a certified diabetes, you know, educator or they're working with a, an, even a dietician or a nurse in their office that participates in some of the education that they have type one diabetes, and those are the ones that I hear from, in terms of the people I work with that I really love my office because of this one person, right? They really get it or they're always taking my calls, even though I know I call a lot. They're taking my calls, and they're getting me some information or some answers, you know, so, listen,

I've heard this story a handful of times. And it's always lovely. It's like you said, like a nurse practitioner who has type one, or somebody else involved in the practices in the room, maybe when you're talking to the NFL, and they'll walk you out and down the hallway. They'll lean in and go Juicebox Podcast, and people and people people go want to go you want to listen to the podcast, it's called juice write it down juice by know what the doctor just said. But listen. So yeah, having somebody who really gets it is very helpful, but I appreciate you doing this with me. Thank you very much. Thank you. A huge thanks to touched by type one for sponsoring this episode of The Juicebox Podcast. Check them out on their website touched by type one.org or on Facebook and Instagram. A huge thanks to Omni pod, not just my longest sponsor, but my first one Omni pod.com/juicebox If you love the podcast, and you love to Bolus insulin pumps, this link is for you omnipod.com/juice box if you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes if you're looking for the diabetes Pro Tip series, it begins at episode 1000. In your podcast player or you can find that at diabetes pro tip.com or juicebox podcast.com. Thank you so much for listening. I'll be back soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way. recording.com

Hello friends and welcome to episode 1139 of the Juicebox Podcast Welcome back to the Grand Rounds series today Jenny Smith and I are going to be discussing the communication needed between doctors and patients. Nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan. Don't forget to save 40% off of your entire order at cosy earth.com. All you have to do is use the offer code juice box at checkout that's juice box at checkout to save 40% at cozy earth.com. When you place your first order for ag one with my link, you'll get five free travel packs and a free year supply of vitamin D. Drink ag one.com/juicebox T one D exchange is looking for you. They're looking for US residents who have type one diabetes or are the caregivers of someone with type one to fill out a short survey, T one D exchange.org. Forward slash juice box. When you completely fill out the survey, you're helping people with type one diabetes, and you're helping to support the podcast. It only takes about 15 minutes T one D exchange.org forward slash juice box this episode of The Juicebox Podcast is sponsored by us med U S med.com/juice box or call 888721151 for us med is where my daughter gets her diabetes supplies from and you could to use the link or number to get your free benefit check and get started today with us met. This episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. Learn more and get started today at contour next one.com/juicebox. Jennifer, welcome back to the Grand Rounds series. Today we're going to talk about communication.

Yay, yeah, let's say munication. That's a broad topic.

Well, we're gonna we're gonna lean on listeners a little bit for this one actually, maybe a little more so than we have in the past, we have a lot of feedback from listeners about what they wish their doctors would do regarding communication. So I'd like to step through it. Yeah, it's kind of a long one. So we'll jump right in. The first one here says I want my doctor to know that I am an entire person who has diabetes, not a diabetic. And that this is not my entire life. It ebbs and it flows, my controls are normal, and they're okay. And in the end, I need to be treated like a person. And I think that's a good way to start. Because, you know, you and I were just speaking before we recorded and we probably should have just said this while we were recording, so I'm gonna bring it back up. Doctors need to talk to you, like they're real, and understanding how to communicate with people and be human and reflect while people are talking, not just talk at them, but see what they're going through. And respond to that, you know, instead of just yelling orders be more collaborative, I guess is the way I would think about it.

Right. And in that collaboration, what you're going to take away, whether you're a doctor, or an educator or a nurse, or you know, whoever is the clinician, that the person with diabetes trying to interact with, they, they need to take that all into consideration for the data that the clinician is looking at, because that data is only truly numbers. And those numbers translate into somebody's life, and why they look the way that they do like you said it might be I've had a really great couple of weeks, everything's been lovely. I had a week off, you know, from my job, I got to relax, I didn't have any crazy, I have to go to school because my kid got in trouble. You know, all the variables that could sneak in, everything was calm, whereas two weeks prior to that, maybe everything was hitting the fan, right? And so, as a clinician, if you're not asking or learning how to communicate on a personal level, you're gonna miss why the information looks the way that it does. If you're really just looking at it black and white people aren't numbers.

I don't imagine that anybody listening has never been in the situation where you kind of look up one day and you think I haven't cooked a meal for myself and days. Like I've been eating leftovers or I stopped on the way home or I did something like that. It builds on you. You don't recognize that you're out of your rhythm. Yes, right. And then if you to go look at that weak of blood sugars and say, I see a lot of spikes here, there's some lows. And you know what happened? Right? That what happened? First of all is mind numbing. Like, I don't know what happened, it was two months ago. That's that's the first problem with it. But the second problem is, even if I could remember, you've probably looked at the chart when Oh, that's the week that I wouldn't put two and two together, I wouldn't say oh, that's the week I stopped cooking for myself that week, because right work was hard, or to feel that humanity is important. Because otherwise, what you're saying is, Hey, what did you do? That's how it feels. And you a don't know what you did? And B, you were trying the entire time, like that, I think is the that's where the damage point comes in, is that these people are working really hard. And trying to do well, it's not going their way. Okay. But instead of saying, What did you do, do better? Find out what happened, if they don't know, then just say, look, let's just look at the graph and see what we can do here. You know, like, Let's offer a suggestion, if you don't have a suggestion than asking what happened is almost cruel. You know what I mean? Correct? Yeah, absolutely.

Because oftentimes, whether the person with diabetes voices that or not, they are coming in, because there is something that is often not going 100% The way that they want it, they may not know themselves, how to communicate that back to you as the clinician. And so for you to, it's almost finger pointing, and it's a blame scenario, when you're saying, Well, what happened here, pointing your finger at, you know, one, high blood sugar, one really extreme low blood sugar. And again, the person may have no idea three weeks ago, what happened. But if there's a recurring theme, then your job as a clinician is to help figure that out, and give them suggestions. And be able to say, Well, I see that, you know, every three weeks, you've got this big project that you're trying to do with your business. And I can see that this translates into meals that aren't, you know, as timely or a lot of stress that keeps things high. Why don't we try this, I can see that this variable is hard for you to make it better and maybe make you feel a little bit better, better, you know, looking blood sugar's would help in this scenario, let's try this, try this setting change, try, try to, you know, have meals ordered at regular time. So they come to your office or give them a solution that they can start with, I guess,

something that is clear, concise, and you know, is going to reasonably speaking work to because I think the other problem can be is when you just start like spitballing and they go home, like you knew, you know, hey, the guy said, you want to go home and you you put it into action, it doesn't work, you're like, well, he doesn't know what he's doing. And I'm still lost, and he's gonna yell at me when I go back again. And even if you're not yelling at them, they feel like they're being yelled at. Right? So it mean, I have a pretty big personality. And I still have been in that doctor's office, and I'm like, Oh, my God, like what's going on? Like, you're coming at me? Like, I don't think she was coming at me. And I think I was somewhere deep down. I knew I'm not doing well at this, you know, like, Arden was little I didn't know what I was doing yet. And any kind of feedback felt attacking because I was I was vulnerable. You know, like, I was in a bad spot. I didn't know what I was doing. I was pretty sure I was hurting my daughter. I was starting to think about long term stuff. Short term, you know, was a mess. And then that's where I don't know. Like, that's where that part of the doctors thing is so important. Like, it's how they approach you. It's like coming at a I don't know, it's like to care approaching a stray cat like kind of very slow. Yeah, exactly. I'm here to help.

Right. And when you when you first come into that, that office space with the person who has come in, they've made their appointment time, and they made the time to bring in some records and reports and whatever your question to them is, I'm always asked, I mean, this is my no one. But well, how are you? Do you have time to hear how I am? Like I could I can tell you how I am right. But what is important right here. And now for you to know about how I am what are the biggest things and this goes to the person with diabetes. It's what are the checklist things that are really, really important so that when they say, how are you you can say, well, I'm okay, or I'm doing really great, I've changed this, I've changed that, you know, this is looking much better. So there has to be enough communication to really, to really, I guess, give to that question of how are you? And you have to be receptive of it too.

Yeah. In my mind, you need to hear people and really see what's going on with them. And at the same time, you need to be a leader, right and not a leader in the way of like, Oh, God, this guy again, but like, you know, like, right, you know, prior to the podcast, and even in the early days of the podcast, I would do like I'd have a lot have phone calls with people where I would just talk to them about their diabetes. And what I learned pretty quickly, is that often, they don't know what they're talking about. They think like, they think they know what's happening. And they're not right now, you still need to listen to them and hear what they're saying. And then I hear what you're saying, you know, and what I think might be. And I never know what to think. Like, how do you know when you're just meeting somebody very quickly, right? You go back to basics. Yes. You just say, look, let's look at your basil first. And let's say that the easiest question I've ever found is away from food or active insulin. Does your blood sugar sit stable? Right? If If yes, where? You know, if that number is 90 I go, Oh, Basil is probably okay. If you tell me Oh, it's very stable at 121 3151 80 I go, Oh, Basil seems weak to me. Let's fix your basil first. And then maybe this will you know, help your meal Bolus is to work better. And I always say like, you know, adjust your basil. Get it right. Be careful while you're boasting and correcting because now you're adding extra basil on these boluses and corrections are gonna eventually need you know, less insulin. Let's get this right first. Give them a path. You know, once you get your Basal right, go back and reevaluate your meal insulin, your carb ratio and your and your insulin sensitivity. And honestly, just telling people that it mostly works for them, you know, like it's but when you start going, I don't know, let's try this at nine o'clock, like, I don't know what you're doing then be entertaining right now make a different problem. So this next person says, you know, it's a long, it's a long story. But basically, they said, I was basically told I'm probably going blind and probably losing my foot, I got very jaded, which really quickly actually did turn into me being non compliant. I stopped going to an endo just went to a GP to get my scripts. And, and I think that the takeaway here was, that hope is just is very important, and that these initial messages over and over again, I want to say initial messaging sets people on path. Contour next one.com/juicebox. That's the link you'll use. To find out more about the contour next gen blood glucose meter. When you get there, there's a little bit at the top, you can click right on blood glucose monitoring, I'll do it with you go to meters, click on any of the meters, I'll click on the Next Gen. And you're going to get more information. It's easy to use and highly accurate. Smart light provides a simple understanding of your blood glucose levels. And of course, with Second Chance sampling technology, you can save money with fewer wasted test strips. As if all that wasn't enough, the contour next gen also has a compatible app for an easy way to share and see your blood glucose results. Contour next one.com/juicebox And if you scroll down at that link, you're gonna see things like a Buy Now button. You could register your meter after you purchase it or what is this download a coupon? Oh, receive a free Contour. Next One blood glucose meter. Do tell contour next one.com/juicebox head over there now get the same accurate and reliable meter that we use. 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. When it's time for art and supplies to be refreshed. We get an email rolls up in your inbox says hi Arden. This is your friendly reorder email from us med. You open up the email to big button it says click here to reorder and you're done. Finally, somebody taking away a responsibility instead of adding one. US med has done that for us. An email arrives we click on a link and the next thing you know your products are at the front door. That simple. Us med.com/juice box are called 888-721-1514. I never have to wonder if Arden has enough supplies. I click on one link. I open up a box. I put the stuff in the drawer. And we're done. US med carries everything from insulin pumps, and diabetes testing supplies to the latest CGM like the libre three and the Dexcom g7. They accept Medicare nationwide, over 800 private insurers. And all you have to do to get started is called 888-721-1514 or go to my link us med.com/juice box using that number or my link helps to support the production of the Juicebox Podcast. So this person thought I'm gonna die anyway. Why try? Why

try right? Why continue to go to somebody who hasn't and in this case, not everybody but in this case they weren't being given anything. Positive, valuable. Yeah, to try positive and valuable and applicable probably to their life. They were Being maybe given some advice about well adjust this here, or change this there? Or maybe it was the don't well don't do this. Why are you eating at McDonald's every day? Or why are you doing right? I mean, don't don't badger somebody into a change that isn't really going to make much different? Yes, for that,

I get the idea. So I think what probably happens is that jaded doctors who have seen more than their fair share, you know, in their defense more than their fair share of people who are just not doing well, and it probably seems hopeless. And they probably think let's just jump to the end and try to scare them. And, you know, because I've seen that work with a few people. And by the way, I've actually heard from adults who the scare thing worked on them. Well, yeah. And but more people than not say, scaring me just scared me, or scaring me froze me, or it made me think I can't win, right? It's why everything goes back to understanding how insulin works, because in every situation you find yourself in whether it's somebody who's struggling forever, or just starting out, if you give them these these basic tools to begin with, they have successes that they can build on. Right, you know, and it relieves stress. And I think that, you know, this next statement here from somebody said, I wish somebody just would have told me I could have with insulin moved my anyone say, it's funny, they just didn't have that idea, like I was told, seven, two, good a one say.

And also almost that the numbers that they were getting, were as good as it was going to possibly get that it was all about almost a stable point of where their body wanted to sit in terms of blood sugar, and that it was going to sit there. And other variables didn't have any impact on that one of them, obviously being insulin, and that an adjustment that's more precise, could actually move the needle in the direction that you wanted to go. Even without adjusting activity or food or anything else. A lot of times it's the right place to adjust the insulin.

And how hard would it be to say, look, the ADA recommends this number, but I'm your doctor, I'm standing in front of you, I don't have diabetes, my one sees probably 4.9, you're not going to probably be able to get that but I bet you we could get you into the sixes. And then work on the fives maybe make some modifications to how you eat. Who knows like, right, if you want to go low carb, maybe we could get you in the forest. Right? But when you say sevens, okay? And the only thing is a quarterly report card, and they hit the seven or even I know it doesn't sound crazy, but 7.9 in somebody's head is still seven. It's still sad. Yeah, like I did it. I'm in the sevens in the sevens. But what's your one thing? Will you tell me?

Will I tell you Sure. My a onesie is 5.5. Okay. That's what we want. That was my last one. The one before that was 5.6. So really, I'm I it's there.

Yeah, right, right. It's there. Right? It's five you have type one diabetes, it's five, five, it's five, six. You know, you manage that by understanding insulin exercise and diet, boom. Like, you know, if I didn't want to exercise if I was Jenny, but I didn't exercise you probably have a six two.

Right? Sure. Yeah, and be using more insulin than I use respond to food differently than I respond. Absolutely. They're those big variables that you do have to understand. But mean insulin is, it's the mover of blood sugar. I mean, right. And if you have it squared away, and you have somebody to guide you, I think, thanks to the podcast, obviously, I think people have a lot better understanding of insulin, and the fear component gets removed and they're willing to do their own trials of changes. But then there are still a good majority of people who are not confident enough about making adjustments and are still going back to their clinical team to make those and because they're not made maybe at most every three months you're left with this idea of again, I'm seven I'm seven one I'm you know, whatever and the doctor says that that's that's in a really great place or it's come down so I'm I'm clearly moving in the right direction and you are but it could be improved even further you could be getting closer to what we would hope for getting in the range of people without diabetes safely. Of course, you

know, and people I think generally speaking humans like reaching right they like seeing something out ahead trying for it and succeeding. It feels good it works it I mean, we spend so much time talking about oh, I'm scrolling it's you know your dopamine your D you can give people a dopamine hit with a with a good blood sugar. Like if somebody came in to this conversation right now. And they said Look, you guys are talking about a seven a one c minus 10. I you know, I'd kill somebody for a seven you don't have to kill somebody for something first of all, you just you know, need some changes insulin, yeah, just make some changes in your settings and how you're, you know, timing your insulin. That's it. I mean, honestly, good settings Pre-Bolus your insulin a once he's somewhere in the 60s, you know, it just, it really well be if you're in the 10s, you don't know what you're doing. That's all for a doctor to look at that and say, Oh, I give up on this one. If you knew what I knew, or what Jenny knew you would go, I could fix this tomorrow. I can, you know, like, what are we doing here? So,

and the unfortunate thing about those a one C, there is sort of a range, right? A onesies over I think it's over about a nine or a 10 really is a deficit of lots of basil and Bolus, if there's a deficit, definitely. And the person with diabetes may not know what to change the clinician, the one with the degree and all of the, you know, panels on their walls and whatever. They're the ones that should be able to say, Hey, your agency is here. Clearly, there's not enough insulin and you might then start to add insulin to hopefully get those those numbers down. Anytime that a one C is kind of like above where you'd want, let's say it's above seven, but kind of under that 10, then we start looking a lot more at mealtimes. And we start looking at, okay, as you said earlier, if you can float around at a at a stable blood sugar, even if it's 120, right, and you're safe there, then your Basal isn't really the wrong thing. What we end up seeing is these major excursions around meal times, which could be relative, that the dose is not necessarily wrong, that it's the timing, people haven't been taught the right timing of their of their dose, it could be both it could be timing, and that the dose has never been appropriately adjusted. And so those those a one sees as a, you know, just average, could be brought down by attention in a different place.

And a little trick to figure out if that's the case is if that stability is higher than you want it to be. But like Jenny's saying, it's very stable. If you missed on a meal prior, like she's saying, you might end up at 120 with a perfect basil. And you know, Basil is doing its job perfectly, it's holding you steady. It's not its job to shoot you down. But I tell people all the time, if you see that stability higher, and you're not sure is this my basil, or did I miss on a meal corrected. And when it starts to go down, if it goes down and stays down, you missed on the meal. If it goes down and it comes back up, that could be your Basal being two weeks. Yep, it's a simple way to just check to see what's happening. That's the thing, you should be able to empower people with this, this person says I want my doctor to not be so by the book, I'd love for her to constantly be educating me, let's talk about off label use for medications if we need to, I'd like her not to be afraid to help me change my settings, to empower me to change my settings. And just because I do have a one C that's lower, it doesn't mean that I don't need help ever. Right. And I made a note next to that, when I said you gotta be a guru a little bit. Like it's, I mean, the by the book thing, it's not going to work for this, like you need their variables, you need your information, need the tools, you need the understanding of how to use insulin, they all have to work together, you can't just say, you know, 15 minutes 15 carbs, like that kind of stuff. It's right, it's too bare bones. It doesn't it doesn't do the right things for you know,

and it I think a lot of the beginning tidbits of information that are given, they're just a starting place, kind of like the 1515 rule, which is really, really old school, obviously at this point. But it's still being taught because it's a, it's a quick and easy teach. But then you have to end up going beyond that as the clinician when you can say, Okay, I've taught them this, they're using it. But now my job is to say this isn't working, maybe you need less, or maybe we need to consider a change to this. Or maybe we need to, to do this and in the visits with people, then you have to bring that in so that they can see why you're making suggestions, or changes. Don't just give them a directive and expect them to move forward. They need to understand why What are you seeing? What are you seeing that suggesting I should change this or to change that or to think about this differently? Because otherwise you're just sending them out with a map that doesn't apply to their life.

I wonder if doctors don't feel almost embarrassed to talk out loud to think out loud. Which would be a shame because it's a large part of how I taught my daughter to take care of herself was just everything that we were doing was spoken. Hey, it's time for you to change your pod. You know, we don't want to leave it on too long. Because you're only supposed to leave your cannula in for you know, about three days. So let's not wait. Let's get that off now. Right. Oh, you know, when we put it on, we'll watch your blood sugar. If it goes up, maybe we'll have to put some insulin in with a new site next time. My daughter doesn't know it. She could not sit down and explain diabetes to you. But she can do it. Right Is it To

become habit, because she just knows what to do,

because I'm narrating her life around diabetes out loud and not all the time. Like, I don't want people to think, oh my god, this guy up this kid, you know what I mean? Like, they just don't just, you know, like, at times when something was happening, we do it, you know, a plate would come out, I'd go, hey, you know what I'm thinking here, we're going to Bolus you think about how much you think it's going to be. And then we'll compare, you know, and she'd say, I think it's 45 carbs. And I go, Alright, where do you see the carbs? You know, don't don't just guess the number. Tell me where you see it. And then I'd say I see what you're seeing too. But I think you're forgetting the breading of the chicken. So let's throw in like seven more for the reading. And that over there is fried. And so I think you're gonna get a little bump later from from the slowdown and your digestion. So why don't we put a little more in for that, too. And then years later, she just knows how to do it. Like it's not. I think that there's that the doctor brain learns differently. I imagine. I don't know, I don't have it, I have more of what you might call like, an artist's brain. Like, I just, you know what I mean? Like,

yeah, I'm a, I'm a talker, when I, when I work with people. And I'm also when I respond to email requests or inquiries about data and whatever. I have very lengthy, like emails and a very lengthy discussion, because I talk a lot. And I want you to go forward with why I'm suggesting a change. Or even if I'm questioning, hey, let's work together. What do you think you know, your life better than I know, I see that we could do it this way. But I also think that we could do it this way. What do you think you'd like to try first, so it gives some options, and it gives them the ability to move forward out of our visit together? To try something without checking back in? Yeah, right away, or without going three months, and then saying, well, it didn't work. I didn't know what else to do. So I just kept doing it.

Look, I don't know how many doctors are allowing emails. Now. I guess there's a lot of portals where you can message people. But people need to feel autonomous, like they just really do they need to like and if even if it's a new person, and you're like God, I can't let them make too many changes. They don't know what they're doing. I mean, they can move their Basil 10%, like you don't I mean, like you could, you could give them a little bit of freedom so that they could like trial and error out a little bit. And I'm assuming that the word error doesn't sound right to a doctor. But that freedom that you give them, it's how you get to where you're trying to take them, like you can't shackle them the whole time and then go, I don't know why they don't run, you know what I mean? Like, like giving

somebody this dose adjustment, maybe you explain it, but then saying, You know what, try this for two or three days. And if this isn't quite enough, or it's just too much, then we're gonna give you this next option, giving them handing it to them and saying, here, here, here's an option. It's not just you're stuck at this. And you know what, for further collaboration, it's checked back in, send me an electronic message, and let me know, did it work? Did it not work, I am happy to check back in with you to make sure that I give you another suggestion, or to see that it actually is safe to continue changing things. Right.

I think also, if you don't believe that conversating with people can lead them to understanding things that you should, I'll tell you this little story. So Jenny, and I have made all these different series together. And the feedback overwhelming, I'm talking about overwhelmingly like hundreds of 1000s of millions of downloads, right? And people come back, I listen to this my one season the sixes, blah, blah. And I even to the point where I sometimes think, what the hell did we say in there? You know, you mean, so like,

what really hit for that person, like God, like,

I don't think I know that much about it. So I did this thing recently. And it's gonna come out on my social media at some point. But I chat GTP like AI has gotten to the point now where it's fascinatingly good at breaking down conversations. So behind the scenes, I'm feeding the transcripts of everything you and I have done together into AI, and I'm telling it just one simple thing. What are the key takeaways for people living with type one diabetes? And it writes in bullet points, my brain doesn't write in bullet points, but it does. Wow, that's cool. It's so good, Jenny, that when I put it in front of you, you're gonna think you wrote that list yourself. Or you're gonna think I wrote it, or you're gonna think we wrote it together. It's really technically

we kind of did. All we're doing is feeding information and something is putting it together and very concise.

It literally can read through it and filter out all the bowls. And just come back with this is what was spoken about. I'll tell you this, we you and I did an episode called setting Basal insulin, the math behind Basal insulin or something like that. You can ask the transcript, what your Basal insurance should be based on your weight and a couple of other things. And it just from our conversation knows the answer. It figures it out for you. That's insane, right? But here's the plan. Here's my bigger point. I know I'm helping people with this conversational style. But I also know there are some people who don't enjoy this conversational style, right? So I'm finding a way to give that information to them the way they want it, doctors have to do that, too. You can't talk to people the way you learn, right? I'm sure all your engineer patients are probably thrilled with you. You don't I mean, like, seriously, but if I came in and you started bullet pointing me to death, I don't know what to do. If you told me right now to take three thoughts that I understand and write bullet points about them, I guarantee you, I'd write them out in a paragraph instead, right, and then I'd have to stop and break the paragraph apart, and then reward them. So they look like bullet points, because my brain doesn't work that way. It's really something I

mean, what you're kind of boiling it down to is what I feel about. Educating the way that I do is getting to know a person, I understand that I have a little bit of a different way to do that. And you know how we work with people. But in an office space, time is really the constraint, I get that. But because I have the time, the nice thing is that I could tell you what impacted someone's blood sugar in one way compared to another's, because I know them, I don't know them just their name. I know them, I likely know the siblings in the house. And I know that this child goes to a grandparents house, you know, four times a week, and they're served these things versus at home, it's different. And so those are some of the things that also go into management, that may not be a setting change. And that you have to be able to learn in order to educate, or to be able to teach a strategy that's applicable to that one person. I know that I teach differently, a little bit differently for each person I have the opportunity to work with, because I meet them where their need is.

I think if a doctor hears you say that and thinks I can't do that, I think yes, you could. You can you just need more practice talking to people. I swear to you just call me like get on the podcast, and we'll chat. And just after an hour, you'll be like, Oh, I can just conversationally talk about diabetes, and people understand it. That's crazy. I'll do that. You know, it's it's so doable. Jenny, this person here says, If you don't know something, just tell me you don't know. Yeah, honestly, would be the bedrock of our of our relationship. And I actually just interviewed someone recently who had that story, she asked a question about her pump, to her doctor. And instead of Bushcare, were sending her to go and go watch a YouTube video. Which, by the way, there are a lot of comments in here from people like do not go tell me to watch a YouTube video, like Teach me how to do the thing. Okay, so if you were the doctor don't know how to do it. I mean, hey, why don't you take a weekend? You know what I mean? Cuz kind of your job. Be honest. And so anyway, this doctor says, I don't know, I'm gonna find out and come back to you. And then they actually followed through and did it? Yes. And it was a big deal for this lady. You know, that would be a

that's a big deal for me. I mean, I have fired essentially, or just not gone back to clinicians through the history of my adult life as choosing my own clinical team. Because I got the sense very much that they couldn't answer my question, they kind of be asked around not knowing how to tell me that they didn't know. And so I was just like, Okay, I'll find somebody else.

I wished my doctor not only knew how to tweak, you know, my diabetes, about my lifestyle, like, have like a, she actually says here, I wish you had a primo list of referrals, mental health, you know, nutrition, stuff like that a CD, they actually knew what was there was willing to work with you. And listen, I'll say this, I know a number of doctors privately. Don't just say like, oh, there's a guy over here. I know the girl in this practice, and you know, they're crap. And you send people to them anyway, because they're part of the system or something like that. You just create another problem. Again, say, you know, I don't know anybody that's going to fit that bill should ask around a little bit, or call some offices, ask some leading questions. How do you guys deal with this? You know, like, pick on your own? But yeah, this person's like, you know, please just help me find other practitioners at times. If you can't do it, just say, I don't know, let's get you to this person.

And sometimes that takes from the clinical or you know, the physician angle that that means that even if you can only refer to people within your organization, then know the people that you do need to refer to, right know the mental health specialists in your organization, get to know a couple of them. Who would you really click with who really would be great and who was kind of iffy and totally wouldn't be somebody for diabetes to talk to right. Get to know kidney specialists get to know good cardiologists get to know your system. I'm because I guarantee that there's not just, there's often not just one practitioner to refer to. And if you get to know those different teams, you'd have a better list that you can easily pull out or look up on your notes on your phone and say, you want to see this person, you could see this person, but they're not my first choice. Why? Who cares? It's important for the person that you're telling.

And if you don't think that's important, this person says, Look, I'm a researcher and a reader. So I ended up clashing with my doctor who just wanted to take complete control and not empower us at all. If you're a doctor is like, that's how I want it, like, I'm gonna crack the whip, and everybody's just gonna do what I'm gonna say, this person said, I switch practices because of that. On top of that, she was told that her and her daughter would difficult patients. Yeah, for wanting to understand how to take care of themselves, they'll think about the psychological ramifications of that. If you're like, not everybody can speak out, here's a person who spoke up, right. And but most people aren't head down. A lot of people are head down, right? If you dominate them, they'll take that, and they'll never stick up for themselves ever. And you will be directly responsible for the poor health outcomes that they have. And you won't think so you get around at a party and tell your tell your friends, what a great job you're doing for everybody. But this is how these people could feel.

Yeah, I think it kind of goes along with a lot of I wouldn't say a lot, but maybe half of the time I hear from parents, especially where their pediatric practice really wants to do the load of the adjustments. They really don't want the parents stepping in and adjusting and doing things in between the visits, which may not be close enough together, as their child is growing. And all those changes are happening. It's not soon enough. Now there are really awesome practices that have a lot of close, you know, I guess communication, but then the other ones do a lot of hand slapping, I did you change this? I would you adjust that. I told you not to do this, or you know, that doesn't help and long term. If the child is in the room, hearing those comments, they're also now learning that they don't have any voice in their own health.

I don't know what I'm doing. And maybe worse, my mom doesn't know what she's doing. Right. I think that's a thing I see all the time, especially when we speak in public Jenny, and, you know, I, you know, I'll go to the parents and all, you know, a license stuff out for them. And then you go to the kids, and you're like, hey, you know, I told your parents and stuff today, and maybe they'll and the kids are like, my mom does not know what she's the devil coming out and say it like, she's tried three things. My one seesaw seven, maybe that's the most just the most terrible thing is taking the a child's you know, confidence in their parent away, you know, like, what's gonna happen at the end of this series, Jenny, and I gave it away a little bit here. But there's going to be an episode where I'm just gonna read the takeaways for everybody. And I'm gonna go over them with other people in like, kind of bonus episodes or supporting episodes for this series. In the end, as a doctor, empathetic kind. If you don't know something, figure it out. Teach people how to use insulin know how to talk about that very fluidly. It's all you have to do. Like, like it just, there's not much more to it than that, then let it be a conversation and give them give them power. Now look, do you have some people who, you know, you're like, Listen, if I give them power, they're gonna kill themselves in five seconds. Like, I'm, I'm not saying sure those people, you know what I mean? But those people can also be helped with basic tools, and a little bit of like, carrot and stick. Like, there's nothing wrong with saying, Hey, you're a 10. No problem. I think in six months, we could be in the eights. Like I'm going to help you get your settings right, then you do a couple things for me, we'll come back do another blood draw, we get you down to the AIDS. Now we're off to the races. I don't see why a year from now you couldn't have a six a one say, like, give people something to work towards? Like, we're basically just ants, Jenny. Humans are not good without a task. No, they're not. No, you gotta give him something to do. You know,

right. You know, and from, from the doctor standpoint, too. I think when we're talking about diabetes, you're talking about a specialty. Right? You're talking about beyond just general practice. You've chosen to go into something that requires you to keep up with the changes that are happening. And this is very specific. And you might be you might end up being an endocrinologist who has nothing to do with diabetes and then that's great. That's your practice is not specific to that but if it is, you should be able to answer a question about a device. You should be able to keep up with what medications what is changing how to use it, who to use it for, you should be a able to answer questions, because you've chosen to specialize, it would

be like if I climbed into a Nissan ultimate, it said driving school on the side of it, got behind the wheel looked over at the person in the other seat and said, which one of these makes it go? And you said, I don't know. I don't know. Well, then what am I paying you for?

Right? Absolutely, I just I don't understand. If you've chosen, as I said, if you've chosen to specialized, you need to know your specialty.

Jennifer, there is no doubt in my mind, that if I wanted to make a living a different way, I could offer private courses to doctors. And I think in three hours teach you how to take care of your patients. I know you could do it, too. There's a lot of people that could do it. But my point is, if that could be done for you, you could probably do that for yourself. You know, like you don't like go like find out that one of the things I'm always fascinated by, if someone comes in the office, they figured it out, they get their agency where they want it, they've got these great stable graphs. And the first thing that happens is Doctor yells at them out of fear. You're too low, you're gonna have a seizure. What about saying, hey, what didn't you do? Right? Could you tell me what you just did? Because I got to be honest with you. I didn't see this coming. Right? It happens all the time. And if they say something like, I listened to a podcast, don't yell at them and say the internet's not a good place for you to learn. Because your doctor's office hasn't been a good place for them to learn. They're trying to figure something out. So in the end, Jenny, meet people where they are, give them agency, and for God's sakes, think before you speak. Yes, leading a sentence in the wrong direction leads 15 minutes into the wrong direction. Start Strong.

I wish to my point, don't point fingers do not

point fingers at people like it's we're in this together and give people I can't believe I'm going to say this. You have to give people their flowers to when they do well. You got to like and it can't feel phony. You got to really mean it. You know, this is amazing. I know how much hard work this took good for you. I think there's more keep going. Right? And

it doesn't have to be with what you what you see as where you would want them to be. If you've got somebody you've been working with who is so fearful of Lowe's that they run blood sugar's at 250 or 300. And now, your work together whatever education they've provided themself, now they're averaging a blood sugar around 190 or 200. That's a give them flowers. That's not a well, we really want to be lower than this. Oh, no, no, no, they've achieved something like, let's keep the ball rolling, right, you have to give them good positive reinforcement, regardless of what your down the road, like goal is for them. My

daughter's first endocrinologist was brilliant. I could tell by talking to her. She never helped me once with diabetes. Just stood in the room smart, and said smart things and

didn't help it that didn't translate into helping you. Oh, no,

no, no, I was in a panic. You know, it might have been easy to say things like, hey, if your blood sugar is too high, you might not have enough insulin, I would have gone. Oh, that makes sense. Thank you, you know, Jenny, there's a note here from you that says Please don't look at a static number and then say everything is great.

Right. And I wonder if I don't know if I gave context to it. But I think that I think that I was possibly talking about a one C two there. Because it is it's we understand that a one C is just an average, you really do have to get into the whereas the agency coming from what are the kind of the data points that are pointing to this because then you have more room as the clinician to say, Gosh, you came in your agency is now you know, 5.8, and it used to be 6.8. And in my mind, that's lower than I want it to be. But gosh, that a Wednesday is really stable. Look, you have like less than 1% of the time low, you have a standard deviation that's like those, those little pieces that go up to make that one standard value. That's really important to

look at. I'm gonna run through a couple of things here at the end for people, I wished my doctor was a resource for other resources. Tell me, why did I have to this person says directly? Why do I have to find this podcast on my own? Listen, there are plenty of doctors and I want to say thank you to all of them that recommend this podcast every hour of every day. The Facebook group, which gets 150 new members every four days is overwhelmingly they have to answer a couple of questions. It's a private group, right? One of those Where did you hear from this from my physician from my doctor from my hospital? Like it's a fair amount of people. So thank you to all of you doing that. Obviously, I don't think we're talking to you. But you know, for everyone else, if you don't know, send me somewhere that might know and don't do that thing of like, well, I don't know what you're going to hear when you get there. Because the thing that's happened thing now is bad. So, no, I don't know like what could go wrong now maybe he wants he's nine and a half. I'm on the fast track here. You know what I mean? Like, good, go try something like whatever happened to like, I don't know get out there and do something like sometimes just doing anything and seeing a little bit of a positive return is enough to supercharge and get you going again, even local support networks, people are asking here like, please know where I can go meet other people. My teenage daughter just hears you're doing Oh, this is I think we've covered this in another one. But there are people who are looking for more, okay, so don't just look at their six five, a one C and go You're doing great. Because they might want to do better. And they'd like to hear from you. I mean, they know they're doing six fives. Great. They know they're doing great. So there's a double edged sword there. You could lull somebody into complacency. But what this person says specifically is when my daughter hears that, then I go home and try to say to her, Hey, listen, we should try Pre-Bolus. In five minutes longer. She goes, Hey, doctor said we're doing great. So yeah, you took away her desire to try to help herself. There's a way to say you're doing well. But there's always room for improvement. So here's some ideas like that kind of stuff. Right? Real quick. They don't make us feel bad about my agency Don't say things like, well, it's okay, this time, please don't use guilt as a communication tool. And then here says this is some feedback from somebody else. It just kind of gave me like a stream of consciousness that I want to kind of end here with she said, relationships, person to person person, the diabetes, clear relationship expectations, level setting, meet people need to feel safe. freedom to express things is very important. psychological safety is a big part of how you can get these visits and your relationship to work in everybody's favor. That's kind of where I'm at today with communication. If you have a minute, I'm going to share something with you, Jenny. Okay, go ahead. Anything you want to say or finish with before I jumped to the end? No,

I was actually going to add one thing to that list is the be supportive of the caregiver. Be supportive of a caregiver, I talk a lot about like parents as the caregiver for kiddos, and be supportive in the way that you would be willing again, this goes along just communication, hear what they need, and also hear what they've tried. And if the child or the teen is in the room, be supportive of the efforts of what the parent is really trying to do. So again, you you may have some things to share with them. But really try to prop them up with all the effort they've been putting in. And if they come to you with questions, being able to again, communicate back in a way that they can understand how could this work? Could this be something that would be better, just really support them?

That's a perfect way to end, I was going to share one of the takeaways with you. So from Episode The second episode of the Grand Rounds series is called diabetes diagnosis. And I asked an artificial intelligence to give me the key takeaways from that episode. And it said doctors and regular primary care settings may diagnose diabetes due to the rarity of the condition and the similarity of symptoms to other illnesses. misdiagnosed excuse me, it is important for patients to clearly communicate their symptoms and concerns when contacting their doctor's office. misdiagnosis or delayed diagnosis can lead to complications such as diabetic ketoacidosis. Doctors should be proactive in ordering appropriate tests such as blood work in your analysis. When patients present with symptoms that could be indicative of diabetes. Patients should not be dismissed or ignored when they expressed concerns or symptoms that could be related to diabetes. education and guidance on diabetes management should be provided to patients at the time of diagnosis, including information on insulin use, blood sugar management, and the impact of diet and exercise on their blood glucose levels. Doctors should be aware of the impact of their words and actions on patients mental health and well being. Collaboration between primary care and diabetes specialist can ensure comprehensive and effective diabetes management. Patients should be directed to reliable sources of information and support such as diabetes education programs and online communities. And doctors should continuously update their knowledge and skills and diabetes management to provide the best care for their patients. That's what AI picked out of your mi conversation. Isn't that fascinating?

Well, and what it actually it's what's interesting about it is that it it sounds like the summary that you'd get in like a research project. We looked at all these things in 3000 participants in this study and these are the key takeaway points in order to be able to provide somebody with diabetes, the right care. That's what it sounds like.

I'm also almost I'm being boastful a little bit here if I'm being honest, because you and I, you're a lovely person who comes on my podcast. I mean, like, We're not sitting in the same office talking to each other for a month about what we're going to do, you and I pop on when you have free time and free time is in quotes, right? Like when you you jump on here and I go, Hey, Jenny, we're going to do that Grand Rounds thing. Let's do what happens when you're diagnosed in your doctor's office today, and you go, okay, and then we chitchat for five minutes about our lives, then we have a conversation that when you asked a I provide key takeaways. That's all it said. That's what he came up with. My point is conversationally, is a good way to get out good information, right? Absolutely. That's how people's brains hear storytelling, not you reading a bullet point list of them. So Right. Also, by the way, in this is pretty far off. But that's not all i Sai. What I said was provide key takeaways in English, Spanish and Hindi. Wow. And it did that. So I finally found a way I think people are always asking for this template in Spanish is a big one. And the podcast has become very big in India, there's a ton of dialects so I don't I just picked the one that I think is the most kind of central, sure to imagine these key takeaways in other languages for diabetes, Pro Tip series for bold beginnings for that kind of stuff. Gonna be nice. So Scott, he's on it in 2024 door. Arden has been getting her diabetes supplies from us med for three years, you can as well, US med.com/juice box or call 888-721-1514. My thanks to us med for sponsoring this episode. And for being longtime sponsors of the Juicebox Podcast. There are links in the show notes and links at juicebox podcast.com. To us Med and all the sponsors. A huge thanks to the contour next gen blood glucose meter for sponsoring this episode of The Juicebox Podcast, learn more and get started today at contour next one.com/juice box. I have one thing to tell you. But I'll do it after the music close. So I waited until 50. People found this on their own to say it out loud. But I've added a thing if you're listening in Apple podcasts, you can actually subscribe to the podcast pay a fee. Now the whole podcast is free. So don't now you're like, Well, why would I do that? Scott, if it's free. If you pay the fee, which I think is like 599 A month or $59 a year I think that's about it. If you do that you will get currently you will get the bowl beginning series without ads and you will get the diabetes Pro Tip series without ads in it. And so far one episode that has all the curses at it. Now, why did I wait until 50 people signed up on their own to bring this up. I wanted to make sure it would kind of pay for itself. This is not like a money. I'm not gonna make any money on this. Because the editing on like pulling ads out of old episodes and you know making episodes with curses in it. It's gonna cost money in editing. But anyway, now there's 50 People, I'm going to tell you about it because if I can get if I can get 50 more people to do it. I can add a another series without ads. And we can start offering episodes once in a while that have all the curses in them. So if I go crazy in some episode, we're cursing all the time, and we can afford the editing. I know that sounds weird that it would cost money to not edit out a curse but I have to edit the episode for the regular show. And then that basically means it has to be edited twice to leave the it's not important. This is just it's what it is. It's an added expense. Anyway, if I see this pop up, another 50 People 100 People something like that, then I'll be able to turn to the editor and say listen every time you get one with a bunch of curses in it, give me two edits give me the Kersey and the non Kersey in that way the people who are paying for the subscription can hear the cursing. And as that builds up a listenership that will also afford me the ability to take ads out of some of the more popular series and offer them to the subscribers as well. Anyway, there's no pressure to do this. But you can if you want. Besides what I mentioned, you get I think you get each episode like 18 hours earlier than normal. And ad free bull beginnings ad free Pro Tip series and some random cursing here and there. Anyway, do it. Don't do it. Please, it's entirely up to you. But it's a great way to help me pay for more content. So if you're up for it, you'll see it right there in your apple podcasts that if you're looking for community around type one diabetes, check out the Juicebox Podcast pro COVID facebook group Juicebox Podcast type one diabetes, but everybody is welcome type one type two gestational loved ones, it doesn't matter to me. If you're impacted by diabetes and you're looking for support, comfort or community, check out Juicebox Podcast type one diabetes on Facebook. Thank you so much for listening. I'll be back soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

Hello friends, and welcome to episode 1148 of the Juicebox Podcast. Jenny's back for another grand rounds episode and today she and I are going to talk about how doctors should be thinking about diabetes management, how to talk to you about using insulin, and so much more. While you're listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan, or becoming bold with insulin. If you'd like to help with type one diabetes research right from the comfort of your home, it's easy to do go to T one D exchange.org/juicebox. and complete the survey. That's it, it takes like 10 minutes. We're looking for US residents who have type one diabetes, or are the caregivers of someone with type one of specific and special note. men and men of color were boys or boys of color. Difficult to get that data. The T one D exchange thinks they could really help people if they had it. If you fit any of these categories, I'm talking about men, boys, girls, ladies have type one, you're the parent of somebody filling out that survey is a great way to help. And it's a great way to help the podcast, it also might end up helping you t one D exchange.org/juicebox. Today's episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. This is the meter that my daughter has on her person right now. It is incredibly accurate and waiting for you at contour next one.com/juice box. This show is sponsored today by the glucagon that my daughter carries G voc hypo pen, find out more at G voc glucagon.com. Forward slash juice box. So today for the Grand Rounds series, we're going to talk about management. That's our that's our our header. And Rod topic. Well, and there's a lot here. So indeed, it is a lot of feedback from people, a lot of feedback from people a lot of notes that you and I made on this document back home, we're talking about doing this. A couple of things. Why don't we just start with a little bit of feedback, and we'll work our way into it. Well, I wish my doctor would have told me that staying high for long periods is just as dangerous as a low. Yeah. So that's education. Right? Like, that's, that's understanding big picture. And whether doctors know it or not, this don't. I was about to say don't have a seizure idea, which is something I really don't want anybody to do. Right? I didn't want to sound like I was minimizing it. But this this better high than low idea. I understand why they might say it initially. But you have to tell people, the rest of that story. And why high and low is bad, why stability is what they're looking for how to get through stability, because just telling them better high than low, I think leads them down the wrong path that that that's difficult to get back from mainly

because there's not enough there's not follow up to it is what that really leads to, they are given a directive of better high than low initially. And you know what? Maybe Okay, right now, but define that, give them a week from now once we're seeing how your insulin is working, once we see where numbers really are, once we see how you're reacting to the current doses and we make some other adjustments. We will talk further about this, right? Because initially, you may actually, I mean it is there's a math equation to figuring out initial starting doses for any age and person. But it's still just a starting place. And it's still not as precise as it eventually will get. So sure, a little higher right now, let's see how things go. We're going to touch base in a week or in a couple of days. We're going to look at this and we're going to say okay, now we can nudge that high. We don't want to stay high, long term down the road. Right now. We're just going to keep things from here to here. Maybe the target range is wide right now. Narrow it when you have follow up and also put that into you know your your notes about what was discussed. We defined blood sugar target range here to here so that whoever is the follow up physician or clinician knows what you've talked about. They can easily see it in the medical record and then that doctor or caregiver can clean that up. Yeah, can help to define that further for you. But when you give a blanket statement that sticks

Yeah, it also makes the next physician, not just the patient, but the next physician leery about changing what's happening right now. Right? Right. Right. They think this is this was for a reason somebody told you to keep your blood sugar at 180 all the time. And you can explain to them no, that's not the case. Because somebody didn't tell you. No, that's not the case. So, right. A lot of this series, I think is about, it's about not just saying the first thing that you that you think to say, but giving it real context and an explanation. This is what we're going to do. This is about the timeframe we're going to do it in, this is why it's important. You just can't forget about it and say, Oh, he said better high than low. And then you go on, you know, from their emergency situation, to you know, a GP, then the GP finally gets you to an endo. And then the endo gets there. And this, oh, everybody's got this person's target set at 180. They might think that's on purpose, because you can't handle it. Or maybe you had lows before they'll make assumptions. And you know, these assumptions are what killed everybody. Right? Yeah. But this is how it comes out. I wish my doctor would have told me that saying hi, for long periods is just as dangerous as a low

end for this person, it might have been that there wasn't enough follow up then. Or maybe they didn't follow up with somebody who could have helped them put the targets a little tighter together, right? Maybe they also didn't know enough to ask, Hey, I was told initially, the higher targets are okay that I shouldn't necessarily live there. But if I touch to 50, after every meal, and four hours later, it comes back down. That must be okay. Right, because that's what I was told it. It takes I think, you know, diabetes, especially is it's an evolving sort of trend of discussion, where this is where I am, this is the scenario, this is the really important stuff to focus on now. Okay, a month from now, a week from now, whatever, you're very likely going to be in a different place, you're ready to get more information, you're ready to ask more questions. And the doctor should also sort of move down that path with you, if you're not bringing up that they should be bringing it up and saying, Well, you're here. And everything looks safe, right? It looks good. But you could be here, right? Let's try this. This is why and that explanation to the why is really important. It's

the nuance of the conversation. Like you can tell somebody, it's not wrong to say to somebody, Hey, if your blood sugar shot to 250 and came back down and leveled out again, that's fine. Not every time, you know, but not every meal. Because if you want now you tell me that's okay. And what you're probably trying to do is, is give a little bit of comfort. You don't I mean, like, Hey, don't don't kill yourself if stress about Yeah, if it jumps up one time it jumps back down, let you you know, that's okay, let it go. But not, once you tell them it's okay. Then breakfast jumps up lunch jumps up, dinner jumps up, a snack jumps up, they get high overnight, but it comes back down three hours later. And before you know it, that's an eight a one C? Yeah, you know, and they in their head, they're like, Well, the doctor said, It's okay, if it goes up and it comes back down again, they don't understand the big picture. Listen, right. Most people don't understand the big picture of health. I was just talking to a nurse on another recording recently. It's not out yet. And she said one of the most shocking things about becoming a nurse was learning how little people knew about their own body. Like she called it. Jenny's making the face. Yeah, like shocking how bad it is. And it led me to say, I saw somebody eating nachos with a bowl full of queso the other day and I saw the bowl, like the size of a softball full of liquid cheese. And I thought you're not supposed to consume that in a year. Right? Yes, yeah, you know, like, and here you are, you know, in one sitting, and then metabolic issues come up, which you don't see right away and are hard to diagnose. And they end up looking like I get headaches all the time, or my knees always hurt or why does my stomach hurt? Or how come I don't poop? Right? Like it's because it's and then you're off to the races. And before you know it your blood sugars are hard to deal with, you have all kinds of other underlying issues. And they don't come to the surface until they come to the surface in a very aggressive way with like some specific problem. And when we're talking about people with diabetes, we're talking about renal and cardiac and your eyes and absolutely big stuff, you know, not just go on a diet for six months and this will all work itself out. You know, what

you said initially is 100% the case unless you have any type of biology avenue of education, you really are left in the dark about what your body is supposed to be able to do. How does it function when I do this, this is what my body does with this, right? And I, one of like my best examples of that was years ago working just as a dietitian in education specifically in diet in gestational diabetes. A woman had come in to me, and we're talking about kind of her eating and how that impacted blood sugar. And I said, Well, you know what, I don't see like, a lot of fresh stuff. And I said, I don't see any fruit at all. And she's like, No, no, I eat fruit every day for breakfast. And I was like, Oh, we didn't mention that. You know, she's like, Yeah, I did ice. It's right here. I eat Froot Loops. i She was not kidding. She was not joking, which means that as an adult age where she was long term, she never knew that Froot Loops don't count as a fruit. Like

me, I out myself for a second. I once said to my wife, I was half joking but contour next one.com/juice box, that's the link you'll use. To find out more about the contour next gen blood glucose meter. When you get there, there's a little bit at the top, you can click right on blood glucose monitoring, I'll do it with you go to meters, click on any of the meters. I'll click on the Next Gen and you're gonna get more information. It's easy to use and highly accurate smartlight provides a simple understanding of your blood glucose levels. And of course with Second Chance sampling technology, you can save money with fewer wasted test strips, as if all that wasn't enough the contour next gen also has a compatible app for an easy way to share and see your blood glucose results contour next one.com/juicebox And if you scroll down at that link, you're gonna see things like a Buy Now button. You could register your meter after you purchase it or what is this download a coupon? Oh, receive a free Contour Next One blood glucose meter. Do tell contour next one.com/juicebox head over there now get the same accurate and reliable meter that we use. If you take insulin or sulfonylureas you are at risk for your blood sugar going too low. You need a safety net when it matters most. Be ready with G voc hypo pen. My daughter carries G voc hypo pen everywhere she goes because it's a ready to use rescue pen for treating very low blood sugar and people with diabetes ages two and above that I trust. Low blood sugar emergencies can happen unexpectedly and they demand quick action. Luckily, G voc hypo pen can be administered in two simple steps even by yourself in certain situations. Show those around you where you storage evoke hypo pen and how to use it. They need to know how to use Tchibo Capo pen before an emergency situation happens. Learn more about why G voc hypo pen is in Ardens diabetes toolkit at G voc glucagon.com/juicebox. G voc shouldn't be used if you have a tumor in the gland on the top of your kidneys called a pheochromocytoma. Or if you have a tumor in your pancreas called an insulinoma. Visit G voc glucagon.com/risk For safety information. But I don't think I was completely joking. She's like you don't get enough vegetables. I ate veggie sticks the other day and she goes Scott, those are potato chips. There's carrots in them.

Yeah. I mean, and there are a little bit of like a humorous component to that. But I was just like I came home and I said to my husband, he's like, No, he's like she was joke. I was like, no, no,

I told you before when my mom looked pre diabetic, a handful years ago, and a doctor told her to change her diet. She put together a diet that was worse than the one she was eating. Yeah. And she was trying trying to eat something that would follow along with what he was saying. Didn't people just don't know. So it's not your fault. But the doctor needs to know that that's the situation. Yeah, you know. So this next person says there are ways to have a lower more healthy a one see there being kind here about the podcast, such as being bold with insulin, let us know that this is possible and help us to achieve better agencies. Please don't shame us for falling short, but do encourage us to do better. I see this a lot, right. Like nobody wants to tell somebody they're not doing right. Well, right. became a social thing for a while. You know what I mean? Like nobody wants nobody wants to tell you the truth. Sometimes

I feel people are worried. On the end of professional people are worried about creating like a shame type of explanation. When really that's, that's your job is to tell somebody when they're not healthy. That's that's your job, right? You didn't go into health care, to tell people to keep eating what they're eating or to keep, you know, not doing what they're not doing. You're

not there to make friends and know that Yeah, you're and I get that I would listen, I would bet the argument back would be, if I push these people, they're not going to come back again. And to that, I might say, least you told them the truth. Right? You know, like, now it's on them, at least, you know, but keeping it from them or pretending they're going to do the right thing. That's not helping anybody. That's just mean, that's, that's you're lying, and they're lying. And we all know each other's lying. And none of us are saying anything about it. It's weird, right? You know, I

see, I see questions often still, in this sort of day that we're in with technology, I still see questions about why people are. And it goes right along with this management and even like, target range for blood sugar and whatever. Why are we explaining blood sugar targets that are outside of the realm of what somebody without diabetes? Right? Why? Why are we saying that? A 200, blood sugar, a 250, that's safe. That's okay. You can come up here, you can kind of settle back down, etcetera. You know, the human body does not do that without diabetes. So why are we constantly telling people that it's okay for you to be in this really wide range, and then down the road, their expectation comes to be? Well, I stuck within these targets. And now I have problems with my eyes, or now I can't feel my feet. And I did what I was told. I was told this is okay.

Yeah, no, I think it's got something to do with the physicians either not understanding it themselves, the mechanics of getting to those other blood sugars, or they've seen so many people fail at it that they think it's not possible. So why am I going to give them a target, they can't reach at least I'll give them one that they can, they can get but, but that's where this this person here says learn how to communicate diabetes, those things, suggestions. So often, we're told to do something, but not given a reason why? And then you and I made a note after that, that said, that says don't just give us a fish. Teach us how to fish. And right. Yeah, right. Yeah,

absolutely. I think you had a thought. Let me bring it back into my brain. Like right there on the tip of my tongue. It'll come back to me.

It's okay. Well, I think we got thrown off when your cat's whiskers came into the camera first.

Yes, I sorry. I was gonna comment. And I was like, No, it's okay. I know she was

you were like you I say something about that or let it go? Yes. Sorry. On the fault, though, I stepped over you. You had a look on your face. Like you were gonna say something. And I said that it's okay. Don't worry about it. I wish it diagnosis. They told us that what we learned at the beginning is foundational. And there are many things to learn. Moving forward for best management like Pre-Bolus and glycemic impact load bolusing for fat and protein, being aggressive when aggressive isn't necessary. Also, I wish they would have emphasized emphasize that ratios and basil will change and what numbers we get aren't set in stone. Okay, so this becomes another big problem. You know, you you set somebody's this happened to me. I remember the doctor was saying what's Arden's insulin to carb ratio. And when I pulled it up, it was like one unit that like, I don't know, like some insanely large number 300 carbs or something like that, because she was diagnosed when she was so little. But we were like, years later, and no one had ever changed it. Oh, and I didn't know anything about it back then. So I'm like, Oh, she's having all these high blood sugars all the time. And I'm like, I'm having a lot of trouble with meals, and I can't figure it out, back then I wasn't the guy who was like, Oh, just do this. I went back to the doctor, and I was like, I don't know what to do. And they pulled that setting out. They're like, Oh, and it was like it was off by like, I think she was one to 100. And it was set at one to three, she was using two thirds, too little insulin at every for every carb. So, you know,

that actually, it kind of made me think of what I was going to. What I was gonna say is that, I think that in, at least initially, and maybe even for somebody who has had diabetes a long time, and now is really coming in with a set of questions. What it boils down to is explaining that this initial information is just that it's a baseline to start with, and navigating diabetes. I wish people would just be honest, and say it's not easy. It can get along the way of learning, you experience a hoz Oh, well, that totally makes sense, right? Or, gosh, this definitely can be built in now. So they're, they're stepping stones, if you will, to management. But as you just said, There's not just a start here, dose this there is again, kind of evolving changes. And that growth has to happen in your understanding, but how you understand it needs to be what comes from the clinical team that's helping you so they should explain to you that this isn't simply just put the insulin in and eat the food, right? That's not how simple this is.

Yeah, I remember a doctor once saying when our was younger Wait, oh, she gets hormones like, oh wait, do you see the female hormones? Oh, and I was like, what she was like, wait a minute, UAH context? Is there any context? You know, oh, hormones make it harder. And I'm like, and, and you don't you mean like, though I figured it out between that and, and when it actually happened for myself, but nobody ever likes in that time no one ever stepped up and said, Are you bolusing? differently? Do you notice any strategies that help or hurt? Or, you know, are there times of the month that are different than others? That conversation never happened? Just oh my gosh, you should see Wait, do you see what happens? And I spent years going like, oh, like,

like, I'm worried I wonder what's gonna happen? Yeah. And as if she didn't have hormones. age that she was,

she was growing, I'm sure she had growth hormones. So at the very end others, this person says, this is kind of funny. bolusing for fat and protein impacts is a type one diabetic should not be considered an advanced topic. And I thought, but that's really true. It's very, very true. You cannot, you can gather up 100 People with type one diabetes and ask them, you know, what is your endocrinologist taught you about dosing for the impacts of fat or protein? They're not gonna, I mean, two people are gonna say somebody had mentioned that to them, you know? Correct. And yet it throws off every meal, almost every meal of every day and someone's management for 24 hours, that turns into a week that turns into a month. And it's it can be at the core of the whole thing the other day, Arden. She's weighed school. And she said, I did get a text from her. Hey, I had to stop at a drive thru on the way back. I'm, you know, I had to grab some DT amount of time. I said, What do you get? She said, I got Chick fil A. And I said, Okay, 45 minutes from now your blood sugar is gonna go up. And I was like, Don't forget. So you know. And by the way, you know what she did? She forgot. And but I was, she was probably driving. Well, she was now at another place doing this homework. And then she had to get into a class and stuff like that. And I said to her, I'm like, I'm like, okay, look, just look at your algorithm. Is it suggesting any insulin? And she said, Yes, I was like, I think you should put it in. You know, because the algorithm was trying to fight. It was trying to fight the fight, but it wasn't going to because it wasn't compensating for the she didn't put fat into the she didn't it didn't know what it was trying to fight. Didn't know what I was doing. Just like this morning, by the way. She thought she lost her ID. Oh, so like, I get this call. I'm like, why did that happen? This is gonna happen a couple of times, I'm pretty sure. Yeah. But while she's searching for the ID and doing the math in her head that she doesn't leave five minutes from now she's gonna be late. And if she's late, and she misses a class, and she only gets the missed so many. And she says I'm watching her blood sugar, it is just going up. It just went from 100 to 120 to 130 to 140 that he got an arrow straight up from trying to find her ideal stress. Yeah, from the stress of it. Oh, Doctor, I gotta tell you that. They're gonna say something like, oh, the mornings, huh? Yeah. Oh, no mornings. They're hard. Thanks a lot. Right. And

that will be as we talked about before, that'll be one of the fingerpointing on the records. We'll see what happened here. Yeah. No, it was probably in school one

month from now if you ask garden, what happened there, she's not going to say I lost my ID thought I was going to be late and got upset. Like she's gonna I don't know what this is, you know, so. But all this goes back to Tools. Like give me this person says, give me the correct tools give me parameters and instructions. Let me know I could probably do this, if I had these these things in place, right. And to what your point is, I always say, it's experiences. Like you have to have them over and over and over again before they just start becoming not just like second nature, but they make sense to you. Like out of nowhere, something happens you I know what to do? Yes. As soon as she drove away, like, you know, she had her ID this morning, and she left. I thought she needs a temporary Basal increase. Like I don't care if she's on an algorithm or not like right now she needs a Temp Basal increase this algorithm is not it doesn't know there's an impact here. It's it's changed rising as if she ate food. And it has not been told there's any food there. So we did that. And it came back down pretty quickly. Yeah.

Good example I have of like those lived experiences. You can provide all the information possible. And then when you get into like, from my angle of providing education, and give you scenarios, things that might happen, but until they really happen, you have nothing to apply that to and you may need to dig deep and think about it right? A good example is somebody I work with, who had emailed me about a scenario and emailed me just to say, You know what, everything that I've learned, I knew how to work around I found it. And I think I did the right thing. Yeah. And 100%, this person had done the right thing, right? blood sugars that were doing something that shouldn't have been happening based on everything else that had led up to that point. And what did the person do? They change their site, they changed their, their insulin, and it all navigated back down. But without some lived experience and some information pointing to Hey, If this, then this, right, right, they're gonna throw their hands up and be like, I don't know what it was not

make that change. I also, you know, that's true. Because oftentimes, you'll see people changing out sites, when it's not the problem, right? When their settings are bad, and they're constantly the pump doesn't work, the pump doesn't work. They over and over, and I, sometimes I online, I'm like, stop there, like, I've changed the pump three times, like, Stop changing the pump. Just stop. It's not your site, right? Like, your settings are bad. Like, we're your settings are great, but something's happening right now. And your settings aren't up for the challenge of what's happening today. You know, like, it's, again, lived experiences. That's how you'll figure this all out. I like this, this feedback here, give me all of the options, not just the ones that you think are best or better or efficient. I would like to make my own decisions, and then craft my own ecosystem of how I deal with this. I think that's a great point. You know, there's more than one way to do this. And everybody's brain doesn't click with the way you say it one time, right? That just you have to give people the autonomy to autonomy is such a big part of this. Because if they don't have that, they don't have all the ideas, and they can pick and choose from it make their own tool belt. That's a problem. But if they don't feel like they can make changes on their own, that's also a problem. Like, that's a big, big problem for people with type one diabetes, the ones that don't feel comfortable, or don't feel like it's their job to make changes to settings. They're the ones I see struggle, the most long term is adults. Do you agree?

Yes, absolutely. Because they from an early on diagnosis, whether it was childhood, and that's how their parents navigated, because that's what they were taught how to do. And then they move into adulthood, managing that way, really only following up with the doctor every six months. And that's when something gets shifted and changed and not not really knowing that they're in the driver's seat. 24/7, between that 1520 minute visit with the endo every six months, right, you are the Navigator. But unfortunately, if you don't tell somebody, it's almost like giving the Okay, many people with this type of a, you know, a use of something that supplies like insulin, right? You really have to be directive and say, You know what, I'm going to give you these starting places. And here are some pointers for adjusting. I'm happy if you adjust. In fact, give me feedback when you try and adjustments so I can help you behind the scenes if there's you know, communication with an electronic record or something like that. But you do you have to almost give the okay to people. Otherwise, they may also come back to the office and not provide feedback that they've been tweaking things on their own, because they may feel like they're gonna get their hand slapped. Yeah.

Oh, that's definitely happening. Right? Yeah, people are definitely lying. They're always like, I can't I can't let my doctor catch me doing this. And when people say that, to me, I'm like, What are you talking about? Like, oh, I want to make an adjustment to the basil, but I'm afraid I'm gonna get in trouble in trouble, like, so. Ironically, you're not in trouble, quote, unquote, for the seven and a half a one C, but you wouldn't be in trouble for putting the Basal up point three an hour and making it a sentence? fascinate, right. Yeah,

absolutely. And insulin, interestingly, is, I think it's, I can't think of any other medications on the market, that people self adjust, right? Like you don't go to your cardiologist and they give you blood pressure medication, you're like, today, I think I'm going to take two of these tablets with you. It's gonna happen, right? Like insulin is one of those. It's I think it's the only thing that really, it does require you to look at your own information and make adjustments based on what you're seeing and where you want to end up. What is the target you're aiming for? What are you trying to get to, things aren't working?

It's also interesting where the line gets drawn, and I had a, I had a root canal go bad. It was like 11 years old. So I was pretty happy. It lasted that long. So I'd have changed out right. And when he got in there, he's like, Hey, there's like a little bit of an infection there. You know, this is really going to hurt tomorrow. Let me give you a prescription for a pain medication. He said, The one I'm going to write for you is highly addictive. He said, so you have to be careful. And I was like, I'm gonna go with Advil if you don't mind, right? And he goes, No, no, you should probably take this script because this is gonna be a problem, blah, blah. And I was like, I'm good. I don't I don't need your script. All right. By the way, I didn't even take an Advil when it was over the guy said, great dentist and did a great job. But he was so willing to be like here, would you like a week's worth of narcotics? Because I dug around in your gum for an hour. And I was like, and I'm like, Wow, look how easily he would have given that to me. Yeah, but then you go ask an endocrinologist. Hey, you know, wouldn't it be cool if that lady could change your basil and they can't handle that? Right? Again, and all that, but you can give them oxy. I was like, right. All right. Can we make sense once in a while? No. All right. This person says, Can you give me your medical opinion, please don't parrot what you're reading, ah, in this example, as their kid was doing a six for a lot of years. And then it rose up. And the doctor went, That's okay. It's still within target. And they're basically just telling them like what the ADA said, like ADA says sevens fine. This is fine. And like, so then that takes the onus away to do better again, it's again, it's just like, oh, whatever, you're fine. It's like, what's your blood pressure supposed to be? I don't know these things. 120 over something. It's

well under 140. And it's like, what let's call it like, 130? Over 80. Okay, right. But in anything kind of, you know, within that sort of the range, but just your blood

pressure was 150 over 90 all the time. What a doctor guts. Alright, it's cool. Not bad. No, no,

they shouldn't.

But you I saw you getting upset earlier talking about those column? 250s. Okay. You know what I mean? Like, that's the same thing. But you don't but that doesn't get seen that way. A cardiologist would never say that to you. an endocrinologist would say that to you all day long. Oh, just 250 it comes back down. You're fine. What? How am I gonna be in 20 years? Right? Yeah, yeah. What do you do you own a LASIK center or something like that. And you're thinking of getting into diabetes surgery to like, what are you trying to have happened to me here? And what and oh, sorry, I got upset. Now you can talk? No,

I was gonna say and for the person who is a little bit more concerned about the lower blood sugars because of whatever fear that was instilled eons ago or whatever. Those numbers that are higher that they've been told are okay, even for lingering or you know, non lingering time periods, like a blip up and then it kind of comes back down. Eventually, they may get to feeling that they're safer. They're okay at those numbers, because in their mind 250 becomes okay, then all the time. Yes, not just the up and it comes back into what you define as the as the healthy brain to be re

in range. Yeah, yeah. Especially with the thing that you don't feel. Listen, if your blood sugar's if you're a one sees rise slowly enough, you won't feel the impacts the physical impacts, your body is going to do a pretty good job of trying not to die and like what it was it this opens up blood vessels that like does all kinds of stuff, right? Like to try to like Yeah, yeah, yeah. To, to do that kind of stuff. So. So when you say it's okay, this person is slowly not becoming themselves anymore, they're altered mentally even, you don't even realize how foggy they are, they get used to that their body gets used to trying to exist like this no different than, you know, how you end up with an enlarged heart from smoking. Right? Right. Same idea. And, and yet, it's like, it's okay. It's okay. It's not okay. Like, it wouldn't be okay for you. If if you were that if the doctor, his blood sugar was 250 all the time. They'd be going like, we gotta fix this, you know, so I don't, I don't know why that that tired. It's just tired. It's lazy. Well,

and again, with today's technology, and everything that we have, that it's got such tight ability to have alerts and alarms to keep people safe. And yes, technology can be a little weird and whatever. Yeah. But the majority of the time, what we have today with the alarms and the alerts, there's no reason to say that you can skirt up to this value as long as you're not under here. And as long as you're not hanging out in the low zone. And again, that's not even often very well defined. Yeah, what's too low? Where do you want to hit? What how long? Can I sit at what you're not telling me about a low number? What do I do it? Again, it's very like Flim

Flam. It's nebulous. It really is. And by the way, even now with a within a non aggressive algorithm, like the eyelet, for example, that thing's still targeting probably under like 180 or 170. And you and I would be like, I mean, listen, it's a great tool, and I think it's going to help a lot of people but I wouldn't rely on my daughter and like, and that's 70 points better than telling somebody to 50s Okay, so I just need to understand speaking Understanding even though we had management under control and a consistent a onesie in the fives, my Endo, my son's endo said that we need to do less work, we need to do less work and let his numbers get higher. So as a one sees more like in the mid sixes or sevens, that whole you're trying too hard thing. I don't get that, like I really don't, because I know they don't want people to go crazy taking care of themselves. Right. But at some point, it does become second nature. Like you don't you mean you? It's a lot of hard work upfront for a lot of benefit long, long term. And

I think in a visit where you the clinician, you're looking at that, let's call it a one C, which again, is not

that shallow, I'm enraged and everything just

not right. Are you asking more in depth about how much work it is taking? Because again, once you've been there for a while, as you said, it becomes more most of it becomes more second nature and you you're able to just navigate and keep that yeah, because you're doing what is pretty typical. And until or unless something changes with a growing child or a teen or something in adult life. For the most part, you're doing a good enough job. And that's when you have to define or ask the person. Gosh, how much are you checking? Yeah, right. If you can see that, you know, even in a visit somebody's like every two seconds, they're like looking at their numbers. There might be something more like on the mental angle to logical

issue. Yeah, they might be under a lot of stress and pressure. But yeah, just assuming, you know, it really does it piggybacks on to this point that you added to here, you told me please bring it up, that seeing a good low a one C and assuming it's from like low blood sugars is a dangerous way to think as a doctor. This is Oh Jenny, this happens constantly the amount of people who listen to this podcast, then head off back to the doctor super excited, oh my god, I got my one seat down. It's nice. It's not that hard. Even I figured it out. Like turns out my settings were wrong. And the doctor yells at them, because they as soon as they see a number that's lower on that agency, they assume you've had multiple, you know, elongated lows to create that agency because they don't even know how to do it. It's such a unknown quantity to them, that they just assume that you've cheated the a one C test by having a lot of lows. Right? Yeah. And some of them won't listen, when people try to explain it to them, or the people are put their head down and you know, don't stick up for themselves. Right? It's a dangerous assumption to make. That's just because somebody has an A one C and the sixes are the five that must mean they're low all the time. My kids never low. Like, like, once in a great while. And even that means a drifting to 55 not like, you know, oh my god, what you know, Bob a lot most of the time her blood sugar's I don't know, it's not it's never usually under 70. Right, you know, honestly. So we have some bullet points that go through here at the end. So we'd like 10 minutes left. Yes, some of them are repetitive, so we might have to pick through them. And I'll skip over the ones I wished my doctor knew that tightly managing my son's blood sugar is far less stressful than living on the roller coaster. That's the thing you wouldn't know unless you lived with it. Correct? Like actually trying and working towards it is not as hard on you as the unknown aspect of it. You know, I think it's the difference between being told you're about to walk through a haunted house and not being told, you know, when stuffs just jumping out from around the corner all the time. You're always like, I don't know what's gonna happen next. Right. But yeah, working hard. I find this to be true for me. I don't know that everybody would find this to be true. I assume you do. Right? Like the work you do is, is worth what you get out of it? Absolutely.

Yeah. 100%. Because I have, I have things that are known. And it makes the majority of my management, more like brushing my teeth. I don't think about the like, brush my teeth, whatever, right? It's not a thought. I have the time it's like out of my brain that you're putting the toothbrush on the brush and brushing and whatever. That's how I think about the majority of my management, unless something is really shifting stress or whatever, or I'm ill. But even that I've got enough enough years of experience to have a go to. Yeah, right. It's a starting point of oh, I can try to do this. And definitely it helps, right?

So I always describe it as walking through a door. I don't like consciously think reach out, grab the knob, turn it pull. I just I just end up outside the door. And that's how diabetes works for you after a while and it is it becomes a muscle like I bet you Mike Tyson hasn't fought in a while but I bet you if you walked up to him and tried to slap him, I bet you his head would move pretty quick and he'd pop you right in the mouth. And so like and that's kind of how diabetes ends up working out. You don't know what to do. happening. But now you have all this experience and you know, blah, blah. This person says, Please tell people that they could actually go into decay with a normal blood sugar number. Yeah.

That's so important. And where do you usually go? If you have ketones, and you're not feeling well, and you can't keep something down? Where are you going back to

the hospital? That doesn't seem to know anything about helping me with my diabetes. And

in that scenario, we actually, unfortunately had a really sort of a bad situation with one of our clinicians who her fiance had to advocate for her. And she's actually kind of corresponding with the hospital system, because of how they navigated it for she knew she was there for five hours, trying to get them to just give her fluids, her blood sugar was normal. They kept telling her she wasn't in detrimental need,

right? Yeah, yeah. But she, I

mean, and that's it. She knew she knew what she needed. I mean, sure, if you can stick your own IV. Oh,

great. Imagine knowing so much about it that you know, you're in this trouble. This is the next need you have you need, you need IV fluids, then you take yourself to the right place, tell the people who are supposed to know and they're the ones who are going to be the impediment between you and not maybe dying. And that's by that happens quick. By the way. I forgot how nursing, how do they put it like it's not compatible with life, the acidity, right? That happens, right? The

changes in all of your electrolytes and all of the things that should be being measured in the body. And ketones are one marker. And obviously, with diabetes, blood sugar would be technically another thing that they look at. But you know, when we talk about you, glycemic DKA, that's unfortunately, a level well above what most emergency departments even understand how to navigate Yeah. So

I'll run through the rest of these here. Somebody said, Please, you should talk about the benefits of like mini glucagon injections for some people, especially with little kids who have trouble with lows. Please tell people about Pre-Bolus thing this woman says how we said this already today, protein and fat and how it impacts blood sugars and spikes. An explanation of insulin resistance would have been nice, when it happens, why it happens and how to manage it. So that's a person saying even if your settings work, when something else happens, I should know, like what to do next. Right? I wish my doctor knew that a one C wasn't everything. As soon as my doctor hears that my a one C is 6.8. I hear from them. You're doing great, don't worry. Meanwhile, I'm on a roller coaster all day long. I've at 50 blood sugars and 400 blood sugars on most days. And I have no idea where to begin. But they saw the 6.8 and said hey, you're doing great, right? Yeah, that's it. I wish they knew that there was no good reason to delay a person from getting a continuous glucose monitor. Within the hospital or as soon as after diagnosis as possible. I still want people to learn how to prick their fingers. But uh, CGM is such a, it's a next level, I think people deserve it. Who have type one diabetes. I think anybody using insulin deserves one. I agree. Same thing with pumps, please tell us about pumps sooner. This person says you should tell people about the podcast that's very nice. Whoever put that in here.

I would say along with the pumps that I think it's gotten better crack. Most practices now have more knowledge about the multiple options that are on the market. But I still see practices that are more prone to offering or suggesting heavily one particular pump versus another. And what that often comes from his just their knowledge about that one particular system and they feel so strongly that it is the right one. Again, this is where individualization needs to come into the picture. So you need to know about everything to help the person pick the right one at the right time.

I think in a world where you know, especially while we're making this episode, these episodes in a world where people are so under educated in the things that you're talking to other people about. I understand where this comes from, like, you know, I figured out how to use this one pump at least I can talk to them over the phone about where the settings at and stuff like that, but you are eliminating choice from people and not just their personal choice but choice that might allow them to find something that actually fits in their lifestyle better. Right. You know, I use I saw a little girl the other day online. So happy holding her tandem. Her ex too. Yeah, she's so thrilled, you know, and someone said, How come you didn't get her an omni pod? There wouldn't have been any tubes. And she said this just works better for her. And like, like for her personality. She said, good. Like, that's great. Yeah, but You shouldn't get like, because the, you know, I mean, because think of how that happens. Why are you? Why do you know one pump better than the other one? Right? I don't know, because the salesperson got there first. You know what I mean? Like, what the heck? Because back in the day before all the laws, they sent the doctors on better vacations. Yeah. Why we're doing this one. Jenny's laughing because that is what they used to do. That's not legal anymore. I'm sure that doesn't happen. Good lunches. That's it. They used to have like meetings, but they'd have them in Hawaii.

Yeah. Or take you out for you know, good, like dinners where it was like a lunch and learn type of experience. Right?

So yes, yeah, a bottle of bourbon and a steak. And all of a sudden, we're getting a pump.

I remember when that all changed. Yeah.

Yeah. Was that was actually a good law. I don't I don't have anything else for this one. So I'm just want to ask you, you know, for your kind of closing thoughts on how doctors should be talking about actual management to people? Yeah,

I think we, I think we discussed the majority of what was I really do, especially along with all of the comments that people offered just in consideration. I think, you know, all of this communication and management and everything that we've talked about so far, it just it It boils down to individualizing. And really knowing starting place and where to move from there with somebody, because that starting place again, is just that you're going to have to move that person along and or help them move along because of the questions that they're bringing you. Maybe they're further along in understanding than you think they would be right so you have to meet them where their need is. Yeah,

I know it sounds I always felt I always feel stupid saying cliche things but meet people where they are big deal. You know, you understanding what you're talking about. Big deal. You being able to communicate what you're talking about big deal and giving people a complete story. And not just snippets is is very, very important. Anyway, thank you for doing this with me. Thank you of course. A huge thanks to the contour next gen blood glucose meter for sponsoring this episode of The Juicebox Podcast. Learn more and get started today at contour next one.com/juice box. A huge thank you to one of today's sponsors, G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com Ford slash juicebox you spell that GVOKEGLUC AG o n.com. Forward slash juice box if you are a loved one has been diagnosed with type one diabetes. The bold beginnings series from the Juicebox Podcast is a terrific place to begin listening. In this series, Jenny Smith and I will go over the questions most often asked at the beginning of type one. Jenny is a certified diabetes care and education specialist who is also a registered and licensed dietitian and Jenny has had type one diabetes for 35 years. My name is Scott Benner and I am the father of a child who has type one diabetes. Our daughter Arden was diagnosed in 2006 at the age of two. I believe that at the core of diabetes management, understanding how insulin works, and how food and other variables impact your system is of the utmost importance. The bold beginning series will lead you down the path of understanding. The series is made up of 24 episodes, and it begins at episode 698. In your podcast, or audio player. I'll list those episodes at the end of this to listen, you can go to juicebox podcast.com. Go up to the menu at the top and choose bold beginnings. Or go into any audio app like Apple podcasts, or Spotify. And then find the episodes that correspond with the series. Those lists again are at Juicebox Podcast up in the menu or if you're in the private Facebook group. In the featured tab. The private Facebook group has over 40,000 members. There are conversations happening right now and 24 hours a day that you'd be incredibly interested in. So don't wait. So don't wait. Check out the bold beginning series today and get started on your journey. Episode 698 defines the bowl beginning series 702, honeymooning 706 adult diagnosis 711 and 712 go over diabetes terminologies hit Episode Seven pick team we talked about fear of insulin in 719 the 1515 rule, Episode 723 long acting insulin 727 target range 731 food choices 735 Pre-Bolus 739 carbs 743 stacking 747 flexibility. In episode 751 We discussed school in Episode 755 Exercise 759 guilt, fears, hope and expectations. In episode 763 of the bowl beginning series, we talk about community 772 journaling, 776 technology and medical supplies. Episode Seven at treating low blood glucose, Episode 784. Dealing with insurance 788 talking to your family and episode 805 illness and ketone management. Check it out it will change your life when you support the Juicebox Podcast by clicking on the advertisers links you are helping to keep the show free and plentiful. I am certainly not asking you to buy something that you don't want. But if you're going to buy something, or use the device from one of the advertisers, getting your purchases set up through my links is incredibly helpful. So if you have the desire or the need, please consider using Juicebox Podcast links to make your purchases. Thank you so much for listening. I'll be back soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

Hello friends, welcome to episode 1151 of the Juicebox Podcast today I'm going to expand the Grand Rounds series. It's not Jenny and I today today, it's Dr. John Oden and myself talking about type one diabetes care. Up until now it's been Jenny and I talking to doctors about what we think people with type one diabetes need. Today we're going to hear from one. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan or becoming bold with insulin. How would you like to help with type one diabetes research from wherever you are right now? In fewer than 10 minutes? Go to T one D exchange.org/juicebox. and complete the survey. That's it. You need to be a US resident who has type one diabetes, or is the caregiver of someone with type one. And they're very interested in hearing from caregivers of Boys, boys of color, men, men of color, but everyone is welcome. If you're a US resident, you have type one where you're the caregiver of someone who is T one D exchange.org/juicebox. You'll be helping, it won't take much time. Please consider it. This episode of The Juicebox Podcast is sponsored by the ever since CGM. And sure all CGM systems use Transcutaneous sensors that are inserted into the skin and lasts seven to 14 days. But the Eversense sensor is inserted completely under the skin lasting six months ever since cgm.com/juice box. This episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. Learn more and get started today at contour next one.com/juice box. This show is sponsored today by the glucagon that my daughter carries. G voc hypo Penn. Find out more at G voc glucagon.com. Forward slash juicebox Hello, I'm

John oden. I am a pediatric endocrinologist in Arkansas. I work mainly at a little rock but go into the Northwest every once in a while. John,

why am I talking to you today from where are you at?

I am currently in a town called Springdale, which is the house of one of our newest pediatric hospitals. For Arkansas Children's. It's our it's Arkansas Children's Northwest. I think our discussion today was born from a couple of my diabetes education people. Roxanna Hutch craft, recommended I reached out to you because, well, I'm an endocrinologist, your podcast is is highlights diabetes quite a bit, which I applaud. I'm an advocate for people with diabetes, and I'm a person who has had diabetes for the past 42 years. And okay, John, how old are you? I am 53 years old. 33.

So you diagnosed your 911 11 Oh, damn, you know, I had nine or 11 in my head has a choice. And I don't know why I went with nine. I also don't know why my brain can't figure that out. But that's,

that's okay. Because I keep thinking I was diagnosed when I was 10. I keep thinking that for some reason. But I was diagnosed in September of, of 81. So I'm sorry, September of 82. So

John, you're diagnosed? You're What do you take in regular mph?

Yeah, two shots a day regular mph? Very strict meals, very strict times exchange diet, if you will. You had to, you know, one slice of bread is a starch. That

kind of stuff. Yeah. Now is there in hindsight, other autoimmune in your family? There

is my mother suffers from thyroid, as does my sister, hypothyroidism. So there is

nothing beyond that, though. Celiac? No,

no. psyllium. But I mean, remember, I mean, my, my, my mother and my sister. You know, they're they're not they weren't born in a time where celiac was a focus. So I can't remember if my doctors ever screened us and I certainly don't know if their endocrinologist screened them. So it's very possible.

Can I ask you a strange one that you might not connect? But I asked about because I've been making the podcast for so long. I hear so many people's answers. How about depression, anxiety, or bipolar? Specifically? You mean for me personally, family, like family member even like either side going back anywhere?

I wouldn't be surprised if there was a touch of depression and anxiety and all of us family members meaning I don't mean to say that in a bad way. They certainly weren't, you know, dark room depressed, you know, they, but you know, every once in a while you could you could probably see the glimmer of some anxiety. My sister and myself. Sure, okay,

I just I, over the years and I'm now well over 1100 episodes, the amount of people who will say there's a bipolar I have a bipolar aunt or uncle is kind of overwhelming when you talk about inflammation and, you know, kind of things that we're still learning. Obviously, we're, I think our medical understanding of a lot of things is very young still. So I just like to ask, okay, so you're 11 years old? Just what you do into a day you're eating very specifically, your parents help a lot, or did you get into a rhythm and it was just on you?

To be honest, it was always on me. And that was not my parents choice. It was mine. From day one. When I was admitted, we were in Houston. So I went to UTMB in Galveston, and from day one nurse walked in, said, Hey, you're gonna start insulin injections. I remember it very clearly, she walked in with this needle that was, you know, six inches long. Not really. They were they were Terumo or BD, you know, big. They were pretty long needles. I took it from her hand. I said, I'm going to do this and ever since then, I can honestly say a nurse has other than vaccinations has never given me a shot.

Do you think you wanted to do it? Or did you not want someone else to do it? Oh, that's

a great question. wasn't afraid of it. So I guess, I guess, you know, it just felt it was on me to take care of it. Okay. And in my practice, you know, you see, you see kids like that. And you know, they're very independent predicts pretty good control. Although, you know, in my instance, it was a lot of obsessive compulsive I want to be controlling things, you know, controlling blood sugar that's part of the reason why my control is so quote unquote good partly why I have as many lows as I do, you know, I don't I don't like to be high. And so part of that is, you know, that obsessive compulsive nature of I want my blood sugar to be x and I'm going to fight to make it x and I want to be the only person that puts a needle in my skin and that's, that's what's gonna happen is

that focus that attitude prevailed through your whole life or is that just how you treat diabetes? Or can you also not can I not have the remote control for watching television or something like that? If you take insulin or sulfonylureas you are at risk for your blood sugar going too low. You need a safety net when it matters most. Be ready with G voc hypo pen. My daughter carries G voc hypo pen everywhere she goes, because it's a ready to use rescue pen for treating very low blood sugar and people with diabetes ages two and above that I trust. Low blood sugar emergencies can happen unexpectedly and they demand quick action. Luckily, G vo Capo pen can be administered in two simple steps even by yourself in certain situations. Show those around you where you storage evoke hypo pen and how to use it. They need to know how to use G Bo Capo pen before an emergency situation happens. Learn more about why G vo Capo pen is in Ardens diabetes toolkit at G voc glucagon.com/juicebox. G voc shouldn't be used if you have a tumor in the gland on the top of your kidneys called a pheochromocytoma. Or if you have a tumor in your pancreas called an insulinoma. Visit G voc glucagon.com/risk For safety information. That contour next gen blood glucose meter is the meter that we use here. Arden has one with her at all times. I have one downstairs in the kitchen, just in case I want to check my blood sugar. And Arden has them at school. They're everywhere that she is contour next one.com/juicebox test strips. And the meters themselves may be less expensive for you in cash out of your pocket than you're paying currently through your insurance for another meter. You can find out about that and much more at my link contour next one.com/juice box contour makes a number of fantastic inaccurate meters. And their second chance test strips are absolutely my favorite part. What does that mean? If you go to get some blood and maybe you touch it and I don't know stumble with your hand and like slip off and go back. It doesn't impact the quality or accuracy of the test so you can hit the blood not good enough, come back get the rest without impacting the accuracy of the test. That's right, you can touch the blood come back and get the rest and you're gonna get an absolutely accurate test. I think that's important because we all stumble and fumble at times. That's not a good reason to have to waste a test trip and with a contour next gen. You won't have to contour next one.com forward slash juicebox you're gonna get a great reading without having to be perfect. Oh

yeah, I you know, I am obsessive compulsive about certain things my wife will tell you I have this compulsive nature to buy vintage audio and repair it and she just gets sick and tired of seeing old tape players. And so there are pieces in my life that that Yeah, I think you can see that. But to the most extent, I feel that it's pretty mild. I'm a pretty open person and willing to hear others others thoughts on how things go. Are you using that

word clinically? Or just kind of colloquially?

Obsessive compulsive? Yeah, I would say mostly colloquially, I think it's, it's somewhat clinical. But over the years, I've learned to kind of manage it. So it doesn't really doesn't really frustrate my family. And I here I am the kind of guy that gets up, you know, right before we go to bed and checks the doors three or four times to make sure that they're locked, even though I know I've checked them 100 times.

Maybe it is clinical, John, I'm not a doctor.

Not medically managed, I guess is what I mean.

So you grew up this way? How long does the exchange diet idea? Go through your life? Like when did they because if you're an 81, when when did they give you I'm trying to guess what you get? Like Basal insulin and like 88 around then?

I never started Lantis? No, no, I always was on mph, I started human log in the early 90s. Okay, the honest with you, if my recollection is correct, and I was one of these people that, you know, I kept my diabetes in pretty good control. And we had to drive 45 minutes to an hour, my parents night to UTMB every, I don't remember, I don't think it was every three months. But it could have been up until I graduated high school. And then I started seeing a dolt. And by that time, I had learned how much insulin to give myself based on carbohydrate volume. So I was already doing kind of a meal ratio before doctors or dieticians had talked to me about it.

Yeah, that's excellent. So you saw it enough in your own life? You're like, I'm going to make an adjustment here on my own. Yeah. But what was the what was the measurement of success? Like you said, you were in good control. But how did they tell you where you are? Because it was it? I mean, you didn't have a meter right for a while, I would imagine at home.

Oh, we so we use those old accucheck meters. So we started using those in the mid 80s. And you know, you had to have a big dollop of blood. And you know, it gave you a range of like 80 to 120 or like a roundabout number, you know, so it wasn't, you know, hugely accurate, it took five minutes to get anything, you had to wash it off with sterile saline, that kind of stuff. It was, you know, very technical. But shortly thereafter, we started seeing meters kind of pop up measure of success was always kind of a one see how many low blood sugars did you have? Were you ever in the hospital? And there was a question on the on the questionnaire at UTMB that always struck my parents. And it was does he use he or she use his or her diabetes to get out of, you know, chores or responsibilities?

So a one C, amount of lows. Have you been in? DKA? Do you use this as an excuse? Interesting. Okay. And how were your lows? Manageable?

I think, you know, back then when we were only kind of checking blood sugars with finger poke. And the chemical Kimmy luminescent strips, you know, that gave you a range or the meters that gave you a range or a roundabout number. I think I probably had a couple of lows a week. But in reality, you and I know that was probably not very accurate. You know, we I probably was experiencing lows once or twice a day.

So John, tell me what you call low under what? Less than 70? Or 70? Where do you feel it? Like? Where do you feel like you're not yourself?

Well, with a rapid drop, I can certainly feel it. So when when my CGM shows me with an arrow down or two arrows down, I'm going for like, I'm going to be very conservative, you know, 200 to, you know, to 90 pretty quickly, I'll feel it, you'll feel a little wobbly. You feel a little, you know, shaky, sweaty. But if it if it's a slow decline, I would say I'd probably start feeling less than 6060.

Where can you not help yourself anymore? Do you know?

Oh, goodness, I've been in a teens and still been able to take care of myself. But then I've had some some pretty significant drops overnight that my wife had had to help me and when we measured it was in the 40s. Okay.

Does that happen to you now as much that there's the technology's better, like Does that still happen? Oh, no. No,

not that it hasn't happened in years. Yeah. You know, we certainly my onesies have been in the lower 60s upper fives for a while. So Right. Yeah. I would say that it's it's very, very rare.

Mm hmm. Now it's just that back then. Right there was, I mean, it's just there wasn't as much precision you didn't have any kind of the main the monitoring was, you know, right catches catch can.

But I've never I never had a severe low I will tell you I'll be honest, I never had a severe low while I was living with my parents never okay, in one time when I did have a low that required glucagon that my wife had to give me. My mom was actually staying with us. And she did not know how to use the glucagon. About that years later. Yeah, years later. And we found that the times that I had severe lows were always associated with like yard work or moving. So if it was hot outside, and I was really active, and got dehydrated, that tend to predict a significant low and so you know, my wife and I are always like, okay, so you chop down a tree today or whatever. You're gonna go, you're getting loads and loads tonight. So tonight, you're going to eat a

lot. What's interesting is what age did that that one low? You're talking about where your mom was visiting where you'd like in your early 20s. And you just gotten married or something? Or?

I was in my fellowship. So I'm guessing I was in my late 20s. Okay.

That's interesting. And what was your management like back then? for that?

I was on a pump. So I started pumps around the same time. If memory serves, I started my pump and my daughter was one. She's 23 now. So it was around the same time.

Yeah. Okay. Do you use an algorithm now?

I'm on the OP five. Okay, so I used to use tandem, but I switched the OP five because I can I can put it in different places on my my torso and my arms. You like

the form factor of the Omni pod? I do. Yeah. And up for that use Control IQ or just the tandem Basal

control IQ? Yeah, okay. I use Basal IQ for a brief period of time, then I switched to control IQ, I find both platforms are just are phenomenal. Yeah,

I agree. Also, it's interesting how quickly they went from baseline IQ to control IQ. They, they almost like, released that first thing like, look what we got, like, approved. And then before I feel like they, they didn't expect the next one to come back quickly, because it was really quickly after that. Yeah, it was it was but the tubing and the form factor meant enough to you to move on from something you enjoyed

the tubing not so much. You get used to the tubing, I just Yeah, I think it was the fact that the pump sites for me, I couldn't put them on my legs, because I'm a runner. And I couldn't discipline myself enough to carefully remove my shirt, so I don't rip my pumps out off of my arm. I tried it a couple of times. So I developed a pretty significant amount of like hypertrophy around my around my, the front of my torso. So I was like, hey, it's time for a change. So you're

overusing your only site that you that you were willing to use. Yeah. I also I don't understand when people say I'm a runner, but that's a different podcast. So you go out and run somewhere on purpose. And nothing's chasing you.

No, nothing's chasing me. No, no, but I can tell you that I am a an amateur runner. I'm not I'm not a person that runs every day. But I am training to do the half marathon this year in Little Rock, which is

all five of your toes pointing forwards still.

Oh, they are lost. Last time I did it. I lost the the big toe nails, which was a little gross for my kids. Yeah,

that's gross for me, John, I don't know you and I can't say it. So it's fantastic. When did when in your life do you say I'm going to do you think you would have been a doctor with or without diabetes? This episode of The Juicebox Podcast is sponsored by ever since and ever since is the implantable CGM that last six months ever since cgm.com/juice. Box. Have you ever been running out the door and knocked your CGM off or had somewhere to be and realize that your adhesive was about to fall off? That won't happen with ever since ever since won't get sweaty and slide off, it won't bang into a door jamb and it lasts six months, not just a couple of days or a week. The ever since CGM has a silicone based adhesive forge transmitter, which you change every day. So it's not one of those super sticky things. It's designed to stay on your forever and ever, even though we know they don't work sometimes. But that's not the point. Because it's not that kind of adhesive. You shouldn't see any skin irritations so if you've had skin irritations with other products, maybe you should try ever since unique, implantable and accurate so if you're tired of dealing with things falling off or being too sticky or not sticky enough or not staying on for the life of the sensor, you probably want to check out ever since ever since cgm.com/juicebox Will links in the show notes links at juicebox podcast.com.

Probably not, I will be honest I, before I was I developed diabetes I am mistake take a step back, my family comes from my mom's side, a lot of people in the Navy and I have a lot of respect for our military. In this country, right? I had planned to become a naval aviator, I wanted to fly a fourteens back in the day, but then after diagnosis, my uncle and I had a conversation about the possibility of a person with diabetes joining the Navy and in any way, shape or form. And he just told me very, very honestly, and frankly, that No, that wouldn't be possible. And that just broke my heart. So thinking back on the days when I was, you know, with Dr. Travis and Dr. Bro hard at UTMB, which is phenomenal group, great doctors. I just liked what they did. And it's it kind of formed an idea in my head to do that. And that's what I, you know, again, with my obsessive compulsive nature, I just kind of went after it.

And when you say that they're good doctors, what in your mind, like with the experience you have now in hindsight, what made them good physicians for you.

They were brilliant. In my eyes, they were brilliant. They knew exactly what they were talking about. So they had this force when they walked into a room, which I don't know anymore, because I'm one of them. So another doctor walking into a room coming in with this knowledge about what's going on. And what's going to be the treatment strategy is just commonplace for me. But back then there was just this, this, you know, this presence in a room and Dr. Travis walked in. I mean, Luther Travis was a big name and diabetes, and they were they were fortunate to have that you haven't met UTMB and Ben, bro hard. Likewise, if memory serves nephrologist, both of those guys went on to write a book about diabetes not too long after I have a copy of it in my office. It's it's in the 80s I think so it's relatively old. But the other thing was that they were just very kind, very direct. They my mom was very anxious at the time, of course, her son was diagnosed with diabetes, but I just remember these guys has been very patient and kind of walking her through the process and walking me through the process. And

I'm going to tell you why I'm asking this in a second. But kind honest and smart is what I heard overall, and that they had a there was a lot about them that they knew what they were doing. Yeah. Okay. And then when they walk in, you put yourself in their hands because of these these ideas, and then they know what they're talking about. They're able to lead you. Right. Okay, so are we talking about leadership? You know, yeah, just, yeah, I'll take let me tell you why I'm asking because I know somebody put you on to being on the podcast, so you might not listen to it. I've been doing a series this year, I've been doing two kinds of concurrently. One I'm having health care providers on and other people around medicine. So anywhere from like a human resources professional, up to a I've had CDs, ER nurses, I've got a doctor on the docket coming up, but these people are coming on. And they're speaking anonymously, we're actually even changing their voices. And they, they're dishing about their jobs. I've heard anywhere from I wouldn't go to the ER that I work at, if I had trouble with my diabetes, to I've been directed over the last 23 years to fire so many people because of their medical problems, you wouldn't believe it. Like like that kind of like so that kind of honesty, right. And at the same time, I'm doing another series with a CDE. I know I don't know if you're very particular about the C D. C 's thing now. But her name is Jenny and Jenny works for Integrated diabetes, which is a company where you can go and they'll manage you remotely and help you. She's type one for like 35 years, she a very similar story to yours, like, you know, grew up on regular mph was eaten on a schedule. She's like, we ate at the exact same time every day, like that kind of stuff. And she's just kind of brilliant about how she talks about diabetes. And she and I are doing a series where we're basically we call it grand rounds. And we went out to the audience of the podcast, which is significant. And ask them what do you wish your doctors would have said to you? What do you wish they would understand, you know, what are you looking for in your interactions? Where do they fall short? And so we're kind of kind of doing this series where we're talking directly to doctors and saying, look, look, this is what people need. And I've just been very involved in it in the last like three or four months now. Hearing from physicians hearing from medical people that my doc I work with doctors that overwhelmingly don't know what they're talking about when it comes to diabetes, or the healthcare system isn't even set up to help people with diabetes. Like you'll come into the emergency room and say like I'm having an issue with my heart, but then you look at them and their type two, for example, and they have, you know, significant gaps and how they care for themselves but nobody even explained to them what they're doing wrong. And it's and sort of just trying to parse through the whole thing. So just to hear a person like yourself, who has good control over a lifetime, is an endocrinologist and thinks back on their doctors as being good. I was really interested because I, there's this phenomenon that happens when people come on, and I'll say, What do you think your doctor and like all my doctors, fantastic. And then through the course of the conversation, I learned that they're a one sees in the high sevens, it has been for 10 years, and I'll stop and ask them, Why do you tell me your doctors, fantastic if you're a one, see 7.9. And then they go on to say, Oh, they're lovely, very nice people, you know, and you tend to realize that the personal partner, they liked the person, but the person is not really doing a good job for them. But when they think about it, they think they're doing a good job, because they like them. Does that all make sense? It does.

It brings up a lot of really sensitive topics, right? I mean, you know, who's responsible for diabetes control in the end, right? It's your doctor, or is it you, likewise, the workforce today is much different than it was in the 80s, there's a lot of meat on that bone that I think you you're gonna, you're gonna pull off a lot of it talking to the right people, I applaud you that. The first one that you described as a hacker, you were probably gonna find a lot of interesting information, depending upon which hospitals you get people from. And then the second one is fantastic. I think asking people what they wish, a doctor would say is, is information that is not taught in medical schools. And I learned after I graduated from fellowship years after a basic saying that that really helps families out. And that's just to look at them in the eye and say this, this wasn't your fault. And that's just one little piece of a conversation that probably needs to be a lot longer than it is now. So I That's great. Well,

I think that what I'm coming up with is that there's some mixture of humanity communication and knowledge that the doctor has to have. Yeah, sometimes. I'm not trying to be funny, but sometimes what makes you a good doctor does not lead you to be a terrific communicator. And that I'm kind of seeing but but I also at the end of the day, and at the end of it, that's not to blame anybody, right? Like it's a, it's, it would be like saying, you know, I mean, I'm gonna build a building, I want a good engineer, this is not the same guy would ask to put on a community play. Right? Like, like, okay, right, traditionally, like that an engineers mindset and personality might not be, you know, right. For other

things. You don't have to be a renaissance man to be a good, a good doctor million

percent, right? And, but at the same time, when I'm hearing these conversations, I came up with the exact same thing that you said, which is, at what point, if I'm a physician? Can I beat my head against that brick wall? telling somebody? All the good information I have, and feeling like they're going to just ignore me anyway? And there are eight and whose responsibility is it? And I think the answer is it's everyone's responsibility. If I had to push it to one side, I have to push it a little more towards the doctor, because I am making an assumption that they at least have a level of intellect that should allow them to get through this problem. I don't know everybody who has diabetes has that. Yeah, yeah. The the capacity. And that's not their fault, right. So you, and at what point, though, does a doctor burnout and just think, I'm not gonna say to this person, it's not even gonna, it's not gonna matter. Like, what happens when they get to that point in their career when, you know, they mean, they start having lower expectations, I guess, and that stops them that

unfortunately, that's true. And that's not just the doctors kind of mindset, or it's not always just burnout, but it's the way we kind of Metra size, or measure satisfaction in clinic. I mean, we can't look at a family who is not doing what we asked them to do, what is standard of care, for example, and tell them, hey, if you don't do what we asked you to do, send us blood sugar logs, take your injections every day exercise, etc, etc. We're gonna have to kind of take this to the next level and talk to, you know, CPS or DHS, or whoever it is. Because satisfaction for both parties really goes down. You have to build this ability. And I know very few doctors who can do this. And I wish they would give some sort of masterclass on it because I am not one of these doctors, but there are doctors out there who can have conversations that are very direct, and kind, but forceful. Hmm.

So yeah, come in from that. That's the one thing you were describing about your doctors that I didn't want to put a label on it first, but they cast a big they cast a big shadow, like they're smart and bright, and we know that they do a good job so that when they come in the room, you kind of step back a little bit and go Oh, there's the guy Like I heard stories, you know what I mean? The guy,

there's the guy that's gonna tell me how to take care of myself and I want to be in good control.

Yeah. And I believe you healthy. Well, what happens? Here's the thing that happens constantly. So I'm in a weird position John, where I have no medical training at all. I have a daughter who has type one diabetes, she was diagnosed when she was two, I was a stay at home dad, she's 19. Now, I started writing a blog about it the year after she was diagnosed, but in honesty was just trying to raise money for JDRF. Right, and then became, I was bad at diabetes like Jen genuinely. And my daughters, they once he was named to the nines, but I went to a very good or she went to a very, very good what you would consider a very good Children's Hospital for for endocrinology. But it didn't matter, right. Like they tell me what to do, I'd go home and do it, it didn't matter. I just didn't have enough knowledge. I didn't have enough tools. And I build them up along the way, as you know, is a very common story. But because I was writing this blog, I started to like, share what was working for me. And then I started seeing it helping other people, right. And I was like, Oh, wow, my experience transferred to you, you end up having the same outcome I have. That's, that's pretty interesting. And, and then I did that for years, 2007, up to 2015. And it was a really, I'm just saying this, for context was a very popular blog, like it had millions and millions of clicks. And then one day, blogging got passe, I guess, people stopped reading. And I pivoted to a podcast in 2015, January. And it was the, I think, the first diabetes podcast that existed. And I started sharing more like, this is what we do. This is how I feel, blah, blah, blah. And now, John, like, the podcast has a collective total of 16 million downloads, or it's in the top 100 chart of like, 48 different countries. And I have a Facebook, private Facebook group with 46,000 people in it, they're almost all active. And if you go in there, and just if you were to go in there right now and say, Hey, my name is John, I'm an endocrinologist. Tell me what about this podcast helps you, you will probably get responses back for the next five days. And, and so the thing, the things that I figured out about diabetes are transferable, and I'm able to share them without knowing you. So without knowing who you are, or knowing any of your details, because it's a one way communication medium. I'm getting people back like maybe once he came down three points, I'm in the sevens now study, I'm in the sixes, I'm in the fives, I know how to use this. I'm very comfortable. Like, all this stuff happens. When I look back, I keep thinking like, Why can't a doctor do that? For people? Like why they come to me because they have no satisfaction through their health care? Like if they didn't, there'd be no reason to go look for help. Right? They, they'd be okay. Yeah, and the only thing I can come up with, is it's the, it's the frequency, it's so that we can keep connecting that you can have bigger conversations, and you can pick ideas out little bits at a time. Anyway, my thought is, and I say this whenever I can, I think endocrinologist should go to like, group appointments. And so instead of someone coming in for 15 minutes, you should come in and sit in a room for a couple of hours where different physicians will come in and speak to their ideas and, and take questions so that other people can hear other people's concerns, and go back and forth. I think it's the only way for that model to like help people in mass. And I don't know what you think about that. I was wondering, like, I know, they like taking out HIPAA things and you know, billing billing, all the problems that would get in the way that do you think that would work, though?

I mean, you're talking about kind of mass education on a frequent on a kind of more frequent level. Right. I mean, that's, that's no, I think that would work if you did take away issues with billing issues with productivity productivity measures, for physicians, because hey, we've got you know, X number of physicians in the state and they have to see one in every 600 Chuck kids three times a year that kind of process that you're you're describing although check yes, I think that would that would do a lot for kids would take a kind of Herculean effort to pull off but I will I will add a little bit a little bit of a variable in your in your calculus for please how how things kind of move at least in my in my opinion, and part of that is transference of blame on in some of these patients eyes, I've had families that you know that after years of seeing me and getting to know me and building a pretty good rapport I you know, I have to say I love all the kids that I see Yeah, I look forward to seeing them. I think they're wonderful. I think their families are all wonderful in all ways, shapes and forms all forms of, of control, I feel for them, I empathize with them. But a few of them have come to me and said, You know, when we were first diagnosed, I blamed you for the diagnosis, because you were in the room, but it happened. And I think that that baggage carries a lot of restrictive emotional absorption, if that, if that makes sense. Meaning, you know, I can tell them all I want to tell them, I can have a 50 minute long conversation about pathophysiology and Treatment and prognosis, and hey, kids with diabetes do great. If they have good control, but in that mindset, for however long it, it lasts, because it doesn't last forever. I don't think in any families, I think they they come to terms with it after a while. But I think the absorption of information with that with that mindset of I am in a, in a medical community, with a physician that told me my child had diabetes and X percentage of them hold that physician responsible.

Yeah, I had this experience when my son was younger, like very smelly had a blockage in his ear, like like a wax buildup, and I took him to the pediatrician who I happen to know. And he sent a nurse in with like a lavage kit. And then he left the room very specifically. And he came back and I asked him afterwards, like privately as like, Why did you run out? And he goes, I don't want him correlating his experience with me. Yeah. And I was like, Oh, no kidding goes, yeah, let them hate the nurse. And I was like, Okay.

I mean, that's, yeah, we have we have families that, you know, they'll come in with our kids. And you know, they'll say, just trying to be funny, mom and dad will say something like, if you don't behave, Doctor is gonna give you a shot. And I'm like, No, I'm not going to give them a shot. Please don't tell him well make me

the bad guy. Right. Right. Yeah, like but, but that is what so, you know, here's the little like, not so dirty secret about the Grand Rounds series that I'm making is, as much as we are talking at doctors. I'm also that's not the only people who are going to be listening. So I am, I'm trying to simultaneously say to a physician, here's what people expect from you. But I'm trying to say to the patients, you know, here's who people are like, they're doctors, they're just people. And you know, here's some of the problems that they have. And you know, some of their hurdles, you have to understand that everybody's got to meet halfway. And you maybe you're the problem, and you think it's the doctor or sometimes, you know, John, I will have people listened to I have a series called diabetes pro tip. It's like 25 episodes, I guarantee you, if you listen to it, you're able to see you'll be in the low sixes. If you if you even reasonably understand what you listen to, if you really understand it, you'll get a high fives I handled whatever you're up to. So but but I'll have people tell me, I listen to the Pro Tip series. I got my a one C down, my variability is better, fewer lows, this whole thing. I go to the doctor, and the doctor says, There's no way you got this a one C without a bunch of lows. And then they Yeah, and then people like No, I didn't but but listen to the chain of events, then John, then they go. No, I listen to a podcast. And then the doctors probably like Oh, okay. And you mean, right? So it gets this missive. And they will tell them bring your A one C up. This is dangerous because they believe so specifically that they must be having a low. So there are physicians out there in maths, who don't even think that a low six is achievable. And if you have one, you're offsetting high blood sugars with very low blood sugars. Yeah,

yeah. No, I've met those guys. And we had it Dallas. I think we had one of our fellows had a conversation with a doctor out in the boonies somewhere who didn't believe the DCCT. And so his goal for the patients he was seeing was not improvement in a onesie. So I absolutely believe you that there are people out there that say you can safely achieve those kinds of numbers Despite improvements in technology

significant. Yeah. Here's some other things that happen all the time. I had a low it. I don't know, two in the morning, or one in the morning, right? And the doctor will tell you, Oh, well then turn your Basal down at like, you know, midnight. They never asked them what they had for dinner, what they ate what the Bolus was three or four hours before, then they make this deficit and in Basal, which then of course creates a high later in the morning. And then then then the next time you come back like hey, I'm getting high at 5am and they they keep messing with it but they don't seem to understand how insulin works. Yeah, you know what I mean? Like that thing you figured out when you were a kid like you You looked and said this amount of carbs needs more insulin I can tell And but it happens so frequently, that I'm going to tell you that the whole basis of the Pro Tip series is just, it's timing and amount. It's understanding how insulin works. And under. That's it. Like, that's the whole thing. Like if if you made me stand up in front of a world full of people using insulin, and said, Scott, you have 30 seconds to fix these people's lives, I'd say it's timing and amount. It's using the right amount of insulin at the right time. I, you know, I don't I don't have time to give you the rest of the details. But that's the entirety of it right there. Go figure that out. Yeah, yeah. But then you're absolutely right. Listen, it's also not brain surgery. John, I was just the first one willing to say it out loud and have my voice recorded that was in, you know, in this kind of medium. If you listen to other diabetes content, they will always artfully speak around giving what they think might be medical advice, I'm don't think I'm not giving medical advice on telling people what I do, they can do whatever they want. And I have a good disclaimer, it's rock solid, John. So don't worry about I just think it's wrong to know this stuff about managing diabetes and not share it with people. But I'm fascinated and dumbfounded by a physician who can't figure out how to adjust a situation for a low blood sugar like, how would you not that my first question would be, what did you eat for dinner? Does it have fat in it? Was it? Did it have protein in it? Did you, you know, what would you eat today? How was your activity? Like just turn your Basal down randomly at midnight, for one low? You saw at 1am? Like, you know, it's just that stuff? That's baffling.

I think what you'll find, as partly an answer is that the medical community now is struggling. You have primary care physicians who really aren't trained in diabetes, but are in some ways forced to see patients with diabetes, because the volume of endocrinologist is dwindling. Well, there's not that many of us left in this world. And there's many reasons for that, that will take hours to discuss, but I understand your argument. And I think you're right, it's It's baffling to think about, but realize that some of these guys and gals are are having to see, you know, 30 kids in an afternoon and one of them happens to be a person with diabetes. And you know, hey, I have a low in the middle of the night, and they're going to be first thing off the top of their head, the easiest answer is going to be exactly what you described. Yeah. And the answer to make all of that better, apart from improving education, which I wholeheartedly support and work towards, in fact, we're wanting to do kind of a endocrinology for pediatrics conference in Arkansas, which we're kind of crossing our fingers we get funding for but the other other issue would be to explore a way to make sure that either primary care physicians are trained in diabetes, or keep bolster the number of endocrinologist that are being trained, which both of which are going to are, are massive undertakings, would it

maybe not be pertinent to to create a new specialty? Like, what why do we ask endocrinologist to know about like, this wide range and diabetes, like there's enough people with diabetes in the world now, like, couldn't a, you know, a specific diabetes endocrinologist be like a lucrative like career for someone? Well, there

has been discussions about changing the fellowship from a three year to a two year program. And that would be kind of a motion towards that. But think about it this way. We graduated maybe 50 or 60 fellows, every year for the past couple of years, there are hundreds and hundreds of open positions, and more and more opening every month, around the country around the world. Yeah, trying to, you know, kind of find that needle in a haystack person like me, or some of my colleagues that want to do specifically diabetes, which is a chronic disease that is difficult to manage and has social barriers to it, financial barriers to it. It would be hard. Without, you know, I don't I don't mean to say financially incentivizing, but some sort of,

kind of It's a hard job. Yeah, you know, I guess John, where I get tripped up is some like 30 years ago, I graduated from high school at the bottom of my class and went to a job at a sheetmetal shop the next morning. And if you ask the right person, you want to come to me to learn about diabetes. So I always feel like if I can do it, like anybody could, like I just I know my communicate. Listen, I understand that my communication style works for a lot of people. I'm sure there are plenty of people who doesn't work for too. That's not the, you know, not up for debate. As far as I'm concerned. I'm sure there are plenty of people that hate me. But like, I know how to talk to people about diabetes. I know how to explain it in a very kind of easily digestible way. And I think that if I can do it, like Jesus, a doctor could do it and been doing it For 16 years, I'm also have a ton of practice. And that is the thing that Yeah, see, I appreciate you saying that because that's even something that I would lose sight of, because I wrote that blog with no, like, it didn't make money. I wasn't trying to make money with it. I, my, my entire focus was to be to share a personal thing with you, John, as I wrote that blog thinking, if I educate enough people about what this is, then one day, if my daughter's out in the world, and she falls over in public, maybe somebody will understand what's happening to her. Like, I really that's what I used to think when she was two years old. And it stemmed from just a newspaper article about a guy that got kicked off the train on the Northeast Corridor, I think, between New York and Washington somewhere, he was on a train, he was strong, they kicked him off at a at a stop. Six o'clock in the morning, when the commuters were coming in, he's laying literally in a stone driveway, and everybody's walking past him and mocking him for being drunk. But this one person who grew up with a sibling with type one diabetes, recognized what was happening with them and stopped and save the guy. Right, because he really had a low blood sugar. And I used to think, maybe odd that crazily, I used to think if I could reach enough people and tell them about diabetes. If my daughter falls over like that somebody might help her one day. And that's a really Pollyanna idea that I had in the beginning, obviously, but I also wasn't trying to make money at it. And I and I was able to have experiences and build on them. And I had feedback coming in from people who were reading so I knew what worked and what didn't work. I could write something and see like, Oh, it doesn't work to speak to people in this tone. It doesn't work to be too specific, too technical. You need to be more you know, it needs to be easier to digest. I had a lot of time to develop this. You should

well I don't know if masterclass is anything that you should do a masterclass on educating people with diabetes.

John, twice a year, a hospital will contact me and ask me to come out and speak to the staff. And then eventually it gets up the ladder far enough at the hospital, somebody puts the kibosh on it never happens. Well, because because I'm not a doctor. Yeah, yeah. But I'll tell you this, John, I did a talk in Austin. This year, or just recently, a couple months ago, it JDRF said, you know, we do these little like, coffee talks, like, would you fly down here and talk to like, there's like, 40 people in our, in our thing, and it's like, if I come down there, it's not gonna be 40 people, like we sold, think every ticket they could for the space, they found, like 350 people showed up. And we had to hold it in the in the Texas State Capitol, which is really cool. She says, so you know, how long do you want this to be an hour and a half? And I was like, No, all day. Oh, well, she goes, people won't sit as like they'll sit. And so we settled finally on 10am to 4am 4pm. So we came in, we did a two hour Jenny came with me. We did this two hour just kind of like chat. It didn't have like, I promised you that Jenny and I talked to each other before we went on stage and said, What do you think we should talk about? And then we went up there started, we talked for two hours, they went to lunch, they came back at one o'clock. We did q&a for three hours. Nobody left. And that evening, I got an email from a woman that said, hey, you know, we did a lot of traveling after we left there. My daughter's blood sugar's normally would have been troublesome in a car, you know, crappy food on the highway, that kind of stuff. And she said, but they weren't they were very stable and and where we wanted them to be. But I don't know why. And I was like, Yeah, you know why? Because we sat around. And we talked about these little like, micro ideas about how to manage and, you know, let's Pre-Bolus And, you know, let's, you know, if you see a high blood sugar, let's knock it back down again, don't look at it. Like, I promise you, there was no slide show. I didn't give any bulleted points. We just had a conversation. And then she left it had a better outcome. And I think that I can I know how to do that. That's the maybe the only thing in the world I'm good at. Chuck, I take your point, that I don't know how a doctor would be expected to accomplish that? Well,

I think it goes back to my idea that, you know, in some ways, a doctor is kind of looked at in a certain way. And the educators looked at it a different way. And I don't know if there's ever a mix between the two where you can kind of separate it where so Dr. Odin is going to give a lecture on how to manage your blood sugars, and it would it would come off as you know, kind of trite and, and unscientific. Whereas a person like you with a vast amount of experience now and knowledge can give just basic tips and comfortable tips on how to do things in the real world. And that's I think that's a that's a huge bonus for our community. I mean, I think that's great that you do that. The

success of the podcast tells me that it works, right because you know, doesn't matter if you have a little kid or a teenager or you're an adult, like I get as many notes from people are like, I've had diabetes for 25 years. Why didn't nobody ever told me this? You know, as I as I do from newly diagnosed people, I think it just works, you know, and this interesting thing that I've been toying with lately, it's nowhere near ready for primetime. But we now have so many conversations, that the way AI works is I've been loading the more management heavy conversations into AI and learning, you can ask it almost anything about diabetes, and it knows the answer. Does

it really, I mean, so you created that? Or is that just something that's I'm like, I'm

using a service, I'm uploading literally the audio from my episodes. And like down to like we have, we have episodes about like how to set your Basal insulin, like the math of your Basal insulin, right. And it's never late. It's just a conversation where we mentioned the math here and there and everything. But you can ask, you can have aI ask that audio, basically, that transcript, I weigh this much. I'm a reasonably active adult, where should I start with my Basal insulin, and they brings back the right range?

It's, it's, it's creepy and cool. At the same time.

Yeah. So I, my my goal is I'm nowhere near done making the podcast but my goal is, the last thing I'd like to leave for people with diabetes is a website where they can just go ask questions about diabetes. Yeah, that's my, that's my end goal for when I'm finished. But for right now, the job is very repetitive. Like, because 150 new people come into my Facebook group every three and a half to four days. And so, you know, you're always kind of saying, you know, you pointed them to the right episodes to get their answers from, and that's also great, too, because they can learn on their own time. They don't have to sit in front of a physician and feel, like judged or like, dumb, which, um, I've, you know, I felt that way, sitting in front of doctors before. So yeah, there's a lot about why it works. Yeah, that's pretty cool. Did I think the truth is, I was talking to somebody about this the other day, they said, every once in awhile, you'll run into somebody who's like, pissed that, like, I don't have diabetes, if that makes sense. I don't know if that would bother you or not, but and I always tell them the same thing. Like, I think I'm able to be like kind of dispassionate about it. Like, I don't have it, right. Like i When my daughter was getting low, I didn't feel low. I just saw a problem that needed to be handled. And so the way I would come up on fixing that problem might be different than the way you would think to if your blood sugar was 50. Yeah. And you know what I mean, and I was motivated, by my, I mean, I want to give my daughter a long life like to be candid. Like I don't I want to die before my kids. Like, that's really like, what most of my focus is. And you know what I mean, I don't want to be a 70 year old guy looking at my daughter, and she's sick. Yeah, yeah, no, I would,

I would, I would tell you, you do have a form of diabetes. My friend, family members who have you know, my wife has been with me for 34 years. And she has a form of diabetes. Yes, she does. She doesn't have to take insulin. But she does have to worry about blood sugars and exercise and routine and pump site changes. And yeah, she has to do that.

It Oh, no, I don't this, I don't discount it. And I appreciate that. I just once in a while online, I'll get some, I'll get from people who are like, I don't know, one person said recently, how much it bothers them that the most popular diabetes podcast in the world is run by a person that doesn't have diabetes?

Yeah, I don't I don't subscribe to that. I think anybody who has a family member that they love and care for with diabetes has a form of diabetes, it's not path. You know, it's not necessarily affecting their their metabolism, but it's certainly affecting their lives.

It's a very thoughtful way to consider it. I appreciate that. So I think I want to make sure I heard right from you that there's a system set up and you said Herculean, at one point, like to sit again, anything really changed is probably unrealistic. So what are we waiting for, for people with diabetes are we waiting for? I mean, eventually is like going to a doctor going to be online? Is it going to be are you going to go to a portal and tell it what's wrong? And it's going to give you like five ideas of what it might be and then put you on a call with a doctor and they'll chat through with you like, do you think it's all going to move in that direction?

I certainly hope not. I think there is a there is a proximity and physicality to to being a doctor. It's I've done telemedicine before, and I think it has its place, not a huge fan of the experience for my patients or for me, as a physician. I like to see people and kind of have a really good conversation before I make any decisions, or recommendations, I guess I should say. So I think in some in some futuristic view of medicine, there is going to have to be somewhat of a change. I think the pendulum changes though from time to time. So now we're more focused on primary care because there's not enough primary care out there and as our numbers dwindle, there is going to be a more focus on subspecialty He's like endocrinology, pediatric endocrinology, which is what what I do. But in the end, we are going to have to rely a lot on technology and AI, as you mentioned, and you know, all the all the things that we can bring to focus to make sure that our kids are safe and happy, live long lives in our healthy

town. Are there? Are there fewer doctors or more people?

Yeah. Okay. I think I think both is very true. And I can tell you, there are fewer and fewer endocrinologist in my, in the past four or five years or so I know, five or six of my close colleagues that have either retired or quit, or passed away. And I can tell you, the people that mentored me when I was coming up in endocrinology, most of them if not all of them, have retired or passed away. But there were a couple of guys in San Francisco that I just idolized. And there was one in North Carolina that I idolized. And they are two of them are gone. And one of them has retired, and the other one

retired, so it's are fewer people becoming doctors. You know, I

don't know that I can't answer that intelligently. I get a sense that we are struggling to fill seats in medical schools. But I can tell you with almost certainty that we are struggling to fill positions in fellowships. And that is going to affect the way that that diabetes and other sub specialties approach their patient, just

applications, the medical school in 2020 to 23, numbered 55,001 88 11.6%, fewer than in 2021 2022. But 4% More than in 2020 to 2021. That can be COVID, though, right? A total of 22,007 12 students enrolled in medical school in 2022 23. Three, about the same as in 2020. Listen, my, my wife wanted to be a physician coming out of college and she had like financial trouble, which just didn't allow her to make a lot of applications. Oh, yeah, border fence is really expensive. She had good MCAT it's like great undergrad like she, she would have been a good doctor. And as she was lamenting that, in the first couple years where she was working in industry, a friend of ours who's a physician said, you know, listen, you're probably going to do better than I do. And you're not going to have to pay all these, like insurance problems. And like all this other stuff, he's like, don't worry about it. Like he actually was telling her like, don't be a doctor. That's doctors telling people don't be doctors. Because of the the headaches that come along with it. Oh, yeah. Yeah. So I mean, I see the slide, the bigger picture is, once you get somebody to be a doctor, they are who they are. And they may or may not be great communicators. I know everybody thinks smart. Right? But not every doctor is brilliant, like, you know, so you're looking for kind on a smart, you know, can be able to communicate, if you're lucky enough to get those things. What if you're then the impediment as the patient? What if you're not, you know, paying attention motivated, etc. There's a lot of a lot of different tripping points through the process.

To that point, every doctor has a bad day. Every doctor has multiple bad days such a good point. Yeah, you're on call the week before. It's Monday, you're you've got a full clinic and you're just tired. You know, sometimes you don't put your best foot forward. And, you know, with the way that we're measuring satisfaction and the way we're measuring productivity, it weighs on you all the reports that we get all the nudges that we get from people that are above us it, it does it weighs on you. It's a stress, and it does, as you mentioned before it contributes to burnout. Yeah,

I use a boutique and Oh, for my daughter. And you know, look, we're lucky our insurance covers that after the fact really well. But I have the ability to text or email a doctor, and she still has trouble keeping up. And she has a limited, you know, practice. She doesn't take everybody actually I don't think she's taken new patients in the years. And still, it's hard. as much of a personal relationship as I feel like we have with her. I still recognize that every time we see or speak to her the first five minutes is you reminding her who you are and what your situation is, because there's no way for her to keep all that in her head like she'll, she'll be like, Oh, I remember all that kind of stuff. But I actually think that's a problem people. Like I see one doctor, the doctor sees hundreds of patients. But when I go to see them, I feel like I'm having such a personal interaction that I just expect that they remember everything that's been said between us. And that's not nearly the case either. In the end, a lot of these conversations, whether they're the cold wind, which is what I'm calling the anonymous conversations or these grand rounds or anything at the end, what I come down to is like this whole process it See human limitation issue on both sides? Yeah, yeah. And that's not a thing you're going to fix or change. No,

yeah. Not not completely and not in the short term now. Right.

So the answer is what you hear people say all the time, you have to advocate for yourself and take your care into your own hands to some degree. Yeah, yeah, I agree. It's pretty, right. Yeah. Well, I guess we keep saying that out loud. Long enough. People will listen. But you know, I don't know. I can't reach everybody. John, I'm trying. Well, I think

you've done a good job. I think the the podcast my educators, some of my education, educators listen to it, and they really enjoy it, and they get something out of it. So that's, I appreciate that. No, I'm

glad a printer and thank you for thanks. So I really that is my underlying goal. You know, day to day, I want to help people living with diabetes, but long term, I just want to impact enough people who will end up in medicine, that maybe they'll say, Hey, you got low, one o'clock? What'd you have for dinner? That's all. Yeah, that's yes, that's my hope. A little bit. I'm just looking for little, little, little advancements on that. I'll ask you one last question. I'll let you go. I know we're up on time. Why do we not talk about the impacts of fat, protein and general food quality with type ones?

Oh, good Lord, I have been, well, I'm not going to blow my own horn, because I certainly don't emphasize this in clinic and in any force at all. But I've always been an advocate for a healthy diet, you know, I grew up on the exchange diet, which was in some way, a healthier diet than kind of a meal ratio diet, which allows kids to eat whatever, whenever. But it's because of the kind of westernized diet that we have that kind of brings that down the ratio down because kids don't have access to really good healthy food. I think the other answer is that the metabolism of protein and fat, although defined in some scientific reports, is difficult in pediatrics, because of their their variability in metabolism. So it's hard to build out a structured education component to, you know, say, for example, a 14 year old football player versus an eight year old gymnast versus a 12 year old who likes to play video games. I mean, how do you build that kind of one size fits all education?

I can tell you how I did it. Say if you see a rise 960 To 90 to 120 minutes after you've eaten, that's another impact that's coming from slower digestion, you should probably Bolus for it.

That's pretty. Yeah. That's one way I was thinking more along the lines of hey, if I'm gonna have a steak and potato, or pizza, or spaghetti and meat sauce, how do I dose for that? Yeah. And that's, that's challenging. You

don't want to set somebody up with an extended Bolus, for example, if their activity will burn through that. Right, that right push, right.

And then again, to some families are set up to where they can they can process that information relatively simply. And then there are other families that, you know, Mom and Dad worked three jobs and you know, sisters helping out in the evening. And, you know, it's hard to kind of get them on board with that. That kind of math.

Yeah. Yeah, I do see the bigger problem. I really do. I just Yeah. But once they ask the question, why don't they get the answer, then, like, once they show the propensity for like, Hey, I don't understand what's happening here. Like, you can't just tell them fat slows down digestion, and because of that your insulin might wane while there's still food being you know, carbs being leached into your system is blood sugar. Like, is that not difficult? No,

no, no, no, no, no, that's not when the question does arise, I think at least I mean, I approach it that way. But I'll tell you, the question doesn't arise very often. What I

tell people all the time is that maybe the phrase I hear the most that I hate the most is, oh, that's just diabetes. works. Yeah. Which gives away the idea that there could be an impact here that we could understand and do something about.

Yeah, yeah. No, I think and then, yeah, it's one of those things. I think, if you had that hour long, two hour long education piece with a very few number of families, and you looked at their downloads, and you could see their, you know, the waves of their blood sugars and insulin boluses. You could probably say, Okay, on Friday at six o'clock, what G and they would say, Oh, we went to you know, Buster Steakhouse. And you would say Oh, so this is probably fat and protein, we need to do it this way. This is how we would do it. But that doesn't happen in real life.

So do you have a minute for another question? Sure. No, great. So for people who are never going to get it? Do we just want them to be on like an eyelet pump for example? Oh,

wow, good question. I think there was space for an eyelid pump and it's curtain current programming for such statement. Yeah,

yeah. Just say look, you got an eight a one say there's nothing and by the way, eights being I'm being polite, right? Like the people who don't get it don't get it to the tune of like 910 11. A one sees, right? Sure. Yeah, yeah. So you say to them, Look, you put this on small meal, it's breakfast, you're gonna get a seven a one C, is that a win? And you because they were never gonna get it anyway, that makes you

look at it from the lens of an agency as being your target metric, then yes, check. And the DCCT did show that I was in a conference a couple of years back where one of my colleagues said something that has just stuck with me. And she was commenting on how some algorithms, you know, shut down insulin delivery for X number of hours. Yeah. And she said, Well, we don't know what happens to your body when it doesn't have any insulin at all. And it alluding to the fact that it could kind of be producing in some small way, you know, metabolites that aren't healthy for you. Interesting. And so I think before we answer that question as to whether or not that pump would be, quote, unquote, good in the long run, we need to know exactly what it's doing to their metabolism. And I think that's going to be, that's not going to come out in the near future that's going to come out over the course of the next five to 10 years. It's

interesting. I've watched a lot of different algorithms work a lot of different ways. My daughter at the moment is wearing Iaps, which is a DIY algorithm. It kind of manages backwards, like it front loads with insulin, and then takes away basil until it needs to come back again. But you're not really without insulin, because you have a pretty large Bolus going. Right? Do you know what I mean? Yeah. Is that person talking about like, when Basal gets cut away for a very long time? To try to try to save a low? And

yeah, and what is a very long time? Is it five minutes? Is it 30 minutes? Is it an hour? Is it two hours? We have we have? It varies, yeah,

in this situation is going to keep it because if you're everything settings, like in algorithms, like your, it's all about your settings. So it's your settings, and you timing your meal, boluses. That's pretty much where you're gonna get success from. But it's an interesting idea. I just think that if someone's going to have that unhealthy of a lifestyle to begin with, and time has proven that, that for whatever reason, they aren't changing that, if you can at least put this thing on them that would keep them in as at a seven. I mean, that's got to be a net positive. Like, I get that I get that you can't say that, for sure would be but it feels like it would be,

it feels like it would be to me as well. Yeah, I don't disagree with you. And I think in some ways, you have to say that it's a win, because, you know, their agencies are better and their blood sugars are better. And their, you know, their triglycerides are probably better. So, metabolism has probably moved to a space that it's it's better, but it's better good enough,

right? Oh, no. Yeah, and I don't think it is. But I guess my question is, what if that's a person who was you just weren't going to reach? Do you know what I mean? Like, it almost feels like, I can't believe I'm saying this feels like a clean needle program for diabetes. Like, I'm not gonna get you to stop using heroin, but I can at least give you a clean needle. Yeah, yeah. No, I mean,

I mean, that's, that's an interesting analogy. But um, I think for now, we can say that it would be a good, a good pump, a good platform to recommend. We can have some baseline assumptions on what it's going to do with some, with some kind of joy in our heart that it's going to do better. But again, do we know that it's the best step forward?

Okay. My last question about algorithms are after seeing people who are paying attention, learned to understand their diabetes go to an algorithm, did they get dumb about diabetes? So they forget things? Or does that not happen?

I don't think so. Yeah, I

don't think so either. But that was a concern at the beginning that people had, like, if we put we keep slapping these algorithms on people, they won't know how to take care of their diabetes, but I don't think that's the case.

I don't think so. I honestly I have noted the opposite. In fact, you know, many of these families, and they come from all different backgrounds, I don't want to say that, you know, there is a certain socio economic norm to those groups, but there are people out there who absorb this stuff. And when they get on an algorithm, they understand a little bit better. And they they apply it a little bit better, and they understand it and they're able to do things independently, and they come to see me and they're like, Oh, hey, Dr. Owen. We're doing great. We just changed his you know, his sensitivity other day, and he's doing great, we don't really need you, thank you very much. And then they're out the door.

I learned more about watching the loop work through like Nightscout I was already but when my daughter started looping a number of years ago now I was really good at diabetes like I had array one C and the fives It was no trouble. I was basically an algorithm already we were you know, Temp Basal Ling taking insole away giving extra that kind of stuff. But watching it do it automate idli I think upped my game. And so I agree with you. I know I keep saying one last thing, but I want to share something with you and get your, your top line reaction from it. So my daughter is 19 and uses Basal 1.1 and our her insulin sensitivity one to 42. Her carb ratios like one to four and a half like pretty, pretty strong stuff, right? But she also has what we thought maybe like some PCOS symptoms, okay, so her physician put her on the lowest dose of ozempic. That's allowable point, like point two, five is as low as you can inject, right? She has not moved up. And she's been doing this for two and a half months now. She lost 10 pounds that honestly, I didn't think she had to lose. But after she lost it, you go okay, that's, that's fair. But that's not the point about the weight part. Her Basal went from 1.1 an hour to point seven, and our insulin sensitivity went from one to 42 to one to 63. And her insulin to carb, I think now is like one to seven and a half or eight. And I'm calculating that show us more than 12,000 fewer units of insulin next year. Yeah, that's great. Yeah, that's great. I have an interview coming out real soon with a third of the mother of like a 13 year old girl has had type one diabetes for over three years, I think was using 70 units of insulin a day on average. And she's down to between four and seven units of injected Basal. She took her pump off and doesn't have to Bolus for food anymore. And she's using weak Ovie for weight loss.

Yeah.

Are you seeing that? Well,

no, because we can't get those medications approved. Yeah,

they're cash based off for sure. Yeah, well, not for the but not for this one little girl because she got it approved for weight loss. And then she just happened to have type one and got all these other benefits from it.

every state and every insurance company is different is what we're finding, and we fight the good fight for a little bit. And we've just been kind of pushed back for the majority were advocating for the GOP ones to be covered. But we haven't quite made that a success story. Yeah,

I think we get there in the next couple of years on that. And that would be great. But I mean, how fascinating is that? That my daughter's needs change, by the way that they would call point two, five of ozempic a non therapeutic dose? Oh, yeah, yeah. It's insane what it did for?

Well, I've had, like I said, I was a runner, and you know, you go on kicks, if not running for very long, and my insulin sensitivity goes down, and my requirements go up. And then I start running again. And, you know, I dropped, you know, 1015 pounds and, you know, comes right back. And it speaks volumes for healthy appetite. I mean, healthy meals, and good exercise every day, which is what we try to instill in all of our kids,

for sure. And I agree with that. But I need to tell you that the my daughter's insulin adjustments came before the weight loss. Like literally within the first four days, we had to start taking her insulin away, she was getting low. Right, right away. It was insane. Yeah, I keep wondering out loud, if we're gonna learn that people have some sort of a GLP deficiency at some point in the future. Because I will tell you that I, I, the only reason I knew about it to talk to the doctor about my daughter is that I used week OB for weight loss. And in a year, less than a year, I've lost 45 pounds, but I haven't really changed anything about my lifestyle. So it's, I lost four pounds in the first five days after shooting it with just the Iso I don't know, like I can't, I'm trying to stay alive long enough to hear the how this ends, John, because I'm very interested.

But these medications are, are going to be critical in the management of type two. And, you know, there may be there may be a space in there. For certain patients with type one, it's

very, it's possible. It's not going to be for everybody. I know that like, I also see I don't know if you're hearing from people or not, but the Manjaro know, or the step down. Like that seems to have fewer kind of impacts on people's bowel habits, I guess and stuff like that, like, kind of like indigestion stuff, but but it's just very, it's very interest. It's all in its infancy. And it's incredibly interesting. I'm excited for people to start talking about it like oh, that's what famous people do to be thin. I'm like, there's a lot of application here. So now I can go. Alright, man, I can't thank you enough for doing this. Was this what you expected?

I hope? Yeah, yeah, this was this was a lot of fun. Thank you very much for accepting my request. Oh, are you kidding?

So some pretty cool people said you were good. So I was like, Alright, oh, good, Lord. So I was like, Alright, I definitely would love to do this. Thank you. Hold on one second for me. Oh. A huge thank you to one of today's sponsors, G voc glucagon. Find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox. you spell that GVOKEGL You see a ag o n.com. Forward slash juice box. Having an easy to use and accurate blood glucose meter is just one click away. Contour next one.com/juice box. That's right Today's episode is sponsored by the contour next gen blood glucose meter. I want to thank the ever since CGM for sponsoring this episode of The Juicebox Podcast and invite you to go to ever since cgm.com/juicebox, to learn more about this terrific device, you can head over now and just absorb everything that the website has to offer. And that way you'll know if ever sense feels right for you. Ever since cgm.com/juice box if you were a loved one was just diagnosed with type one diabetes, and you're looking for some fresh perspective. The bowl beginning series from the Juicebox Podcast is a terrific place to start. That series is with myself and Jenny Smith. Jenny is a CDC es a registered dietitian and a type one for over 35 years. And in the bowl beginning series Jenny and I are going to answer the questions that most people have after a type one diabetes diagnosis. The series begins at episode 698. In your podcast player, where you can go to juicebox podcast.com and click on bold beginnings in the menu. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome type one type two gestational loved ones. It doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community check out Juicebox Podcast type one diabetes on Facebook. Thank you so much for listening. I'll be back soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

Hello friends, welcome to episode 1155 of the Juicebox Podcast Welcome back everyone to the Grand Rounds series. I hope you're enjoying it. Today's episode is for school nurses. If you know a school nurse who'd like to know more about type one diabetes, send this one to them. Nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes. If you'd like to help with type one diabetes research, you can do that right there from your smartphone or your tablet in just 10 minutes. T one D exchange.org/juicebox. They're looking for US residents who have type one diabetes or are the caregivers of someone with type one. You're going to help people living with type one diabetes, you may help yourself you're definitely going to support the podcast in less than 10 minutes T one D exchange.org/juice box please go fill out that survey. I cannot tell you how much it helps. This episode of The Juicebox Podcast is sponsored by cozy earth.com Cozy Earth is where I get my clothing, linens and towels from they're incredibly comfortable and temperate. I love them. I really do love them. And I love that I can give you an offer code that will save you 40% off of your entire order. Just use the offer code juice box at checkout and you will save 40% at cosy earth.com This episode of The Juicebox Podcast is sponsored by the ever since CGM. Ever since is going to let you break away from some of the CGM norms you may be accustomed to no more weekly or bi weekly hassles of sensor changes. Never again, will you be able to accidentally bump your sensor off. You won't have to carry around CGM supplies and worrying about your adhesive lasting. Well that's the thing of the past. Ever since cgm.com/juicebox. This show is sponsored today by the glucagon that my daughter carries. G voc hypo Penn. Find out more at G voc glucagon.com. Forward slash juicebox. Good morning Jenny. How are you?

I'm fine. How are you?

It's Monday, I'm on my way to the dentist after this. I don't know how good I am actually.

Oh fun. Hopefully they find nothing. They say you have sparkling tea.

This is the end of a thing for me. So this is this is the easy visit after the two where he's like, sorry for the pinch and then stuck a needle through the palate of my mouth. Oh, oh, sorry, for the pinch. What a way to put that the pinch, sorry that it feels like someone's running a hot poker through your face. Actually, our dentist is terrific. So I shouldn't say that he's very good at making injections. Today, we're gonna go over the school nurse portion of the Grand Rounds series. And this one is great, because we added it late to the list you and I did. But then through happenstance, I started seeing a mass flood of school nurses come into the private Facebook group. And it turns out that just it just took one person in a different Facebook group for school nurses to say, hey, if you're having trouble with helping kids with type one, you should go check out Juicebox Podcast. So like a serious influx came in. And I took that opportunity to make a post and say to everybody that's in there, 45,000 people in there, there's gonna be a bunch of new school nurses in here, new members that are school nurses, what would you like to tell them? And then oh, my gosh, Jenny, the post ended up reaching 18,000 of my members, which if you don't know how the Facebook algorithm works, that's generous. Because even though there's 45,000 people in there, it doesn't serve it to everybody all the time. And it's

interesting. I know nothing about the like people, they are looking at putting a picture in here for the algorithm. I have no idea what that means.

Means the algorithm likes pictures, so it'll show it the more people and people like picture so they click on them. But this post got 170 replies, wow, after being seen by 18,000 of the members. Nice. And all I said was there's a large influx of school nurses who have just joined the group. I'd love to see a vibrant conversation aimed at them. What are your best tips? So that's what we're gonna go over today. Great. Yeah. So this is feedback from the community. These are from real moms and dads, and I have some input because I had a kid go completely through school. With a with type one diabetes, yes, I want to start by highlighting the anxiety that I felt our daughter was diagnosed when she was two. She was MDI for a couple of years. My first compelling feeling about getting a pump was I don't want another person to stick my daughter with a needle every day. Oh, interesting. That was just it. I mean, I don't know why that occurred to me like that. But I was like, I don't want that. So we got Arden and Omni pod. And that took away that one little thing, but you know, didn't really help anything else. So,

right, it still means somebody else is pushing buttons. Yeah, right. And I don't know, like, I've always felt when I've gone to the doctor, and had to supply the thing to have them download. It's almost like taking a piece of my body and handing it over is kind of how I felt. And it feels very weird to hand that over. So I can imagine being a caregiver of a child or some, you know, or for somebody else. Yeah, the idea of that being touched, right?

I'm glad you brought that up. Because I had this experience with Arden all the time, where I found, like, she's the nominee pod, right? So it's an insulin pump, that's tubeless. And the controller for it is therefore not attached to her. Right. But it has a physical distance limitation. It won't work if you're a certain distance away from somebody. And I used to have to tell her, Hey, stay still for a second, like stand here. While this thing makes a connection. It wasn't long, but it felt the humanizing to me a little bit.

Yeah, I can see that. Because from a tubed perspective, you already have that mental piece of understanding that it's there. Sure, I have to sit here and a child might even not think about the fact that they need to sit there because the tubing clearly is a is a visible connection piece, also

push a button on a two pump and hand the pump back to them. And then it does what it's going to do while they're walking away. And yes, before, I don't know, I just did something that always stuck with me that there was something not right about, even though it wasn't a demand, it was all done very kindly, but it was like you have to stand here stand here for a second. And it just made me think of that when you said, even just handing my data over to somebody else feels like I'm giving something away. It does. Yeah. So anyway, I would say keep that in mind. You know, when you're dealing with these kids that, you know, and you'll see as you go through the feedback here that there are a lot of opportunities to create moments where they get to feel poorly about things and and you're not gonna know they're happening, you know,

and I think that in this same kind of line of talk, as a school caregiver or school nurse, that piece of hand the product over to me, when I mean, this is a beginning start of talking to the family, does the child actually know how to button push, and all you really do need to do is truly watch them push the button and make sure that the figures in the facts that they're putting into it are exactly what they need to be then great. Don't touch the product. There's there's no reason or anxiety,

if they're going to do it wrong. Give it to me. If that makes the person feel like Oh, I'm that you lose your autonomy, right? Yeah. And I'm sure there are kids who aren't old enough or don't know how to do it or anything like that. That's one thing. But that is needed, you make a good point. I'm going to start here with this, this person just says I absolutely love our school nurse, she and the two ladies that helped her have become like, Mom, number two to my son. Oh, yeah. And the other diabetic kiddos at the school, I couldn't ask for better support system, and I have them, they're willing to learn more willing to help my child, I don't even think they realize how hard it is for me to give up control, but I completely trust them. Now, that's great. And many of you might be doing that already. But as we get through other feedback, you're gonna see that that's not everybody's experience. And I'm always the one the first one to say like, school nurses are no different than other health care professionals. You don't know who you're getting until you get them. And, you know, my problem always is that if you get somebody who's combative, or egotistical, or whatever might happen there and you have you get into this battle with them, you could just think this is normal and just take it. And that's, you know, upsetting to

you. And as you bring that in, I think I've seen that more in working with families. I've seen that attitude, if you will happen a lot more with nurses who have and again, this is not all of them. But nurses who've been around for a while and have had experience with type one diabetes, or have an idea in their head about it, and how it should be managed. But it's very aged information. It's the old 15 and 15 rule right for treating lows, it gets stuck there. And no matter what is told to them, that's what they're going to do. And this is where those plans that you come in to school with, to care for a child who has some type of medical special need, like diabetes, those become really important and can be more of a teaching tool, then to say, Hey, I see that you, you didn't know what you were doing. But that was years ago, and we have to update this or each child that diabetes is into, you know, an individual same

for every person, or even every food and people bring this up in their feedback, two main messages through through all these 170 comments are, please don't talk down to us. What I'm hearing is that that's how people these are their experiences and work with us. You know, like, yeah, and that that struck me too, is like, how did it become adversarial so quickly? I just want my kid to be healthy and in class and not missing time. And I'm assuming you want that as well. Right? How's it possible? We're arguing, you know, like, like, we're, we're literally on the same team. This person just says, Please don't talk down to parents about how they manage. This journey has been evolving over time. For us. It was quite emotional in the beginning. I didn't appreciate the discussions about checking everything through the doctor. Yeah, so it sounds like the school nurse anytime the mom said hey, could we change this or give her a little more a little less? Well, we'll have to call the doctor. I'm assuming from the school nurse side. That's something they have to do. But you got to see what it feels like here like I know what I'm talking about. Give them another half a unit I've lived through this 50 times right? Like on oh, we're gonna call the doctor with a law you're calling the doctor which is not going to get a response today. And maybe not this week. Right now my kid's blood sugar is going to be high all week long. Because you know, what's the point like at some point you got to be a an ally in this. If you take insulin or sulfonylureas you are at risk for your blood sugar going too low. You need a safety net when it matters most. Be ready with G voc hypo pen. My daughter carries G voc hypo pen everywhere she goes because it's a ready to use rescue pen for treating very low blood sugar and people with diabetes ages two and above that I trust. Low blood sugar emergencies can happen unexpectedly and they demand quick action. Luckily G vo Capo pen can be administered in two simple steps even by yourself in certain situations. Show those around you where you storage evoke hypo pen and how to use it. They need to know how to use G vo Capo pen before an emergency situation happens. Learn more about why G voc hypo pen is in Ardens diabetes toolkit at G voc glucagon.com/juicebox. G voc shouldn't be used if you have a tumor in the gland on the top of your kidneys called a pheochromocytoma. Or if you have a tumor in your pancreas called an insulinoma visit G voc glucagon.com/risk For safety information. This episode of The Juicebox Podcast is sponsored by cozy Earth and right now I'm looking at cozy earth.com to see what's going on. I got oh look at this bamboo pajama set for ladies. That jogger pants for ladies looks like plush lounge socks. That's one of Oprah's Favorite Things. There's the bath collection. We love the waffle towels, but there's also premium plush bath towels. Everything that you see here can be had for 40% off with the offer code juice box at checkout. Even the sheets now we use the bamboo sheets, you may choose different linens I don't know what you're going to love when you get to cozy earth.com But we sleep on bamboo sheets from cozy Earth. They are incredibly comfortable. And I bought them myself with my own money using my own offer code juice box at checkout 40% off is what I saved you can as well at cozy earth.com today's podcast is sponsored by the ever since CGM boasting a six month sensor. The ever sent CGM offers you these key advantages distinct on body vibe alerts with higher low, a consistent and exceptional accuracy over a six month period. And you only need two sensors per year. No longer will you have to carry your CGM supplies with you. You won't have to be concerned about your adhesive not lasting, accidentally knocking off a sensor or wasting a sensor when you have to replace your transmitter. That's right. There's no more weekly or bi weekly hassles of sensor changes. Not the Eversense CGM. It's implantable and it's accurate ever since cgm.com/juicebox, the Eversense CGM is the first and only long term CGM ever since sits comfortably right under the skin and your upper arm, and it lasts way longer than any other CGM sensor. Never again will you have to worry about your sensor falling off before the end of its life. So if you want an incredibly accurate CGM that can't get knocked off and won't fall off. You're looking for the ever since CGM ever since cgm.com/juicebox. You know.

And I think another piece that adds into this, especially more recently is that a good majority of people are using some type of an algorithm driven pump. Yeah. And that brings in some adjustment to what the parents have learned how to navigate because they're with it 24/7, right every minute of every day, and they're looking at data, and they're analyzing it for adjustments and what to do and what works. And while school nurses have kids every day of the school week, their interactions with them are very momentary. They're right, they're not all the time. And so again, what they might have learned about something like treating a lower blood sugar, is there's a difference now with algorithms in how you treat and how quick you leave, how quickly and what amount you use in the same for highs. Maybe the pump is suggesting this amount, but you know a little bit better because of your experience. Those are things that, again, they technically have to be written down as a guiding post for the nurse to use. But they may shift and change through the course of the year, especially because kids grow.

And even if they're not using an algorithm, they might be acting as one, not even knowing it, like oh, you know, correct after this meal, we always do a Temp Basal increase, or, you know, like, little adjustments to insulin, which in the end is what an algorithm is doing, making like, unseen adjustments. But these people might already know, like, Oh, I know that with popcorn, and this drink. She needs you know, X, Y, Z insulin, right? That's not going to be reflected in the orders that the doctor put together that said, like, you know, for every 10 carbs, it's a unit of insulin, right? Yeah, except for when she eats like this, or except after lunch, or I mean, after gym or something like that, like they might have? I mean, might they're definitely going to know something about this, you don't know. And then the touch point here is that you've put yourself in a position where if you're not being flexible as the school nurse, you are now in the power position, you're holding these people hostage, right? They're trying to do something with their with their health, you're saying no, you're not a doctor, you're not even their doctors. They don't know you, you know, I mean, you're the person at the school who's a school nurse, like that's a lovely job. And everyone's thrilled you're there. And thank god, you're there, because plenty of schools that don't even have nurses. But you can't become the I don't know the border guard and say, No, you're not allowed to do that, like I do this 24 hours a day when I'm not with you like why are you the you know, the end all be on this? I think that that's just important to hear if you're the school nurse, like, Oh, is that how that could feel? On the other side? I'm just trying to do the right thing. I'm following the orders here, right now. And

I think too, because there's there's a lot to navigate in a school environment, right? There's a lot as you mentioned it before, that we don't really want kids to be consistently pulled from class, it decreases what they're therefore which is learning, right? And especially if that pull is always at the time of a class that's already kind of harder for the student or that they might be falling behind in because they're constantly being pulled from that class. So I think, you know, in using a lot of these tricks that as the parent or the caregiver, you've learned, you also have to think about it from the angle of the nurse as well, and the angle of your child in that we want to simplify as much as possible. So that, you know, little Lucy doesn't always have to go back and forth to the office four times a day to figure out what is typical coverage for this type of a meal. Maybe you don't feed that meal at school then, right? Maybe they're reserved for the weekends when you have the navigation tool, and you make the weekday a little bit more simplified. I mean, there are there are ways to work it on both angles. I think school nurses, they tried to do as well as they can in some school nurses don't even have coverage of just one school. They're not there all day. They might be navigating between five schools. Yeah,

I've never met an ill intended school nurse. Right. Right. But I have dealt with some of them that were problematic for our life. Yeah. Oh, I'm, I'm quite sure. Yeah. So I know I've said this on the podcast in other places, but it very much fits here in second grade. My daughter had a standard time she'd go to the school nurse to have her blood sugar check. There were no CGM at that point. And she went every day, every day at this certain time. And then she'd come back. She was only gone for a couple of minutes, 10 minutes she was back, and we were on our way again. But she was falling behind significantly at math at like, really, really badly. And it, we didn't know why. And it wasn't till the following year, because her teacher carried over with her class. She went, she took took on the same class and third graders she hadn't second grade. And over the summer, she like literally called me and said, I know why Arden is struggling with math. And I was like, why is that she was while I was just sitting down and filling out my lesson plans and getting my book ready for next year. We are sending her to the nurse, right? Like two minutes before the math portion of the day. And she's missing the explanation every day, like every day, but she comes back and she puts her head down and tries to figure it out. She doesn't make you know, she doesn't say anything. But in a year and a half. Like we were literally I've joked about this before we thought like oh, maybe he's a little dumb. You know, like, like she was really she she was really struggling in math. And you know, it took a couple of years to like, get her caught back up again. But that wasn't the worst part. The worst part was that for years and years after that, Arden believed she was not good at math. Oh, but she is, you know, and it's taken a number of like now that she's in college has taken a number of advanced like, mathematics stuff that you look I look at and I go I don't understand why numbers and letters are on the same piece of paper. And like, what's that shape? But she gets that now but lived a long portion of her young life thinking?

I'm just not good at that. I'm

not good at this. Yeah. And that's just from that one decision. Let's send her every day at 9:45am. Right.

And it was a decision that was we

had to do it.

You had to do it right. And it circulated around one piece of her life, which was diabetes is circulated around when we don't have a CGM. This is the time that we need to have a blood sugar or some visibility to what's happening. Probably it was coming into snack or maybe it was just before lunch or whatever was happening. But you have to kind of mold all of these things together to make it work for the child. Yeah,

if you go through these, this list of people, please let my kids stay in class, do everything you can to let them stay in the classroom. One person says, if you have the ability to go do what you need to do in the classroom, like don't even make them come to your office. You know, also, you know, there are a lot of sick people in the nurse's office, right? And I'm not looking to get sick. The you don't I mean, like I don't want the cold is going around the building. Like don't bring me into the small room with all the sick people. If

you don't everybody is vomiting, please. There's

some kids, they drink a juice. They're like, I'm good. They're like now you gotta sit here. Now you're sitting there for 15 or 20 minutes. And you know, right. Also, psychologically, I'm always with sick people. Right? Like the kid you intersect in the nurse's office on Mondays? Not the same kid you see on Thursday. Correct? All your brain sees is that I'm always with sick people. Right? And am I sick? You don't I mean, right?

There's making a connection for the child of I have diabetes, it must be an illness. I'm sick i n. You know, unfortunately, that kind of crosses over into a lot of them. You know, what they might hear in the doctor's office about being safe and being careful. And you know, you're more prone to getting ill and like, kids hear an awful lot even though they may not verbalize or question what they're hearing. But eventually it kind of starts to sink in. So that's a very good point to make. Honestly,

when Arden got into high school, the we were at the meeting in the summertime and the nurses like where your daughter and I were going to be best friends. And I was like, Listen, I don't want my daughter in your office at all if we can help it right. Yeah, I don't. Don't be friendly. I mean, you can be friendly with her. But like, don't keep her there. You don't I mean, this isn't a club. She's like, got the kids hanging out. I'm like, no, no, they're at school. are hanging out with you? This is not the sick kid club. No, thank you. Like, like, but she meant it so positively sure, you know, and upbeat. And then then there's a pushback. And then we had to explain, you know, listen, in the summer before art and went to kindergarten, I went to the elementary school that was local to me where my son had already gone. So I was a person who they at least knew. I went into the office and they said, Hey, I'd like to set up the groundwork. You know, for my daughter being here with diabetes. And they said Your daughter's not here. I said, No, no, it should be here next year. And they laughed, like literally stood the office and laughed at me. I was like, No, I really think this is something we should be ahead of you Yeah, there's like, no, no, like, we're gonna get your 504 plan set up. It's gonna be fine, right? I was like, Okay, I don't know anything about it, Jenny. I was like, my kid had only had diabetes for a couple years. I'd never send a kid with diabetes through school. And they said, We're gonna have a 504 meeting. And I was like, great. So they bring me in a couple of weeks before school starts. If they sit down to give me a piece of paper, I'm not lying to you had five bullet points on it, I'm sure. And it was the most basic stuff. And they were like, This is the plan we're going to follow. And I looked at it, and then I got the laugh at them. You're like, I know, I said, if this is all you know about diabetes, my kid's gonna be dead in a month. Like so like, this isn't gonna do it. She's five, she weighs not very much her blood sugar bounces around a lot. CGM is weren't a thing yet. Like, you know, like, this is right. Using going to work, you know. So I went home. And I read, I think three different 504 plans that were available online. I think I got one from the ADEA. I got one from JDRF. I got one from somewhere else. I read over them. And then I cherry picked from them the things that I thought impacted her. And I built a 504 plan. I brought it back and this is the 504 plan. And they laughed at me. They're like, we're not doing all this. And I was like, oh, no, you are. And then we got into it. Right. I did not win that fight. And about whenever the spring was, you know, so a few months later, they had a system like we had Oregon come down at certain times, I was able to get that done. Check her blood sugar at this time. Bring her back before recess. Check her blood sugar before she goes outside for recess. Check her blood sugar before lunch, give her insulin, check her blood sugar two hours after lunch. I think that's about how I had it set up. So one day, this little boy comes into the nurse's office with a breathing problem. And they had to give them a breathing treatment. And it was a lot of like it was unexpected. Sure. And you know, a lot of running around I guess in the office a little bit. But it happened right before Arden's recess. So they just forgot Arden they were supposed to call down to have her come up. They didn't do the call. She's five, she just was like, right out on roles right out on the playground. Now, Scotty had a backup plan. Okay, so all the stuff that was set up, I had an alarm on my phone. So I know I'm supposed to hear from them. At this time. I give a little bit of leeway. But a couple minutes later, I'm like, I call the nurses office. I said, Hey, you didn't call me about art. And the nurse goes up. Oh, Arden and then hangs up the phone. I was like, Okay,

so like, can you get in your car and you're driving, sat

next to the phone going, Oh, my God, like just my heart, my throat. Oh, and I get a call back. Obviously about 10 minutes later, hey, it's us. Arden's fine, and I'm like, oh, yeah, she goes, and she tells me all about the kid with the breathing treatment. I'm like, fantastic. I said, where, you know, how's Arden doing? Well, she was low. And then goes on to tell me how she's on the top of one of those turtle like jungle gym things crawling around, and they tested her blood sugar. It was like 52. So I took that opportunity to say, look, that stuff I brought you in the 504 plan that you laughed at me about this is why it's there. Pretty important. Yeah, you know, and we use that opportunity to move forward. But it was a it was a growing experience for them. Because they finally were like, Oh, that guy's not crazy. The thing he said was gonna go wrong, actually went wrong. You know, and that was the beginning of the relationship. Then those two nurses and I all through elementary school, we were like, thick as thieves because they trusted me that right. But I was a soothsayer, I predicted the future. Right? You know, and, but we had such a great process. And then I'll tell you that the what we did then is when art and went to like middle school after that, I brought those nurses with me to meet the nurses from the middle school for the first time. That's a great idea. Because they sat there, they're like, whatever that guy says. Just do it. And like like getting a you don't and that built that I had built in confidence then with the new nurse. And then we did it again. At high school. I brought the middle school nice to the high school when the high school nurse started pushing back, that middle school nurse was like, Listen, I have never seen a kid with a stable or steady blood sugar's as this kid, like, listen to what he's saying, you know, but there's a lot or Jenny, like it was a ton. It's

an enormous amount of work. And then when you've got schools that really do give a lot of pushback, no matter what information and what data you provide, to prove what you're trying to have written into their plan of care. I mean, that is a lot of the reason that, you know, I actually encourage people that you sit down with your endo and go through that and even get their signature on it because as you said early on, many times they're gonna say, Well, we have to call the doctor about that. But the doctor signatures at the bottom of that plan If you're more likely to decrease the need to call the doctor because clearly everything on this plan was already okayed by the doctor

I have or had when Artem was in school. I don't know the sentence Exactly. But there was a sentence in the 504 plan that said, you know, these are all the rules, but decisions about food dosing, all that stuff are adjustable by the parents. Yeah, that was it. You know, another

similar line that, again, something usual written on a lot of people's, as parents have final say, or final decision in dosing, meals, snacks, low treatments, all of that kind of stuff. This is the plan. But, you know, if questions, call the parent, the parent has the final say, it

protects the nurse, honestly. And also, I think, allows the nurse to feel a little comfortable, because, I mean, I can put myself in their position, the doctor's orders, say, you know, three units for this, and I'm like, No, do four. And they're like, Oh, I'm gonna do put an extra unit and so on this kid, send it back to class, so they can pass out, right? And then I didn't know, you know, like, so it's a big deal to get that into your 504. If you can, right? This person says, Please be careful about how you talk to children. They are sensitive, they know a lot. Don't comment on their numbers, or the carbs on their plate. Don't scare them about high low blood sugars. Be patient with them, because their blood sugars can affect their moods. This lady also says please, please don't ask me to do more than I'm already doing. Like, I have enough on my plate till I'm doing the best I can. I think that's a big deal. They're like, don't scare the kids don't try to it is, you know, I don't know, take what you think, you know, and pass it on to them in a split second in passing moment when their blood sugars are all over the place. Correct.

And I think from that judgment standpoint, it was this person said something about, you know, don't judge on the carb kind of thing. Don't judge on the food in general, right? That's not your job. As a school nurse, quite honestly, there's probably somebody else in the background, who's already assisting the family to navigate proper nutrition and an intake and everything that might be needed. And you know what, maybe the kid has a lot of really considerable food preferences, right? Maybe the only three different things at lunch, and that's what has to be sent. And maybe it is 80 grams of carbohydrate. And as a school nurse, you're like, well, their blood sugar will look better if they didn't eat so much carbohydrate, that's not your business, just not their

blood sugar would look better if their pancreas was working, right. But a lot of ifs in there, the no shame thing comes up over and over again, with the feedback from people like please don't shame my kid. It's all hard enough already. Open communication, big deal. You know, like, let's go back and forth be on the same team? Why are we fighting with each other? Like, that one's fascinating. You know why, right? Like the nurse is protecting their professional life. And, you know, and you're trying to protect your kids health. And you know, that in the middle are these orders that are probably not going to work most of the time. So, you know, sucks? Could you help us with our 504 plan, so that, yeah, I'm throwing that in there for school nurses, like people don't know what the hell a 504 plan is, when their kids are diagnosed, usually, it'd be helpful for them, if you could walk them through it, tell them how the process works through the school, that kind of stuff.

And if you've worked with somebody who has a system that's working really well with type one, and you have their 504, obviously, getting rid of all the personal information that might be in it, but maybe have those as a good example, for families who are new that you're working with and are questioning, I don't even know where to start with a 504 plan. Or maybe you have a list of sites of available examples to be able to provide them with. And then they can pick and choose because again, all of these 504 plans being very individualized, you're very likely to find one that is almost similar enough to what you're doing with your child. And you can start it as a template that it works better than somebody else's 504 plan that's like, you know, not eating very much, or whatever it is,

yeah, and make little adjustments to fit you. And I also I like to say to, Don't be unreasonable in it. Because when you start being like, hey, you know, my kid really needs a Ferris wheel, you start making big asks, or like, you're trying to take advantage of this. And then you don't get taken seriously, because you look like you're, you're grabbing. You know, like, I think that's important. I also, I like to remind people that usually as the kids grow, there's something on your 504 plan that was super important in second grade, that doesn't matter in fourth grade anymore. And if you want to be a real hero at your 504 meeting, say oh, you know, like line three there, we can strike that you guys don't need to do that anymore. Like it feels like you're giving something back to them. You know, like there's one less thing for them to worry about. So, you know, I think that's a good idea too, especially

as things like recess and whatnot change. I mean, my, my little guy has two to three recess sessions a day. And my not so little older child has only two recesses once he gets to middle school, he'll only have one recess a day. So all those things are, as you said, their points of navigation from one year to the next that may change based on schedule, and what's going on for that child. And there might be some new things, there might be several things that are able to be taken out. Yeah,

two opportunities in that example, to not replicate out of a classroom, for example, you know, that kind of stuff. This person says, I, our school nurses, terrific, I have nothing bad to say, but here's why she's terrific. She'll like discreetly pop into my son's classroom, check on him for a second, make sure everything's alright, slipped back out again, instead of him leaving class and missing that class time. But she goes on and on. But I think what she's really saying here is she has a school nurse who's putting that kid in the same polling that kids health at the same level as the mom does, yes. Like, do you know what I mean? Like she's, that's that extra effort that you have to put in when you you have a kid with type one. And

in today's world, with the technology that we have, it's lovely that the school nurses even just popping ahead in to just visibly see that the child looks like they're okay. But I've gotten a lot of families whose school nurses are absolutely able and willing to do like, like Dexcom has Dexcom follow, or they might be using something like sugar meat in which they can look and follow online, they can even make notes about what was what was used for a treatment or whatnot, which translates right over into the parents. So it's a it's almost a seamless communication. And there's a lot less texting and stuff that kind of can happen. i There are there are kids, teachers and classrooms and even nursing stations that have things like was it sugar pixel and the glucose just visit they might have the name on, you know, so they know which one they're looking at. And again, that means that the nurse doesn't necessarily have to get up out of her office. She's just visibly able to see where are things going. What's this next child's schedule look like? You know, from that standpoint, it can be useful tools, technology

was brought up over and over again from people especially because a lot of people do get into that situation where I think I've seen it, I'm seeing it shift more over the last couple of years. But in the beginning was CGM. So for people who are listening who don't know a continuous glucose monitor the device that the kids wearing, it's reporting back their blood sugar in real time that you can see on a number of different devices, right, like phones, Android, Apple phones, iPads, stuff like that. There was a time where they would say, well, we don't want that data, because then it's a liability, because now I know if the kids low, and if I don't react well or I don't see it for some reason, or my phone's not near me. Now it's my fault if the kid has a low blood sugar. To me, that was a really strange way to think about it. But it is that was the initial pushback from from school nurses. Like, I'm not at fault, if I don't know. So don't tell me. Some nurses were like, Yeah, give me the information. I want that. And more and more. I am seeing nurses following kids on CGM in schools, just to watch a kid's blood sugar for a day or two, it would take so much of your anxiety away, you don't I mean, you'd see what's happening. You can make adjustments or in you know, in concert with the parents make adjustments and not have all the worries that you had before. So embrace the technology, for sure. Right?

Learn a little bit about it. I mean, that might be an additional session that you end up spending with the parents to learn from them. What what is the technology doing, especially if again, like I mentioned before, they are using an algorithm type of pumping system, learn what's the system really doing? How does it act, because all of them are a little bit different, right? And so it's really important to understand what one child system might do that another one's not necessarily going to do the same way. Yeah,

I have some stuff here from actual school nurses. It says I am a school nurse, but I'm also a type one parent. It's extremely hard to follow doctor's orders when you know that that's not the right thing to do for the student. Luckily, I am the school nurse for my son so I can do what I want. But it's very frustrating when having to follow the typical standard orders that don't fit for everyone with other students. Yeah, then that's something to really remember is that you might have a great school nurse who is right there with you. I don't know why they wouldn't say that though. Like why why why not just like whisper go, Hey, listen, you know, I'm stuck here. Let's fix the water. So I can give me a little more autonomy here to help you write another school nurse on the school nurse and also a mom of a type one. school nurses with diabetics just have to understand that each student's diabetes needs are different. Just like student's educational needs are different in the classroom as a parent with type two a type one. What I didn't understand until working as a nurse in school is that you are held to the doctor's orders. Yes, the parents know how to manage, they know how to manage better. They know how to help keep the numbers in check, but I've got to do what the doctor put So on that piece of paper, yeah, so that's really, it goes all back. It's that one sentence on the 504. Yeah. Would you say you put it eloquently and succinctly?

Yeah, it's just parents have final say it's dosing, snacks, treatments, etc. Whatever you want to include in that statement is that follow the orders. But parents have final say

this parent says, I would just love to know what the nurse needs from me. Yeah, like, I want to help you help my kid like, so if your hands are tied, or you're having trouble with something come to me and tell me that let's see if we can work it out together. Right? That's excellent. This person made your point from earlier, don't settle for the way things used to be done. Yeah, a lot has changed significantly for the better for type one diabetes, for kids for health and safety, embrace the new technology, try to dive into it. This is exactly everything you said. If you've been at this for a long time, learn how to use an iPad, if you don't know how you figured out the apps that you can track the kids on, help us to push our kids to take, you know, good control for themselves. Sometimes an outside caregiver can really help the transition to more in dependency, that's a good point. Like, you have an opportunity there, right? Because the parents might be butting heads with a kid. But all of a sudden, you know, what's that analogy? I always say like, you know, if your kids play baseball, and you're the coach and your kids the pitcher, you never go out and talk to your own kid, you know, send a different coach out there, right? Not gonna go well. So work with the parents, not against them be an ally, stand up for my kids. This was interesting. Oh, that's a great one. If the district is making some ridiculous policy, or school administrators aren't allowing you to do something like for instance, a remote monitor with a CGM, you could use your voice to stand up. You could say, Hey, I know this is the rule. But these people are right. This would be great. If we did this, you know,

and bring in safety whenever you're right. Very likely what the parents are bringing up and that you know yourself. It's a safety consideration. And if you can prove that what they're asking for actually increases the safety and decreases the risk to the school. That's a hit point.

One of the best moments for Arden in going through schools regarding her diabetes care. It's also one of the saddest moments I've experienced. So I came up with something that I think is it's episode for the podcast. It's I think that episode is called texting diabetes. And there was this day where I was in the house and Arden was upstairs. And she I could see on her CGM, she needed a little more insulin. And I was about to get up and walk upstairs and tell her and I just didn't feel like it now post lazy and I was like, I don't want to do this. I picked up my phone and I was like, hey, I need you to Bolus a half a unit and admitted to later she goes, okay. And then I was like, Oh my god. That was easy. That was so easy. To move again. And my brain started racing. I was like, it worked from here to upstairs. It would work from here to down the street at her friend's house. Schools not that much farther. It would work from here. Oh, wait a minute. And then I froze, because I had trouble doing it at first. But I had trouble doing it. Because it turns out when she was in the house, and I felt like oh, if something went wrong, I was there to help. Right? Yeah. When she's not with me, I didn't have that same comfort. But then suddenly, I was like, well at school. I mean, the nurses there they have glucagon. They know what to do. I've explained it 1000 times. Like, you know, Arden was never a seizure at school. Like I don't want that. But I bet she'd be okay. Right. And then I stretch my legs. I was like, alright, well, now we're gonna start doing it at school. Arden's blood sugar's were never so good. As when she and I are in concert, we're just managing right through through texting. It's the it's the unsung hero of diabetes, texting seriously. And you

may have also had leeway then in terms of what she could have on her person. I know some schools are really strict. And even if doctor writes that it's okay, or whatever their protocol is that things like, especially the older school blood glucose meters, or like the PDM for the controller, or what's now the controller for Omnipod had to stay in the nurse's office, it couldn't even stay with the child. Right? And so in that case, texting diabetes is a great idea. But you're not going to get anywhere because the child no longer holds their product to you. Well, I

had to what did I have to do? I had to get her phone set up as a medical device in her 504 plan. That was the first thing I had to accomplish. Then I had to get them to put her phone on the teachers Wi Fi. Oh, so that we had, you know, stage stable communication. And that came with we had to go to a meeting where they got to look at Arden and tell her like you're not allowed to use your phone during school. Like like nowadays, I don't think it matters. I honestly I think that things have changed so much since then that's probably laughable to kids, but She took it very seriously. Like I told her, I was like, Look, this is a thing they're letting us do. It's making your day much easier. Like, you know, it's nice to say to kids, like your health is better, but kids don't think about that day to day. I'm like, Look, your life is easier. You're not going to the nurse. You know, if you need a little bit of insulin, you and I are talking it takes a split second, instead of you having to go through this whole rigmarole like, just be cool. And don't use your phone at school, right? One day she came home so seriously, she was so earnest. She goes, we got out of class early today. I was like, great, because I opened Instagram, do you think I'm gonna get in trouble? I was like, Oh, honey, I don't think anybody's gonna know. So

it was like after getting out of bed, it was

done. It was just the day was over. But she's like, I did open it while I was on the Wi Fi. And I was like, what an opportunity. I wish a teacher could have seen how much it meant to her to have that access. You know what I mean? But yeah, those are the things we had to do. Because the regular school Wi Fi sucks. Most of your buildings are built out of bricks and blocks, and you're not going to get good signals in some places. And that's going to panic the hell out of you. You know, when you can see the blood sugar, see it see it all of a sudden, it's just gone. So school teachers Wi Fi. In the end, they were very cool about it. I had a really wonderful experience throughout art in school. But I want to say this too. I recognized early on. When I came in that day, you know that that before kindergarten started that to those people I looked at in my mind. Like, do you mean like you were that you did? Yeah, I know. I wasn't I know that pre planning was the right thing to do. But to them, it wasn't something that we're used to I look, I look like a crackpot. And so I spent a lot of time not looking crazy. And I and I found the best way to do that is you don't over explain. Because diabetes has so many variables and steps and intricacies and nooks and crannies, that when you just start talking about it, you sound nuts. Like, you know, maybe you're like You're like because if the insulin goes into soon, and then she gets active, that activity is gonna bring her insulin down, then she might have a seizure, she has a seat like you You sound crazy to other people you're not by the

way, you're not it's like a it's like a flow of everything that you honestly don't know. Right. But it's in terms of what needs to be applied in the school setting. That's all they need to know.

Yeah, I'll also tell you, this emails that you send to nurses or people in the office that go over about three or four sentences make you look crazy. Gets into manifesto types. Yeah, you're also seeing it as a, you know, I hate to say like, seeing it as a, you know, a marathon, not a sprint, because it sounds, you know, sounds sounds douchey. But like it it is like, right? Like, you're not trying to get all the information to them today. Like, you know, it's it's a slow process, you're given an out a little bit by a little bit, you're building a relationship, you don't want end their people to they're just at work, right? You know what I mean? Like, don't, don't beat the hell out of them. They're, they're not, they're not, you know, they're just at work, like you go to work to you don't want people lump of extra stuff for you to do on all day. So pick and choose and, and try to, you know, try to not ask for more than is really necessary. Right? You know, it's all you're looking for is for your kids blood sugar to be stable and to be able to like, react to emergencies,

and to allow them to also stay in class as much as feasibly possible. Right. I mean, that's again, what they're there for.

This person said, you know, please be compassionate show patients over and over again, I want to point out how thankful people were in the feedback for the nurses and all the things they do this one person says, I think the Joslin diabetes Center in Boston has school nurse training sessions of maybe twice a year. Oh, yeah, that may be your local hospital has something like that? Yeah. Do you have anything to add that you think we might have missed? No.

But that's interesting. Along the same lines, if you are a school nurse, and in your area there is a pediatric endocrine practice are several of them. It may behoove you to actually call and see if any of them have class type of education for people with type one. And that you could very well get some good information by just attending even one of those classes. Yeah. Right. Because that's free information. And while it is your time, yeah.

Also joining the Facebook group for the podcast. Even if you just lurk in there for a couple of weeks, your understanding will lift way up. I don't want to end on a sour note. But I do want to bring this up. There is a line to like, you have to know your place a little bit. So I don't remember I honestly don't remember what it was but in high school, art in school nurse had a question about her care plan that she didn't understand. And instead of asking me are Arden she called our doctor's office? Yeah, no, yeah. And then I yelled at her a lot on the phone. So That's not any of your business. Like that is not uncommon, by the way, I see a lot. That happens a lot. Like, I don't know what you think you're doing calling somebody's doctor, but don't do. Yeah, yeah. And I want to say to this episode comes very much from the perspective of people who are trying really hard, who were very involved. And you may be also involved as a school nurse with people who don't understand a damn thing about diabetes and aren't putting any effort into it. But you got to not be jaded when you get to the next person who is trying, like, right, like, those are two different situations. I don't know how to tell you to help those people. I really don't. But, you know, right. Anyway,

outside of giving them information about where they can get better. Yeah, information, go

check this out. Have you heard you know, like, there's probably nice little ways to drop that in there. But saying things like, your numbers are crazy. And you're gonna, like, that's doesn't work, it doesn't work for doctors, it's not going to work for your school nurse. And anyway, I appreciate all the great school nurses that my daughter's had over the years. They were all fantastic. In one way or another. I would say that any stumbling blocks we came upon. I stayed calm, they stayed calm, we got past them. You know, the worst thing you can do, in my opinion, as a parent, is be the person who, when you walk into the building, or when the phone rings, they think Oh, it's this one. Like you don't you don't want your comes Jenny. your loins? Yeah, like, you don't want to be that person. Like, it's no, it's definitely not gonna have a good ending anyway. And I think too, as

a as kind of a last point, it's also, you know, your child has one thing, or maybe a couple of different health things to navigate. And in those, I guess, instances, you expect the school nurse to become really knowledgeable about that issue. And you have to think that the school nurse isn't just there to navigate kids who have type one diabetes, they're there to navigate a whole host, you know, allergy medications, dosing of specific things for for irritations and allergies are through their heads. Yeah, there is. And so you have to understand that while you're, your child's needs are absolutely important. There are other kids who have needs that are just as important to and so expecting to establish some type of schedule that obviously works based on what's happening for the school nurse, ya

know, it's, there's, there's a lot to consider there's a lot of human beings involved a lot of pressure. And, you know, I think there's some grace has to come from all sides to be perfectly honest, you know, and in the end, you're trying to help the kid be healthier, happier, become educated, and not leave with some sort of a feeling that they're, you know, broken or a problem or, you know, that kind of thing. So, anyway, I appreciate when everybody does, and I appreciate you, Jenny. So I'll talk to you soon. A huge thank you to one of today's sponsors, G voc glucagon, find out more about Chivo Capo pen at G Vogue glucagon.com forward slash juicebox. You spell that g VOKEGL. You see ag o n.com. Forward slash juicebox. I want to thank the ever since CGM for sponsoring this episode of The Juicebox Podcast and invite you to go to ever since cgm.com/juice box to learn more about this terrific device. You can head over now and just absorb everything that the website has to offer. And that way you'll know if ever since feels right for you. Ever since cgm.com/juice box. I'd like to thank cozy Earth for sponsoring this episode of The Juicebox Podcast and remind you that using my offer code juice box at checkout will save you 40% off of your entire order at cozy earth.com That's the sheets, the towels, the clothing, anything available on the website. If you or a loved one was just diagnosed with type one diabetes, and you're looking for some fresh perspective, the bold beginning series from the Juicebox Podcast is a terrific place to start. That series is with myself and Jenny Smith. Jenny is a CDC es a registered dietitian and a type one for over 35 years. And in the bowl beginning series Jenny and I are going to answer the questions that most people have after a type one diabetes diagnosis. The series begins at episode 698 In your podcast player, or you can go to juicebox podcast.com and click on bold beginnings in the menu. I know that Facebook has a bad reputation, but please give the private Facebook group for the Juicebox Podcast a hell The once over Juicebox Podcast, type one diabetes. The group now has 47,000 members in it, it gets 150 new members a day, it is completely free. And at the very least, you can watch other people talk about diabetes, and everybody is welcome type one type two gestational loved ones, everyone is welcome. Go up into the feature tab of the private Facebook group. And there you'll see lists upon lists of all of the management series that are available to you for free in the Juicebox Podcast, becoming a member of that group. I really think it will help you it will at least give you a community. You'll be able to kind of lurk around see what people are talking about. Pick up some tips and tricks. Maybe you can ask a question or offer some help Juicebox Podcast type on diabetes on Facebook. Thank you so much for listening. I'll be back soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

Hello friends, welcome to episode 1162 of the Juicebox Podcast. Today, Jenny and I finish up the Grand Rounds series with something I'm calling hodgepodge because it's kind of all of the questions that were left plus some conversation. If you're a doctor who's listened to this, I hope it helped, please share it with someone else and reach out to me, I'd love to have you on the show. Nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome type one type two gestational loved ones. It doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community check out Juicebox Podcast type one diabetes on Facebook. Don't forget to save 40% off of your entire order at Cozi earth.com. All you have to do is use the offer code juice box at checkout that's juice box at checkout to save 40% at cosy earth.com and go fill out that survey AT T one D exchange.org/juicebox. This episode of The Juicebox Podcast is sponsored by the insulin pump that my daughter wears Omni pod. Learn more and get started today with the Omni pod dash or the Omni pod five at my link Omni pod.com/juice box. This episode of The Juicebox Podcast is sponsored by the ever sent CGM and implantable six month sensor is what you get with ever since. But you get so much more exceptional and consistent accuracy over six months, and distinct on body vibe alerts when you're higher low on body vibe alerts. You don't even know what that means. Do you ever since cgm.com/juicebox Go find out. Jenny. This may be our last Grand Rounds episode for a bit you and I

oh yeah, I thought we were I thought we were done. So it's kind of a yeah, great buttoning

up, we're gonna call it so we know hospital diagnosis, insulin safety foods, CGM BGMs, pumps, humanity, communication management, pregnancy school nurses. And what I have left is just marked on my list as this part will be long. To get means more conversational. And then I'm actually going to do like a wrap up episode that I won't bother you for a while just kind of like go over the the high marks because there won't be any, you know, any conversation back and forth.

You're never bothering me. Remember, I

know I know don't but we have other things that bother my to do list for Jenny's got other stuff on it, we got to keep moving. Okay. So I have this note here from someone that just says, I wish that they took more of a whole health approach with me, instead of just viewing my diabetes as separate. I wish they understood that everything seems to affect my blood sugar. And the diabetes is more than just my blood sugar being affected. I wish they understood that sometimes you can do everything right, diabetes is still you know, everything doesn't turn out the way you want. Also, I have other health issues, other autoimmune issues, and that also affects my diabetes care. I wish they understood that because it's tiring. I wish they understood that I don't want to come in every three months that's not fun that I hate waiting 45 minutes after my appointment time for them to spend five minutes with me and then not offer anything valuable. Yes, I wish they would run the lab work in the office I wish they would let me have the results without making me make oh my god a second appointment to get the results. And then when I get there, tell me you're so healthy, nothing's wrong. Do you have any questions?

That last bit about the labs if I was going to restructure anything in terms of medical like visits regardless of the condition that you're talking about? It would be that if you're coming in for a visit labs will be done ahead of this visit that's on the doctor to order that right I mean the person with diabetes or whatever else needs to be evaluated you know health wise for the person sure they they should have an idea of what is kind of do or what hasn't been looked at in a while but that's really on the doctor to have that order in and then the person knows my appointment is March 1, I need to go in the end of February I need to get the labs done because then the second appointment isn't needed.

Discuss that's not right. That's not like a I don't want to say scam but that's not like a billing thing is it trying to Get in there twice? I

don't believe so I think it's not proper thinking about what would be most beneficial timewise. And to make the best use of the visit in terms of strategizing, right and talking through what might be some of the things that we do need to address, well look, you know, cholesterol levels, or a one C or vitamin D, they've changed. We've got something that we need to talk about here, right? If you have to come back, and it's really annoying for the person whose life is now interrupted twice, yeah, every

three months, right? I'm kind of like baffled by how it's not obvious that a person in the office just takes the schedule every day, I don't know three weeks in advance and call somebody on the phone and says, Hey, Jenny, you're coming in three weeks from now, doctors got the labs here for you. Where would you like me to send off the script? Go ahead and get that blood draw for us? Right, you know, don't come in without that test. Right? It would take not much to do that. And then not much to get people accustomed to it as well.

And what do we have today, we have so much automation in systems, that doesn't even have to be a phone call. Yeah, that could be an online, like my chart, or whatever electronic medical health system you're using, that could absolutely be built into that electronic record system that visits here coincide with these type of labs, the note gets sent to the person via email or text or through their online, you know, record portal, they get the notification. And they're the ones that then they have to make the appointment to come in for the labs. But at least it's a notification, it's a reminder to do so.

Yeah, around here, labs are easy, you just me basically just walk into like a quest, or LabCorp or something like that. And you hold your script in the hand. And that's that, or my doctor sometimes just sends it electronically, and you show up and you say, Hey, this is my name. There should be orders in here for me. Yeah, that makes sense. But all the rest of it to get to hear what that person is really saying. Understanding that other autoimmune impacts management that blood sugar is not the whole thing. Like those little like, that seemed like little things, if you really listen to the way this person lays this out, this is the entirety of their struggle right here. You know, like, just if you could just understand these concepts, and not I'm guessing fight me on them all the time, all the way, you make my life better, not just this appointment better.

I mean, what I honestly hear is the fact that anyone caring for somebody with diabetes, it's a whole picture look, but what it makes me really consider is that they need to, they need to listen to the variables and really, like listen to all the things that in a day could have impact, including many other health conditions, whether it's thyroid, or it could be any other autoimmune conditions that may have an impact on energy levels, or sleep, or other medications that you're taking that may impact the way that your insulin or other medications for diabetes. There are many, many layers right to evaluate. And it isn't just blood sugar,

right? Well, you're some more stuff. today's podcast is sponsored by the ever since CGM. Boasting a six month sensor. The Eversense CGM offers you these key advantages distinct on body vibe alerts when higher low, a consistent and exceptional accuracy over a six month period. And you only need two sensors per year. No longer will you have to carry your CGM supplies with you. You won't have to be concerned about your adhesive not lasting, accidentally knocking off a sensor or wasting a sensor when you have to replace your transmitter. That's right. There's no more weekly or bi weekly hassles of sensor changes. Not with the ever sent CGM. It's implantable and it's accurate ever since cgm.com/juicebox. The ever since CGM is the first and only long term CGM ever since sits comfortably right under the skin and your upper arm and it lasts way longer than any other CGM sensor. Never again will you have to worry about your sensor falling off before the end of its life. So if you want an incredibly accurate CGM that can't get knocked off, and won't fall off. You're looking for the ever since CGM ever since cgm.com/juicebox. Today's episode of The Juicebox Podcast is sponsored by Omni pod. And before I tell you about Omni pod, the device I'd like to tell you about Omni pod, the company. I approached on the pod in 2015 and asked them to buy an ad on a podcast that I hadn't even begun to make yet. Because the podcast didn't have any listeners. All I could promise them was that I was going to try to help people living with type one diabetes, and that was enough for Omni pod. They bought their first ad And I use that money to support myself while I was growing the Juicebox Podcast. You might even say that Omni pod is the firm foundation of the Juicebox Podcast. And it's actually the firm foundation of how my daughter manages her type one diabetes every day. Omni pod.com/juicebox whether you want the Omni pod five, or the Omni pod dash, using my link, lets Omni pod know what a good decision they made in 2015 and continue to make to this day. Omni pod is easy to use, easy to fill, easy to wear. And I know that because my daughter has been wearing one every day since she was four years old, and she will be 20 this year. There is not enough time in an ad for me to tell you everything that I know about Omni pod. But please take a look. Omni pod.com/juice box. I think Omni pod could be a good friend to you. Just like it has been to my daughter and my family. This is gonna be a nice hodgepodge episode I like this person just says I wish they would acknowledge that this takes an entire team, not just me to take care of you know, no one should be discharged from a hospital without all their follow up appointments handled with their diabetes education, registered dietitian, probably a mental health professional this person says continually reassessing readiness to learn a patient coming to you with questions about things they have read or heard. Those people are ready for a deeper dive, right? That's why they're coming to you and saying these things. They want to be more empowered, this is your opportunity to do that for them treat this patient as though they are the primary member of this healthcare team. I like that idea. Like we're a team, but you're the leader as the person with diabetes, right? They should have input on their treatment plan. This is what I have found helpful during the 24 years that I've dealt with this for both my son and now myself. That's good advice. Yeah, if you're I don't have anything to say about that. Other than if you're a doctor, and you were treating the person, like you know, a microphone in the room that just is listening to you and they're not really part of it. I think that's the outcome you're gonna get most times is people feeling disconnected and unheard. But what I

also hear kind of behind that is in being heard, you have to analyze from the person and say, Are they ready for the next level? Right? You have to know where they are, what they're talking about, where they're asking to get to, because if they're at no starting step number two, and they really want to know, answers that are really like ninja level. Right? You have to say, Okay, I absolutely, we need to get to that. But we're kind of right here, we need to address this. First, we need to move up here. We need to inch forward and so that you really can grasp what you want to know about. Because that's a level of understanding and application of medication adjustment and whatnot. That you're you're not really a yet with what I see happening.

I know for sure. Hey, just because this person says just because someone has bad numbers in quotes, doesn't mean they aren't trying their best.

I hate that word. I

did. I did too. But like this is the obviously this is this person's experience, right? They feel like I'm coming in there with numbers that somebody's judging is not being good. But I am trying. And I'm trying sincerely like she's like, sometimes I screw things up. But sometimes I just don't know what I'm doing. Sure. Sometimes I just get the math wrong. Sometimes the Chick fil A gives us regular Dr. Pepper instead of diet. Sounds like a personal remembering, yes. When I get to my appointment, I am also not going to remember that two months ago, Chick fil A gave me regular Dr. Pepper instead aside, so don't ask me about that, right? Anyway, this never goes away. There's going to be awful days. And you know, you got to do better at it. It does get easier, but you have to as a doctor appreciate the journey that it takes to go from, you know, being diagnosed, not probably given having, you know, gotten great direction, living through it day to day when you don't know what you're doing, eventually, hopefully figuring right out. And then that Diet Dr. Pepper comes for you. And now this doctor goes, Hey, what happened here? What's this? Right, you know, and that feels terrible after being through that whole thing. And I think

that might be the that picking apart component. You know, what happened here two months ago. I think it's the clinicians way to try to get into some type of education about what could have been done differently. It's never really asked in the right way. It's always asked in a sense of the person with diabetes feels like they're being like, blamed. Like what did you do here? Right when the person's like God I have no idea what happened there. In that sense. It's more the broad picture of what are we looking at? What trends what sticks out? And can you remember anything about what kind of sticks out that you didn't really want to happen? And if not, then again, it's more, it's more generalized.

This next person makes such a an interesting statement. She says, look, a lot of people in the US and probably other places to struggle to pay for their supplies. I'd love a pump. I'd love a CGM. I really would, but I can't afford it. So now, you know, I'm struggling financially, you're coming to me with hereby these things that you can't afford, I can't afford them. That's hard for me, then I get treated like, Well, I'm not interested in my care, right? And then and this is a quote, then you put me on that? Wait, then the docs are gonna get us all killed with their stupid type two style management that they give people on MDI. Oh, no. So that right, right. So that's, that's this person's comment. So obviously, what happened was somebody said, Hey, get this. And she said, I can't afford that. And they were like, Oh, you're not serious about this, then just, you know, hear some level mirin, you know, beyond. And I will

also say that that, then that team, that clinical team doesn't know a lot about the products and what is available for people who have less or don't have good insurance coverage or can't afford, because a lot of the different companies have programs to assist. Yeah. So the doctors should know that. That's

the problem with everybody being so siloed all the time, though. Yeah. Like, you know, the doctors, like, hey, get a pump you I can't afford it. They're okay. They just move to the next they don't say, oh, did you know that? You know, this company has an Access Program, or, you know, they have everyone, everyone I've ever been involved with, or heard about has access programs. 100%.

And I will guarantee that if they are being visited by a rep from any of the companies, they have been told about the Access Program, yeah. 10 years ago, when I was working with an endocrine practice, our reps that came in consistently gave us information about the access programs and the discounts, and the the, you know, the little discount cards or codes or whatever was available.

And some of them are significant, by the way. Yeah, like, I've seen like $500 items reduced to 20 bucks with a coupon, like, you know, so, again, but it's almost only half of the problem. The first part is you should have helped her find out how to do this. And correct when you couldn't figure it out or didn't want to figure it out? Why do you relegate her to like second class status as far as her management goes, and if I'm going to add on one for me, you could have still taught her how to take care of herself with MDI, because plenty of people do it well, but they also know how to use insulin. So then you have to educate like, it's a, you know, it's an if this, then that series, oh, by the way, going back to another thought here. It doesn't mean they would have gotten good direction, even if she could have afforded a pump because this person says I work in an ICU. And my kid has type one diabetes. So I'm aware of this enough that I was paying attention on the day that a person came in in DKA. In their early 20s. The endo had put them on an Omnipod five saw an algorithm based pump. Okay, but they were using libre because Dexcom wasn't covered. So they couldn't do the algorithm. But the person signed up for the whole thing because they wanted the automation.

By God. Did they think that they were getting automated delivery because they had a system and a CGM. And he told them,

yeah, you got it. There you go, Oh, my God. It's running around and automated the kids running around and automated and the pumps not talking. And it's not giving any, which is how he ended up in TK. So anyway, scrolling on. I wish they would have told me, I wish they would have known that I would have been willing to go much farther. This is a motivated person. I'm an adult who doesn't mind injections, I would have diluted insulin if I needed to. I would have used vials and syringes, I would have been willing to finger Poke 20 times a day. I just didn't know about any of that. Until I found this podcast. I thought that half unit pens with four needles and six test strips. was all I needed to stay healthy. Wow, how about that?

Yeah, that's actually what I was gonna say. I mean, even for somebody who, let's say they really can't afford a CGM, even with all of this stuff. Test strips can be written as a script for plenty a day. Even the generic ones which are good enough to give you enough information to go by through the course of the day. With MDI, you can absolutely make it work. Yeah, no, have somebody guide you through that.

But that person statement is more about saying that vial syringes and a couple of test trips a day was all I needed, that means that they were told, shoot this to inject this at a meal, check every once in a while, which by the way, doctors have the funniest way of having you check your blood sugar in this scenario when it's going to be the best, of course. So that yeah, that's always fascinate like, look, you're good. But, you know, maybe you wouldn't think to test yourself two hours prior to see that you're 300 After the meal, and then it came back down again. Right? Right. It's really sad that this person goes on to say, I'm just compelled to send this in, because I didn't realize that I was being set up with bare minimum to survive. Like, I actually thought I was out there just killing it. You don't I mean, that's sad. And

in this day, and age, bare minimum, that person's bare minimum was what it was eons ago, when that was the standard, there was nothing different to be able to do. So the fact that people are being told this bare minimum at this point, with the technology and the programs that are available to be able to get and use things appropriately. That's really sad. Yeah.

Let's see, I wish my doctor knew that you can have you know, quote unquote, non diabetic a one sees without being consistently low. Every time I have a one C under six, this doctor scours my clarity report looking for lows. And even if I have less than 1% lows, I get a warning about how dangerously I'm acting with a six. I don't even know what to say. I mean, you know, I'm gonna get upset, Jenny, I'm trying not to it's Friday. But if you are a doctor, and you find yourself going, Oh, I've done that. You really need to learn more so that you don't say stupid things to people, this person is having massive amounts of success. And you're yelling at him about it. You know what I mean? That's crazy. Yeah.

And the opposite of that. The other really sad thing is that, I wouldn't say endocrinology, but definitely more of the just general medicine, unfortunately, wouldn't even look at a problem with a blood sugar or within a onesie of sick, right?

They wouldn't say, hey, maybe five is available to you right now. They just Yeah. Or maybe

that's not in the range of somebody who doesn't have something going on with their blood sugar. It is being mismanaged. If you're a one C is six, and you don't have a diagnosis of diabetes. Oh,

I see what you're saying. Yeah. Oh, you're thinking people? Oh, I see what you're saying. A regular GP. It's just gonna be like a six. That's fine. That's just Jesus coming for you one day, but it's not a problem today. Don't worry about it. You know, that attitude? I mean, it was like, Oh, yeah. Oh, watch it. We'll watch it. I had somebody the other day. Tell me a doctor told him they were watching. Oh, no, we're watching. We're watching for me to fall over. I had a woman tell me the other day about her thyroid. And she said, I hated my doctor. Tell me we're gonna we're gonna put a watch on this five TSH, I was like a watch. I said, What are your symptoms? My hair's falling out. I'm tired. I can't get rested. My fingernails are breaking. I've lost my sex drive. I like she like rattled off. 10 things. She told the doctor and a doctor goes, We're gonna keep an eye on that. I kept an eye on it already helped me. Right, right. Same thing with a diabetes like a six a one. See how you're alright, that's not too bad. Yeah, this lady says that would really really nice if we stopped acting like talking about the digestion of fat and protein for people using insulin was an advanced topic. Oh, yeah, I have been brushed off and treated as if I was an idiot for suggesting that fat and or protein could be impacting high blood sugars. That's off course. And we'll just say it again. If you're listening, and you think though, that doesn't impact it, you're wrong. So learn more,

because it's all about carbohydrate. Yeah, I mean, in there, it is all about carbohydrate. So why would we need to talk about fat and protein? my soapbox to get on is that nobody is guided in how much they need. In terms of portion. Just count your carbs and take your insulin and the other stuff, just eat it? Well, so I can eat a cow. It

doesn't affect my blush. Like if you're a physician and you've got somebody in front of you who's type one who wasn't before. It might be you know, instead of just complaining about it on social media or at dinner or whatever, bitching about it in your to yourself when you're driving home in your car that people don't eat? Well, why don't you say hey, listen, this is a great time to go over this. Before type one diabetes, you were killing yourself very, very slowly. You wouldn't have even noticed it happened in probably and then one day you would have been like, Oh, what's that feeling? Then you would have been gone. But now you have type one. So we're going to pay really close attention to what you're eating. This is the part where I tell you that that is six portions not one portion, you know like that. Yeah, like that. You don't need 6000 calories a day. You know, like you know that all this other stuff and you're we're gonna see it now and you're in your in your blood sugar right away like you didn't know before, because you didn't have type one, but now we're looking, what a great opportunity for you to make some adjustments here right and be healthier beyond diabetes. Right? You know, but if I said that to a doctor, and I know that because I've done it that you like, they're gonna say to me people don't listen. Which is like saying, I don't know what it's like it's saying it's like saying that you're a half a mile from a cliff that no one can see. And you know, it's there. And you see people walking and falling off the cliff. But you don't bother telling anybody Hey, slow down. There's a cliff coming cuz some people don't listen to you,

or turn the other way. Don't go that way. Let's Speaker 1 25:27 make an adjustment now. But But the bigger point is that like, well, it's not worth me opening my mouth, because they might not listen to me. First of all, what else are you doing? Isn't that your whole goddamn job? Right? Everyone's not gonna listen. It doesn't mean it's not incumbent upon you to say it. Also, it's will seem disconnected. But parenting, same thing. You don't just get to say it once. And it happens. Oh, no, it's your goddamn lifelong job to stand there and go. Oh, my God. Okay. Put that away. This trash has got to go out. You can't leave that on the floor. Please don't hit your sister. Right? Like, like, you don't just get to say that one time, and it's over. Like, and if you think that, then I don't know what you expected when you became a doctor. You don't I mean, right. Yeah, right.

It's much like it. That's a very good connection. It's like being a parent who constantly has to tell your child, the underwear go in the thing right here that on the floor in front of it, it goes in the basket, right? Or we don't leave toothpaste, spit in the sink. We rinse it down right away.

We're not going to look at an eight a one C and go, Hey, that's not so bad. Yeah, yeah, it's not so bad if you're on your way to better, but if that's where you're gonna live for the rest of your life, it's going to catch up to you pretty quickly, it just right. There's a lot of repeat, and nobody talks about it that way. And I even listen, I'll go out on a limb here. And I'll even say I understand that socially for the last couple of years. Maybe we've drifted away from being honest with people all the time. Is that a fair way to say that, like, I have been protecting people's feelings a little bit, Jenny is making a face because I know there's a private conversation we had recently that we can't talk about on here. But no, it's still your job. Like you're not supposed to hurt people's feelings. You're not supposed to treat them poorly. But they deserve good information. And they deserve tools. And they deserve direction, like and if you have to repeat it over and over again. You don't just get to say, oh, here comes Scott. He don't listen, I'm not gonna say it again. I'm still paying you. Right? You're my insurance company's pocket do your job. You don't I mean, if I don't listen to you, it's on me. But come on. I don't know. It's very upsetting all this. There's no way any doctors are left listening to this, Jenny.

I really hope that they're, I mean, you know, if I was a clinician, I guess I just I mean, I know my personality. I am very much if you've got something, and I don't know much about it. And I could do better than I would rather sit here and be like, out I was really wrong. Like man, like, you know, I can do better. I can clean this up. I can turn this around, I can do better for whatever the job is that I have. I can do better. Right? But that's an that's the attitude. I think anybody who's in healthcare should really have what are you in this for? Are you in this to improve people's lives,

I did a recording this morning with a anesthesiologist, who has been diagnosed with type one later in life. She's had it now for about five years, she came down to talk about what an anesthesiologist should know. And I'm actually going to make it part of this series, which I was terrific, right. And she's lovely. And we had a great conversation. But at one point, she said this thing that I hear people say all the time, she you know, she goes well, you know, there's a lot of burnout in health care. And I'm like, yeah, there's a lot of burnout in factory work, too. But you don't get to like not run the crane and pick up the piece of steel and put it where it goes. Because you're just sick of it. You don't you mean like I actually said to her, these are my words, Jenny. I said, if if people work for me, you motherfuckers would be upset because I'd fire y'all. Like Like, I don't I don't want to hear i I'm burned out what? You make over six figures. go on vacation. Like Like, I don't know, take a walk smoke weed, leave me out of it. Do your job anymore.

Make changes in your organization. If you're burned out, that means that something in the organizational structure of your day to day

schedule, how you're beating you up? Yeah, correct. Yeah,

beating you up so much that you're feeling burned out. And absolutely, that needs to be taken care of. But it doesn't mean that the people then that you're taking care of in your practice. Yeah.

Do you know that during that recording, I turned to a browser window, I opened up chat GTP don't laugh for a minute, okay. And I said, please tell me what an anesthesiologist should know about how insulin pumps work and what how they should manage them during surgery, and it spit out something that I read back to her and she goes That's all accurate. So, my point to her was, if people keep making the same mistakes over and over again, we just need one person to write down the rules, maybe start an email chain, right? Like every day, you guys get an email to remind you about people with type one diabetes and pumps. And this is it or people who come in with, I don't know, like, you know, hypertension, like, here's the thing to remember. And she said, some people don't read their emails, I'm like, what what point is there going to be like, what are we going to hold people to account to do their job? You don't I mean, and I get there's human failings, which I don't even mean in a pejorative way. Like I understand there are limitations of people. But as an organization, I get if Jenny's tired on a Thursday, or if I'm in a bad mood last week, or something like that, but just the whole organization take a dive, like, like, how does that happen? And it just seems like, I mean, I hate to say this, it just seems like laziness to me. I mean, am I being harsh? look good? You know, just, I think what I said to her was, she's like, well, people have to come in and advocate for themselves, which I don't know how doctors don't hear. That should be insulting to them like that. I'm so bad at my job, someone has to come in and remind me of what it is when I get there that I'm supposed to be doing. Yeah. But I said, like, I don't go get four new tires and remind the guy when I dropped off my keys to put the lug nuts back on, I just assumed that's going to happen. Like, do you mean, like, do I have to assume a doctor's not gonna follow through? Or do the thing like, come on? Doesn't make any sense to me at all? So yeah,

I mean, I think in general ordering and those kinds of things. I think a lot of it is so already organized within a lot of the electronic medical kind of charting and whatnot, that things get checked off pretty easily, and may not be something that gets revisited then. Right?

Yeah. Actually, thinking about that electronic aspect of it. This was something I brought up to, I didn't quite say it this way, then. But I, I'm thinking to say it now, if you're a doctor, and you have some dreams of your kid, being a doctor, the way you're doing your job, right now, you're making the profession, it's not going to work the same way, they're going to put, they are going to put a chat bot in charge of the medicine, and you're going to be a technician making the same dollar everybody else is making. So if you like your $300,000 a year, and you want your kid to have it to maybe do a job that makes us all think this is a profession that should keep going in this direction, because right now it feels like you're being overpaid, to give me an eight, a one C and have me out of here in my mid 50s. Like that's how it feels, if I have diabetes, right?

Well, and with the way that things are going, you know, with AI, quite honestly, there are going to be algorithms that now take some of that job out, right. At some point, there will be algorithms that evaluate glucose trends that evaluate insulin pump data, and give some feedback. And then at that point, like you really do become kind of just a prescriber. Yeah,

you're a technician, right? You're not You're not a doctor anymore. You're the person that understands all the words enough to like, point me in the towards the right room where I gotta pay and stuff like somebody

with diabetes myself, I would rather have a very personal conversation with a person and get their feedback. Sure, it would be lovely, if a computer could just spit out, Hey, I see these problems, fix this, change this do this. That would be nice. But for some of those variables and things that you just can't teach personality, right? To a computer, it's

starting to seem like you can't teach personality to a lot of physicians either. So but I sorry, I know being smart is tough, probably all little like, you know, awkward and everything, but it's but but listen, I'm pretty smart. And I've got a personality, like, just try harder. I'm not saying I think computers should just become doctors. I'm saying that I think we're gonna get forced in that direction. Right? Because the physicians aren't giving enough pushback. Otherwise you're not it's they feel like union people who are like add spine. We don't want to be in a union anymore, like you want to hold on to your union, or do you want it to go a different way? And I think you're right, though, I think that moving it to a computer knowing the actual answer, but you still needed to come through a person. It's another Kenny that's another example of maybe we maybe that doesn't need to be a doctor, maybe it needs to be an actual person who is good at connecting with human beings and understands the medicine just enough to be a bridge for that. There's a guy on here one time, his name Sam fold. And Sam is the general manager of the Philadelphia Phillies. Wow. But he also played baseball for like nine years professionally. But he also went to what like pretty much almost an Ivy League school for economics. So he was a very interesting and different blend of intelligent and baseball player. And the reason he's the general manager the Phillies now is because the first job they gave him was to be a bridge between the analytics and the guy holding the bat. Sure, and now I'm not wondering if this isn't the same Same way, this is gonna go one day, like we knew you don't I mean, we need a, we need a person down the middle who understands both sides, they don't need to be a nine year trained physician to agree that chat gfpt got this one, right or whatever that's gonna happen in the future. And as crazy as that sounds to people, and Jenny knows that I'm doing this, but it's a very slow process, and it's in the background. But my last, the last thing I want to do with this podcast is leave behind a chatbot that has taught itself off of the entirety of the 1000s of hours of the podcast. And I'm already having these amazing experiences where I'm just teaching it like the Pro Tip series. And by teaching I mean, you're just feeding it into it, you're hard pressed to ask it a diabetes question, it doesn't have a good answer to just from learning from listening to all of our conversations, you, me and all the other people who come on here, it's really, really fascinating, like, so I think I can leave something like that behind. If I can do that. I'm assuming a hospital can figure it out. Of course. Yeah. So this is my last thought. I'm going to put it in this episode. And let's talk it through for a couple of minutes. And then we'll be on our merry way. And thank everybody for listening to the Grand Rounds, episodes, etc. While you and I were recording this, I jotted down in my notes, follow one patient a month to learn Oh, and we didn't really go over it. But I found myself thinking that every doctor should just find one patient that has a glucose monitor and is interested in helping and say to them, Hey, can I follow your CGM for a month? Could we text once in a while, I might text you and say, Hey, tell me what just happened. Now, when your blood sugar did this? Or did you just eat it feels like you just ate and or, you know, I saw you ate but you didn't get high. What happened here just a month, I swear to God, one month, I know nobody's gonna do this. For me, he's gonna tell me it's a HIPAA violation or some crap, I don't care. I'm telling you, if you followed one person a month, and you did it for a year, you would learn a lot, you could be on this podcast next year putting me to shame talking about diabetes. So and anybody you would learn so much in just just that one idea, and it's so doable. It's free. And it would take a limited amount of effort on the doctors part part and on a patient's part. And you all know one patient who's cool that you could approach about this, you know what I mean? And it

also teaches you an awful lot about the actual product,

right? Yeah, you might learn how it works, you

might actually learn some of the ins and outs of that particular CGM, or some of the ins and outs of that particular pump and what you thought it would do. And then when you actually see it performing in the here, and now real time, you can say, Well, God, that recommendation I've been giving

what the hell I'm talking about, I saw my daughter's graph today. Just her graph. I looked at it, I thought, Oh, she ran out of insulin. And it's her day off. It's her sleeping day, right? Because this is their one day off a week from school. And I was like, there's no doubt in my mind. She is asleep. And she ran out of insulin. I knew in 15 minutes by looking at a graph. I called her up, I woke her up was like, Hey, is your pump empty? And she goes, Oh, thank you. And she was just like that. I knew that from looking at a graph. And you'd be amazed at what you'd learn. If you just follow along for a month, right? And then let them go and then go pick somebody else. Now we'll do it with a kid or talk to their mom, like, you know what I mean? Like, I swear to God in a year, you would, you'd be a genius at this. And it wouldn't cost you anything, you wouldn't have to go to a meeting on a Saturday, like all the stuff that I hear, you know, and you maybe you wouldn't feel so burned out, Jenny, if you were actually helping people and not walking around all the time feeling like, Oh, nobody listens to me. And this sucks. And why am I bothering? So? I don't know. All sounds like common sense to me. But they'll say,

Oh, that's a common sense. You bring up something that many people are not unique.

Story. When you think of this series, we have a couple of minutes before you have to go. Did you enjoy making this? Do you think it of course, do you think it hit the mark? Or do you think that doctors would listen that and be like, Don't bash me because they call it doctor bashing if you're critical of them?

Well, you know, and I think if you have an open mind that you would start listening to this to begin with, or you feel like you are missing something. I would expect that you're going to gain something out of this, even if it's just one episode that really hit and you're like, oh, yeah, that makes sense. Yeah. And depending on what type of physician you are, you know, emergency department or, you know, a specific, you know, specialty like endocrine or whatever it might be. I would have again my personality. Yeah, I would have been very, very excited to be able to hear something that I could have gotten something out of even even if it made me feel like ah, I'm clearly not hitting the mark here. I can do better than this. Right? Yeah,

I hope so. I really do. I hope also that they heard that Really, if you have a type two using insulin, it's enough of the same game that you could use some a lot of the same concepts to help those people because I, you know, you are going to hear some people say, well, type ones are such a small portion of the of the population, I can't put that much effort into learning for this many people, but a lot of what you're gonna know and help a type one with, you could help us type two with as well. And that's it. You know, if mass appeal is your is your game, then? You know, there you go. Absolutely. Yeah, I mean, until they start putting GLP into the water, I guess which will be.

Personally, I really hope that I have to filter all my while. I'm

not advocating for that I am what I, what I actually think is it's funny, I'm in between on that idea. I'm seeing GLP has helped people with type one and type two diabetes all over the place. And I am for whatever makes you healthier. But at the same time, I think we're going to eventually do the thing where we skip over the value in this thing, and then just start mass, giving it out to everybody to try to avoid the problem to begin with. Which is I mean, maybe is a reasonable answer, but I don't know. It's it's so far in the future. It just it always scares me that when something's easy, we stopped thinking about it. You know what I mean? So, anyway,

no, I think the series was, I think it was needed. And for whoever grabs it and really listens to it and can step back from an ego and say, I can get something from this. I don't agree with this. But I do agree with that. Or I can you know, take something away from this. I think it was important.

I do too. I my bigger hope. And my bigger my my more reasonable expectation is that we're hitting people who are younger and just in med school or thinking about going to med school and maybe you're gonna this is going to be a thing that helps the next generation of people maybe more than this, but I hope not. I hope everybody got something from it. Anyway, I always enjoy working with you and doing these things. So I can't thank you enough for helping me. Of course, you know, I

always enjoy it as well. Thank you

a huge thanks to Omnipod not just my longest sponsor, but my first one Omni pod.com/juice box if you love the podcast, and you love tubeless insulin pumps, this link is for you. Omni pod.com/juice box. I want to thank the ever since CGM for sponsoring this episode of The Juicebox Podcast. Learn more about its implantable sensor, smart transmitter and terrific mobile application at ever since cgm.com/juicebox. Get the only implantable sensor for long term wear get ever since. If you're ready to level up your diabetes care, the diabetes Pro Tip series from the Juicebox Podcast focuses on simple strategies for living well with type one. The pro tip episodes contain easy to understand concepts that will increase your knowledge of how insulin works and so much more. My daughter has had an A one C between five two and six for since 2014 with zero diet restrictions, and some of those years include her in college. This information works for children, adults, and for the newly diagnosed and for those who have been struggling for years. Go to juicebox podcast.com and click on diabetes pro tip in the menu or head over to Episode 1000 of the Juicebox Podcast to get started today. With the episode newly diagnosed we're starting over and then continue right on to Episode 1025. That's the entire Pro Tip Series, Episode 1002 1025. If you or a loved one was just diagnosed with type one diabetes, and you're looking for some fresh perspective, the bold beginning series from the Juicebox Podcast is a terrific place to start. That series is with myself and Jenny Smith. Jenny is a CDC es a registered dietitian and a type one for over 35 years. And in the bowl beginning series Jenny and I are going to answer the questions that most people have after a type one diabetes diagnosis. The series begins at episode 698. In your podcast player, where you can go to juicebox podcast.com and click on bold beginnings in the menu. Thank you so much for listening. I'll be back soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

Hello friends and welcome to episode 1173 of the Juicebox Podcast. Today we'll be speaking with Dr. Maggie Mueller. She is an associate professor of obstetrics and gynecology, an OBGYN and a reconstructive pelvic surgeon. She is also the mother of a child with type one diabetes, and she'll be lending us her perspective today. As we expand on the Grand Rounds series. Nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. If you have type one diabetes, or the caregiver of someone with type one and a US resident, this is your opportunity right now from your phone or tablet to help with type one diabetes research. T one D exchange.org/juicebox. Head over there. Answer the questions in the survey completely. And when you're done, you've helped it's super simple and you won't be asked one question that you don't know the answer to T one D exchange.org/juicebox. You can help. When you place your first order for ag one with my link, you'll get five free travel packs and a free year supply of vitamin D. Drink ag one.com/juicebox. podcast if you're ready to level up your diabetes care, the diabetes Pro Tip series from the Juicebox Podcast focuses on simple strategies for living well with type one. The pro tip episodes contain easy to understand concepts that will increase your knowledge of how insulin works and so much more. My daughter has had an A one C between five two and six for since 2014 with zero diet restrictions, and some of those years include her in college. This information works for children, adults, and for the newly diagnosed and for those who have been struggling for years. Go to juicebox podcast.com and click on diabetes pro tip in the menu or head over to Episode 1000 of the Juicebox Podcast to get started today. With the episode newly diagnosed we're starting over and then continue right on to Episode 1025. That's the entire Pro Tip Series, Episode 1002 Episode 1026 This episode of The Juicebox Podcast is sponsored by the insulin pump that my daughter wears Omni pod learn more and get started today with the Omni pod dash or the Omni pod five at my link Omni pod.com/juicebox This episode of The Juicebox Podcast is sponsored by the ever sent CGM and implantable six month sensor is what you get with ever since. But you get so much more exceptional and consistent accuracy over six months, and distinct on body vibe alerts when you're higher low on body vibe alerts. You don't even know what that means. Do you ever since cgm.com/juicebox Go find out?

Well my name is Maggie Mueller Knut SIG. I am a mom of a type one son who was diagnosed almost two years ago who's now 10 years old. His name is Hudson. by trade. I am a surgeon. I am a Euro gynecologic and reconstructive pelvic surgeon. I work at the University of Chicago and I'm very excited to be on your podcast.

I have to tell you that I could have guessed Chicago by the last name of the man you married.

Oh really? Because it's not common in Chicago. He's from Minnesota, where everyone? Everyone can pronounce that last name. You know, here when we go out to dinner, we use my last name for a reservation. Otherwise I have to spell out every single letter

in my mind. I was just like Wisconsin, Chicago, Minnesota somewhere around there. You nailed it. Yeah. Sounds like something that would have been in a like a name that would have come from like, I don't know, a first Bueller movie or planes, trains and automobiles or something like that. So that's what got me there. That's what got me there. Okay, so Hudson was diagnosed two years ago.

About two years ago, February of 2022.

Okay, okay. And how old is he now?

He's 10. So he was diagnosed at eight. Okay. Do you have any other children? Yes. My daughter. Our daughter Greta is seven. Any

other type one in either of your families? Your husband's yours?

No, no type ones.

Any other autoimmune stuff.

My husband Tyler has vitiligo. I have hypothyroidism.

You guys are a little cocktail. Okay? Yeah, there we go. His vitiligo very obvious, not so much.

Not so much. You really, you know, maybe a little bit on his hands when he's out in the sun, but you can't really tell if you Just a very light complexion blonde

is your hypothyroidism Hashimotos? Or have you never been tested for antibodies?

Yeah, it was Hashimotos I think I was tested for antibodies when the timeline is foggy now, but it was either college or medical school.

Okay, how old? Are you just for context?

I am 41.

Okay. All right, do you manage just with a Synthroid or a tiersen, or some sort of T three or T four? Excuse me? Yeah, I just take Synthroid, and that's fine. Your energy is good and all that stuff is there. Yeah,

I mean, I wish I had more energy. has anything to do with the hypothyroidism

I have to tell you without a T three supplement a tiny little bit of side ml my daughter shuts off. Really? Yeah. Yeah, like exhaustion can't rest nothing. It's terrible. Got it's the smallest dose of cider mill you can get is at point five micrograms. Maybe I'm not sure. Or five. Oh, no, I'd like maybe huge difference for her. Okay. Am I need to look into that. Her body carries extra weight without it and her there's no, no energy whatsoever? Oh, yeah. It's terrible. Because yours to figure it out, actually. Yeah. Okay. So what was Hudson's diagnosis? Like? Was it obvious because you're a doctor, right? You knew right away on the first day imagine.

I mean, this is where it becomes more embarrassing than anything. So. So this was, you know, kind of post COVID slash people were still masking at the time. He what we what we really noticed was that he was going to the bathroom all the time, it kind of became like a little bit of a joke, we would, you know, get in the car, we would have to stop after 15 minutes. And we just thought maybe he was just drinking too much or wasn't going to the bathroom at the right times. And then it would wax and wane, it would go away. We wouldn't think much of it. He is an active kid. He's been playing hockey, travel or travel hockey since he was seven. So the monitoring of the amount of food that he was eating, I mean, he just seemed like he was a growing a growing kid who had a really big appetite. And was always on the kind of skinny or muscular side. Looking back at it. I remember it was my husband Tyler's birthday, a week and a half before he was diagnosed, and I cooked salmon. And Hudson, who was eight at the time, he had five filets of salmon that night. And I remember thinking like, Wow, he really must be working out a lot. I'm burning a lot of energy, because he's eating so much. And then there were some other things like we saw him, he was tired a lot, you know, he, but again, we attributed that too. He's playing hockey five times a day. And then, you know, looking a little bit more carefully, we started to hear from the teachers at school, like it's Have you noticed, it takes him a long time to do something like he'll go to the bathroom, and he'll be gone for a really long time, or we'll have to remind him to do these things, which again, was easy to write off. As, you know, he's an eight year old boy, you know, it takes him a long time to do things you need to remind him. So I think we went for a really long time. You know, just kind of writing off some of these symptoms until the night he was diagnosed. I think Tyler had gotten he was at home, I was at work, I was actually in the or, I had finished my cases. And he had told me, you know, we, we really need to like test his urine. I thought maybe he had a UTI because he was going to the bathroom so much. And so I was gonna bring home some urine test strips. And then Tyler called me to just make sure that I had I was already in my car, I was downtown, and I had forgotten the urine test strips. But I turned around and went back up to my office, I grabbed the urine test strips, went home, it was a Thursday night. And you know, had Hudson pee in a cup to see if he had a UTI. And when I took the urine test strip out, like it didn't have any signs of infection, there were no white blood cells, the nitrate was negative. And it was just positive for like the largest amount of ketones and the largest amount of sugar. So I, you know, being a stupid surgeon texted some of my family medicine friends that I went to medical school with and said, you know, is there any other reason to have, you know, sugar and ketones in your urine? And most of them replied, No, it's that that's really abnormal. It sounds like it could be diabetes. And then the next thing was, is this an emergency? Can I you know, wait until the morning. And it just so happened that another one of my friends that I reached out to her friend was a an ER doctor at Larry's Children's Hospital in Chicago and said, You need to pack a bag, you need to come to the hospital. He's gonna get admitted. So all of this was happening actually. When my sister Her and her children, were making a surprise visit to come visit me for my 40th birthday. Surprise. Yeah, so she honestly walked through the door right after I had tested his urine and was figuring out that he was diabetic. And her kids are the same age as my kids. So we have this video where like, I'm in the background, probably crying. And you know, the the kids are all just like hugging and embracing. They used to live here. And then they moved to South Charleston, South Carolina. And then, you know, she walked in further and saw that there was something wrong in order to get Hudson. Now in the midst of all this, before we went to the hospital, so my family, my parents were at our house too, because they knew my sister was coming in to surprise us. So I sent my dad to the Walgreens to get a glucometer. But unfortunately, the first time he came back with just the glucometer. Then he came back with just test strips and something out. I mean, he went there three times. And I said, like, just go talk to the pharmacist and ask, you know, what exactly do you need to take somebody's blood sugar. So finally he came back after the third time, and we took Hudson's blood sugar and it was like, 590 or something like that. When

you tested all your friends, or texted all your friends, were you did you know it was diabetes? You were just hoping it could be something else or did you really not know? No, I

mean, I really was. I was caught so off guard. I thought that he you know had a UTI. Yeah. Sorry. I just was really I was you

were taken aback. Okay. Yeah, I just I wasn't certain because I don't know if like, I mean, I guess people would listen from the outside and think you're a surgeon like you you put it together. You said oh I have Hashimotos has been has been a Lago. These are all autoimmune disease, but that's not how it works. You're just a regular person in that moment.

Yeah, I mean, to be honest, I didn't really I mean, until Hudson was diagnosed, I didn't really equate type one diabetes with autoimmune diseases. So I That wasn't even like, on my radar at all. I just knew, I mean, I think I think I knew it's not normal to have, you know, sugar in your urine to be spilling sugar in your urine. And it's not normal to have ketones in your urine. I just was kind of hoping that it was potentially something else. And probably clinging to a little bit of a little bit of hope. But I I definitely wasn't putting all of that together.

This episode of The Juicebox Podcast is sponsored by the only six month were implantable CGM on the market. And it's very unique. So you go into an office, it's I've actually seen an insertion done online like a live one like, well, they recorded the entire videos less than eight minutes long. And they're talking most of the time the insertion took no time at all right? So you go into the office, they insert the sensor, now it's in there and working for six months, you go back six months later, they pop out that one put in another one, so two office visits a year to get really accurate and consistent CGM data that's neither here nor there for what I'm trying to say. So this thing's under your skin, right? And you then wear a transmitter over top of it. Transmitters got this nice, gentle silicone adhesive that you change daily, so very little chance of having skin irritations. That's a plus. So you put the transmitter on it talks to your phone app tells you your blood sugar, your your alert, show arms, etc. But if you want to be discreet, for some reason, you take the transmitter off just comes right off no, like, you know, not like peeling at or having to rub off it. He's just kind of pops right off the silicone stuff really cool. You'll say it. And now you're ready for your big day. Whatever that day is. It could be a prom, or a wedding or just a moment when you don't want something hanging on your arm. The ever since CGM allows you to do that without wasting a sensor because you just take the transmitter off and then when you're ready to use it again, you pop it back on. Maybe you just want to take a shower without rocking a sensor with a bar of soap. Just remove the transmitter and put it back on when you're ready. Ever since cgm.com/juicebox, you really should check it out. Members of my private Facebook group are constantly posting about how much they love Omni pod five. Maybe you've seen those posts and thought I wish I could have that experience with an insulin pump. If you've had those feelings you might be experiencing fu fear of missing out on Omnipod. Symptoms of flu may include but are not limited to wishing you could wear outfits without pockets dreaming about walking past doorknobs without getting your tubing caught. fantasizing about jumping into a swimming pool without disconnecting from your insulin pump first. Well, I've got good news. You don't have to suffer from FOMO any longer. You can see what you're missing by trying Omni pod five for yourself. Visit Omni pod.com/juicebox To get started, for full safety and risk information, also visit Omni pod.com/juicebox. There are links to ever sent on the pod and all the sponsors in the show notes of your podcast player and at juicebox podcast.com. You know, it's funny yesterday, this is such an odd story. But yesterday I was standing in line paying for my Christmas tree. And this young woman, like probably 30 years old was off to my right. She was talking to a couple of people. And I guess her husband was ahead of me in line. So she calls past me like over me to him, Hey, honey, what's that thing I have? That's what she said to him. And he turns around, he goes, what she goes, you know, my cold fingers? What's that syndrome I have? And he goes, Raynaud's like that. And she does. She turns back to the end, she keeps talking, and she kind of made eye contact with me. And I said, Hey, does anybody else in your family have any autoimmune diseases? And she looked at me and I said, like, you know, celiac, or diabetes or anything like that, and she gets this look on her face, like, Holy hell are you from the future? And she's like, my sister has celiac. And my mom has type one diabetes, and I went, Okay, wait, wait, stop. She goes, How did you know that? And I said, Well, I didn't know I was just guessing. But I said, what you just said, Raynaud's, it's a autoimmune issue. And sometimes they run in families. So celiac, and so it was type one. And the friends she was talking to looked at me like he must be a television doctor. And I was. It was very, it was such an odd moment, and very funny. But the whole story is about the look on her face. Like, how would you know that? Possibly. And then it's funny, because I think how do you not know that? But then I realized I'm the only one making this podcast. So like it, you know it? It does make sense. Wow. So okay, I've got the scene set. Your family has just arrived, your father is inept, at best, no offense to him.

I love him to death. And he was so helpful. And he did go back three times. But

a surgeon I know, we're all wondering it. So like, so. So anyway, so like, this is all happening. You're really like you're distraught. Would you say? Yes, yeah, at this time?

How's Hudson? He's also hysterical, because we wanted to prick his finger and get, you know, the blood sugar. And, you know, this is another like, I didn't know how to do this. So I had whatever Lancet, my dad had come back from whatever, visit back to the pharmacy, whichever, you know, series was one, two, or three. I mean, I think I like really jabbed his finger to get blood to come out. So he was hysterical from that. And then I didn't read the directions, of course, and I don't think that I had assembled everything correctly the first time, then I had to do it again. So he was hysterical, just with the finger pricking. And then when we needed to go to the hospital, you know, he was hysterical about that. So we actually had to, I had to put my nephew in the car along with Hudson, and drag both of them to the ER, because Hudson wouldn't go without his nephew or without his cousin. So that's kind of where things started. Oh,

sorry. So once you get to the ER, and they get him admitted, and you're in a room, do you suddenly think, well, I'm trained on this, I went to medical school like, or do you feel as lost as everybody else in that moment?

Well, I remember being happy. So I remember the first thing they it was very quick, you know, even in a very busy er, when I went and told the, whoever was taking intake, what we were there for, I mean, we got, you know, shuttled into a triage room. We didn't wait at all, when I said that his blood sugar was, you know, 500 something. And I remember they did it what, you know, an abg, not a real AVG, but whatever they must fit, poke your finger, not the way that we he used to have to get arterial blood gases, and they knew that he wasn't acidotic. So I was happy that he wasn't in DKA. But it turns out, you know, I guess the term they use is DK No, a so he was ketotic, but not acidotic. So I remember being happy that he didn't have DKA because I knew that was going to change things a little bit. But no, I remember being really still kind of dumbfounded. The nurses are there. And then we might have seen him a resident and then another faculty from the endocrinology team that night when we were still in the ER, and I remember them, asking about family history. And, you know, Tyler has some type two diabetes on his family, but no one had type one. And we were just, you know, we didn't really realize that this could happen. And I still wasn't even exactly sure. You know, I think they were giving him they gave him a little bit of insulin IV through you know, they had him on a drip for a little bit, and then made it plan to kind of transition in the next day. But I mean, I didn't know what was happening at all. Basically,

were you about to say you didn't. At that point, you didn't even realize he was gonna need insulin. Through his life. No, I

knew he was going to need insulin, but I didn't really know what that was going to look like, acutely, you know, how are they going to get him through this acute.

Okay, situation, right? Your husband goes with you. Does everyone else come or who's in the hospital with you?

So yeah, so my tie what was driving he was probably parking when I brought him up there. The first, you know, very quickly. Yes, I had, it was COVID. So they were strict about things still at the time. So I had, we were all together. Tyler was there. And then I had my poor nephew Fox with me, because Hudson wouldn't go by himself. So all four of us were in this room until my sister was able to kind of coax her son back home, you know?

Oh, yeah. So that the thing is gonna start happening. And everyone's not not completely knocked off kilter by this. And, by the way, how crazy that that's on an a family visit from like, cross country. Oh,

yeah. I mean, it was just like, how could this be happening? And, yeah,

that ended up being helpful that she was there. It was so helpful.

I think that it was helpful that she, I mean, she did help with a lot. My sister's not medical, but she helped with a ton of things at home. You know, I think that we obviously, would have not wanted any of this to be happening. But she was really helpful. I think my mom was also very nervous at the time. So it was helpful to have my sister there. She's very level headed, and just kind of was ready to say like, Okay, what do we need to do to make this work?

It's nice that it's, I found it helpful to have support. Oh, yeah. Even when we just got home. My mother in law came and cleaned the whole house. I think she didn't know what else to do. And we did. And she was like, what if I like what would help you? And I remember saying, if the house was clean, and the laundry was done, I think I could like, focus on this for a couple of days. Like she came to our house. I cleaned everything, did the laundry. I was like, Oh my gosh, the only good thing that came out, Arden's diabetes was like, three loads of laundry. Okay, so he's he's admitted, now, things are moving along. They're getting his blood sugar to calm down. Now, the the education starts. Yes. And so I mean, I'm really I have you on here to hear your story. But I also want to hear from you. I think you have an insight that a lot of people don't have. So you know, when you hear people come on this podcast, and it's a it's a crapshoot, right, either somebody says, I got a great doctor. And they actually weren't right. Or they are like, Oh, my God, my doctor didn't teach me anything. Like, there's not usually a lot of in between, like, sometimes there's people are a little overwhelmed. They don't absorb everything. Or sometimes people give doctors a ton of credit. And then as I talk to them, like, I don't understand, like your agency is eight and a half, and you've had diabetes for six years. But you're sitting here telling me that you have a great endocrinologist. How can that be? And then when they really pick through it, they go, Oh, well, I guess, maybe I liked them a lot. And then you find out that people judge their doctors, by if they like them, not really as much about their outcomes, which is fascinating. But I'm trying to figure out, what do doctors know? What should they know? And is there a way that we can get that information to them? And I think you're in an incredibly unique situation, maybe to walk through that a little bit?

Yeah, I mean, I think that, you know, from our experience, I think it is the acute diagnosis period requires so much support during the education. So it should be prefaced that, you know, Hudson was highly motivated to get out of the hospital. So I mean, every single time anyone came into the room, he asked, When can I go home. And, you know, being medical, I knew that it was Friday, nothing was going to happen over the weekend, like, there wouldn't be any education. I understood. They told us what needed to happen that we needed to meet with the diabetic educator that we need to meet with the nutritionist. And I was worried that none of this stuff would happen before the weekend, and we would be there until Monday etc. So they were actually very helpful and we were able to get fast tracked. We got the Dexcom in the hospital. Tyler, you know, ran over to the Apple store and bought a phone because we understood that that was the way that we needed to, you know, track the blood sugar. So we got a phone that day, and we were able to be discharged Friday night. So it was very, very quick.

Who the hell told you about a Dexcom on your first day?

So the diabetic educator said that, you know, one of the things they were waiting And they wanted to make sure that all the prescriptions were going through. And, you know, they had put the Dexcom prescription through. And so, you know, once we had the phone, she was going to come in and show us how to use the Dexcom.

Okay, well, he had it on his first day. Yeah. So that I'm very

when I hear people say that they left the hospital without a Dexcom. I mean, I'm floored. I don't know how you would deal with that.

Can I ask you? I'm sorry, I some people find this very personal. But I'm just very interested because you had it on the first day. What's his a one c three months later?

I think it probably was like in the sevens I want to say it's

fair. Has it gone down since then? It has

I mean, and that was another thing. So we didn't start off on a pump right away. I think it was probably six weeks before we got on the dash. And then I remember in June we got on the Omni pod live. Yeah. Omnipod. Five.

Yeah. And that's just this past June. So he had diabetes for a few months, maybe a couple of months, MDI, then using a manual pump with Dash and now for the last four or five months, he's had an algorithm. No,

sorry. So it was he was on dash, I think in April, right after his diagnosis. And then June after his diagnosis, we switched him to Omnipod. Fi

Oh, that quickly. Okay.

I was really like, I really wanted that, you know, immediately for the, for the night, we had a lot of lows with the dash and nighttime.

So how'd you find out about the algorithm? I'm

sure I mean, my husband and I both listened to your podcast a lot. I think we found out a ton of information. Also, you know, very, you know, we're very thankful for this. So at the time Hudson, one of his hockey teammates, his older brother, I did not know this beforehand, but his older brother had type one diabetes, and think he was 13 at the time. So I had spoken to the mom, once her son had seen, you know, us doing some I might have been like giving him some insulin or something like that. And so we learned a little bit more about looping because her son was looping at the time. And that sounded very intriguing. But I think we were so overwhelmed with everything at that point in time, like, there was no way that we were going to be able to figure that out. I understand that. Yeah, kind of where we were. And I also was just trying to understand, you know, what the hesitancy you know, right after diagnosis to getting a kid on a pump, I didn't really understand why there's any waiting period, like, Why was there any MDI for, for whatever purpose, and I understood, like, you have to know how to do that for backup, but it just seems like if there's a better way, why wouldn't we be pursuing the better way? So that was, you know, difficult for me, you know, as a parent to, to know that there was something which I perceived to be better. And it wasn't really clear why we couldn't start with that right off the

bat. I keep thinking that I would have loved to have seen the Apple employees face when he was like trying to be upbeat with your husband use Excel, you get a new phone. Hmm. Just take the credit card, and let me get the hell out of here. Yeah, this is not a big happy moment, my friend. Did. That's crazy. How did you find out about the podcast? Actually,

someone who was on your podcast, who actually lives in our neighborhood, told us about the podcast. So she was on the podcast where her daughter was diagnosed. Yeah, camp in Maine. So

oh, oh, yeah. And she had the flight. I mean, that person lives in your neighborhood,

where she lives like, you know, I live we live in Glencoe, it's very small. So it's like 8000 people. So

well, that's even crazier. Maggie, I interviewed somebody that lives in a group of 8000 people and they know you and they helped you with your diabetes, pretty

high. And we meet we met all these people kind of around the same time. So you know, Hudson, he didn't he might I think he took a week off of school. And when he went back, he was first he didn't want to tell anyone the teacher asked Do you want to tell your classmates about and he said no. And then he reconsidered. And then I heard later that day from a mom who was in who has has a daughter in Hudson's class, who she came back home and told her parents that Hudson has type one diabetes because her parents have type one diabetes. So then they reached out and kind of set us up with I mean, I think we had like three to four people, at least that we were speaking with, right off the bat, you know, in our in Glencoe, and then another person that was kind of, you know, we called her like the diabetes fairy who was also in the community and was helping us a lot in the hospital and making sure that we had like the the right lens sets and things like that. I mean, I'm very thankful and we're all very grateful that we live in such a supportive community. But yeah, we had a bunch of people to talk to right off the bat that either had type one Diabetes themselves or their children habit. So

between the people you were lucky enough to meet, and this podcast, and doctors, where's the most help come from?

I think we all would have been really struggling without the support of the community that, you know, these, I think there were four or five individuals that were extremely helpful. And that pointed us in the direction of the podcast that just allowed us, you know, we learned so much about it. And you know, Tyler is not medical. So he learned a ton about it. You know, we listened to it all the time I left I listened to it on the way to work. I mean, it was it was really helpful. I think it's a hard pill to swallow when you leave the hospital, we left the hospital. And we were set up with an endocrinologist in three months. And that is really scary. Yeah, the team was great. I mean, we called the nurses when we know when we needed to check in and they would change things, but it was really nerve wracking, not having, you know, that appointment for so

long. Yeah, that's actually kind of uncommon for for children. Yeah, for adults, it's very common, but for children, it's not usually.

Yeah. And we're also lucky because our endocrinologist lives in our neighborhoods. So we did have that, you know, she's, she's been very helpful and was able to expedite everything. And, you know, she's our neighbor. So we've benefited a lot. Do you

kind of see the podcasts and, and people as sort of one group, like a community feeling? Absolutely. Yeah. Okay, so not only is it a three month wait to get to the endocrinologist, by the way, you don't have any poll. What happened there? Geez, Oh, yeah. What good is that Tina? Doctor?

Oh, I know. I know. Well, that I think is what really made me very nervous for lots of families. So

that's my next question is how do you think that people who aren't you fair in this situation?

Yeah, not Well, I, it was really eye opening. I'm a quality of life surgeon, I deal with zero things that are life threatening. But we have these metrics where like, I need to be able to see a new patient in one week, or we get dinged, I just didn't understand how, you know, a child with a life threatening illness was given an appointment, three months later, that seemed kind of crazy to me. And I, we are thankful that we have connections and great people to advocate for us. And we were able to get in there sooner. But I realized that many people don't. And even you know, they might not have the background information that we had. You know, when you?

God, does that happen? Maggie? Do you get the doctor three months later and find out, you've learned more in the last three months? And they're able to tell you?

I mean, I think that we, by the time we ended up seeing our endocrinologist, we were I can't I don't even really remember the first appointment that we went to anything. We were just trying to understand what exactly did we need to do in order to get the pump? I mean, I feel like that's what the entire

it's about how to how to get around the insurance system. Yeah,

it was just you know, what steps needed to happen in order to get the pump? Did

you have to ask any questions at that point? I mean, you're still a seven a one, say seven and a half. So you're not like killing it or anything like that. So did you come in with questions that they were able to answer for you? Well, I

remember. There was a great at the time, the the nurse that was there. I feel like she also had type one diabetes. Or she might have Yeah, I shouldn't. She was the nurse educator that worked with our doctor, she kind of leveled with us a lot. But a lot of the problems that we were having with the MDI was just, you know, he, he would basically just not want to eat anything that required an injection. So he would come home from school, and you know, he probably wanted to eat a snack, but he didn't want to eat any he didn't want a cheese stick or a salami stick. And I don't think that he wanted to have an injection. So he would just say that he wasn't hungry. And then other things that are so much better dealt with, with a pod or pum. You know, when he was going to have anything that required split dosing. He was also very difficult because he would not want to have a second injection, right. So we were struggling with these things that I think when you're talking to somebody who's been on a pump for a really long time, it's almost hard to even like remember oh, how do you deal with all that?

Yeah, you know, the other day Arden started using I'm not going to talk about this on the show why the hell not? I wasn't sure if I was ready or not for this one, but I can I can say this much about it for now. they'll have enough details to be more valuable at the moment. But Arden began using a GLP the other day. And it's just the first injection. And I know I've talked about on here enough that people who listen no Ardennes, like, doesn't like needles. Yeah. And as a matter of fact, she has given herself one insulin injection in her entire life. That's that maybe as a little kid, but like, she's one that she recalls. And she was getting ready to go away to college. And I said, Listen, in case there's a catastrophic failure of all of our technology, I need you to be able to inject insulin. Yeah. So your next correction today, like go ahead and draw it up in this syringe and give it to yourself. And I'm still trying to get her on here to talk about that process. But I'm telling you, she sat in the bathroom with the door closed for 90 minutes before she came out and said, I did it. And she she looked like she had a run with the bulls. By the time she came out, like like, she just she just came out like she was in a car wreck. Then a bull chased her, and then someone picked her up in a helicopter and dropped her on the ground. And then she was alive somehow. And she's like, I did it. I'm dead. I did. I did it. And I'm like, Oh, okay. So the other day, she has to get this injection. And she's like, whoa, whoa, whoa, whoa, whoa, whoa. Like Arden Come on. And she did it. And it wasn't that big of a deal. But I'm going to tell you that she defended herself three times with her hand, as I came in with the the GLP pen. Yeah, like, like, not like harshly, but she reached out and defended herself, like almost uncontrollably. Yeah. And so I get when people don't want to, I daughter's had diabetes for 15 years. I get when people don't like needles, you know, like I really do. And she still, every time she answers something, she's like, Oh, come on. And I I've come to realize it's not about the pain. It's about she just, she's averse to the process. She just really is. So but but for people to hear the real story here is there are people, children, adults who are not eating the way they should, because they're trying to avoid injections. Oh, for sure. Yeah. And that's, you know, a tough fact, but needs to be heard by by physicians. I think I'm sorry, I took you off balance there. But

no, that's, I think another thing and I think we're all really, you know, everyone, but specific, specifically physicians, nurses, we're just always very careful about what we say and, and now we know how careful we need to be when we were in the hospital. I think it was a diabetic educator who told me that, you know, there 95% He had sure he has type one diabetes or diabetes, but there's a 5% chance that he doesn't. And so I was like, waiting at home to hear what these antibody results were because I thought that it meant there was a 5% chance that we were wrong, and he doesn't have diabetes at all. And so they called me back to let me know that like every single antibody was positive, but also Oh, yeah, he has hypothyroidism too. But we were told that over the phone, because obviously we'd been discharged from the hospital there. Whoever called us said, Well, it's Don't worry, it's not as bad as type one.

Person call to go, Hey, I'm just calling with test results. You have hypothyroidism, but don't worry, that's not nearly as bad as type one. And you're like, Oh, we got that too. Thanks.

At that time, I was crying. You know, it was just like another thing. And I know that it's not as bad as type one diabetes, but he also has that

look harder at the chart before you try to make me feel better.

There's just like, oh, gosh, you know, it's it's just one of those things like I was clinging on to this potential 5% chance to have diabetes 5% chance that it was what I think they meant looking back at it, I think they meant type two diabetes, because they hadn't gotten the confirmatory antibodies back.

Oh, that's not that. So you took way more hope in that than they meant? Oh, yeah. I

thought the chance that he was like, fully misdiagnosed, and this was going to be not happening.

Yeah. Have you ever heard me talking about when that happened to me? No, I didn't had this weird honeymoon. Oh, it lasted like two and a half or three days, where she just needed her Basal insulin and nothing for food and was getting low. And I I waited like two days into it. I called my friend who's a pediatrician. And I knew by the way, I knew it wasn't true. But I wanted it to be true so badly, but I I hedged my bets, and I started the conversation. I wonder if he remembers me calling him and I said, I know I'm wrong. Just tell me to get off the phone. But here's what's happening. Is that possible? Arden doesn't have diabetes, and he's like, She's had it for like, two years, or like, like, it'd been like a long time and he goes, No, no, no, she has diabetes. And I was like, Okay, thank you. And he goes, hang up, and I'm like, I will and I just got off the phone. But I had that feeling I know The exact feeling you're talking about. Yeah, like when you've got a scratcher in your hand, and you're like, I'm not gonna work again, if this is just the club dammit. Exactly. Yeah, no, it's terrible. Oh, I'm so sorry.

No, no. And then after that we're off. It was my, you know, I really I had heard about to prism app and the trials that were going on. So I was desperate to find, you know, a trial that was still enrolling, you know, so I knew that University of Chicago was a site. So I emailed all the people there. And it, it just so happened that they had stopped enrolling his age group, you know, a couple months beforehand. So then I was devastated that we didn't have that option. So there were just a lot of ups and downs in that period.

I think guilt in here. When you he has hypothyroidism Hashem, as you do, too.

I don't think I even put that together. I think that oh, sorry,

my introducing this for the first time for I didn't know, I mean, that that

period of time? I don't think I did. You know, I think probably honestly, when we were in the hospital, and somebody if anyone asked about auto immune, I don't even think we both Tyler and I would have come up with a, you know, he probably wouldn't have talked about vitiligo, and I probably wouldn't have talked about hypothyroidism. You know, I've had it for so long, and I just didn't, it's like a vitamin

you take out, I would imagine at this point. Right. Exactly. Yeah. And

so there wasn't, you know, a lot of guilt. I think that, again, being so close around COVID. So I remember when we were leaving to the hospital, my mother, who I also love to pieces, you know, said Do you think this has something to do with the COVID vaccine? Because I Kittson vaccinated so that they go back to school. And so then I carried this guilt around that potentially, it was the COVID vaccine that caused the type one diabetes. So, you know, I had to be the person in the hospital to ask the doctor like the embarrassing question, you know, is this at all related to the COVID vaccine? And a remember her saying this is probably based on his a one see, it's probably been going on for a year or so, you know, and he had had the COVID vaccine, like a couple of months beforehand. So then that reassured me a little bit more.

I mean, honestly, if there's anything there, I mean, maybe the virus from the vaccine, like sped up the process, but it sounds like the process has been going on for a very long time. First of all, and, you know, I mean, viruses do bring on diagnosis, but they don't, it's so hard to, to know if people understand how that works or not when they hear it. It's it's not I sneezed. And so I got type one diabetes. Yeah, these pieces cause type one diabetes, it's, I was going to get type one diabetes. And did you notice these this speeded up? Yeah, that's the vibe. But what you hear people say is, you know, a virus has caused type one, viruses don't cause type one viruses can cause type one in people who were predisposed, and already at some point in their life, likely going to get type one diabetes, and so different, like, I guess it's like, once you have it, it's who cares? What came first, but it when it's spoken about, it gets spoken about colloquially? And I think it just gives people the idea that oh, you know, you just get a thing. And then that happens. Like it's cause and effect. But it's, it's not it's hard to? I don't know, it's hard to explain sometimes. Well,

yeah. Especially because there is this increase. And so people oftentimes ask, you know, why are there so many more kids with type one diabetes now? And I think everybody does want to have an explanation. And then it gets this game of telephone and all of these potential things that cause type one diabetes, when

somebody says to me, what do you make of all the type one increased diagnosis during COVID? I say, yeah, there's a lot of people out there walking around with antibodies, who at some point in their life, we're going to get type one diabetes. And it just so happened. There's a virus covered the whole planet, and so they all got it at the same time, doesn't mean COVID gave them type one diabetes, right? Yeah. And so I don't know, it's just a hard thing. And then people, they don't like to believe some, some people are like, No, that's not what happened. I'm like, Okay, I don't know what to say, you know, so. My daughter had Coxsackie virus, and got type one. If I say that on the podcast, three episodes in a row. I'm gonna get five emails about like a day about oh, my kinetic coxsackievirus probably got type one. Yeah, it's a virus. Get your kid just like my kid had antibodies. They got a virus and their immune system was like, Hey, I'm confused. And then, you know, here we go. So exactly. It's kind of what it is. Socks. I'll tell you that much. He's doing well. Hudson is right. Yeah. You know, needle phobia is like, that's that's not an issue with pot. You think if you went back and needles though, do you think he'd be like I'm not hungry? No, thank you. Yes.

So we've had, you know, a variety of incidents that have required I heard, you know, the potential for injections. So most recently, he was in a sailing camp, I bought some very expensive, waterproof family fanny pack to keep his phone and PDM min, which works very well, if you zip it closed. You know, he's uptick closed, or he thought he's uptick closed, he, you know, capsized. And, you know, this was, I had sent him to a sailing camp, which is about an hour and 15 minutes away, my parents have a house on a lake there. And, you know, that's where the Yacht Club is. And he was sailing there. But I was working in Chicago. And I get a call from my mom that this happened. She's gonna take the PDM home and put it in the dryer to see if you know she can. Because it wasn't working. So obviously I asked her not to put it in the dryer,

I was gonna ask which one of your parents you took after being a surgeon? But I think you might be adopted? Yeah. Very

helpful. And, you know, trying to do the right thing. But obviously, it was very much broken.

Thank you. What if I put the phone on the grill and see if I can dry it out.

I mean, it wasn't even like rice or anything. It was in the dryer. It didn't go in the dryer. But I told her, you know, if he's going to, I knew it was this last day of sailing, and there was going to be pizza. So I said, you know, he's gonna need an injection if he eats anything. Okay, yeah. So I get in my car, we actually had a backup PDM. Thankfully, I get in my car to go to manage that, which I also was listening to the podcast at that point in time, because I had to reset the PDM. So I was wondering, like, what did I need to change based on the algorithm? What should I put in? So I was, you know, taking the Crash Course. And I think there was one episode that you had that was resetting that some something similar had happened, and someone was talking about how they manage that, right. But the long story short, you know, he was told not to eat before getting an injection. And, you know, I got a picture on my phone for my mom, which showed like to half eaten pizzas and pieces of pizza and a popsicle or something that he just went ahead and ate without, you know, taking any insulin for

did he do that on his own Maggie? Or did your mom not have the fortitude to stop him? Do you know what happened? Will you ever find out?

Yeah, I think he was by on his own and just made a conscious decision that he was going to eat these pieces of pizza and have this popsicle without any insulin, then his blood sugar was course, like over 400 He ultimately, you know, they convinced him to take an injection. And then, you know, I was able to restart the pod and get things working. Yeah,

about that. Jeez, yeah. Oh, good times. You say here that you sent me a note before you're on. He said physicians need to know that this is a chronic disease that requires constant manipulation and reliance on pharmacies, technology, doctors, nurses, and all this can change. And that also all affects the aspects of your life different aspects of your life. I wondered, do you have a message? Like if you if you could talk to other physicians? And are you talking about and those and everyone else or everyone else?

I think it's I mean, I do think that endocrinologist probably know this best that it does take so much care coordination. I don't think many other physicians know that. You know, they see like, Oh, you're on a prescription for insulin, like make sure you get your prescription for insulin. But there are so many other things that go into this. And I also think like there was absolutely no way I did not know, I really I think we both Tyler and I struggled with this, we thought it was a mathematic equation, like I'm going to eat this many carbs, I'm going to cover with this much insulin and like my blood sugar will be perfect. And we had no idea that there were variables that existed that were going to make it so that no meal will ever be the same. No activities ever gonna behave the same. I had no idea about that. And I don't think a lot of people know about that. Let alone you know, like, specific. Maybe endocrinologist but not other physicians for sure. And I think it's, you know, easy to say like, why isn't your hemoglobin a one C better? Aren't you taking your insulin? There's just so much more to that. I add the way that this affects caregivers, the actual patient that has diabetes, there are a lot of you know, I we have Hudson, I would describe as happy go lucky type child. When we left the hospital that day, he asked, you know, he was super excited to leave the hospital. And his comment was well, because I don't have to take another shot. You really just don't understand what you're dealing with. And the amount of rationalization that can happen but also the way that it affects just, you know, he wanted to be a normal kid. He wanted to keep playing all the things things that he did, I think that we had him in a hockey game the night, the morning after he was diagnosed from the hospital, and we were trying to manage his blood sugar, you know, less than 12 hours outside of the hospital in a hockey game, it really does affect kids, it changes everything, you know, he has to go to the nurse and carry this bag and all these things that I think that Ty and I were like, well, this isn't gonna change your life at all, we minimize the fact that it definitely has changed your life, and you have to do things a little bit more or sometimes harder than some of your friends do. And I think that that was something that we neglected to validate, I guess,

who says to you, you mentioned how come your agency, isn't that better? Why certain range? Are you not using it? It's on Have you gotten messaging like that? From doctors? Who does that? I

mean, I've probably been someone who said that, as a doctor, you know, just being completely naive about what is required to improve your hemoglobin? Anyone see, I mean, in my field of work, it's elective surgery. So I never operated on anyone with a hemoglobin anyone see of under over eight, that was like a hard cut off. And, you know, we would cancel surgeries. And I think I probably did have an attitude, like, in a nice way, but you know, yeah, you need to get your hemoglobin AOC down better and like, are you taking insulin, I mean, it's

just very never occurred to you to say, This person is struggling, maybe I should help them get their agency down. Like, that's just that's not how any of this works, right? Like, it's Yeah, they'll have to figure that out.

Well, like, um, you know, work with your endocrinologist or work with your primary care doctor. And honestly, probably, neither of those things is going to change things that much. They just needed to, you know, there were probably many things that were affecting their hemoglobin a one C, and I just, I was blissfully unaware of all of the different things that need to happen in order to successfully manage diabetes.

Can you explain to a regular person, a person who is not a physician has not going to medical school doesn't work in a hospital, doctor's office, etc? Why it is that they shouldn't expect their surgeon who's going to work on their pelvic floor or whatever, to understand diabetes? Why do other doctors besides endocrinologist, not understand type one. I mean, they don't understand a lot of different things, and which you and I understand to be reasonable, but to the outside person, just a regular person who looks up and says, that's a doctor. Why in the hell don't they understand? You're very in a very siloed profession, is that correct? Yeah,

I'm, I'm like, I always tell people, I do like seven surgeries. And that's it. So I'm so siloed. And I also, you know, I don't have a background in Internal Medicine where we would probably, you know, practically learn so much about that. So I'm relying on things that I learned in medical school. Lots has changed, right? I mean, we don't the insulin is different. Pumps are really mainstay now. So it's really difficult for people who are not in it every day to be keeping up with this. And I think yes, I would hope that doctors have a cursory understanding of type one diabetes, I think most of them could tell you the difference between type two, they could probably come up with some other types of diabetes. And certainly they know that when your blood sugar is high, you need insulin, when it's low, you need sugar, which, you know, that seems like that's

acute stuff. And that's probably all they know. Yeah, yeah. Also, I did not mean to use a mean to use, I did not mean to use a douchey corporate terminologies just that silo just means like, Oh, I just realized when I said I was like, That's just the thing I hear my wife say,

No, it did come off to me that I am really siloed. For sure.

When you're so isolated, I guess the like a more of like, a more real world way of saying it might be that I don't know the offensive lineman on your favorite football team doesn't know what the cornerback is doing. And yeah, they're not only don't they play corner ever, but they're not even in the defensive meetings. They don't even know what the defense is doing. They know what they're doing. They've learned a job and they do it over and over again. Just like you I run block for the left, I run block to the right I pass block for the left or but like You're like I do seven different surgeries. Like it's fun to say like what kind of doctor are you again?

I'm a Euro gynecologist, reconstructive pelvic surgeon. It's a mouthful,

I'll see. But when you say that also, there's a joke in there. It's inappropriate because you're such a nice person but like, I hear a lot. But but like there when that's your title, and that's what you do. And then I hear you say in plain English. I really only do seven different surgeries. I bet you that's not a thing people would think of you they probably think you're a magician. A wizard. Do you know what I mean? Because of that title and how long they in their mind. They believe you've gone to bed Medical School. I mean, what? Think about it what you do it you did your undergrad on

time in medical school for four years. I did a residency for four years. And then I did a three year surgical fellowship.

That's 11 years. Yeah, yeah. Okay. So you went to school for 11 years to learn how to do seven surgeries? Exactly. Yeah. And then if I say to you, how does type one diabetes work? You go, sugar makes you high insulin brings it down. Type One is, I think it I think it might be genetic. Is it auto? I think that's where you'd be stuck. If I if I went and found you three or four years ago, right?

Yeah, I would have known that, like I would have associated type one with insulin dependent. Like, that's what I would have associated at the time.

Okay. Now, I'm going to ask you to be I don't know if this is fair or not, we'll see if you're comfortable doing this? If I asked you to. So there, we've addressed why most people in the medical field don't understand it. It's not something that no, but if if people are, are with an endocrinologist, or nurse practitioner for diabetes, these kinds of like jobs, and they're not getting good information from them. How does that happen? So even take it out of diabetes, like forget diabetes, just like I shouldn't have asked it that way. How does it happen that some doctors with 11 years of practice, still aren't very adept at what they're doing. And how common is that?

I mean, I can't really speak for, like diet, I've we've had such a good experience with our endocrinologist and I don't have enough experience with, you know, I hear some things sometimes like on the Facebook podcast, and it is concerning, like, I don't really know, why some would be less, you know, forthcoming or are in the mix. In my own specialty, I think that, you know, we this, you it requires my specialty requires fellowship training, that three year training, and also boards that are certification in this fellowship. So it's a sub specialized board certification, and I think, possibly, if I had to guess, maybe the people who are getting that subpart care or are just not seeing those specialists, could

it be a communication piece, because it occurs to me as you're talking, you don't have to communicate to anybody to do your job really well. Like you don't like, you'll sit the person down and say, look, here's what we're gonna do, you know, this is what's happening. I don't know how you say it in your lady parts, and we're gonna do this. And then and then we're gonna do that. And this is what's going to alleviate, it's going to bring this to your life, it's gonna take me about this long, here's how long recovery is, you know, I have a buddy, you probably then you probably brag about, like your infection rate being low or something like that. You kick them out of the room, and you put them on the schedule, you do the thing for him, and they end up okay. Not you know, more,

more of I don't have many long term relationships with my patient, right.

But you don't have to explain anything to them for them to maintain that work that you've done for them. So you're more of a Gosh, I don't mean this pejoratively. But you're more of a, you're swinging a hammer. Really? You don't I mean, yeah, yeah, yeah. Whereas I'm expecting. I'm expecting an endocrinologist to help me with my diabetes by being able to initially, initially communicate what I need to know, to watch me grow or not grow and re communicate things or move me along and teach me and to picture what's happening when they're not around, and then accurately make adjustments to me without barely even being able to see what I do day to day. And some people are good at that. And some people aren't. It's more of a job of communication than it is of of medicine, isn't it? Oh, yeah.

And I think that there are so many constraints right now on people in the medical profession, you know, physicians, nurse practitioners, etc. I mean, when I'm at those endocrinology appointments, the amount of stuff that has to happen, there's a lot of stuff that has to happen, you know, they review the, the Dexcom reports and things like that, and then all the preventive stuff. I mean, there's just so much that happens. So maybe focus gets lost on one area more than the other, or there's just not time spent doing some of those things with you. I think the patients also have to kind of understand where the problems are, too. Yeah. And that's hard, too. It just requires so much patient education.

But fair enough, though, part of your success for your son is that you're engaged, intelligent, paying attention, you know, asking questions, going out on your own and finding out more information, you're actively participating if not directing his care. Yeah,

I would say both Tyler and I are very active in his care. And, you know, even you know, identifying things like you He's struggling with, you know, the fact that he's different and things like that, and what do we need to do to address that? That has been? We've been able to address that. And I'm thankful that we were but yeah, I say, I think that if we weren't in tune with him that probably wouldn't have been identified.

Yeah. Actually just made a note for myself for a different series, because it occurred to me that while it would not be easy to hear, for some people, it might be interesting to get a an anonymous doctor on a whistleblower X episode and have them whistleblow on patients, like telling me like, what what is really standing in your way if he didn't have to be polite? What is happening? Like, what are you battling against when you come into your job every day? Because fully Yeah, yeah, cuz I bet you that. I bet you that's, that would be eye opening for some people, too. Yeah, it just so that's interesting. So most physicians jobs don't require communicating directions beyond maybe a for the first 12 hours, put ice on this every three hours, or, you know, this is what this is going to feel like after your surgery. But don't worry, you're gonna come back and I'll check you if everything's good, you'll be alright, in six weeks like that. That's how most of this stuff goes. And that's our expectation is people because most of our medical problems have gone exactly like that up until you get a chronic illness.

Well, yeah, and I think the other thing is that it's like an endocrinologist is kind of the directing the care, right? There's many other players of the team that provide information that's probably, you know, very, very helpful, like the diabetic educators, they feel such a huge role. And it does take off some of the burden from the endocrinologist and I think I think someone was asking me, like, you know, my endocrinologist doesn't seem to know a lot about how the different pumps work. And it's like, Well, how could your endocrinologist know every single aspect about every pump that's available? That's why they have other people on their team to help with this. It's just, I think people might have an unrealistic expectation about how much one single person can do maybe

is it? Is it unreasonable for me to expect that my endocrinologist spends a weekend figuring out the three major pumps and how they work? Well,

I think the three major pumps, I think that the endocrinologist do know that they probably know one more than the other, they're, you know, more familiar with it for whatever reason with their patient population. But they're, I mean, these pumps are really intricate and lots of different. If you're asking, like, does this one, what about the, you know, I mean, first of all, the Omnipod five algorithm is still very mysterious. And I think that, you know, you, a lot of people don't know exactly how everything works, I think you you know a lot about how the algorithm works, but it's all proprietary, right. And there are small, little tiny things that you can tweak that some endocrinologist probably know about, but I don't know if everyone knows about that,

you know, again, it comes down to communication. And because I have this story rattling in my head that often tell you, so you'll know it, but I just had a person online tell me or was it in an interview, someone told me, they were, you know, kind of wrapping up their endocrinology appointment? And the doctor said, Hey, could you spend a couple of minutes longer? Right? Can I ask you a question? And the person's like, yeah, what do you need to know? And the doctor said, Can you explain how that pump works to me? And that, like, shook that person's confidence to their core about their doctor. And yeah, you know, but and I wonder if it wouldn't be as simple as saying, you know, because I don't live with diabetes. And I'm only getting information, you know, from people in the short visits. Could you spend a couple of minutes with me, let me ask you a few questions about the pump, I'd like to dig down and get more information. If if it was just said that much differently, then the feeling that that person left with wouldn't have been what it was, and the feeling they left with was, Oh, my God, my doctor doesn't know what the hell they're doing that because that's the feeling they left with. And I wonder if that now was true. Or if the doctor just didn't do a good job of explaining what they wanted? Like, I don't I wasn't there, obviously. But yeah,

yeah. I mean, I would have before you explained your real, you know, rationale for probably why that happened. I would have probably thought the same thing. I bet that that doctor was trying to say like, Hey, you know this best because you deal with it every day, you're the expert, like what are some of the things that I need to know to better take care of my patients, but not all doctors are really good communicators? You know, they're, I think there's a lot of room for improvement in communication, just in general, but I suspect, you know, doctors all want to help people and treat people that's why we become doctors. They don't want to be, you know, providing some therapy that they don't understand how to do and I'm sure that that endocrinologist or physician didn't wasn't prescribing something they didn't know how to use. They just probably wanted that Patient Experience aspects.

I wonder that too now that I think about that way, you know, I think in the end, I think it is what it is. I hate to say it like that. But I there's people running around all the time, like, how are we going to fix this? How are we going to get doctors? I'm like, I don't think you're going to change anything. I think it's human nature. To some degree, there's gonna be some better ones than others, there's going to be some bad ones. There's going to be some fantastic, you know, people that you meet along the way. And that communication. I mean, listen, if if communicating was something everyone was good at, I don't think the divorce rate would be one and two. So like, you know, like, yeah, people are not great communicators in general. And just because they're doctors doesn't make them better. And I don't know that there's a Listen, I'll say this. I think I'm a fairly good communicator. Yeah. I don't know that I could teach it to somebody, though. You know, I mean, like, I'm not sure how to do that. Like, I think you learned from the podcast, because I have a way of speaking about what I do. I do a good job of speaking about high level stuff. But it doesn't feel high level, I don't talk over your head, I don't actually have the ability to talk over your head, which is, which is really helpful. Because who knows if I would or not, but I understand this topic really well. I speak in pictures, which I think people find helpful.

Yeah, but you also have the empathy, like you, you knew where you were, and like you're trying to communicate to a person in that position. Yeah, that

helps as well. I guess it's funny, I, I don't even know why I'm a good communicator in this specific situation, like, so I don't, I guess what I'm trying to say is, I don't know how we could expect some maybe rigid guy or like, you know, some, some person, or some woman who's a little, I don't know, like, particular or whatever, like, you know, like, people's like, personalities are all weird and different. Or maybe they're very engineer brain like, and that's why they're a doctor. And now all of a sudden, we're expecting them to like get down on your level, commiserate with you understand this really complex thing and be able to communicate back the way to handle it. Maybe it's just not ever going to happen.

I mean, I think I have a rosier outlook. I will I mean, I just, I am really a glass half full type person. And I think that, first of all, having people hear these experiences is is really important. Again, I really, I think that if doctors heard that, you know, they potentially their patients weren't getting, seeing the results that they wanted to. And we think that it's related to communication, I think everyone would want to fix that. I just think that there are so many constraints right now. And they're, you know, it's easier to say like, well, I am going to concentrate on the medical things like make sure XYZ, and I have this diabetic educator who's really going to help with like the day to day, all that other stuff, and a lot of the education and a lot of the communication. And then this nurse is going to do that, too. So I think that some of it does, unfortunately get parsed out to other individuals. And perhaps maybe that's why, you know, the the lead physician is really being seen as not communicating all that much. And so I guess maybe more of a team based approach might change that perception.

Okay, yeah. I'm gonna ask this question a lot of physicians this year on the podcast, but what do you think of my idea about group instruction?

Well, I think that's great. That would

work right, instead of coming in for 15 or 20 minutes or half an hour at a time. What if everybody showed up and it was two and a half hours long, and it was a, you know, it was partly a q&a. And then partly, while you know, you could go off to the side and private and do whatever you needed to do with your physician while the q&a was going on? Like, I think that would be such a good idea.

Yeah, well, I mean, that's definitely been shown. There's research behind that. I'm not familiar with the diabetes research. But in small group education in different disease states, there's a lot of research to, to support that. And I believe that they do something similar at the University of Chicago, I've seen flyers for diabetic education, they meet in the cafeteria and things like that. So there definitely are. There's a lot of research to support that. I think that's a fantastic idea.

Okay, yeah, I mean, I keep thinking over and over again. It's this one simple idea that I have if if me, I am a person who listened between you and I, Maggie, you went to more like secondary school than I went to like, regular school. So I barely like crawled out of high school. I was, I was not an interested student. I did not grow up with a family who told me to be interested in academics. Yeah. And I bet like when I graduated, I was like, huh, a trick somebody. And somebody right now is not doing their job given me this diploma. And I, and I'm out in the world. But somehow, there's no other place. Right now. Like Like, I'm sure there are hospitals that do great job. I'm not saying that there's no other place. I'm saying that that visible publicly, I speak to more people with diabetes than anyone else on the planet. Yeah. And it doesn't make sense sometimes, other than to say that this format works for a lot of people. And that the one thing I think I've done, that I think everyone could do is that I've boiled diabetes down in my own head when I'm talking about it into a formula that anybody can understand what I'm saying it. And mostly, what it gives them is a very firm base to start with. And it leads to outcomes and understanding that lead you to have, like further education for yourself like you might the outcomes I give you give you some understanding, you have those experiences, build on them, and get better and better at it as you go up to the level you desire. I imagine. And that's, I think what I'm good at, I think what I'm good at is talking about diabetes and boiling it down into understandable, digestible chunks. I think that's all I've done. I mean, if I've done more than that, I'm literally not aware of it. I don't understand why a doctor can't do that.

Well, I mean, I think that, you know, part, again, part of I think, you know, on a higher level definitely brought together community. And I think that that's huge. You've definitely, you know, distilled diabetes, and made it a little bit easier to understand for lots of people, I mean, including caregivers, which, you know, that can be really hard for people that aren't, they don't live with it every day, you know, but other like grandparents and things like that. But that sense of community is really huge. And I think that comes from that empathetic, you know, whether you're meeting that aspect or not like that, certainly.

Oh, no, I haven't. No, I know how you all feel. Yeah. I mean, to some degree, I know how you feel. And by the way, by interviewing so many people who have diabetes, while I don't have it myself, I might be one of the closer people who doesn't have diabetes, to understanding what it feels like than many people because I've had these long, in depth conversations with people I've and I am an empathetic person. So I do absorb. I do I baits are hard on me sometimes, but I do absorb how they feel when I'm talking about it. And I maintain it. I will say, I think the community aspect is insanely important. I don't I don't mean to, to minimize that. But if I was going to, if I was going to say one of the things that I think that I'm doing that is leading to the success, it is something that a doctor can't do. And well, and here's what it is. And I don't know if people know the secret or not. I put out an episode of this podcast every day. I create a world where there's always something there for you. And because everybody doesn't listen every day, like some people do. Don't get me wrong. This people are like, They're my heroes right there. I put it there waiting for a new episode. Do you have any idea how many people told me like, hey, when's this coming out? Like I don't have anything to listen to over the weekend. I'm like, Hey, I'm doing my best, you know, but, but by putting content out Monday, Tuesday, Wednesday, Thursday, Friday, and having it be a mix. This is a guy who's got type one, here's a woman who has type one who is a mom, here's a dad, here's something with Jenny, here's something with Erica, we're going to talk about the psychological sides of it, like keeping that stuff all mixed together constantly. Even if you're not up for listening to the psychological part of it. You might be up for management, you're not up for management, you might not be for you might be up for a story. There's always something there to keep you connected. And that connection is the somehow unquantifiable reason why people take good care of themselves. And I don't understand completely why it is. But I know if you're listening to this podcast, you're gonna have better outcomes. And it's not always going to be because I taught you something about care. I think that's true. And that's not something we could ask a doctor to do. No, yeah, yeah, I get it. Thank you actually now teaching me with the podcast. That's Maggie appreciate

explaining the way that we I mean, it is been so helpful, and I think it is filling something and I just my view is I don't think that a doctor is responsible for that. Like it just can't happen in this day and age maybe 40 years ago. But it's it's not happening. It can't there's there's too many constraints, things have gotten too complicated. Diseases are more complicated. The management of these diseases is more complicated. There have to be other people, team members, you know, that are responsible for filling in these gaps. It's It's It's untenable for a single human to manage that is that

over and over again, and I can accomplish it because I don't actually have to sit down with each of you individually. Exactly. Yeah, that's interesting. But it's my Yeah, I guess it doesn't work. Like even what I it's easy to say, can't you just do what I'm doing? But what I'm doing is having daily connections with people. And they can't do that either. Exactly.

I mean, I think, and I think that maybe this is, you know, just an experiment in that kind of group education and checkpoints and things like that. That I do think, again, I would fully support, I think that there are probably many other benefits, you know, even seeing that sense of community in that setting. Yeah. Oh,

it would easily start like that. Because people be like, Oh, I live around here. And they start talking to each other. And I keep bringing this up Maggie over the last couple of years, because I'm convinced that's the answer. Like for institutions. I've said on the podcast, I love thinking somebody will take me up for it, I'll come out and give the talks like like, hell, I'll come out for a week, we'll do it every day for a week, you bring in 50 people a day or something like that, and let the staff listen and hear how Yeah, awesome, yeah, but nobody, in the end, what ends up happening. And this is not going to surprise you because you're in the game. But these conversations get pretty high at some institutions. And eventually what happens is, well, you're not a doctor. So we can't do that. That's what that's how it gets shut off. Eventually, it gets to some level of the organization that goes, What's his credentials, and they're like, he almost got out of high school unscathed. And they, eventually it goes away. So I don't know, I'm gonna keep making the podcast and asking the questions. And hopefully someday someone does it. Because I think to your point you just made a minute ago, I think I've proven the point. This works. But yeah, why is this not what we're doing for people? Like, because I'm reaching a lot of people, I can't reach nearly all of them. That's not possible. So I'm reaching the people who are have an iPhone or an Android phone, have the time to listen to a podcast know somebody else who would tell them about the podcast, or have the wherewithal to look for information outside of their doctor's office? I'm already limited to how many people I can reach? Yeah. So anyway, all right. I

do hope that it moves in that direction. I really do. I think it would be beneficial. And, again, I think we would feel very isolated without you know, having these. I don't know Hudson would he? We're lucky enough. Again, one of the community members, I already mentioned that the family with their eldest being a type one diabetic in hockey, they the year that Hudson was diagnosed, they actually ran the first year of this camp that's dedicated to kids with type one diabetes, that's a hockey camp. It draws from Canada and the United States. And it's doubled in size. And Hudson has friends. From this. He calls him his T one D bros from this T one timer camp. That's a bunch of kids that play hockey that have type one diabetes, and they text constantly throughout the year until they can't wait for the next camp session. And I think

it's just really important. Yeah, that's awesome. And he's got so he's got his own little community as well. Exactly. That's great. Okay, well, you were terrific. Is there anything I didn't ask you that I should have or anything we missed?

No, this was a pleasure speaking with you. And I really, really hope that your idea to kind of moves things in the direction of that group education, I really do hope that it moves in that direction, I think it would be really helpful for so many reasons, and just want to thank you on behalf of my family and where we are now. You've really been instrumental.

I really appreciate that. If I ever have any problems with my pelvic floor, I'm going to call you to find Yeah, 100%, I will tell you this on your way out the door. I just did a live event, I was in person somewhere. And we, you know, they invite me out. And they're like, he'd come out and talk for an hour. And I was like, oh, not flying there to talk for an hour. I was like, let's, let's do this. And I proposed this big idea. I said, Why don't we do four or five hours. They're like, what I'm like are we'll give him a break in the middle of eat food. And she goes, No one's gonna stay that long. And I was like, Are they well, don't worry. And so we did. I think we meet and graded it like nine I think we started talking at 10. We did a two hour talk. And I brought Jenny with me, by the way I could I don't I don't want to take anything away from Jenny. I could have done it on my own. But I thought it would be really nice for people to see Jenny. Let's like have general you know, so Jenny and I talked for two hours about diabetes. We just talked and if I'm gonna tell you, no slideshow behind me, no pre planned idea of what we were going to talk about. She and I chatted for five minutes before we took the stage. And we were like, Let's kind of start in this direction. See where it goes. And she's like, Yeah, that sounds good. And then she's like, what about this? And I said, Oh, good idea. And then we just started we sat down, said hello. We started talking to hours, everybody went to lunch. At one o'clock. Everybody came back, nobody left. So we didn't lose anybody. And then from one o'clock, two o'clock, three o'clock, four o'clock. I think a little after that, Jenny and I just talked more into q&a live with the audience. That's all we did. And the next day, a person sent me a note and said, I don't think I've had a day go better than the day that we had after we left you and the day after, like, so the next 36 hours after leaving that talk, went so well. And we were at restaurants and traveling because we had to drive to come and see you. And all these ideas that like just being around the conversations and hearing other people's questions made lightbulbs go off for even some people who never raised their hand. And that's what I'm talking about. That's, that's what I think happens. I think you give them a podcast in person. I'm not saying every doctor's appointment should be five hours long. But if every three months, you came out for a more targeted 90 minute conversation. And then you I don't know, I don't know, I don't know how dark you're gonna have to figure it out yourself. But having that that kind of like feeling and that experience for those people, they're going to take more from that than they ever would from sitting in office and hoping that they remember to ask the questions that hopefully you have the answers to, you know, it just does it's not ever going to work that way. So anyway, I appreciate your You're very kind to come on and what you said just now was was lovely. I really do appreciate it very much. Thank you. Well,

thank you so much for having me. This is wonderful. My pleasure.

Head over to Omni pod.com/juice box to get rid of your FUBU Omni pod.com/juice box get yourself an omni pod five. A huge thank you to ever since CGM for sponsoring this episode of the podcast. Are you tired of having to change your sensor every seven to 14 days with the ever sent CGM, you just replace it once every six months via a simple in office visit. Learn more and get started today at ever since cgm.com/juicebox. I know that Facebook has a bad reputation. But please give the private Facebook group for the Juicebox Podcast. A healthy once over Juicebox Podcast type one diabetes. That Juicebox Podcast is full of so many series that you want and need afterdark s Gatan Jenny, algorithm pumping bold beginnings defining diabetes the finding thyroid, the diabetes Pro Tip series for type one, the diabetes variable series mental wellness, type two diabetes pro tip, how we eat. Oh my goodness, there's so much at juicebox podcast.com. Add up into that menu and pick around. And if you're in the private Facebook group, just go to the feature tab for lists upon lists of all of the series. always free. Always helpful. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

Hello friends, and welcome to episode 1192 of the Juicebox Podcast. Today, Dr. Marwan joins the Grand Rounds series. He's a pediatric endocrinologist who also teaches medical students from both Johns Hopkins and Washington University School of Medicine. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan, or becoming bold with insulin. The diabetes variable series from the Juicebox Podcast goes over all the little things that affect your diabetes that you might not think about. Travel and exercise the hydration and even trampolines juicebox podcast.com Go up in the menu and click on diabetes variables. Are you a US resident who has type one diabetes, or is the caregiver of someone with type one and you'd like to help? You can do a lot right from your sofa with your phone in your hand, go to T one D exchange.org/juicebox. and complete their survey when you do that. Your answers to simple questions will help to move type one diabetes research forward. T one D exchange.org/juicebox. podcast this episode of The Juicebox Podcast is sponsored by the only implantable sensor rated for long term where up to six months. The ever since CGM ever since cgm.com/juice Box. Today's episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. This is the meter that my daughter has on her person right now. It is incredibly accurate and waiting for you at contour next one.com/juice box. This show is sponsored today by the glucagon that my daughter carries. G voc hypo Penn. Find out more at G voc glucagon.com. Forward slash juicebox.

Hey, thanks for having me. I'm Dr. Bara Marwan I'm a pediatric endocrinologist at Sinai Hospital in Baltimore. I also teach medical students from Johns Hopkins University and George Washington University School of Medicine.

Wow. How did we get in contact? Okay, so

it's through a patient of mine who actually follows you or podcast. She said Dr. Moore, what you need to meet Scott, you need to be in that podcast. So I thank them for that introduction.

Oh, that's nice. Okay, so let's go over a couple of things about you. How long have you been a pediatric Endo? Alright, so

I started fellowship back in 2018, and July, and so been in the field for now almost six years, then and quote unquote, gainful employment since July 2021. So almost three years as an independent practitioner, but six years almost integral taking care of kids with diabetes. I like to start that my my initial training experience was in camp Sweeney. They threw us for a few weeks at camp with the campers suddenly the camp doctor that I have to prescribe and adjust insulin doses. And I was like, Oh my gosh, that's so complicated. How can I even do something like this. So that really was a very good eye opener for me to not just look at it from a medical standpoint, because as a pediatric resident, my exposure to diabetes was mostly through sick kids in the hospital, or just a few brief clinic appointments, but their one on one contact in the camp just helped me really realize what kids with diabetes have to go through every single day. So kind of gave was a real eye opener when I started fellowships six years ago, that's

something they do with everyone, or were you just lucky to have that opportunity?

I think it's common practice for programs to send their fellows, at least in my program at UT Southwestern, this is considered work so we actually do work hours at camp, but I'm not sure how other programs have it. But it's, it's typically a an opportunity that a lot of fellows like to kind of get themselves into,

you know, it's interesting, you think about it, the people who you were helping, were probably thinking, Oh, this guy, he knows what he's doing. And you were thinking, Oh, how do I do this?

Right? And I was like, Oh my gosh, it's so like, I don't know those devices. Can you please teach me what this guy does? what this button does, like I understand basics of what I mean, they all need insulin, but it's like how we're how we're operating it with so many new devices. So many new tools, that was the first time I actually got introduced to like a continuous glucose monitor, for example. So by that, at that point, it still required a lot of calibration and a lot of work, but it was still a very, very fruitful experience, I would say,

when you start off, so let's kind of step through this, you leave high school, you go to college, when you're an undergrad, you know, you want to be a doctor. Alright,

I'm an international graduate. So I, the way we do it in Saudi where I went to medical school is we do a high school and then directly into medical school, and that's called a Bachelors of medicine. It is equivalent to an MD, it's a longer program. So it's six years of medical school and a year of internship. So it's different from the way it's done typically in the United States and Canada where typically you do undergrad and then you do the MCAT. And then you decide to become a doctor and to become an MD and that's like a postgraduate not just straight from high school.

So when you pick the you know, when you pick endocrinology, is there a reason that you chose endocrinology is something that interested you about it something you were good at or had a personal connection to, if you take insulin or sulfonylureas you are at risk for your blood sugar going too low. You need a safety net when it matters most. Be ready with G voc hypo pen. My daughter carries G voc hypo pen everywhere she goes because it's a ready to use rescue pen for treating very low blood sugar and people with diabetes ages two and above that I trust. Low blood sugar emergencies can happen unexpectedly and they demand quick action. Luckily, G voc hypo pen can be administered in two simple steps even by yourself and certain situations. Show those around you where you storage evoke hypo pen and how to use it. They need to know how to use Chivo Capo pen before an emergency situation happens. Learn more about why G voc hypo pen is in Ardens diabetes toolkit at G voc glucagon.com/juicebox. G voc shouldn't be used if you have a tumor in the gland on the top of your kidneys called a pheochromocytoma. Or if you have a tumor in your pancreas called an insulinoma. Visit G voc glucagon.com/risk For safety information.

Big question. So zero personal connections at that point. So I was in the middle of pediatric residency. So basically graduated medical school applied for residency and matched to a US hospital in New York where I was doing pediatrics. But throughout those three years of training, it prepares me to become a general pediatrician. And then I have the opportunity to do three additional years of training in whatever field that I'm interested in. So whether it's being like a heart doctor, a cardiologist or an endocrinologist that comes in, after we do those three years of general, whether it's internal medicine, if you want to be an adult endocrinologist or pediatrics, if you want to do a pediatric endocrinologist. Okay, so my first year in and like as a pediatric resident, I was like, I know that I don't want to do general pediatrics, I think yes, I love taking care of patients in a Well Child setting. But I do like to take care of kids who have chronic diseases. And so whether it's being an asthma doctor or like a, like rheumatoid doctor or a heart doctor, or like I wanted to take it a step further. And so, at that time, I was also doing my master's in public health. And I had, at that point, wanted to be involved in some kind of research. And during that time, the fellows who were in my program wanted a statistician to help them run those numbers and analysis. So I kind of find myself really, with the people with the group of endocrine fellows and the endocrine attendings who were amazing. And they got me involved into the diabetes research. And I was like, You know what, I actually liked that, but I did not know how much I would love it. I was like, Okay, I don't mind being an endo or an asthma doctor. But now it's like, looking back. I don't want to do anything about diabetes and Endocrinology. So I'm glad that it's kind of the stars aligned this way for me. Yeah.

What about it captured your imagination.

I knew I love working with numbers and I'm a caring person. So I think I found that kind of right mix within paediatric endocrinology. But at that point, I was like, Okay, I like to get results right away. So I was thinking maybe I can do a hospitalist job where I can just take care of very sick kids in the house. Fill er the ICU or neonatology. But then, like, I love to also have a work life balance and spend the nights really at home with my family and not really have to spend so many nights of my adult career in the hospital. So that's where a subspecialty like endocrinology came in as a natural fit. It's

interesting how many little variables go into your course.

Right? Yeah,

really, it is really something. So once you decide that you're going to, you're going to help kids, you know, in a clinical setting, what do you know about diabetes, I guess, in the beginning, and how do you learn what you know now? Because it's not from medical, because people would be keen to believe that go you go to medical school. So now you understand diabetes? That's not really how it works. So what's the pathway to to really becoming proficient?

Right. So honestly, if without having a one on one, diabetes training, I don't know how I would have been one because yes, we do study how insulin works. That's something that they teach us in medical school, they we study the different kinds of insulin we study, there is a pump, we study about DKA. They teach us in the hospital, of course, in the emergency room, how to take care of a sick child, but they don't really teach us what goes into the day to day management of diabetes. This is not a common thing that a general doctor, I mean, yes, they know that the kid needs insulin, but that's pretty much where it ends in terms of what they teach us in pediatric training. Not every pediatrician does endocrinology. So yes, a lot of my trainees currently in the hospital, where I'm at, they just see kids with diabetes in the hospital, they never really have that connection with kids who never landed the hospitals to begin with. So I think, again, if somebody wants to really get into diabetes, they need to actually experience then just deal with people who live with it.

Okay. Yeah. So it's just the experience just having conversations, watching people struggle or succeed and taking information from that building on top of it. Absolutely,

yes. And again, staying. I was very, very lucky to have very good mentors in Dallas, where I did my a year of fellowship. I mean, we just was excellent, 16 endocrinologist and I was the only fellow that years. So again, I felt that there's a lot of responsibility, but at the same time, it's that joy of learning something new, and really being able to slowly understand how those doctors think about going about medically making the right decisions. But then after that, I realized there is a there is very limited that doctors do in clinic appointments. And it's like, and this is always a question that I asked myself, like, what's my job as a diabetes doctor? What's my role? I mean, at this point, at least when I was in Dallas, the nurses would pre charge prepare all the prescriptions for diabetes, there is a protocol for when to do the labs and when to do that blood sugar checks. And even in terms of trend management, giving more or less carb ratios are long acting or just making a pump change. Again, that's also mostly handled by our nursing and diabetes educator team. So it's kind of like that struggle is like diabetes is like no other disease is. It's not just that you need the medicine. Pretty much everyone universally, Nellis you need insulin for type one diabetes, but it's more of how can you tailor that treatment to that individual in front of you?

What did you decide your job was?

At that point in Dallas, it was a much more structured way where we had diabetes educators routinely go in with a doctor's for a visit, that all changed. When I actually started here working at Sinai was COVID. Most people were remote. And we were just starting to get people back to the office. And I found myself basically doing it alone. It's like an old man. Like it's an it's a one man show, for the most part for the diabetes care and follow up where I had maybe three or four people helped me in my visit, I kind of took a different approach to what other doctors might do. It was more of a concierge, so to speak, kind of practice in a community hospital, where I, I personally again, it was like, okay, somebody needs to provide that education. If I don't have the nursing Task Force. I don't have that skeleton. Hey, I mean, I still want my kids to get the best care possible. And I'll just go ahead and do my own education. So I was very, very fortunate to have that capacity. It's like yes, we are a smaller house. spittle, and we have lots of hospitals in the area in Baltimore. It's not a big patient load, we get around maybe one new diabetic every single week. That's different from Dallas, for example, when I used to get a diabetic every single day, the the load there was much bigger. So with having a diabetic every week, it was more of a process of how can I make sure that my patients are up to speed with that education process. So for me, my goal was mostly an educator. And I'm like a teacher. And basically having a little curriculum in my mind, even though it's an unwritten curriculum about, okay, this is what you need to learn when you first leave the hospital. This is what you leave, leave to learn, like, a month or two, down the line. Of course, we all are different in how fast we learn. But at least understanding the basics, the concepts, I would like all my patients to learn how to do trade management, of course, not everybody is able to do so. But it's mostly structuring the education. So I think founding my role as a physician educator was very, very fulfilling, I then decided, okay, you know, what I put in all those hours, I was able to put in my diabetes educator exam, I'm now very one of the very few doctors who are certified diabetes educators, and also board certified in advanced diabetes management. So basically, it's just from an A to Z kind of standpoint where I could just cover not just the doctor, yes, I know how to look at prescriptions and look at trends and make those adjustments, but also educate and empower my patients to be able to really achieve what they need. By the time I see them. The next time, of course, what do I use to measure? what's the, what's the variable that I'm tracking? It's like, of course, I track their time and range, and they're a one see that everybody does, but of course, it's not just a one. See, that happens in three months, I always ask myself, there is a lot of room as a window for opportunity between those visits that we could probably work on.

What do you feel like a newly diagnosed person needs to understand? First, it feels like you have it broken into steps, right? What are the steps? diabetes

is a life changing diagnosis, there's a lot of stress. But then at that point, families are very eager to learn. And I found it that really what we teach in that first week, or that first few weeks, really stick with them for a very long period of time. And it's kind of like this is the unshakable truth. So I think the most important things I teach or focus on, I think everyone can learn eventually how to check a sugar level, or how to give insulin injection, this is not my point of focus, our nurses in the hospital can even they're not diabetes educators, they can also teach those basic mechanical skills, what I focus on is the understanding of diabetes targets as like, Okay, this is a prediction game. Even if you're off by a point, upper or lower, you have the numbers to track and to kind of teach a good target, I always say I want to make diabetes, invisible disease. And so I give Dexcom during that first admission, or like any other as mostly Dexcom. To allow for monitoring, I've got I've given some Libras to my type twos, basically a continuous glucose monitor, so that we can continuously monitor and when they can reach out the first few days after because I'm having a patient a week or so I try to not just say, make this change, but explain why I'm making those changes. So it's kind of like slow learning process that hey, this is a an imperfect disease, we do our best we try to come up with a certain dose. But if it doesn't work out, doesn't mean that you're doing anything wrong. This is the nature of diabetes, and let's try to kind of work on improving all the time.

You're teaching them the way you learned from your fellows. Correct. Okay, and you're taking the experience that you had at diabetes camp, right for yourself, remembering that you didn't know anything, and you had to go over and over and over again until it started to make sense to you. You're just doing what worked for you. For them. Yes.

I was like, Okay, it's they're very worried initially about a high number. I always say it was much higher just a week or two ago when it was running at a super high levels. We did not know it. diabetes was a thing. But now we know it, we can see it, we can act we have the tools to respond to it. And so yes, it's always those kind of questions. Can we have a snack after we had a meal or they like we always try to not give concrete answers, but always try to reference Hey, oh, my gauge is your numbers. And this is what I want to try to kind of perfect and so my focus is yes, you need to learn how to perform those skills how to use The Corporate shell. But eventually, if we do the math, and the numbers are not where they need to be, we need to think about how can we make it better the next day. So kind of make it like a process. And not you do this, and we'll fix that kind of thing.

I think that one of the nicest things I heard you say, Was that what you tell them in the beginning becomes this unshakable truth. So then, you know, to that if you lead them in the wrong way, in the beginning, it's hard to break them free from that as well. Right? And

I look at it just like I'm building a house, I need to set up a solid foundation. Yeah. Yeah. And how do I mean, again, it's this is what makes the diabetes doctor different from like, say, hematol, like an oncology Doctor, where you're setting up all the plans, for example, for treatment of a tumor, mostly in the hospital. I mean, what our job is, is to empower people to do the tasks of diabetes at home. And that's what makes our job much more again, demand. And what we're asking for is something that is very demanding 24/7 365 kinds of jobs. So it's this is I think, what makes it all a it's also very

uncommon in health care. Far too often, we accept the blood glucose meter that someone hands to us, the doctor reaches into a drawer and goes here, take this one. That is that is the one you want. Is that accurate, you have no way of knowing. But if you want accuracy, and you want to be confident in the blood glucose readings that you're getting from your meter, you want that contour next gen. It's incredibly easy to get the same meter that Arden uses, just go to contour next one.com/juicebox That's all you have to do. The contour next gen is easy to use and highly accurate. It features a smart light that provides a simple understanding of your blood glucose levels. And of course, Second Chance sampling technology that can help you to save money with fewer wasted strips. Contour next one.com/juicebox This episode of The Juicebox Podcast is sponsored by the ever since CGM ever since cgm.com/juicebox. The ever since CGM is the only long term CGM with six months of real time glucose readings giving you more convenience, confidence and flexibility. And you didn't hear me wrong. I didn't say 14 days. I said six months. So if you're tired of changing your CGM sensor every week, you're tired of it falling off or the adhesive not lasting as long as it showed or the sensor failing before the time is up. If you're tired of all that, you really owe it to yourself to try the ever since CGM. Ever since cgm.com/juicebox, I'm here to tell you that if the hassle of changing your sensors multiple times a month is just more than you want to deal with. If you're tired of things falling off and not sticking or sticking too much, or having to carry around a whole bunch of extra supplies in case something does fall off. Then taking a few minutes to check out ever since cgm.com/juice box might be the right thing for you. When you use my link, you're supporting the production of the podcast and helping to keep it free and plentiful. Ever since cgm.com/juice. box right? Because you usually things are measured, take the pill at one o'clock take it at five o'clock, I want you to do the albuterol before you have this hat like like it's all very structured diabetes isn't like that at all. diabetes it is but it doesn't feel like it, it feels like it feels like it's always flowing and moving and changing. And I need you to do this all at home and make changes to that. So how long until you empower them to make dosing decisions that are different from what you've written down? Oh,

it's like a few weeks down the line. Okay, so I think because I'm with them pretty much every day or every other day when they leave the hospital. And so it's a lot of hand holding initially, but then slowly they realize what I would do. And then I start to ask questions in the Socratic manner be like, okay, they would reach out we're having lows when we're intrigued that honeymoon phase and it's like, okay, you see those lows? What do you think caused that? And what insolent change do you want to do? And I always say, this is purely educational. If you don't know the answer, or if you ask the wrong question is okay, and I'll then put in my recommendation myself, or if I see that they put in a recommendation and it really is what I would suggest and I was like okay, yes, this is what I want.

This is how I do it online. I when I talk to people I almost always say to them some version of what do you think, you know, where you ask them a question to get them to think in a direction that they're you don't know to go into? Have you ever done that kind of leap like little carrot and stick lead them towards it?

Oh, yes, absolutely. You I slowly and sometimes I say, Okay, I usually go down. I mean, sometimes I just when I see somebody is just really stuck and frustrated, I'll say, Okay, we'll do a 20% decrease, what do you think that will do? So at least I'll make them do one task out of the process. Yeah. So at least getting them engaged in there. It's more of where's the center of control, I wanted to be with the families, I want them to feel that they're under control of their disease, yes, they get their prescriptions and the guidance from the doctor's office, but it's mostly I want to empower them to really be able to be independent in taking care of that disease. So they don't need a doctor's input, Allah down the line,

it becomes crippling if you infantilize them, and don't let them make decisions, then down the road, when you're not as connected any longer. They don't know what to do. And then they just start taking those outcomes as this is how it's supposed to be. And so they don't even reach for more at that point. They just accept it.

Right? Yeah. And honestly, I feel that my personal anecdotal experience in my practice or care model, is that I really, really value starting a sensor they won and having that hand holding process throughout, because it's a very critical moment. This is when they're very eager to learn. And this is when I can really get somebody to get a buy in with me teaching versus somebody who's had diabetes for five or six years, I might use the exact same skills, it might not stick, because this is not what they've been used to. It's very hard to change someone's behavior once we get to that level. Yeah. So

that's insurance, though, right? If they have insurance, then they get one if they you know, but are there people who you want to put on them? You can't get them for? Pretty

much, at least in Maryland, I know other states might have it differently. But in Maryland, it's universally covered for anyone who needs insulin four times a day. Oh, wow. So I have samples in my office that I give at the hospital. And so the first one is just a free sample. And that buys me 1014 days until I figured out a prescription and prior auth pretty much they're getting continuous numbers since they are in the hospital for that first appointment.

Do you see people becoming overloaded with data? Or do they handle it? Well,

people handle it differently. But I feel that I want them to be overloaded with data. That's the whole point is to make them to let them know diabetes is messy. And let's try to solve this together and trying to just walk them through my thought process about making it less of a messy disease, so to speak. I

appreciate that attitude. I really do because I think that everyone should leave the hospital with a CGM, right? Yeah, after diagnosis, it's just so valuable. And you learn so much about how food and insulin impacts things. It makes you just Ultra aware of all the things that would look completely invisible and unknowable if you didn't see the data. Correct? Yeah. So fantastic.

I honestly, again, it's this so this is kind of the I'm sure that down the line, we'll have more studies to support that. But I think at this point, even without a study, I think I already know that this is the route that probably the future we'll see this model get more generalizable. Right now I have a very busy clinic, a clinics a week, they really don't have time to kind of sit down for academia and research. And then important topics to kind of just review, evaluate, not in terms of control because I think if we resist studying control in a month or two, I don't think that's a good outcome. Because I think eventually mother nature allows honeymoon to kick in and everybody gets a good, relatively good a one see in like few weeks, a few months down the line,

some stability happens. And yeah, a year down

the line or two years down the line, the understanding the level of being able to handle the burden of diabetes. Initially, I had a mom who was very, very worried about how discrepant the numbers are between the Dexcom and the glucose levels. And she was almost going to write off Dexcom in the hospital. But then I was like, Okay, we need to be patient with this. This is a tool. So it was more of that explanation. But eventually now she's like talking about Well, thank you so much for walking us through it because otherwise we might have not even started it. And I've had it here now where I have a patient who was seven years into their diagnosis, they are still refusing to wear a CGM because they had one bad experience. So I think if we just say that this is the way this is the standard of care is to take care of diabetes with a CGM, despite its limitations, and let's walk through it and let's teach you a sugar stick as a backup. I think this is the message that I want us I want them to stick with and not the fact that oh I can take care of Diabetes with finger pricks? Yes, you can, but you're not gonna get the good control that you would get otherwise with a continuous glucose monitor. What

do you think about the algorithms? Do you put algorithms on people? So

algorithms? Do you mean DIY systems?

No, we're all them. Omnipod five control IQ, Medtronic 780 G like, do you? Do you give those to people?

Oh, absolutely, yes. Yeah, that's what I do most of my day is I look at my most of my day is it tech support, so to speak, because hey, somebody just we need to connect them and we need to get their numbers, the algorithms I day one, I tell them, we have this is Basal Bolus. This is how we can do it at the hospital is a backup system, but yet you need to learn. But I always introduce to families that, listen, it's just a transient phase, but most of my kids will need to transition to a pump process of some sort, to get the good control. So I always say this is just the stage to learn, I kind of try to give the analogy of a elementary school student we don't we don't give them calculators until they have mastered how to do addition and subtraction on paper. So like, I always put them in the mindset that this disease requires technology to fix it at this point, we can only do so much with shots, eventually, the goal is to transition them to a pump of some sort of a closed loop system. So you're

of the opinion that they should know how to use a manual pump first,

that manual pump but at least know how to master injections. First, a lot of families asked me in the hospital, can you get a pump right now? And I was like, No, it's mostly educational. I mean, if they already had another sibling on a pump and family has gone through the process training, then yes, I don't mind a week one or two after diagnosis.

I was gonna ask you, can you dig down into that a little bit for me, tell me what the benefits are that you see coming from being MDI for a while? Oh,

so I think understanding the process, diabetes, understanding the relationship between insulin and food, yes, we can also get that in a pump. But I think with shots, it will make more of a physical, like you are actually getting that insulin to see the effect of food. But then eventually, I think, with any pump, there is a chance of technology failure. So I do want them to be very overwhelmed when technology fails, and we have to resort to some sort of either manual mode or MDI. I

say, if you could be certain that there wouldn't be any bad sites or mechanical like, I don't know, hiccups, then would you have any trouble with them starting on a pump, then?

The family knows how to revert to MDI. I wouldn't mind that, okay. Meaning the family should be very well versed with MDI, they should not I mean, it's not like, oh, we just learned about it for a day in a hospital. No, they should have really a full understanding of it. This is how you do the long lasting, this is how you do your rapid and this is how we calculate the doses manually. It will help them understand how we think about insulin doses. Yes, I do prescribe the bionic pancreas against prescribing it that first week of diagnosis, I think it's important to understand how insulin works, and to see okay, what does five units mean to my child to my meal and what it does and how different doses deal with like, again, how do how they affect insulin levels, like just make it more of a an understanding and break the barrier of Oh, diabetes is difficult. And then I want them to feel that, oh, diabetes is not too difficult. And we really know and it's only repetitive and I think this is when somebody's ready for a for an upgrade. And this is why it's like at least I give them a few weeks of MDI.

Give an example of something that you've seen go wrong when someone starts off without that understanding.

I started like I've had that Pharaoh who was so much into technology. And they requested a an ink pen and ink pen is a smart pen that would have a Bolus calculator and would tell me, Okay, how much you program the current ratio is the correction factor. And the pen will calculate is an onboard pretty much like a very old school Bolus wizard, right and we'll log in the insulin doses. So I had it been who requested that they wanted to hospital and I was I was able to actually provide an NPN as part of their discharge prescriptions. I think the problems that happened is that they became I'm so dependent on that recommendation of the pen thinking that this is an absolute recommendation. And it kind of made them not think about how good is this those working? Or is it time for me to make a dose change. And so they would be like, Okay, that's what the pump recommended. Sorry. That's what the pen recommended. That's why we gave it and not really there. Okay, now, this is something that's manmade, that we came up with those programming settings, and we need to continue changing it kind of thing. So

is this a situation where month it's given over to the pump, that if they see it, I don't know, if they see a situation that doesn't react the way they expect it to. They don't think about it any more deeply, because they believe that the pump has told them the right thing to do. Happens

all the time. Yet, I say, this is where I would like people to think beyond just what's happened. And unfortunately, that might sometimes lead to DKA. Because hey, the pumps told us to not give anything when the pump was actually kinked or something. And someone might try pushing an insulin and despite you reading a chai for many, many, many hours, and then the kids just have comes to the to the emergency room with a DKA diagnosis I so so I try to kind of prevent that reliance on technology. And I try to say it's not like it's not a foolproof thing you foolproof is you need to know how to do the shots, right? I need you to know how to give insulin manually, and how to be able to just put a pause on diabetes technology if you need to. Okay,

very nice. I appreciate you explaining all that. Oh, of course. Yeah. No, it's fascinating. So I guess my question is, you said you also you teach people how to do their jobs now, like So you've now become a person who, who helps younger doctors learn what to do and what to expect. Right? What do you think are some of the most important lessons that they can learn when they're younger? Those doctors, right.

So I think just being humbled to diabetes and learn from your patients, because my patients teach me something every single day. Like it's always a new trick, or hack that I did not know about whether it's in technology and how they do things, I've found, really, yes, I learned a lot from my teachers and my mentors and my professors, but my patients, I really, I'm very, very grateful for all the discussions and the interactions we've had together. I think that's the number one thing is be humble and understand that what it is that we're dealing with every day, what we study in textbook is really nowhere close to what this again, what what people would diabetes in their families have to deal with every day. And again, I think my other advice would be to not prejudge a patient or a family. I think a lot of doctors fall into the trap of the judge a diabetic based on their agency or their race of admission for DKA. I think sometimes we as doctors need to step back and look at the full, holistic picture of what's happening. What are the barriers to care, don't look at it as sometimes people used to us from the doctors world, labeled patients as non compliant and just call it a day. And I think this is the easy, lazy way to do things. I would say they are not adhering to the plan of care. What are the barriers and let's break down those barriers. And so this is the process that I try to teach all my training doctors who come here to like, okay, their agency is high this time, what are the barriers and let's try to kind of break them one by one and try to hopefully work on making it better the next time. Whether it is an educational barrier, or the technology barriers supply barrier insurance barrier, no matter what barriers there are, I always say hey, mother, nature's plan for this kid is to have the agency as 17% or higher. So whatever number that's lower, there is some work that had been done and it always celebrate the successes and try to kind of work on improving it the next time. That's

excellent. What percentage of the students do you think, learn those lessons? How many out of 10 do we send off into the world to be good, thoughtful, quality endocrinologist, and how many of them just end up writing down noncompliant if they don't get the result they want back?

So right now in my capacity, I'm training general pediatricians. So I'll be very honest. I'm not training actual endocrinology fellows who are about to be in the chronologist. But I'm trying to teach your pediatricians if they have if they see their kids with diabetes, whether in the emergency room or hospital or their outpatient clinics, kind of what to look for and kind of how to approach a high agency in that scenario.

So that's not a fair question for you then on that form, but let me ask you this then, how do we get the overall quality that people see like him? This is happening at your hospital and you know, at your facility, but that doesn't mean it happens everywhere. Like, how do you think we can turn endocrinology into something for type ones that is very specific to them instead of you know, what often happens to adults, for example, is that they end up at an endo that handles mostly type two, and they don't know anything about type one. And they get no direction whatsoever. Like, like, I know, what's the thing you have to learn? And I know, it's not the same as being other kinds of doctors, where there's just rules or, you know, when we take the medication, or when we put in the implant or something like that. Have you thought about that? Have you thought about ways to spread good care to type ones?

That's a very good question. Because honestly, even my care model, I could not even I will say, share it among peer endocrinologist in just again, in my surroundings. So not everybody is hardwired to kind of function this way, so to speak, because endocrinology is very algorithmic, so to speak, I mean, you have low levels of thyroid, you give thyroid medicines, you check labs in two months. So I think if we put diabetes into the umbrella, this is where a wrong thing happened. And this is where it's very, very hard, because we're all doctors are humans at the end of the day, and we are just as varied as again, the variation of human nature. I mean, some people are more patient than others, some people are more rushed than others. And people like to rush through things. But I think if we were looking at it from a systematic standpoint, then yes, we do have a lot of potential in terms of educating an endocrinologist about type one diabetes when they're in their fellowship. But also, actually, I think, and this is what I always tell my families is that they can share some information with their own doctors about, hey, this is something that I'm interested in. And the doctor needs to also explore those things and needs to be very honest, if that's something that they do everyday or not. And I'll be very honest, not every industry knowledge is fit to kind of tap on diabetes. Again, some people it's that's not their thing, and they shouldn't be forced into that field. I mean, you should have a passion for a topic if you really would like to take care of it. Right? I find it hard to answer that question. Because, again, it's goes into a lot of political. No,

no, I expected your answer. I just wanted to just say it, that's all. Because because it is random, like there are people who will just luck of the draw, get get you. And there are people who luck of the draw will get somebody who's not well suited for it. And and then their health follows that path. And they don't even know like, that's the part that's that I think heartbreaking to me is that, you know, I could have got you but I got somebody else. And now my eight one C is seven instead of five. And I'll never know that my whole life. I'll just think that I went to the doctor, they told me the right thing, and a seven is what I'm able to accomplish. And, you know, it makes me wonder so much if we're not going to see a significant change in this through I don't know AI, honestly, over the next 10 years, like how soon until AI is connected to your CGM data, and it knows how many carbs you've taken. And then it starts making suggestions to you about, hey, I think we should change the carb ratio to this or I think we should change your insulin sensitivity to that, like that stuff can't be that far off.

Right. And I think it's already you're already in the bionic pancreas. Sarah, just to give you as little perspective, I mean, I've had a lot of patients who had, everyone was like, okay, my normal agency is 910. And I was like, This is not normal. I mean, and so, especially in lower like underprivileged communities, and this is most of the kids that I serve here are from underprivileged community, Medicaid, mostly government insurance population and for pediatrics. And like you said, they don't know any better about, oh, really, there is a pump that can do that. And so a lot of doctors would put themselves as basically the judges of how good someone is, and they would think of a pump as a price as like, no, it's a tool I would give a for my criteria to start a pump are very, very low, meaning you just have to have type one diabetes, and you have to care a little bit about getting it better. I mean, it's like you need to charge any pump, you need to keep it on your skin, you cannot just disconnect it, you need to be to have somewhat of a caring thing about your pump. So not your question about AI and technologies. So I always think about that every single day is like, When can I play offense and not defense to diabetes? If I see somebody in the hospital in DKA, or and they're wearing a Dexcom, you don't know how many times I looked at a Dexcom where it was reading 383 90 for like many days, and we are looking at that data. Of course nobody alerted us to look at it otherwise we would have guided the families on what they need to do. But we wait until they land in our emergency room when they are very sick, when we could have kind of picked on those early signs of a deteriorating disease early on, I think it would be interesting to see what the future would hold in terms of not just the corporations, I think this is a very advanced thing, but at least there's something going off and you're spending time before hundreds, maybe it's time to alert the doctor, we don't even have that as an option in most of those data analytics software's that we currently utilize. So there is no way for me to soar with skills, so to speak, I need my help. And unfortunately, some kids go into a mental health crisis. And then diabetes control goes south. And I wouldn't know and this would be the kids that I would expect to control from them the least because they it's again, typically it's something outside of medicine, it's not that they do have a medication, it's mostly something social that impacted their diabetes management.

How often do you see people with a three ad for days that they don't do anything about and what do you what do you think that causes them not to react?

People just become numb to just hey, we were used to being numbers, like the numbers, this highs, like and this is what I mean, like people were not taught the targets they want, they don't know what to expect. And some people just treat diabetes symptomatically I don't feel bad. I feel okay. I don't care what the numbers are. This is the struggle that I always try to make them care. I always say I need to make the height or painless, but I need to make it painful. I need to make them feel that this is not right for my body. And so I think a lot of times there is a fear of dropping low there is like okay, there, we're not even checking. They're not having the alarm set, or nobody's actually looking at that data until they see me in clinic.

Right. So for the group of people who are not scared of being alone, they're just not motivated. Right? Do you think they don't understand the impacts on their health? Do you think they don't care? From my perspective, as a person who sees a 135 blood sugar and things? I think we could bring that down? I don't understand staring at a 380 for days, but I'm trying to put myself into the mindset of a person, because it's not just apathy. Right? It's not that they don't care. Like there's other things at play. Right.

And I think it's that invisibility, feeling that, okay, you know what I mean? Nothing is gonna happen to me, even if I go into DKA, I know that the doctors will fix that for me, kind of thing. So it's especially I mean, again, I'm a pediatric person. So I deal with a lot of children and young adults, I mean, adult children don't think the way we think of things like I wouldn't expect a 16 year old to think about a 401 K. So right, but

their parents don't get involved either. Did they do that thing? Or they're like I tried, I told them, but they don't listen.

Yes, all the time. Again, it's more of we give them the tools we bring into the doctor's appointments. We try we best, but we also have to work three kinds of jobs. And I cannot be there with it to baby my child anymore. Yeah,

I see the problem. Okay.

So this is kind of the struggle that I have to kind of deal with. And this is where I think AI, like on the spa. And this is where honestly, again, sometimes even an Omnipod five algorithm might really not work for that person. So I honestly took a lot of people out of Omnipod, five into some other pumps and vice versa, taking some people to the Omnipod five, some people would do better with a tube, some people would do better without a tube, some people would really like that a we did something different about what we were dealing with every day. And I mean, I've had a kid who really did not pay attention to the Omnipod five, and then the Omnipod five will go into manual mode because it's reached its automated delivery settings, I switch them to bionic pancreas. And today, I saw not great results because the kid was not connected to that to their pump most of the night. So again, it's this is the kind of chart I think, yes, there is a role for technology. But I think we are at a decent stage. from a technology standpoint, it's more the psychology and having the buy in from the people living with diabetes to say, No, I really want to feel better. I really want to make sure that my my numbers are better. I mean, that might sound like common sense to us adults, but for a lot of my kids it's not and some kids do, but some some kids are some of the lessons they just it is a struggle for them dealing with the DS they'd rather not think about it or just take as long as I'm okay I'm not in the hospital I did. I reach my goal. So I tried to be patient try to take it step by step I tried to kind of go focus on little goals and actionable things that they can do to try to kind of prevent a, so to speak of like a major relapse in diabetes, like like a DKA admission, but also to really make sure that we're back to the process of hey, you need to see too You see 100 Most of the time and not 250. And you feel that this is okay. And so trying to change that mindset is a hard thing. I think, again, I am not a behavioral person myself, but my wife does a lot of work with applied behavioral analysis. My parent, my father is a psychiatrist. So again, I was surrounded by a lot of mental health experts in my home. So I got a lot of training there about maybe a behavior prescription so to speak, which so I think is helpful.

Yeah, no, I would imagine it would be greatly valuable. Can I ask you, so I find myself like wondering out loud about the eyelet pump, the BT bionics pump. And I think, well, if somebody's not going to do anything, at least if you put them on that they maybe could get an A one C and the sevens with it. But you're telling me that you might be intersecting people who won't put the pump on even? Right?

Yes, I mean, not put up on par for quite some time. And again, of course, the huge wall, I'm not getting my shipment from my supplier. It's like the usual frustration, and then okay, we don't know what to do as a backup, because we and then our numbers are just running very, very high. So I think, again, until there is a biologic fix to type one diabetes, which I'm hoping for will happen in the next half decade or two, but And so until we're there, I don't think technology by itself, can everybody fix diabetes, I think there should be also a lot of work on the psychology and the social work services that we provide, and not social work in terms of I don't want someone holding a stick, what am I called a social worker, and told the mother, if you don't follow this plan will take the child away from you. I mean, it should not be confrontational, some social workers just don't understand the complexities of this disease, and they want to try to get a black and white answer. And there are lots of shades of grey, and there are some there. Again, there's this difference between somebody who's just overwhelmed, frustrated, diabetes, fatigue, versus somebody who truly is completely completely negligent of their child. And that's, that's a fine line. And I always find myself thinking about those things. But at least, if I have somebody who reaches out to me, when they have trouble, then we have that open line of communication. And we're able to do really, again, it's a partnership, it's like trying to get to a place where they're in harmony with their disease. And what I mean by Harmony is that they're doing what there's something that they're comfortable doing, and they're seeing the results that they're seeing. I mean, you will be surprised how many times I would be somebody with an agency of 12 per sentence as how things are going, and they feel like things are okay, yeah. But in my mind, things are not okay, we need to fix things.

You're dealing with so many different types of people. And yes, and situations on top of that, anywhere from someone who's very interested and able, for a number of reasons, and is probably keeping an agency in the fives to somebody who you're just like, Look, you have to put the pump on or you're gonna end up in the hospital, right? And everywhere in between and parents that can be involved in parents that can't be involved in kids that do care and ones that don't care. That's exhausting. No,

it is very exhausting. Yes, yeah. I love the experience of it all. Whether it's somebody that I was able to, again, at least move the needle in the right direction, and trying to at least make them leave the office with a positive attitude about Yes, I can handle this. Yes, I can. This is something that I learned from the doctor, I can totally make this better the next time and just celebrate the little victories as we go.

Do you have any luck explaining to people that high blood sugars lead to cloudy thinking that they are sluggish and, and generally less healthy, and they wouldn't even know it at this point, they don't care. So

I deal a lot with kids who are taken care of by caregivers. And so a lot of times I tell the parents, please, for the next few weeks, you need to take away all their independence privileges, and you need to be on charge. Not all your life, but give me a week of very solid control, otherwise, your kid will land at the hospital. Right? So I mean, at least I tried to make such an advice very, like very indirect, but at the same time very actionable to say, Hey, listen, it's like they're sick, and they don't understand that they're sick. Like we need to do ABCD you need to follow it as a protocol. And just remember the day you left the hospital, you were calling us every day or every two days, we have to kind of push a hard reset button on diabetes and get it there. Otherwise, I'll have to do this for you in a hospital setting. And so a lot of times, I was able to call, so to speak, press a hard reset on diabetes.

How often do you experience someone who has struggled like this, but eventually just breaks it? out of it. Like, do you see them come around eventually?

Yes, all the time. And this is what makes it very, very fruitful. I mean, I've had people both type one and type two who had very difficult diseases. Sometimes it's just giving them the right tool. And sometimes just listening to them. Sometimes it's empowering them and seen a lot of people who just again, previous endocrinologist would always be like, okay, noncompliant, you stuck in the 10 11% a one sees, but I think I see a nice slow decline, because, like, they feel that they are now empowered to really do this. And they find that, okay, it's not that bad to follow the doctor's advice. I don't have to be defined as a teenager, I, the doctors might say something that's going to help me. And so trying to kind of work with them, and not to kind of be their dictator, kind of like, I'm not mandating you to do this. But hey, why don't we do this and try to make it something that, like, I use a lot of salesperson tactic. Let me put it this way. And I try to not celebrate victories very early, because a lot of times I see a sharp decline, but then things might go south socially, and then I might see a spike back up. So there is no finish line and diabetes is always how can I make it better, so that the following time we can continue? Where we are. So even for my kids who have very good control? My appointments are still very long, because I like them to stay in that range and not really rebound.

Yeah, not to feel like, Oh, I did it. Now I can stop doing it. Right, right. How often do you find yourself without hope for somebody?

I mean, I think when I feel that the person is not connecting with me, I tell them, Listen, maybe I'm not the right fit for you. Maybe you need another endocrinologist. I mean, I can't force people to like me, or I mean, it's just, but if I feel that I cannot partner with someone, when I feel that there are barriers to I mean, I take a lot of no shows people can sometimes not show up to an appointment, it's fine, I'll try to accommodate another time. But if somebody has not seen me for a year and a half, I put a hard stop and say you need to see a doctor or otherwise I cannot keep on being your insulin dispensing machine. So. So that was my heart stop. But otherwise, pretty much I tried to not give up on someone. Because if I do that, I know that knowing my colleagues in the field, I don't know if someone else will be able to provide them the care and just the hand holding that I might be able to provide. But again, I would like to give them the option and eventually to really be able to self manage, so they don't need the doctor. So yes, I have patients that I need to see every two weeks or every week, two patients that I can see every six months, and I had somebody who canceled that six month appointment, and a year later that he was still 6%. So back to my questions like what's the role of a doctor? It's like, yes, we are the educators, we are the coaches, we are the guides, but we are basically the captains of the chef's we need to make sure that things are getting in the right direction.

Have you imagined a magic wand fix for problems like this yet? Like is there? Do you look at people and think if I could just make them believe? Do I feel something that this would all go the right way? Like do you know the path and you just can't get them on it, or you're not certain of what the path is at times as well.

Sometimes not because especially if it's a complex social disease. So say if somebody is struggling with major depression and diabetes, it's very hard for me to fix that without to Central Health help. And I don't have a psychologist or social worker in my office. So I try to be the social worker, even though I'm not a trained social worker, I tried to be the psychologist even though I'm not a psychologist, I tried to not at psychology in a professional setting, but in a way so to speak good heart, somebody who listens to them and try to acknowledge what they're going through and try to at least in a way, be neutral through what they're going through and be a, so to speak diabetes mechanic. My focus here is diabetes and not a mental health professional. Right? My focus here is, hey, yes, you're going through a lot. But can we? What are the things that you can do for your diabetes so that as a diabetes guard, your diabetes is not going out of nowhere? I mean, whether you're having a good day or a bad day, you number should not have a bad day. That's my mantra there. It's like, it's I would like to make a good day for diabetes, no matter what the psychology is. And this is where technology really helps in that regard. If somebody's into that habit into that routine, then the better what life brings good days or bad days, we'll have a good control of their diabetes. So

yes, we can see people being like, I guess, emotionally overmatched by how often do you see people who are intellectually overmatched by it and what do you do about that?

So is it more that they feel that they're defeated by their numbers and diabetes? Since then it's hard for them to kind of predict what's going to happen.

I mean, I'm saying, Are there people who just IQ wise just can't keep up with what's going on, they can't juggle all the balls and understand the math. Yeah, I've

had a few families. And again, this is where there is no magic wand, you have to take it step by step and focus on one tool and work with it. I mean, we have had a toddler with diabetes recently. And it was a very big shock for them to have to deal with diabetes every day. Initially, I because the kid was not eating solids. So I did not need to teach carb counting initially, I needed to this this, this is how much you're feeding. This is how much insulin you need to give for that amount of milk, because having and then slowly introduced card counting slowly introduced ratios. And so I'm thinking maybe if it's good, I'll put it on a bionic pancreas. Because I don't know if they'll grasp insulin in a toddler. But again, I want them to understand that any device can fail or cannot give insulin, if the numbers are high, we need to do something about it. Unfortunately, this kid is averaging 350. And they're very sensitive to insulin. And if they get insulin, they get very low. So it's a very, very hard balance.

Well, it's just a terrible thing to have to deal with. For sure. Yeah. Yeah. So my gosh, well, I'm going to put this episode in with my series called Grand Rounds that I've been making this year, where myself and a CDE, who has had type one diabetes for 35 years, we took people's feedback listeners feedback about what they wish their doctors would understand. And we did episodes about that. And now I'm adding on conversations with doctors about how they work in endocrinology. So I can't tell you how grateful I am for you taking the time to do this.

Oh, of course. No, thank you so much for giving me that part in that platform. Because yes, I I heard about the Juicebox Podcast, I think I've listened to one or two a few years ago. But I am very, very grateful to be here today.

No, I am. I'm very grateful for you taking the time because I'm very interested in this entire dynamic about, you know, different people, different scenarios, different variables, different doctors, and how do we get as many people as possible to lower stable a one sees that allow them to go live their life and not think about diabetes quite so much. You know, if you listen to some people, they'll just say, my doctor socks, and I'm sure some of them do. But I also think that there's I don't want to say culpability, but there's responsibility on both sides. Right. And oftentimes, the doctors don't know when they're falling short. And the patients don't know when they're falling short. And they're very apt to blame each other in that scenario. And I don't think it's that simple.

And this is where I feel that hey, I mean, if it doesn't work out by somebody else, maybe it's not a good fit. I mean, I've had some some of my colleagues who are very, I would say robotic, and the way they approach diabetes, where it's just numbers. I mean, some people just want that kind of doctor, you know, if it's like, make sure that my numbers and my pumps are okay, and I will take care of the rest. And these are typically parents who or families who are already pharmacist or medical professionals or highly educated people. But that's not that does not capture that majority of people who's living with type one diabetes every day. How

progressive? Are you with other things? Do you aggressively manage people's thyroids for example?

Oh, yes, absolutely. Yeah. I mean, I think once I have a problem I try. It's all in our lap. That's, that's my style. You

medicate symptoms? Not numbers? Pretty

much. Yes. I, I take numbers into context for sure. Sure. And of course, our numbers. I mean, if numbers don't make sense, or if I feel that medication, won't really hell, then I

use it just to use I'm not going to use it right. But if you're symptomatic and you have a three TSH, then you're getting Synthroid, for example,

I don't think so. No, I think at least a higher number. So depending on what we, again, I try to be logical and try to see hey, I'm I always tell my families I'm like a hormone judge. Is the thyroid guilty or not guilty? Is the pancreas guilty or not guilty? And then I have to kind of give back whatever hormones the body's missing.

Once you're confident that it's thyroid, what are your TSH goals?

Oh, just in the target goal. So say if it's if it's in the reference range for a lab, then I'll take it but of course, if somebody is symptomatic and there is room to increase the dose, I don't mind giving up on the deals and give a keeping a trial and error. But I mean, typically teaching is TSH of 10 or higher is what you treat. If somebody who's not known to have died disease. However, I've had someone that I treated as seven or eight because they had some symptoms. And I thought, You know what, it's very plausible that those symptoms might be contributing. Let's give it a try. It kind of helped the symptoms, the constipation, but it now made the kids now irritable. So I'm not sure what tease apart. So I think it's not, it's not a straightforward trade line of thinking. It's more of it's a tool. I mean, medications hormones are out, there are tools for us. And if we could utilize them to really improve someone's health,

then do so yeah. Yeah,

let's let's do it. Yeah.

Can I ask you, when you do blood work for people? Do you look at their iron ferritin levels, things like that? Not

typically, for type one, unless if someone has specific like symptoms, or they have anemia, I would okay, but not my typical screening, I typically follow the ADA screening guidelines to the book from that regard.

I asked, and I wonder because I feel like I see a lot of people with digestion, and then absorption issues. So once you have like, type one, or autoimmune, you can see poor digestion. And a lot of people like you must have kids or like my stomach always heard stuff like that. And then, you know, we've been having a lot of conversations on the podcast, people using different aids like digestive enzymes and things like that, that have been taking away a lot of that pain, where their endocrinologist will sometimes tell them, Well, you just you have gastroparesis. And it turns out that maybe they've just needed some help with the digestion process. And when that digestion gets messed up, oftentimes nutrition uptake gets messed up along with it. And then I'm seeing a lot of people with low ferritin issues, who have type one, I see a lot of different interesting connections, having so many conversations, I have over 1200 episodes that I've recorded over the years, and for instance, to talk to people and say, you know, hey, you know, what other autoimmune do you have in your family? And as I'm asking them, I'll always say, How about bipolar? Do you see a lot of bipolar? And you'd be surprised how many people have a bipolar relative, when there's autoimmune or type one in their family? Little stuff you would never see connection to if you didn't have the opportunity to ask so many different people. Right?

So no, I mean, very, very grateful for all those things. Again, this is kind of I think, this is how science, this is what sparked science and scientific research is like, Okay, you, you look at a connection. And then we kind of put it to the test with a with a scientific research question. And I think there's a lot to be understood, there's a lot we need to learn about what causes type one diabetes, what might be a link with other digestive or autoimmune disorders, and I'm sure there are a lot of unanswered questions that will continue learning. I mean, we already have achieved a lot, but there's still a lot to learn about diabetes. And what's happening. I'm excited

that people like you were involved. Can I ask a question? Of course, what do you think? Or have you thought about where we're going to see GLP medication to use with type ones in the future?

So I am a very aggressive users of GLP. And type one, probably more than my other colleagues in the field. I feel that if someone has signs of insulin resistance and their insulin daily requirements are much higher, and there is their family history of type two diabetes, I think they have two diseases, they have both type one and type two diabetes for the same person. I have specially for my kids who have type one diabetes and who are overweight and who needs for example, 150 units a day, should I just give you more insulin? Yes, I need to give you more insulin. But I always ask myself, why do you need 150 units a day? And these are the kids who end up typically getting a GLP one prescription along with their insulin type one treatment therapies. So in terms of I think, the question about a GLP. One for people who don't fit this umbrella for people who were type one, they're not overweight, there is no family history of type two, can we give a low dose of GLP? One to kind of hell, just with some endocrine function. I have brought it up with one or two patients who had like who were in honeymoon and they wanted to think about hey, can we prolong honeymoon this way? I'm not sure if you're aware, but the New England Journal of medicines submitted, there was a research that was published. For small clinical study only 12 participants who had longer honeymoon longer see peptide if they took a small dose of semaglutide much slower even the dose that I would start somebody with type two. So for type one, can I give them a small dose of a GLP one agonists to kind of help preserve some pancreatic function, especially if they're in that honeymoon phase. I Think this is a question for science to answer in a few years, I feel that I look up GLP, one agonist as in a ways, getting the effects of exercise into the blood sugar level, but without actually exercising, it's nice how their insulin requirements would come down. And insulin, diabetes will be an easier disease to manage with those medications, plus also the impact of the effects of appetite and lowering the appetite, it might also impact and improve those, those glucose levels.

The study you you spoke about Do you happen to know was periactin Dona involved in that one? Let me pull it up really quickly, because I'm about to have him on the show. And I've had a mother of a like a 13 year old child, who's had type one for three years more using 70 units a day, but with a background of the family of PCOS. And they gave the child we go V, and they're down to seven units a day, and they're not even shooting Bolus insulin anymore. Yeah,

I think there is a lot of potential. I think we are going out. I think the biggest barrier for me prescribing it off label a lot is insurance. Take comments. But for example, I think if somebody is overweight, and using a lot of insulin units a day, I have been able to convince insurance to to start them,

have you. Yeah, that's amazing if you're able to get type ones covered, because I'm right now, my daughter has PCOS, and type one. And I'm having to buy ozempic out of Canada just to give her a non therapeutic dose. And you should see how much it's helping her. It's significant her, her insulin sensitivity went from one unit moves her 43 to one unit moves at 93.

Wow. So yes, this doctor didn't didn't Donna, and Donna and Dr. Choudry.

Yeah, I'm in contact with him right now setting up having him on the show. Wonderful. Yeah, no, I'm excited.

So I think my trick there, I would mention that this is an element of type two diabetes, and I make it that this is, yes, we have a background of type one. But please look at the data, it is suggestive of type two in the intermix of the picture like this is this is part of what we're seeing right now, really. And so I was able to get insurance buy in and a lot of and once I get approval, it's very hard that they come back and deny it again. After that,

I have to ask you if, if you have any tips and tricks for that, if you'd email them to me, I'd like to share them with my daughter's endocrinologist. Of course, yes,

I think it's with insurance. It's always a game. That's another side of what we have to do behind the scenes to try to make sure that we can write the right things to convince insurance for what we are doing is really sound and really medically reasonable and makes sense. I think

there's gonna be a lot of application for it. I really do. And there's other stuff coming too, right? Isn't one of the companies is working on a daily pill instead of a weekly injection? I think there's a lot, right, I have to tell you, I don't have type one. But my daughter does. And I've been using a GLP for a year now. And I would tell you that I lost I've lost 50 pounds in a year. But I was never a poor eater or, or a person who wasn't moving. And if I had one way to characterize what I think is happening to me, it feels like I have a GLP deficiency. Because in the first four days on point two, five of weego V i lost four pounds, my digestion changed like everything. I was a person who would have to get iron infusions all the time, because I wasn't absorbing my nutrients. But now I've been on a GLP for a year, my ferritin levels 188 When it was just tested, I haven't had an infusion in like 18 months.

Wonderful. That's great to hear that crazy. Yeah, it's it's amazing again, how those new medications are out there. I mean, we did not speak about type two, but I also treat our adolescent type two diabetes in my clinic. And we I mean, we see it very, very commonly, much more commonly than when I started like, six, seven years ago, we're seeing an app spike in type two diabetes, right? I think when doctors three type two is type one, this is the wrong thing, because we keep giving them more insulin and we kind of playing catch 22. And so I tried to get them out of the insulin cycle by prescribing a GLP one agonist for a lot of my kids, especially now that we have a pediatric indication for three GLP one agonists and I'm sure that more will have more choices for pediatrics as well. As we progress, yeah,

they're working on it. And a lot of them even for pregnancy, they're looking at it now like to be able to keep people it's Listen, my brother, I'm adopted, so not by blood, but my brother is type two. And I've seen I talked him into pushing for a GLP. And his a once he went from the sevens into the fives, yeah. So,

and these are people who've had it for four years. So why so even though my training is in pediatric one that was all just pediatric endocrinology. I'm now a board certified in advanced diabetes management, meaning I can still take care of adults or diabetes across the lifespan. So I face it sometimes I do help some parents with their own diabetes when they ask me questions about diabetes. And so there was that that girl who came to see me again, PCOS, insulin resistance type two and severe obesity, the mother had the same problems. But somebody told the mother that she had type one diabetes after she had gestational diabetes, because she she was very hyperglycemic. And this mother to think was under the care of her endocrinologist for, again, more than a decade treated as a type one. But I was I counseled her, even though I at that point, it was a very brief interaction. I strongly suggested that she presses for GLP one, and she went down from dealing 150 units from Protandim to down to like 20 units a day for tandem. That's wonderful,

isn't it? No. Hey, you're a little go getter. Dr. Morrow, I see all the letters after your name, by the way here. Sorry, I see you out there hustling?

I enjoy taking exams, I don't mind them. Well, I think

your letters are going to be in a different line if you get a couple more of them. So it's probably

I mean, again, so I get all those emails like hey, come certifies like yeah, you know what, why not? I'll get back now that I think it makes me a better doctor or worse doctor, but I think it just it's nice to have show that hey, I to learn to learn, of course, and also to be able to present that Yes. Now, I'm not just an endocrinologist, I also do care about this disease.

Yeah. No, I love your energy around this. I really do think I appreciate this very much. I might have to ask you to come back on again. One day. This was wonderful.

Thank you so much. I will probably be moving to Saudi Arabia. Oh, okay. We'll be probably like this summer. So my contract here in Baltimore is terminated like is ending. And so I might be coming closer to family that might be the next personal big news. But of course where I am, wherever I am, I'll have access to zoom. I'll be in touch.

Well, listen, they need it to you. I have a number of people in my Instagram, DMS from that part of the world and they're struggling pretty mightily to understand their diabetes as well. Right. So your help will definitely be valuable anywhere you go.

Well, thank you so much. I appreciate it. And again, that's that's that's really again, and this is what makes being a doctor really fulfilling you know, it's like you're able to impact lives and try to kind of make try to help improve people's lives.

Well, I hope other doctors heard you and they can. I hope they try to match your enthusiasm. That I guess that's what I hope that's really fantastic. Thank you so much.

Thank you so much. Thank you, thank you.

If you're a physician and you'd like to be on the Grand Rounds series, please send me an email through juicebox podcast.com. I want to thank the ever since CGM for sponsoring this episode of The Juicebox Podcast. Learn more about its implantable sensor, smart transmitter and terrific mobile application at ever since cgm.com/juicebox. Get the only implantable sensor for long term wear. Get ever since having an easy to use and accurate blood glucose meter is just one click away. Contour next one.com/juicebox That's right Today's episode is sponsored by the contour next gen blood glucose meter. A huge thank you to one of today's sponsors G voc glucagon find out more about Chivo Capo pen at G Vogue glucagon.com Ford slash juicebox you spell that GVOKEGLUC AG o n.com. Forward slash juicebox. The Juicebox Podcast is full of so many series that you want and need afterdark s gotten Jenny algorithm pumping bold beginnings defining diabetes defining thyroid, the diabetes Pro Tip series for type one diabetes variable series mental wellness type two diabetes protip how we eat oh my goodness, there's so much at juicebox podcast.com head up into that menu and pick around. And if you're in the private Facebook group, just go to the feature tab for lists upon lists of all of the series. always free. Always helpful. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

Hello friends, welcome to episode 1228 of the Juicebox Podcast. Today, we're gonna be adding to the Grand Rounds series with Dr. Hutchins. She's a pediatric endocrinologist and a member of the private Facebook group for the Juicebox Podcast. Nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. If you or a loved one has type one diabetes, and you and that loved one or a US resident, go to T one D exchange.org/juicebox. and complete the survey. This quick survey is going to help type one diabetes research move forward, it's going to help you it's going to help me it's going to help other people T one D exchange.org/juice. Box complete the survey. When you place your first order for ag one with my link you'll get five free travel packs and a free year's supply of vitamin D. Drink ag one.com/juice box. I know that Facebook has a bad reputation, but please give the private Facebook group for the Juicebox Podcast a healthy once over Juicebox Podcast type one diabetes today's episode of The Juicebox Podcast is sponsored by Dexcom, makers of the Dexcom G seven and G six continuous glucose monitoring systems. dexcom.com/juicebox Today's episode is sponsored by Medtronic diabetes, a company that's bringing people together to redefine what it means to live with diabetes. Later in this episode, I'll be speaking with Jalen, he was diagnosed with type one diabetes at 14. He's 29. Now he's going to tell you a little bit about his story. To hear more stories with Medtronic champions. Go to Medtronic diabetes.com/juicebox or search the hashtag Medtronic champion on your favorite social media platform. The touch by type one event live in Orlando is coming up fast. September 14. Tickets are available. They're free. I'm going to be there today I found out Jenny Smith is going to be there head now to touch by type one.org. Go to the program's tab and get yourself some absolutely free ticks. Ticks. That's short for tickets. It's free. Go register now.

Hello. I'm Dr. Jessica Hutchins. I am a pediatric endocrinologist in Georgia.

Do I call you Jessica or Dr. Hodge?

You can call me Jessica. Thank

you, Jessica. I feel like I know you even though I probably couldn't pick you out of a lineup if I had to. It's been like

over two years, I think at least two? Yeah, definitely. Well over two years that we've I've been on the Facebook group and sending patients to the podcast and the Facebook group. So yeah. Can I

start there? How do you make your way to it?

I actually found out from a family a patient. One of my patients moms asked me one day, had you heard of the Juicebox Podcast? I was like no. And honestly, I think when she asked me I wasn't really like I had just kind of started getting into podcasts in general. And so I just had not been a podcast person before and then kind of started listening, dab dab dabbling in podcast listening. And then she mentioned that so then I was like, yeah, I gotta check that out. And then like, since then, was just kind of like, hooked to it. And I really liked a lot of the episodes like, I mean, I enjoyed the episodes of people telling their story, but I actually enjoy the education ones that you and Jenny do and like the series because it helps me have little fun ways to like explain things to patients like it just gives me like little tips and ways to think about stuff. When I'm trying to think of it through the lens of like a parent of a child with type one. So that's kind of the ones I actually listen to more I'll go back and sometimes listen to the story ones but actually like the educational ones best

very touching because I think of you as a very tuned in thoughtful progressive Endo.

Yeah, I would consider myself that. Yes.

So so you won't know this till I tell you. But you're one of my measurement points for me. Like when when I'm quietly trying to decide if I'm doing the right thing. If I'm, you know, making the best use of the platform. I have all that stuff. I think Jessica is in my Facebook group a lot. And she seems to agree with me. So yes. So I take that as like I'm doing okay. Yes,

no, you're doing great. I think you offer Yeah, it's just it's a All these families because I mean, I, I don't have type one nor do my children. But you know, I just think it's, I always tell families like I literally just saw a new onset diabetic today in the hospital, 14 year old girl. And, you know, no family history like this. And so, you know, they kind of blindsided. But I was telling him I'm like, the parents, I don't know if he listened to podcast, but there's a podcast. So we actually have it. All of our new onset skit like a folder with tons of you know, information, and I have one page is like, books, podcasts and Facebook groups to join and like Juicebox Podcast is on there. And then I have sugar surfing, and the doctor ponders like page, which you've had him on your show before. And we have like a Georgia type one diabetes, Facebook group for like, support group for Georgia. So I feel nice to jump in there. But just, I really think it just connecting families and I always, when I tell families about your podcast, I always say like, you know, his daughter was diagnosed as a toddler. She's now in college, like he's been doing this a long time. And you know, just kind of tell them, you know, there's the new onset to always say, hey, go find go on the Facebook group, they have a list of all the episodes to listen to, you know, for new onset, from the beginning, just that you can wrap your brain around, like, you know, what type one is and how insulin works. I said, because, you know, obviously, they get education in the hospital, but that's what like two days, and then they go home, and it's like, you just got this life changing diagnosis. And if they have no family history of type one, you know, it's it's a lot to take in in such a short period of time. And there's so many nuances and managing it that you can't, you know, like isn't going to be kind of explained in the very, you know, the very beginning, we're trying to just teach them like survival skills to get home safely. And then once they're home, then obviously, that's when they start learning, although, like more they want things that they'll they'll hopefully pick up on over over time.

It's funny, the first question that pops up that you don't have an answer from from that hospital visit, and it hits you like a ton of bricks, like oh, I don't know anything about what I'm talking about?

Yes, yeah. And actually it so we have like a really cool setup here. So I'm in Georgia, I'm in like a smaller, like academic facility. And so we have, like residents and stuff like that. But we actually when patients go home, I have a nurse practitioner that works with us, virtually, she used to be works in the hospital. So she worked a lot with our diabetic families in the hospital, but then now she's all virtual. And so when they go home from the hospital, they usually see us in the office in about a month. But up until that appointment, they have virtual visits with this nurse practitioner, to that way, they literally kind of have her like almost at their disposal at first month to ask all the like, you know, silly questions that they can think of, you know, just like, just any little question they can think of, and then she'll review those numbers and adjust their doses and just like helps them kind of, by the time they get to my first appointment, I feel like they're all in a lot better place. Like, just understanding and just from a mental standpoint, just like a mental health standpoint, just they've, they've had that like hand holding for that first month, which has been really awesome. So, so it's been this

setup you you like it? I love it. Yeah. And you're seeing, like, you're seeing dividends from it.

I know that parents, I mean, it's hard to, you know, one of the things initially the idea was like, oh, like, let's see if this like decreases like DKA I mean, the thing is, like, I mean, majority of my new onsets aren't like back in decay and a few months. I mean, hopefully not. But you know, we have obviously frequent flyer, you know, kids that come in and DK but for the new onset, I think it's more so the benefit I see is that the families feel more comfortable with the diagnosis, the first visit and the office post no discharge, I think goes by smoother and they've already gotten a lot of their questions answered. And they've aren't they just feel and like the our nurse practitioner that does the program like she's great with them. And you know, she again, she'd handholds a lot which is for people who are listening that are an adult diabetic versus a peds, diabetic, peds and adult world is very different in endocrinology. Like in feeds, we know we do a lot of hand holding and in the adult world sometimes I feel like it's sink or swim like you know, if you're not going to put the effort in then the provider may not put the effort in not everybody but in general when I talk you know to friends who go to adult endocrinologist versus like how I know we operate in peds. I do feel like in peds, we do a little bit more hand holding, because it's just it's a lot because you're not dealing with just the patient the child but it's also the parents and that adds in you know, another level of dynamics in addition to like, you know, puberty and all the stuff, the social, you know, stressors that these kids have at school and things like that. So, so

when you Oh, I should ask this did you learn Listen to the Grand Rounds series. Did you bother you or did you like it? Did you not hear it? Today's episode of the podcast is sponsored by Dexcom. And I'd like to take this opportunity to tell you a little bit about the continuous glucose monitor that my daughter wears the Dexcom G seven, the Dexcom G seven is small, it is accurate and it is easy to use. And where Arden has been wearing a Dexcom G seven since almost day one when they came out, and she's having a fantastic experience with it. We love the G six but man is the G seven small the profile so much closer to your body, the weight, you can't really feel it and that's coming from me. And I've worn one. I've worn a G six I've worn a G seven. I found both of the experiences to be lovely. But my gosh is that g7 Tiny and the accuracy has been fantastic. Arden's a onesies are right where we expect them to be. And we actually use the Dexcom clarity app to keep track of those things. That app is built right in to Arden's Dexcom G seven app on her iPhone. Oh, did you not know about that? You can use an iPhone or an Android device to see your Dexcom data. If you have a compatible phone, your Dexcom goes right to the Dexcom app. You don't have to carry the receiver but if you don't want to use the phone, that's fine. Use the Dexcom receiver it's up to you. Choice is yours with Dexcom and now that choice includes direct to Apple Watch dexcom.com/juicebox

podcast have I listened the one that you did recently with another peds? Endo? I listened to that one which is after I listened to that one that's when I emailed him was like hey, let me let let's schedule something I've been meeting like I had been meeting I've been chatting for like two years, like hey, we're gonna do an episode so I've heard like, I haven't listened to like every episode but I have listened to quite a few of those. I don't really get bothered by you know, on the Facebook group or when y'all talk about it on the podcast when when people when people take like hits to the doctors like when my doctors stupid or say stupid things. I don't personally get very offended from that or even you and other people like stressing like advocating, you know parents or if they're an adult type one like advocating themselves like hey, if you want to pop or you want this like advocate for yourself, like I don't really get offended by that personally, the only thing I laugh at is when posts like, oh, you know, like I asked my doctor for whatever, an omni pod and they only want to prescribe a tandem like they must be getting paid from tandem. I'm like y'all are funny. Like, yeah, we don't get any kickbacks from anybody, like trust me, like, if you're in peds and David's because you like you enjoy pizza. No, because

I'm not saying I take a kickback, but I've never been offered one.

I mean, the biggest kickback I'm getting is like I get like a free lunch, you know, every few months, when they come in, you know, like, tell us about whatever new thing is going on with their product and update us on what's going on. Like,

can you imagine if someone was like, I want an omni pod? You're like, Nope, I'm giving you a T slim because I got a ham sandwich four months ago.

I mean, you know, I mean, we get like Olive Garden sometimes like, you know, it's you know, we're fancy over here.

I didn't know. I didn't know they were handing out diarrhea. The doctors never. Exactly,

yeah. So there is no kickbacks, especially if he's in debt. And really, I mean, honestly, and in pharma and pharma. There is like that all got I mean, years ago, a long time ago, before my time as a physician, they there was a lot of probably shady stuff going on. But there's they can even give us free pens. And

what is that called? That? Is it the Sunshine Act? Is that like,

they really and they actually keep track of all that. Like, I think you can actually look up like any provider and find out like how even like for me, I was like because every time we get a meal, we have to sign that we accepted the meal. And so I think there's like somewhere you can look up to see like how much any provider has like gotten, even if it's like meals, like just the money, the money value that they've gotten from like every different company or something like that. But yeah, I think for me, like when it comes to like that, so like the technology stuff, like pump type, I mean, for the most part, like how I'll give people what they want there. Sometimes I think there's some pumps because all the pumps are a little different. There's some pumps that work better, I think would work better for certain patients, but in general, but yeah, I don't really get I don't get upset when people talk about. I say bashing doctors to an extent like I mean, I think because I do know that there are some patients that are not listened to or not heard and I get why families get frustrated.

Does it feel like bashing to you when you read it even though you're not upset by it? Where do you see their perspective?

I see I see their perspective but I could say I could understand where the other like other providers Just who maybe I think some providers are just very like, I'm a doctor, and I know everything. And you're just a normal person. And you know, don't know what you're talking about. Doctor

voice. Hey, can I ask you a question? Are you nervous? Or do you just talk fast?

I just talk fast. Okay,

I know, don't be sorry. I think this is the first episode, people might be able to turn the speed down on. Fascinating. When I think that you speak quickly. You speak quickly. It's like, when I hear somebody go, like, like, like, Scott talks a lot. I'm like, huh, I do. And then when I get into a conversation, I'm like, I can't even get into this conversation. I'm like, Oh, my God, these people are like, professionals. You can keep me out of talking, then you're doing something. But I love all your Don't. Don't Don't curb yourself. Like I like what you're saying. I just want to tell people real quickly. The Sunshine Act is officially known as the physicians payments, Sunshine Act in the US. It's a law that aims to increase transparency in the financial relationship between healthcare providers and pharmaceutical manufacturers and acted as part of the Affordable Care Act in 2010. It goes online, you can totally google it. If you want to understand how it works. Yes. But I think prior to that, though, a lot of those lunches happen on Waikiki. You know

what I mean? Oh, yeah, for sure. And like the golf like, I mean, I'm not a golfer, but like, yeah, like, oh, let's go play some round of golf. And you know, hear about, you know, whatever.

This is a famous golfer, he's gonna play with us today. Can I tell you about our insulin pump? No, exactly. Yeah, that

doesn't. That doesn't happen. I did get I mean, this isn't like, this is not a kickback. This is, this was really cool. I my T slim and Dexcom. Rep. Both of them nominated me to go to their facilities out in California to go I get to go and tour both of the facility. Okay, because they're both really close to each other. And get to here, I guess, I don't know what they're going to tell me like, I guess here all the new stuff. I don't know. But let's have my reps nominated me. So I do get together that I am excited about that. But that's like, literally go there, see it and come back the next day? So

yeah, oh, yeah. There's not gonna be you're not going to be luxuriating in San Diego for a couple of weeks. No, let me ask you a question. In the course of a year rough number, how many people diabetes or families do you talk to?

Gosh, like talk to?

So I'm going to assume like one person you see a couple times a year, so don't don't count them four times count before?

Yeah. Okay. So in a given week, my like scheduled template for my clinic, I probably have about 15 to 20 diabetic patients, that's type two and type two, type one and type two a week. Well, I know last year, or we had a little over 80 new onset submitted to our admitted to our hospital, which we had met all of our new onset type ones, because of just the amount of education and then we admit any presumed type two that's going to need insulin. So if there a one c is greater than 10. So we had met all those just because of the amount of education and we serve a rural area. So a lot of patients live two and three hours away, and don't have, you know, like local hospitals or local hospitals that are mostly adult focused, and so we just feel safer admitting them. And that's Aedes that's type one and type two, you know, we have seen an increase in type two diabetics and in pediatric patients in the last few years, especially post COVID. We also get a lot of new onsets in the clinic, mostly type twos that are not on insulin that we see like as new patients. So we are the numbers have been, I think, I started where I'm at now. And 2019, right before six months before COVID hit. And I think at that point, it was about 16 Iwan sets a year admitted, so we've been like, slowly increasing. So

tell me something, I'm trying to figure something out. I'm trying to figure out how much information that goes into people's heads ends up coming out in their management, like meaning, like, how many people take seriously what they heard, put more effort into it, because if you see 80 people a week, then just based off of you, my podcast should be bigger than it is. And you're not the only doctor out there whispering in people's ears if you put it in a on a pamphlet, which, by the way, I really appreciate but you know, what happens in the hallways, and a lot of the offices while they're walking in or out, the practitioner will grab you and go juicebox podcast.com. Yeah, like, right, like, right, like, Yeah, I know what the guy in there is about to say to you go find a Facebook group called like, you know what I mean? So, like, what's that like being a doctor knowing that you're going to talk to 80 people and only a small percentage of them are maybe going to elevate from what you've said to them? Yeah,

it's definitely and I think, I mean, I'm pretty sure on the adult world is very similar in the peds world. There so many dynamics. And also for me particular, the patient population I serve. You know, there's a lot of, for instance, a lot of my families, I, I'm talking to a mother who is a single mother with multiple children, working two jobs, and has, you know, grandma and aunts and uncles and friends and just older siblings that are caring for helping to care for their child with type one. And so whether it's diabetes, or say they're coming for pre diabetes, and obesity, sometimes I feel like, I try to be realistic and my, like, I want to give them the information, but just to be, you know, when I'm realistically thinking, like, when does this person have time to, like, sit down, and you know, like, so much of our family's life, like, they are living in a constant state of trauma and flight or flight mode, like 24/7. So and then you added on this, like, very, you know, big chronic illness on top of that. And so I think that's a lot of it. And so it can be, it can be frustrating, and it can be disheartening and sad when especially when we have the patients that come in, you know, multiple DK DK episodes a year. And you know, every time you see them, it's still like, you know, a once he's greater than 10. And you, you feel like you talk to you're blue in the face. And it just seems like nothing's getting through, you know, I tried to simplify management as much as much as possible for families, especially if, you know, like, either maybe education level isn't as high and or they just like, they just can't they just, there's too much going on in their life. And, you know, they're just worried about like, can I put food on the table and a roof over my kid's head. So it's just,

it's hard to worry about 30 years from now, when you're not 100% sure that on Friday, the water is going to be hot. This episode is sponsored by Medtronic, diabetes, Medtronic diabetes.com/juice box. And now we're going to hear from Medtronic champion Jalen. I was Speaker 1 22:07 going straight into high school. So it was a summer heading into high school was that particularly difficult and imaginable, you know, I missed my entire summer. So I went to I was going to a brand new school, I was around a bunch of new people that I had not been going to school with. So it was hard trying to balance that while also explaining to people what type one diabetes was, my hometown did not have an endocrinologist. So I was traveling over an hour to the nearest endocrinologist for children. So you know, outside of that I didn't have any type of support in my hometown.

Did you try to explain to people or did you find it easier just to stay private? Speaker 1 22:45 I honestly I just held back I didn't really like talking about it. It was just it felt like it was just an repeating record where I was saying things and people weren't understanding it. And I also was still in the process of learning it. So I just kept it to myself didn't really talk about it. Did

you eventually find people in real life that you could confide in, I Speaker 1 23:04 never really got the experience until after getting to college. And then once I graduated college, it's all I see, you know, you can easily search Medtronic champions, you see people that pop up, and you're like, wow, look at all this content. And I think that's something that motivates me started embracing more, you know, how I'm able to type one diabetes,

Medtronic diabetes.com/juice box to hear more stories from the Medtronic champion community.

Exactly. And that, that, that adds a whole nother level of like, you know, just nuance to with patients. And I can't remember there was one episode, I can't remember what episode it was. And I was thinking about it. And even talking to my rep with tz old tz old is the newer infusion that recently got FDA approval, it's been over almost two years now, I guess. FDA approve that if you catch someone that has two antibodies or more for type one, and they're in that pre diabetes stage, you can give tz old which is a two week infusion to 30 minute infusion and the hope and what the clinical trial showed is that you can delay onset of type one. Yeah, so I have not personally been able to give this give it yet. One is finding the patients and two is like just logistics. Because it's every day for two weeks. So you know, and even talking to my rep. I was you know, saying really hard again, I serve like a rural part of Georgia. So when patients live two hours away, one I'm going to give this like in the hospital I'm not going to like do this infusion at home I don't feel comfortable doing that yet just because of the side effects I can have. Yeah, and they you know, again, if people live you know, really far from like, a decent you know, like a hospital that I would feel comfortable them comfortable than with them going to. So it's like then again, how do I if I have you know, A single parent that has other kids and then has like a job where she doesn't get PTO that it's like, Oh, hey, come to, you know, come here for two weeks straight for a 30 minute a day infusion it's like look like it just how is that going to work logistically like it just. And so I was telling my rep I said, I feel bad I said, because I feel like, it almost feels like it's an injustice of who can even have an opportunity to probably use this because of just the dynamics of like, their social situation. Like I just don't know how to do it. It's

an inflammatory word. But this is where your privilege comes in. Yes, you're sure you have it? Yeah. Yeah. And I don't care. Listen, I don't mean privilege in the in the zeitgeist overtone that's gonna make half of you pissed one way and half, you piss the other way. I'm just talking about like the opportunity, or the, you know, like, I interviewed a white lady one time, I don't know that it's ever going to be on the podcasts. I'm trying to get along. She got a job. And the job is trying to block her from being on the podcast, but Oh, no, but you know, and she said, like, you know, the TZ old infusion, it was here, we got a hotel, we stayed for a week. And I'm like, Yeah, that's already more than most people can do. Oh, yeah. Yeah. And, you know, like, so that's the kind of stuff that you don't understand. The reason I'm asking you about it, is because you're in a unique situation, like, you know, good information to tell people, and you're willing to tell them about other stuff they can go find on their own. And yet, you're having the same frustrations, you and I have the exact same professional frustrations, like, unless I'm wrong, and I, I'd love to hear from you on it. But I think you go listen to that Pro Tip series, you'd have to really not understand it not to end up with an A one C and the six is in the next six months or a year after that. Do you think that's reasonable to say by me? Again,

I think if you if you have to use the word privilege, if you have the privilege to sit down and listen to a podcast for 24 hours, absorb the information, be able to apply it knowing again that like you may, it's not just you there's other caregivers involved, then yes, I think if like because I have patients who again, probably do have more privilege like that, they they have listened and they have been able to apply and you know, they're doing great. They can they can get these, you know, amazing AOCs, like in the fives and sixes. How do

you make the time and the space for that if you're running from one job to another and then home? And then

yes, you know, I mean, even I mean, even for me personally, like, just in between, like, I have three, three kids, three young kids, I have three young kids full time physician and then like, amongst other things, and then you know, even trying to listen to like, you know, I'm in this like parenting coaching group that I like pay money for. And like it has all these lessons about, like, really like a gentle, gentle conscious parenting because I've been trying to like, adopt more of that and my parenting style. And like, I've been in this thing program for like, two years, and I barely get to listen to all the episodes and that I'm that I'm paying for because I just don't have to die. So like, I can't imagine

like, what was your parenting style, like that got you to want to join the group. I

didn't really have one. But I was me and my husband were raised like very differently. So like it just immersive, that's like the gentle positive parenting is more about like connection, over like, the shame and guilt that we often do. And parents, and honestly, part of it, I felt I feel like a lot of times with my families with you know, parents, especially in the teenage years, and maybe you can speak to this with you and Arden, but the teenage years can get really rough. No, and when the kids are more independent, and they're more out on their own, but the parents still wants to control a lot. And you know, when I have families coming in and it's like, you know, the kid is like, you know, never Bolus saying you know, I give them all that later they have all the technology they have the pumps, they have the sensors, but they're just like not doing squat and you know, the parent and the kid are always fighting you know, and I hear you know, half the visit is the parent just like throwing the kid under the bus to me the whole time and like oh tell her Tell her how you like keep sneaking snacks and tell her you know whatever and say like I don't

think Go is Oh my God listen to me you're all such terrible communicators

and so it's always this weird dynamic and are then touchy when you add driving into the mix it's like because I mean as a parent like if my child was type one like I would like you know really be worried about them being behind the wheel I mean obviously probably more for hypoglycemia than hyper but I mean sometimes when your blood sugar is really high you are not right the hit like you feel really you know affected by that too mentally, you know, between driving and just privileges and like, you know, are all struggle with like, oh, they get get they get things taken away because of they're not managing their diabetes. And when I compare that to like, the things I'm learning with like more like positive conscious parenting I'm like I don't know if that's gonna help, you know, like, but I don't know, like, it's hard because I'm like, I'm not the parent of a type one. And I just in my head I like I'm like, I just don't, I don't think that's going to work like taking things away from them or not letting them go out with friends. But then I still am personally still trying to figure out like, How can I help these parents, especially at the teens? Like, yeah, how can I help them get through this rough patch? Because I feel like it can be an I mean, it's frustrating for me as a provider, because I'm like, their agencies going up their parents, you know, the kids getting older, they're more independent. It's like, they want to be more independent, but they're not doing it. So then it's like, okay, well, where does that like, you know, sometimes I try to approach the kid and I'm like, Hey, like,

your mom seems crazy. What?

Like, when you're home, like, why don't you just like, let your mom do it? Like, if you're on the pot, like if they're on the pot mom, like, you're home and you already either, like, let let your mom do it for you like, but it's like, again, one of those things where like the you know, mom is texting or asking the kid like, what's your sugar? Did you give your insulin, your blood sugar is going high? Or did you treat your low? And it's like, the kid is like, frustrated? And it is this like this battle back and forth. And sometimes I'm just like, I, I don't know what to tell this, this parent or this kid, like how can Hey,

listen one time are in push back on me. And I sent her a number. And she goes, and it was like $1 number and she goes, What's that? I'm like, That's how much college is going to cost you if you don't change that pump right now. Because, um, but we also have like, a, we have a similar sense of humor. So I think it helps to, I mean, listen, if you're going in the doctor's office, and making Jessica, judge, jury and executioner for the things you can't get your kid to do. That is not going to be a winning formula.

No, it's usually not like, oh, like, and I try to make the kids feel better. And in the parents like, less than like, you're not the only one. Like, your kid isn't the only one that like eats food and doesn't Bolus and doesn't tell you they eat like, this is like this happens. This is

regular kid stuff. But it's magnified because of health. Exact otherwise, you would ignore it. You'd be like, stop playing Call of Duty and they wouldn't stop and you go up. Yeah, he loves Call of Duty. Exactly. Yeah. And then that would be the end of it. Or I wish they'd stop looking at tick tock I told him not to but they're not going to and then 30 years from now, when something happens, you'll be like 70 unit, but like, I try my best.

Like, right? Yeah. When it's when it's their health, like you're hurting me. As a parent. I get it. You feel. Jessica,

do you know the funniest thing you've said, so far? We've been talking for 28 minutes and 41 seconds.

What is the funniest thing I said?

I'll slow down.

Slow down. I think I did slow down for like a few minutes. My favorite parts when I talked about I think when I talked about TV, all that slowed down. Because you

were like, oh, there's things legally I have to say here. I think Well listen, let me say this because I tried to jump into that part of the conversation. It did not work for me. Screen it like you mean it by the time this episode comes out, there'll be sponsors on the podcast. And it's screened for type one.com SCR II N fo RT y p e one.com. Screen it like you mean it's for. I don't know how I'm like, allowed to explain it. But I think it's a public relations movement to talk about the importance of screening your extended family for type one diabetes, but you'll hear those ads throughout. Because they're on I think a completely almost impossible journey. Like they're gonna go tell you, Hey, listen, does your kid have type one diabetes, you should go tell your sister and her kids that they maybe should get screened for type one, which penalties is great advice. Right? And but man, how do you get people to do that? Like, based on your, on your conversation about how we can't even find time for people to go listen to a podcast? Like how are they? How are they going to go get screened for type one diabetes, when that doesn't seem like one of the top 100 things on their list today?

Yeah, well, and then honestly, even parents of some of my type ones, when I mentioned about screening the siblings, I have some that don't, they just don't want to know, right? They they would rather just watch for the symptoms, which, again, if you know if you have like an a parent who's paying attention and has the ability to pay attention, and recognize the symptoms early than you know, but even then by the time you're having symptoms, you're you're probably you're gonna probably be already past the point where you could get the TCL because you Yeah, you have to be like in that pre diabetes range. And so I mean, I get it for some parents, knowing that the other kid has an antibody is more nerve wracking and anxiety provoking. Then than not knowing again, everybody's personality is different.

I think it's all about your level of anxiety and how it screws with you. Because the same because anxiety could make one person say I have to know and that same and anxiety touched the different persons slightly differently makes them go I can't know that this is coming. It's interesting.

I tested my son even though we have no history but he he had, he was set six or seven at the time, but he had like, wet the bed a couple times. And it was he had not done that, really since he had been potty trained. And I was like, what? What's going on? And so like, one day he was in my office and I, I checked as a onesie on our like pointed care machine in the office, and it was 5.7. And I was like, Why do you have a 5.7? A one C? Like, that makes no sense. So then I ordered the kit that at that time was I think it was an maybe enable sciences like you could order the kit. they mailed it to your house, you did a finger stick and you just had to put like three blots of blood on the little card and you mailed it back and they checked, I think three of the antibodies, and three in those three were negative. So I was like, okay, like, and I started out over, no, and actually, I repeated as a one C and it was like 5.6, which still I'm like, he shouldn't have a 5.6 I would see i One day he did something else that like even after I had the antibody results back I like, I can't remember he was like just being more drinking more has something about him just seemed too often I like, grabbed, I was at home and I like it was like the day before we were going on vacation somewhere and I grabbed his finger and like I had a meter at home and I just like no, let me just check your blood sugar. If I stupidly did not wash his hands before I did this. And I just like grabbed it and poked it and it was like 390 And I was like my heart like stop and my boss then I'm pretty sure like, walked into our bedroom. It was like praying. Like he like was that scared? And then I was like, no, let's go wash your hands. And anyway, he washed his hands and we rechecked it. It was like 94 I was like, Okay,

could he be could he have anemia?

I'm trying to think when he if he would have checked that at his last day.

Doctor? Well,

you know, like his primary care. Yeah.

I mean, I heard you just slipped into the a onesie machine one day, so

I'll have to get I can probably check when he actually has a checkup coming up next week. So I asked

our overlords check GPT forro. Can children have an elevated a one C and not be diabetic or pre diabetic? Yes, children can have an elevated a one C and not be diabetic or pre diabetic hemoglobin variants, iron deficiency anemia and chronic kidney disease stress and illness medication or laboratory error.

I mean, really like a one C? I mean, it really isn't like the best test really time and range is like a better, you know, a better

CGM on him. Well, I

tried one on him, but he was not having it. He was, you know, he, they've seen me wear them because I've worn all of them just to like, you know, try them out. And so they've seen me wear it. But when I attempted to put it on on him, he ran, he ran circles around the house and was screaming, I was like, Okay, fine. Hey,

when you said you and your husband were raised differently, can you give me context for that?

What just like he grew up more like in a Yeah, like his parents would use like spankings and my mom was not a spanker. At all, my mom was more like,

I love you, Jessica, why are you doing this, she would just fuss at you. And then

like, she was just tired. Like, she worked and had three kids. I also am a lot older than all my siblings. And so honestly, I was a pretty good kid. And once my siblings came, I was like a little, another little mom, like I helped with the kids and babysat all the time. So my mom could just use like, a tone of voice with me and I would cry. So like, she didn't really have to, like do much, you know? I mean, maybe like once I was in high school, I think I got grounded a few times for like, going to a party when I said that I was going to be at a friend's house or something like that. But in general, like I was a pretty good kid. So

not a lot to do for you. Okay, let's see some stuff you just said. I'm open to talking about anything looping pumping, diet, thyroid, working with families, etc. Okay, so let's pick through this list a little bit. How much time do you have for me today? Okay. Okay. Arden by the way, on her way home from college right now she's driving home from Georgia to here as we speak. That type of drive. Yeah, I think she just got into South Carolina because she just left about an hour and a half ago. She had to pack all her stuff like for her boyfriend flew down helped her move into her next place for next year. Yeah, and then he's gonna tandem drive with her on the way home she's exhausted. She's been doing all nighters for like, off and on for like a month and a half getting through her finals.

What does she want to do when she's done? Like what will be its what's her dream job?

I think she wants to design her own line of clothing and manufacture and sell it herself in a in a like maybe a small setting. Cool. Yeah, that's your goal. But she's where you are right now is what I was just gonna say. Yeah, just a little East maybe. Yeah. Okay, so let's let's pick through your list. Let's go to pumping first. So do you put families on loop. Where do they come to you? And then you go, that's fine with me if you want to do that, but I have to tell you legally that I can't support it. Like, how does that all work?

My first Looper was that was actually the dad and his son both had type one. And they were both on Omni pod. This was pre Omnipod five, and he was getting ready to like he had another year before he was going to college. A mom was like, anxious because she wanted him to be on a closed loop system. For Omnipod five, you know, you know, in the beginning, it took forever for it to come on. I felt like there was like one as they kind of come and say she was just like, I don't like waiting anymore. And I had mentioned looping to them. The dad, the dad is an engineer and the patient like he also like, he's, he's at Georgia Tech, with doing engineering. So both very, very smart. And like, I was like, you know, there's this looping thing. And so they looked, they looked it up, they think the kid and the dad built, you know, built it themselves. And so he was my first looper. And then after that, I had another family who because they had really crappy insurance, they were using the libre, because the Dexcom was too expensive for them as for the out of pocket costs, they use the APS system and so they can they could live with the libre and they have this little thing called the bubble that they put like that the libre like goes around the libre and that would allow this was on the libre two that would allow the libre to to like talk to the APS app. De loop and his dad is like in the medical field, like he's a PA, I think. So he was you know, they're very, like the parents were like, they understand how insulin works. So like, and honestly, because the APS system and the looping like on the iPhone is a little bit different. And so honestly, like, I feel like they understand it better than I do. Because I can't go through, like all the pages and books and all the education they have to do to like, like, learn every little intricacy of the system. And then I have recently in the last few months, put a toddler on loop. And that was, again, I suggested it to mom. And then I have another family the mom, the mom is a math teacher, they were on op five. And she just she just wanted more control. So I was like, why don't you do looping? They actually ended up using T one pal, I think is the Yeah. Like help them? Yeah, they like put the they build the system for them. And like help them get set up. And then she ended up paying like extra money to do some sessions with somebody from Integrated diabetes. I think Virginie works, after she started looping. And so

that's how she got four. Yeah, there you go.

Are leapers thinking

about having like, you know, opportunity can afford to become an app developer can afford to, or to pay somebody to do it for you can afford the call Jenny and have her explain the whole thing to you. That's probably I mean, I'm guessing 1000 to $2,000 of you know, extra income to get set up on this thing? Yes, yeah. Yes. For sure. Yeah. So there's varying levels of people's abilities, right, varying levels of their effort, their understanding, etc. You have to assess those people? Do you put them on a pump based on that? Like, do you really mean like you look at somebody and go, you're not really going to be that involved with this, take the Omnipod five, or you're gonna probably want to be more aggressive. Why don't you try tandem? Or, or you're never going to count a carb right? Have you heard of the islet? Like, is it going? Is it going like that?

Yes. And then some people, you know, like, Well, some people, like I said, you know, come in and they already Googled for the kids but on tick tock or something, and they already have like, decided they want something. Usually it's probably the Omni pod because it's tubeless. But it depends on the family. Like if somebody basically just what you said, like I have patients who you know, now that Isla is out, I have a handful of patients on the island. Now, if they were already we're not carb counting like I already had them on like a set dosing regimen because they weren't carb counting and you know, they chronically have not controlled their diabetes. Well, then I've been like, kind of showing them the eyelet most patients I show, I like him I was like, Well, I don't I don't actually have anybody on Medtronic. I have not been a huge Medtronic fan. So far in my career. Have

you seen the seven at GE?

I have not used it. I have seen it, but it's still

in America. It's still using the old CGM, though, right. I

think it's Yeah, I don't think it's I don't like the CGM. I don't like that. You have to like, charge the transmitter and then it's like all that weird tape that you have to put on it. I mean, I know you don't have to, like calibrate it anymore. That you know, like you used to, but I think for me, even when Medtronic first came out, I felt like it was false advertisement because it was you start to calibrate and it really I just did. In the pediatric world of personally, people that were on it, they were very rarely in the like auto mode or whatever, I felt like they were getting kicked out all the time. And so they weren't really getting the benefits of an AI D pump anyway. And so I think

when Medtronic gets when they're gonna really like blades back into this, it's going to be when they're newer CGM comes out in America and they pair it with the 780 G. I think that's when people will take it seriously. Again,

I mean, I've seen there's been some, some guy that's been posting in the in the Facebook group about the seven ad and how much he loves it. And I've seen pictures of his graph. And like, it looks promising, I think I mean, from my understanding their target goes down to 100, which is the lowest, you know, on the market outside of looping. I think just because I hadn't, hadn't really been working with it much. I just have steered away from it in general. But

by the way, shout out to Bill whose name I know, because I know who you're talking about. Because he does post about it all the time. And I always say, Yeah,

and it looks good. Ooh, that looks good. Anyway, so but yeah, so usually, I would show patients, you know, showing the tandem show I'm Omni pod, like, Okay, which one do you want? Some patients? You know, I'll tell my diabetes educator like, hey, like, you know, just show them the island because like, there's no way they're carbs. There's no way they're carb counting. I do feel like, like, as far as like, the carb counting issue outside it before the islet came. I do feel like Omni pod five is a little more unforgiving for patients who struggle with doing that, because we've caught with carb counting. Once you're too hive. Well, like if you're not announcing meals are like really off on your carb counting. Because if you stay high for too long, it will make it will kind of force you into manual mode.

Just let me ask you a question. Because that fries my mind. People don't Bolus their meals regularly? No. Okay. Yeah, I'm so used to talking about the way that I know works and the way we do it. And I'm, I have to tell you that one of the things that I get shocked about more than anything, to put all this kind of high minded effort into this podcast and all this, like, there's, here's the variable series, the finding, if you understand the definitions, you're gonna be able to do it better, blah, blah, and people come to me, they go, Oh, my God, I'm doing so much better. I go, What did you do? They're like, yum, Pre-Bolus eating my food. I'm like, Wait, that's it. Like, yeah, they just, like, it feels like some days, it feels like the podcast could be three minutes long. One episode, and I'd reach just as many people and and yeah, but so that's that's not just me, this is what you see, too. Oh, yeah.

I mean, that's a lot. I mean, again, especially especially in the teenage years, I mean, whether it's the kid like a younger kid who just like gets into snacks and doesn't cover or like the teenagers who just, they just eat and don't Bolus, they just they weren't, they were the pump. And they just, they just let it ride and hope the basil covers it. And so the way that Omni pod fight is algorithm works with like the learning. And so, you know, they get kicked into manual mode. And the one thing I keep telling my rep is like, when you get when it forces them in the manual mode from a high, then it doesn't alert you that you're like, still in manual mode. So like, they'll I'll look at the report, and there'll be like a manual mode for days. And they're sitting there wondering like, why am I still high? Because the pump isn't, you know, obviously adjusting for the high, because they don't realize that they're in manual mode. And so, do

people not know they're killing themselves? How do you stop yourself from saying,

I mean, we talk about the effects of uncontrolled diabetes, and honestly, like, with, especially with my teens, like, a lot of times the parents will be like, you know, they'll have you know, maybe family members that are like type two that have like, lost limbs and are on dialysis. And so sometimes the parent will be like, you know, like, oh, like, you're gonna, you're gonna die or you're gonna, like, you're gonna have dialysis and sometimes I'll use that but personally, like, again, like the teenage brain in particular, well, like all kids, but like teenagers in particular one, they're in that phase of like, thinking they're invincible, too. They're like frontal lobe is not developed enough to like, understand, like, future consequences. And so for the most part, to me, telling a teenager who's not controlling your diabetes about like, Oh, you're gonna die or you're gonna lose your, you know, lose your toes or whatever. Like, that probably is like, literally, like Charlie Brown, like, you know, wow, they don't, they're not hearing me. What I do try to bring up in kids is like, especially if they're athletes, like hey, like, if you want to be stronger if you want to be faster, especially like the boys like if you want to, you're trying to gain muscle, like you're, you know, in the weight room because you play football and you're like not picking up muscle mass. You need to take your insulin like the glucose cannot get into your muscle cells, unless you take the insulin, the insulin is the key to open that, you know, open that door. And so I tried to like focus on that. And then other the other thing I sometimes mentioned to Teenage boys has erectile dysfunction. Yeah, like hey, like, I mean, I'll like always preface that, like, I'm not condoning like, section your teenage years. But like if I'm

trying to imagine me being like 16 in my office, and my doctor looks up at me, just because like, Hey, you want to Boehner? Is that deep? Because that ain't gonna happen? And you're like, oh, wait a minute, I didn't know what you're talking about important stuff here. Oh, yeah, I'm like, Would it be quicker to tell them that a high a one C makes their place? They should not work? Like, would that be fair? Because as you're sitting here talking, right, I know this, I understand the nature of man, I know the seasons of growth and understanding and your brain and your understanding of life and your desire. I mean, listen, you hear me, I tell people all the time, people help each other, help themselves normally, for other people before for themselves, like you have to go through these have experiences. So you understand. And hopefully, you'll be lucky enough to be, you know, like, still healthy to take advantage of these things you've learned. Knowing it. And then hearing you say it is two different things. For some reason to me like it just like it just flipped me out and made me upset. I was like, like,

I can have patient I have patients, I have patients that I mean, I've been like, I have been carrying them for years. And literally, they're a one c is greater than 14% on my machine every time I check it, kids, a kid Yes. Or their parents not involved. Sometimes, but sometimes again, like it's that the privilege thing, like, I mean, they're there, but

privilege runs beyond your ability to do beyond your ability to afford something and it might run into like, do you have the privilege of having a parent who is interested enough intellectually minded enough, etc, to actually help you with this thing? Exactly. Exactly. Gotcha.

Yeah. And it's like if the kid you know, and it's not common, but you know, there have been times where like, kids have ended up in foster care, but that ends up not lending nest, usually any better. Yeah. Because they get put into homes where the person isn't always educated by diabetes, we, you know, we don't always know when they're gonna get moved to a new foster home to educate families ahead of time. And so it can end up being just as much of a hassle like conflict the kid just and then, you know, that adds the whole nother, like, social dynamic of now you're like, what this person that's like a stranger, and you're taken away from your family. So then you're not happy about that? How

often do you see desire without intellect? Like, I want to help? I just can't I don't I can't do it. I can't think my way through it. Is that common? Or is it more common for them to have the ability but not the drive?

I think it's probably more like, they could have the ability, but not the draw, I say, I say the ability, like I think they're like, intellectually, they could do it. But I think not lack of drive. And just like our lack of like, again, like if you are literally like, again, like I said earlier, like just trying to feed your kid and provide a roof over their head, you know, you care about your kid, you love your kid, like, they'll come to the appointments. And they, I mean, like, you can ask them the questions and they can answer them, like, you know, even the kids like, what's your current ratio, which your correction factor, like they can rattle it off. They know how to do the math, like, it's not a lack of knowing is just like they just, you know,

I always think like, what are we doing this for? If we haven't future proofed it? Like, like, why am I go into those jobs and exhausted and having these fights and standing in the grocery store at 730. And like, you know, arguing with these kids and living in a place like, you know, maybe I can't even afford and I have all these problems in my life. And you mean, I'm gonna fight through these things, to raise that kid to watch something terrible happened to it when it's 30? Like, what did we do it for them? Like, like, you get put is that not? I'm upset is that

it's maddening? And it's just it honestly, it's, it's sad, like, and I, you know, some providers, like, you know, may kind of like discharge patients, you know, they're just non compliant. I, in general, don't do that. Like, because I'm like, what does that date it's not gonna solve anything. I mean, I think sometimes, like, you may as a provider, you may recognize like, okay, me and this patient in this family are not like clicking, you know, like, we're not on you know, we just happen, right? Well, yeah. And like, do you think okay, that another provider may be able to, like, help them better in general like, I mean, unless you're unless the family you know, if somebody's like being disrespectful to like my staff or like, you know, whatever, then they may get discharged. But in general, like, just for like, you can't get your agency in control. I'm like, I'm like making you go somewhere else isn't gonna solve a problem probably either. I

mean, kick a kid out of class for not being able to fly like you're trying to teach them something they're fundamentally not going to be able to do Yeah, and so you're then become what their, their guide through as good as we can get it.

Yeah, essentially, and I just hope like honestly, I have, I don't know If you follow there's a girl on social media her her Facebook is T one D chick, she, she's probably in her 20s or 30s. But she her and her brother, both type ones. And I follow her on social media and she talks about, like, when she was a teenager, she, you know, had like, greater than 10 A once he just had those years where she was just like, in a funk and just wasn't applying herself. I mean, and now she's, you know, like, actually now she's pregnant. And so, you know, obviously super tight control, but she's on a tandem and she like is like a diabetes influencer now, and you know, usually maintains an agency in the fives. And so like, sometimes I see her story, and I'm just like, I just in my head, just think, please, like, let that be all my patients that I

have right now. That's where I want them to get. Yeah, like, hopefully one

day, like, just that frontal lobe develops, and you know, they just take care of them. And I think, and I think too, like, again, a lot of these patients again, if you're like living essentially, if you're like living in a lot of trauma and living, in some ways, sometimes like a hopeless state, I think even for the kid, like, it's hard for them to understand like that, like, life can be better like life. I mean, it's just, I think it's easy to get, you know, like, if you have like, Y'all struggle at home, and then you have diabetes, and you have people at school, like you know, teasing you or like you feel different because you're you're wearing all this technology,

I've had my fair share of seeing some parents, like say like, I don't know why my kid won't do this. And I look at them. And I think God, if you were my mom, I'd give up to you don't no one ever sees themselves in these situations. Right? Like, yeah, I just think

it's just hard for some of these kids. And I mean, just the mental health aspect, you know, is, is a lot

is the answer for people finding themselves in that situation. Islet? Is that the answer?

For some of them, I'm trying actually, like, I just ordered the eyelid on to my patients who are frequent flyer decay patients. And again, like a one c is greater than 14, like all the time, and I told my educate my diabetes educator, I'm like, You know what, let's just try the eyelet. Like, at this point, what do I have to lose? Like, you know, a lot of times, you know, as an endocrinologist, when we're like assessing is a patient pump ready. One of those things is like, well, they're always like, coming in DKA, you're hesitant to, you know, and not paying attention, you're hesitant to start a pump, because it's like, well, that could increase their risk of DKA. If they're not paying attention to their Dexcom. Like when they're running high and going through all like checking the ketones and changing your pumps, I thought it off, but they're not doing that anyway. Right? Exactly. They're not taking their long acting, they're always indicates and that's why I told my educator, like, at this point, like, what do I have to lose, like, they're gonna go in decay again, like that already happened. I had this one kid, I will like and actually still see him but he, like, always had anyone see above 10. And he was just like, really quiet, like, super introverted. And I was just like, the mom was a nurse, like, she's not a lack of education. And I just like want to ask the kid I'm like, like, dude, like, what's the deal? Like, he's like, I hate injecting myself in hurts. I don't want I he would take as long acting, but he just like, wouldn't take a short acting. He's just like, I hate injecting myself and I, but he would wear that he wore the next camo. I was like, You know what, let's just try. Let's try tandem. And he has been on a tandem now, I think for going on three years with an agency and the sexes ever since then went from above 10 to sixes. And it was just like he just needed. He just didn't like injecting was off. But once he got on the pump, I mean, it's like all business. Beautiful. Yeah,

that's what you're looking for. I listen, I think that I think that's old timey backwards thinking about yes, if they're ready for a pump or not like, well, they're not doing this thing you're not going to just try doesn't make any sense. Or there's the stories of when people have their pumps taken from them. I'm always like, there's nothing about that story. That would make me think you shouldn't have this pump. It feels like knee jerk reactions from doctors sometimes.

I did actually, like about a year ago, I had one kid that I did tell him like, we're done because because we literally went from a onesies usually like, I mean, not stellar, but like, you know, eights and nines, but like, started the pump and had multiple decay episodes and a onesie went up to 14. So I was like, No, you were

at least, at least you're injecting your long acting insulin.

Yeah. And so we ended up switching to the end pants. I was like, that way I could still get the data, you know, from the shots and the short acting.

So is there a piece of your mind that says, Look, I just I can't save everybody.

I mean, yeah, I mean, I try but like, I mean, it's just, you know, again, I literally always just hope like, okay, maybe like, it's like, you plant I'm planting seeds now and the hope that like, they'll turn into that person who pulls it all together, that person that can figure it out and you know, and not someone who just, you know, continues down this path of just like, you know, and I think it's hard to take is the other thing I think about when I'm talking to my teenagers is like, Okay, what's your plan for life like kind of job are you gonna have like, like you have diabetes? Like you need a job that has like good insurance? Because this is an expensive disease? Yeah.

Oh, you think a person who can't inject their insulin is planning for 10 years from now? Well,

no, but like, I've heard talking about her because I'm like, Okay, what's the plan? But like, you know, yeah, I mean, I do have those patients who like, or I have some, especially teenage girls sometimes are like this, like, they are stellar in school, like straight A student cheerleader, does all the things but then like, diabetes control, like they just like, they just can't put pull it together. Like they just don't Bolus and whatever. I have that sometimes, but more often than not, the kids who are not managing their diabetes, while are also not doing well in school and are also like struggling at home. You know, there's like family dynamics that are like, you know, yeah, not ideal at home. So it's usually like their whole life that's like, struggling, you

know, what I've noticed, helping Arden the dynamic settings in the Iaps are really valuable, like adjusting her Basal. Her insulin sensitivity and her carb ratio based on like, perceived need based on like, the history of what's happening. I think that's taken another level of having to think about diabetes away from hard. Like, I think it's what got her through her finals. This this last time I see you're saying, Yeah, cuz you can adjust all that stuff. Yeah. Because it's easy to think like, oh, yeah, well, Scott's kid does it. It's easy for him to say, my kid won't do it. But there's plenty of times my kid doesn't do it. She Bolus is her food. That's a thing, right? And she Pre-Bolus is most of the time. So I'm happy. But if she's in the middle of a project in college, and she misses a Bolus, and her blood sugar goes to 200. She's not correcting. But the algorithm corrects. Exactly, yeah. And it hits hit and now Fair, fair, she believes it's going to do that now. So maybe she feels like I don't, I don't need to look, this is how this works. Yeah, there's probably been five times in the last six months, I've texted her and said, Please, Bolus, whatever suggested insulin there is, because this algorithm is never gotten ahead of this. But in keeping with what it's trying to do, and I won't even get, like, I don't even get a response. I just see on Nightscout at the Bolus that she does it. Yeah. And I'm like, okay, good. No, but she's also she's incredibly busy. Like, I do want to point out that she is really busy. But you know, there could be other kids who are going to be, you know, really drunk or really busy or studying or like, whatever. So like, there's always levels of why am I not looking at this? And all this is just because this whole conversation is just about the way humans minds work. Oh, yeah. It's all this is right. So

literally, I mean, you would probably cringe like, I mean, I can look like, I will have some, you know, I'll pull up a Dexcom clarity report. And literally, it will just be like, greater than 400 for like days in a row. And I'm like, I don't

why not? It's what even once just for fun, like, yeah, the wonder what would have nothing, they're literally not looking at all? No. So

those are the patients sometimes, like as far as like, the pump candidates, like for people literally who I can tell, like, you're not even looking at your Dexcom. Like, I do sometimes get worried about putting them on a pump, because I'm like, oh, man, they were uncontrolled. But not in DKA a lot than those patients I do get worried about because I'm like, okay, they probably were at least taking their long acting, lease, like half the week, you know, or something, just enough to keep them out of decay. But like, if they're never looking at their Dexcom, I do worry, like, are you really going to change the pump and pay attention? And you know, troubleshoot it? If you know, if you're let

me pivot here for a minute and ask you so obviously, what I'm hearing from you is that I have successfully found a way to reach certain people. Now, yes. Is there something that could be done for those other people? Like, am I just not creating the right content? Like, is there a thing I say that if I said it differently, or presented it differently? Where would they just never look? Even if it was there? Like how do you lead the horse to water? And and once they get there? Is the water that I have available the right water for them? Or do they need different?

I honestly feel like that like education, like the episodes like you and Jenny do. I mean, I feel like for the most part, those are very, I say, dumbed down. You know what I mean? Like in layman's terms, and like,

Yeah, I know. Exactly. Yeah.

I mean, like, not in a derogatory way dumb, but it just is in layman's term. It's not doesn't feel like Doctor talk. And so, I mean, I feel like from that standpoint, that helps. That part is fine. Again, it's just it's just the broken healthcare system, you know, and just like, what is

it or is it just there in a like, I mean, you're saying to me that these people would magically respond if the healthcare system was different.

Well, broken healthcare settlement, okay. Not just health care, broken health care, but also just like a broken I just have I have a broken system like, you know, again, when you talk about privilege and food deserts and racism, and all of the things like I think that's where a lot of that can come in. And just, that's not

wrong, by the way, right? Like, even from a doctor to look at somebody go, I know you people don't do this. So I won't bother bringing it up. Like that kind of thing, where I know how your people eat or something like that.

I mean, you have to ask, you know, I mean, like, I mean, we shouldn't assume but like it happens, right? Not? Oh, yes, it happens. Yeah, that's even part of the issue. And that's where I even like, when I was talking to my tz old rep. That's what like, we were talking about that I said, I said, Honestly, there's some families who I probably wouldn't even mention it to them, because logistically, I don't see this. They don't know if they'd ever be able to use it. And that it's like, Is this even it feels like you're just dangling something in front of their face that they're never able to access. But then, but then I was telling him, I said, Then I was checking myself. And I said, Well, really, I should, should always I should be mentioning it to everyone. And then let them be the one to figure out if they can make it work or not, you know, but

that's you making an assessment based on your knowledge and then saying, like, geez, well, maybe everybody wouldn't have that. But I also don't have a ton of time to go over every goddamn last thing. Like I gotta make decisions about what we're going to talk about. Yeah,

exactly. Yeah. And then I just, and sometimes it's again, just like finding resources. I do think sometimes I do feel like having community I think helps, even for the families like if you just having that community my nurse practitioner, we were talking she had a patient of hers, too. It was a type one and then I don't know if it's like the moms knew each other and somehow the kids met or something but the other the other girl that's also our patient was a type two but insulin dependent type two and always in very poor control. And then the moms ended up like linking up the girls and then all of a sudden like the type one who was very controlled like rubbed off on the tight on this little girl at type two and like literally that the girl with type two used to always have like a onesies yeah great but then 14 and has been in running in her agencies in the eights for like over a year now.

That's why I love the Facebook group actually is because having that like positive peer push, it allows you to sit in the background and watch it happen without having to be involved in the conversation it just sort of like rubs on you a little bit you're like yeah, I mean all these people are doing this I could probably do this. I

do mention the Facebook, you know like I mean I'll mention the podcast but I know a lot people may not even they just don't do podcast but like I do notice like I have quite a few people in the Facebook group and again even if they're just like a fly on the wall watching it and like listening watching posts, I still think it they can learn from it and

do you have that personal pain? I know what the podcast does for people like I've I've tons of feedback it's not it's not just one person or a couple of people that happen to you'll hear like varying levels of like I started episode one and I took me a year and I listened to the whole thing and hey Mia once he has five five Look at this. Like right like I see that I see people are like I listened to the Pro Tip series and I got my one seat down to a six and a half and I'm like god it's great or you know, newly diagnosed into bold beginnings which is basically kind of pro tip light for newer diagnosed people and like and it got me on the right path and two years later here we are like I know it works and when I can't get it into people's hands it feels like a like a personal failure. And when you see like the Facebook group is such a great example brings in 150 new people like every three days and I don't see those people one to one translate into listeners and and I think oh my god I got you I feel like I brought them like right to the finish line. And I couldn't I couldn't talk them into taking the last three steps and and do you feel like that and your job like oh my god I know what to do I could help you if you listened or if blah blah blah. Does it feel personally like forget all the business aside and like what you feel like as a doctor like when you're at home and it's quiet Do you think like I feel like I let people down? Do you ever feel like that?

I don't know if I felt I honestly feel like I let them down because I feel like I'm trying like I'm trying I mean I get frustrated and I get I get sad like I get it just that this is the state of it for many patients like I can educate till I'm blue in the face and it just it doesn't seem to be like getting in or whether there's a lack of understanding or a lack of ability or drive or whatever that is and more so I mean I think I get more like in my head I like Okay, what else could I do like what what else could we do as an office or you know as a health system like to better support these families it's probably more aware like not as like that I let them down but just more so like more of like okay, what what are we missing? What can we do? Yeah, to try to, like reach these people to try to help this person not, you know, come in and decay again or you know, to, to get that success of like, coming into our visit and their agency like coming down.

I have an idea, but I'm going to share with you when we're not recording because people will rip me off and I can't have that seriously. The other day, I watched, like you said earlier about like a diabetes influencer. And I wanted to joke and say, like, I didn't know, there were other people doing this, I thought it was just me. But I do see people like, I'll put out an episode about something on Monday, and by Friday, they're talking about that topic. And they're, you know, on their channel stuff. And I'm like, you sons of bitches. Just damn idea and leave me alone place. But listen, the other side of that is, I feel like I'm having a positive influence on the noise that happens in the space, it helps people move towards good stuff. And so I am very happy about that. Like, but yeah, business side. I'm like, you know, have your because these are, trust me, those all those influencers? They're all making money. Oh, yeah. Or they're trying? Yeah. And God damn, trust me, because I've seen it, I see it happen every year. If they can't make money off it, they're gonna stop helping you with your diabetes. I'm the only one who was like, I'll do this for free. I think I can turn it into something. And I've turned it into something that's popular enough that I don't have to worry about my electric bill getting paid anymore. Just it happens now, right? So I can throw myself into the podcast. Most of those people are not in that situation. They are trying to make $100 from a pump company to say a pumps name out loud. Yeah, it's a hustle. Trust me. Yeah. You know, but I have an idea. And I think it'll work. I'm worried that I'm not the right one to face it. And then I don't know how to handle that. Yeah,

definitely. Yeah. Tell me your Yeah, we'll

see. You can steal my idea. And I'm just getting like, no, because I do want to get your input just not when we're being recorded.

Yeah. Yeah. I think like I mentioned just the community aspect, I think I think there is some benefit to that, especially when I think as parents like raising

is that where camp could come in for people who are struggling like that?

Yes. Yeah. So we actually last year I started. So in Georgia, we have camp kudzu, which is based out of Atlanta, the children's type one camp for children with type one diabetes, it's actually this is the 25th year. I've been involved with that camp since I was in my year off between undergrad and medical school when I worked at an adult endocrinology office, which is where I discovered my like love for endocrinology, and started volunteering at camp and had been kind of on and off throughout my training and whatnot. And so this past year, we started a new like session closer to in like the middle and South Georgia area to serve the patients that I serve. And so we started that session last summer, we do to the overnight summer camp, but we also do like little one day events, they can't cuz he doesn't all over Georgia and different cities, in just a chance for the family to come together. And they also do family camp on weekends, I think two or three times a year. So I'm hoping that I'll get a family camp session going at the location that I use for my camp session, again, just to pull people together. When we did one of our one day events, Dr. Ponder actually came and talked on it. And he gave a sugar surfing lecture to the parents while the kids were playing. And then then we all kind of came together and did games and stuff with the whole family and the kids. And I mean, just the parents like hearing his lecture lecture and then like getting some time just to like talk to each other. Like, from that it like spawned a whole like they made their own little Facebook group and they you know, like just being able to meet other families that are going through what they were going through was such a, you know, eye opener and the kids I mean, all loved it to the kids. One of my patients, he's type one and Down syndrome. He came to our overnight camp last year and we did an interview an interview about camp a few weeks ago and like literally, like the bright when he first saw me he was like Dr. Hutchins, like what's going to be the carb count for lunch on the first day of camp and I was like, I have no idea. But he was just so funny. Like he was like, literally could not stop talking to you by camp like he was so excited about camp and I've never been invited. I just want to say Oh, I would trust me like that is like something I yeah, that's in the works. Especially when I saw Arden was in Georgia. I was like okay, Scott's gonna be in Georgia so I gotta figure it out when he's here and I can get into something that is that is in the back of my head.

I would definitely come. So but there's no pressure obviously if you don't you don't want me and as far as like,

um, a lot of my patients listen to the podcast and like they would definitely I mean even Dr. Ponder coming was a big deal and but a lot of people didn't No ponder, like if they were like newer diabetics, just because it was I felt like some of the older diabetics, you know, are familiar with his stuff. But newer diabetics are familiar with you.

This has got nothing to do with Dr. Ponder, but it's so hard to stay in the zeitgeist once you get into it. And like that, I tell people, like, I'll say it on here too, like, but I talked privately about all the time, like, like, you know, doing business and stuff like that. And people are like, what are you most proud of? And I was like, longevity. I was like, Yeah, keeping this train Moving is hard. And keeping it popular is hard. Like, you can say something really valuable. But how do you say it again, tomorrow without people gone? I heard you say that already? Yeah. And how do you stay in it long enough to get to the next group of people? And then how do you not get bored? Because you're like, Oh, I just said this to a bunch of people three months ago. Like there's that, like, that's hard. I'm good at it. Like so. Like, that's it, meaning I don't get bored by helping people in the early parts of their diabetes. Yeah. So it's just and it's so in the social media part of it. Like I listen, I I'm not begrudging anybody who's trying to knock out a couple 100 bucks at a time going, like if I weren't on the pod, like good for you. Like, I think that's terrific, right? But that's not a thing. You can keep going for long. Yeah, yeah, you have to, it's not a real job. It doesn't grow into the thing you think it's gonna grow into? And then how do you keep and it's content. People want content constantly. I laugh when I used to sit around, and I rang my hands for two years. Could I put two episodes out a week? Or would that make people upset? I don't know what I should do to I think they're going to stop listening. If I put two out. And then I put two out and people like, Oh, my God, this is great. Can you do more? And I was like, Sure. Here's three. And they were like, well, what do I suppose let's do on Thursday. And I was like, valid point. And then you know, like, and before I knew it, it was like five days a week. And then I like last weekend, I was like, I've got all this extra stuff, like I'm just gonna pull up on the week. And I thought, well, this is definitely gonna piss people off. Except this was a really popular week of the podcast, if there being two episodes on on Saturday and Sunday. That's too funny. Like, I was just downstairs right before you and I talked, right? My son is applying for a job. My wife is at home working. And I'm like, Hey, I gotta go work. And my son laughs because he's like, you're gonna go sit and talk to somebody? And I was like, Well, yeah, that's work. That's my job. Like, it's my job. And so I'm gonna go do that. And I sit down, I'm gonna take a quick break. And then I'm gonna do it again. I'm in a half an hour, Jessica. I'm recording with Erica, on a resilience series that we're putting together.

She's the site the site. Yeah, yeah. I've listened to some of hers. And

then I'm getting to get done. And I'm gonna take a deep breath and eat something. And then I'm gonna come up here and put episodes together for you guys for next week. Yeah, if that's not actually your job, there's no way to keep it going. There just isn't. So these are the influencers, who you're thinking of right now. Like in your mind, you're like, Oh, I love this person on Instagram or something like that, write their name down, and then go into your phone and say, Hey, Siri, 12 months from now remind me to go look for this Instagram account.

The other group one of the things I mentioned on the list of things I would talk about diet. So the other group that I follow, and I guess that I'm quote unquote, popular and is the low, low carb group. And so I am low carb friendly. In your practice, in my practice, like a lot of peds endos are not low carb friendly. I have, you know, a few patients who come to me because, like, I'm familiar with, like Dr. Bernstein's method, and the like, type one, Greg, type, type one grid, and like, let me be 83. So I have some who like, just come to me for that, like with a new onset, I'm not like, Hey, you must do low carb, you know, if people asked me, you know, I did have a patient that when I first started, it was actually a friend, a person I met at church and then she found out I was a pediatric endocrinologist and then she was like, Hey, you like my son has like a pre diabetic agency and his pediatrician been watching it and I was like, Okay, check the antibodies he had like, all for like for the antibodies were positive and like, okay, he is going to get type one and like, at this point is a once he was like 6.2%, and I was like, and I didn't start work for like, another month. So I was like, Okay, so now until then, just like, try to go lower carb just, you can maybe delay this until I start working. And so they went lower carb he was actually able to go two years like he basically honeymoon with a completely normal agency in the low fives for two years. It was amazing. And he's still low carb because they at this point, they're used to it and he now is at the point where he needs injections pretty much every time he eats but they're like some of my low carb patients, they use the regular insulin for like the protein to match the like Rise of the protein. And so they use like long acting and they have to use are not not Every meal, mostly dinner because that's when he eats like a lot more protein is at dinner. So I am like, familiar with that. As far as like dosing with our and so yeah, in that way, like you mentioned earlier about me being progressive. So I feel like in that ways like with the looping and like being like low carb aware and friendly, it makes me a little bit more progressive,

because that's who you are. Judge me on that? How am I with how people eat?

I think you're like me like you're like you do you like, because you'd like did the whole diet series where you like, and you had low carb people on there. Not yet. I think in the Facebook group, like some people, like can get back and forth about it, you know, whatever. But I mean, I think you're like me, I think you're like you do like, if that's what you want to do, then you can do that. At the end of the day, you just want to make sure like they know how to manage and so on. So

that's exactly how I feel. But I every once in a while I'll get like, the somebody comes after me like a very like, zealous person will come after me and be like, you're stopping us from talking about this. I'm like, I'm not stalking you about anything. I'm like, you just can't come in here. And like, ring a bell and proselytize and tell people that if they eat a car, they're gonna die like or, and that's like, that's not what I said. I'm like, You should reread what you just wrote it because I don't have a horse in the race. I don't even care. Yeah, it's meaningless to me how you manage your your food, you should eat whatever you want, I really genuinely mean that. And but when I'm managing the group, it's a different scenario. Like I have to I have to protect everybody, not just some people, like there's a post that went up the other day, I'm actually going to get the record with the person soon. And I'm excited about that, because it's a really nice kind person who's trying to share what they figured out. And they put up this, this post, and I can't wait to ask them face to face. Like, what did you think the tone of this was? Right? Because I bet you they were excited and sharing good news. And if you read it, it feels a little like, if you just did what I did, you'd be healthier. Yeah, like, right. And and so I'm also not saying that's not true. Like I'm just saying like, yeah, I guess my point is, is that if just telling somebody what the right thing to do was than the last hour of our conversation wouldn't have sounded like it did? And the answer to those, those people's problems isn't eat low carb. Yeah, for

some people, that's not even, that isn't an option. Again, it goes back to like the privilege, like, it can be pretty, a little bit more expensive to eat lunch. Also,

if just saying the right thing out loud made the world correct, then we wouldn't have any of the problems we have. You just go Oh, no, no, you know what, you can't do that. And people go, Oh, I didn't realize and that would be the end of it. That's not how it works, right? And so when these people come in with their super excitement, and I'll say, hey, look, you know, just please be keep in mind the tone of what you're saying here, it feels a little judgmental, blah, blah, blah. And then somebody will go, will you tell people they can eat a cupcake. And they come in here and ask how to dose for something on a restaurant that's obviously got 150 carbs in it. And that's not healthy for them, and blah, blah, blah, blah, blah, I'm like, what does that have to do with anything? I'm not telling them to eat that any more than I'm telling them not to eat. I'm not telling them not to be low carb. And I'm not telling them to go get a waffle with a pancake on top of it and a Sunday. Like I didn't say that either. You know what I mean? Like, all I'm saying is, whether it's the waffle with the pancake with the Sunday with the cupcake, or it's a steak, you got to know that there might be a protein rise from that steak. Exactly. And you got to know that the waffle with the Pig egg with the thing is gonna need like a half an hour Pre-Bolus And like, like a cartload of insulin, and you might get really low later. And you should pay attention to all that like, exactly. It's not my job to teach people how to eat. And by the way, it's no one's job. And if it was your job, it would be an absolute loser of a job that you would never all you you're gonna preach to the choir and think that you're converting people, but you're not you're just converting people who were up to be converted anyway. And I feel comfortable saying that, because there are times that I think my podcast maybe isn't as valuable as I think it is. It's just valuable for the people who is right for. And I would like it to be valuable for more people. That's what I'm trying to figure out. And I got them well guarantee that telling them what to do is not the way to get them to it. So I just mixed two issues together, but at the same time. Oh, yeah, they're the same thing. You're a doctor. I feel weird. And you go to church and I just cursed. bleep that out. Rob, please. Gosh, my. You're also from the south. I assume you're cursed all the time.

I laugh because like my husband, like petite, I did not grow up going to church. My husband did and so like, Oh, he's dry. I curse he like gives you the side eye and I'm like, like, you're fine. Like,

isn't that interesting? The lady who got was brought up nicely didn't go to church, the guy who was getting backhanded did go to church. Well, I don't want to get into that right now. But

don't you know that that's what you know, the Bible says, well, the rod whatever.

I don't know. Listen, I don't want to hit P before but every once in a while, it'd be nice if I gave him a five minute pass. Yeah, I'm sure we all feel like that. Anyway, ya

know, so I get I dropped a few curse words there every every now and again. So a person does not offend me.

I love to curse. It's one of my favorite things. Alright, well listen, you have your own problems. You gotta go figure out how to parent small children, which it sounds like, if I'm being honest, you're struggling with and. And by the way, I want to thank you for coming on here. People know who you are. You're a physician. You're an endo. And you said a lot of things that sounded like Oh, no. And I thought that was really honest. And I appreciate that very much. Because I think it'll help people to hear you say, like, I can't get my kid to put on a CGM. And you know, like, he ran away from me like what do you want me to like? And you were just like, whatever. So chasing down right?

I chased a little bit but then it was like, was there currently then yeah, if he if I knew he was if he was actually did he actually had diabetes? His butt would be wearing a sensor like there wouldn't be an option.

Did you consider money? I would have dropped money on the problem like nothing. Either been running away I've been like, can you smell this? 20 I'm waving in the air smells like Legos. American.

He responded to money he probably would he would probably respond to like Roblox, you know, like money on his Roblox sign pad game or something.

I just gotta explain it to them correctly. That's all you got. Understand where the push and pull comes from? Yeah, you're great. I I'm sorry. It took us so many years to do this. Oh, no, you're fine. And at the very end here, let me thank you personally for the help you gave me when Arden wasn't feeling well, last year. I appreciate it. So

now, I know you've been on for a long time. But I do want to hear more about her GLP as you were talking about that, at our r&d, the GLP one

you want five minutes. I'll give you five minutes. Yeah, you can. Yeah, give me give me. So I had Dr. Blevins on yesterday. And he'll be on again in a few weeks and on again a third time answering questions. He is another care ologists from Austin, Texas, who I found through YouTube. I was watching YouTube videos back when I was trying to understand what it was I was taking. I had that moment, a few minutes, a few weeks or into my use of a GLP medication for weight loss where I was like, I should probably know what this is. Well, I try to understand exactly what I'm injecting into myself. Right. And so I looked into it, I found him just doing a talking head video that I just found to be very clear and thoughtful and well sourced I thought and so I invited him on. Anyway, he's been on there's an episode about a 15 year old girl whose daily use if you haven't heard this one, Jessica, her daily use. She's a three year type one. She ended up on we go V because of what they thought was PCOS weight gain. And her daily insulin has gone from 70 down to six. Like daily. Yeah, she took her pump off. And she's only shooting Basal right now after having type one for three years and using 70 units a day. And so that's happening. I am almost to my absolute lowest weight right now since I started back in April of 2023. Is that when I started? That's awesome. Yeah. Arden is using it. We are like scraping it together any way we can. We're about to get our doctors about to take a different stab at getting it covered by insurance again. So we're getting ready for that. But she's doing five milligrams Manjaro right now. Actually last I would say weekly, but last week, she's like that I shot it like nine days after I shot it the next time she's like I just I was in class and I forgot. Yeah, she has forgotten but you can literally see the difference.

I remember yesterday, you were saying on the episode. Now excited. She wasn't really like overweight. Did she lose weight to or not really? Oh, she lost

weight? Yeah, she did. Yeah, she looks. Now there are going to be some people. And Dr. Blevins and I are going to talk about this on one of the episodes where people just have this knee jerk reaction where they're like, You're too thin like that feeling. She's not too thin. She looks incredibly healthy, healthy. I'm not too thin. I think it's possible. We're all just used to seeing heavy people at this

point grade. Yeah, I mean, I mean, often, like we get referrals for like, obesity. And, you know, a lot of times I feel like the family will be like, I mean, they look normal to me. And I'm like, I mean, honestly, like compared to a lot of their peers, they probably do like about average. And it's like the kids who are like normal weight. The parents like they're so skinny. I'm like, Nope, they're 50 percentile. They're perfect.

There are times that people put pictures of their overweight kids online eating really crappy food. And I think, oh, wow, this is an indication of what they feel is normal. Like, it really is interesting, right? Because even just from like in, I mean, I'll tell you from my personal perspective, if if when I was 45 pounds heavier, you weren't gonna catch a picture of me having a pancake somewhere. Like like you don't even because you're like, because you're self conscious about it. Oh, because I'd be like, I probably look like that because I eat this pancake. And so like but you know, like, but it's Interesting. I'm not judging people. I'm saying it's a very interesting look into popular culture and all that. Then my point being is that people will come up to me and go, Oh my God, you got to stop losing weight. And I'm like, I need to lose 20 more pounds. Yeah, you're like, I'm not at my ideal weight. Yeah. And forget ideal. Like, do you not see the fat right here? Like, this is right in the heart attack spot? Like, yeah, you know what I mean? And like, and they're like, oh, no, you look great. I'm like, I look better than I used to. And I And listen, I do look great. But I'm not healthy yet. And that I don't care how I look. I care about not dying. Like, right. Yeah. So are you with Arden

out of curiosity, so I know does she have to Windows JLC or regular Endo? And then also the one that's like, the lady that did the thyroid episode, she just sees her now. Okay, he's very curious. I was like, what her? I was wondering, did her other endo prescribe the GLP? One, or this is the one that's more like, functional medicine, naturopathic kind of, like sees it. And

makes sense. Yeah. Because when when Arden turned the age, chop was like, Get out of here. And they were like, you know, she's in college right now. So we'll help her for another couple of months till you can get back. But then you gotta get out. And I'm like, Okay, I would think you'd want the guy from the podcast around, but that's fine. And so lols and insurance and everything. Exactly. One of the luckiest things that's ever happened to Arden is that Addy took her on as a type one patient, because it doesn't even take new patients type one, okay, and she doesn't manage type ones, for the most part. You manage her type one.

I mean, like, it was like she she just refilling your insulin and your pods and Dexcom. She's like,

she's like, What am I supposed to be looking at here? And I'm like, Oh, don't forget to ask about her eyes every once in a while, like, you know, like, but But no, like, she's terrific doctor and looks into things. She's the one who was telling me two years ago, like, hey, maybe let's try putting it on Metformin and see what happens to her insulin sensitivity,

that it helps I use metformin and my type one we never did,

we went right to the GLP. The GLP has happened so quickly that by the time we got our head wrapped around what we were going to do, she's like, let's just give her a GLP. Now, you're right. It's not covered by insurance. But we got a sample pen, and a couple of them. And then we hit her with the pen. And I was like, I will do anything for her to have this helped her so much. Yeah. Now, in fairness, it is not costing me $1,200 a month. We're buying a pen. We're using it more sparingly than that, like that kind of stuff. And we've we've relied on a couple of samples here and there. We're literally in a flux period where I have to find a way to get insurance to cover it. Yeah, like I can't keep doing I

have had I had one patient with type one. And now he aged out and he's in the adult world. But he was type one that weighed like 300 plus pounds. And not the most compliant teenage boy and I with lots of fighting with his insurance. And I think they had like anthem or something or one of those at the time. It was private insurance. We were able to get it covered. And this was actually like, three years ago. So that was a Victoza because that's what was like kind of out then

what they're doing now is you're getting a double diagnosis. They're basically diagnosing you. You have type one and you have insulin resistance.

Yeah, well, and you're morbidly obese. Like, I mean, you're you need it for your well that Yeah, I mean, nowadays, when he was on it, he lost like 20 pounds, he'd never lost 20 pounds. And I mean, his a once he got it got a little better. I mean, again, he still wasn't very compliant with its insulin regimen. So but that

person now could would be right for week over years that bound and it would probably be covered by their insurance for heart and like, you know, it's going to be it's going to be insulin resistance, like like, so does it meet the the BMI criteria? I'm assuming you didn't meet the criteria. When we started. Yeah, yeah. But what she does meet is her insulin needs significantly dropped. Her spikes are lesser her acne is cleared up, or periods are easier. They don't have studies yet on what it impacts. And yeah, but if you go to any reasonable OB, at this point, they're going to be like, Hey, if you have PCOS, try to get GLP if you can, that's literally how they talk about it to you. They're like, Hey, if you can talk to a doctor and given it to you, you should I've had a GYN tell RT and like I can't prescribe it, they'll turn it down. Like she's like, but if you went to your Endo, and like there are there are other reasons. And so we started off with like, like, this is just good. Try it. Now we're about to we just my wife just switched jobs. So we're about to put it back into the new job and try again. And I think ADDIE is going to just say, Look, you call it whatever you want, but this girl's got insulin resistance, and she's got type one. So if you want to say she's type two because of coding, I don't care. This is what's going on. Now. I don't know how long insurance companies are going to do that because right now they seem to be doing it, but they could change their but I

have a lot of Medicaid patients. So Medicaid like I mean, I can get my type twos on it but like obesity and Anything outside of a diagnosis of type two, like they're not good, they won't cover it. Yeah. And even then a lot of them, it's like, they'll cover trulicity, which I just did. Trulicity isn't really working.

Like this stuff. This stuff's like, I don't want to call it magic. But holy crap, magic. Yeah, I upped my dose two and a half weeks ago, I've lost six pounds,

I need to get on it. I had gotten a sample of like, the logo V A long time ago, but it was like, the backorder was so bad. And so like, I got the sample the point two, five. And I didn't really feel anything on the point two, five. But then when it was time for me to like, get a refill on the next dose, like it was nowhere to be found. And then I just didn't go back and pursue it.

You need it, do it. It's

worth it. Yeah, I have a two and a half year old and have yet to like lose that extra 30 pounds. Because baby,

let me tell you something right now, I was out today. And this young girl comes to help me. And I looked at her and I thought, how is she like, it's the middle of the day, how she not in school. And then I thought, oh, high school is over. And so I said to her, I'm like, Oh, I was just about to say to you like, shouldn't you be in school? Like, you know, and she goes, I should but I'm in college. And so you can even say her like see her going? Like I know people think I look really young and everything, but I'm not in high school. I'm in college. And I said, Don't worry, looking young will really help you when you get older. And we were chatting for a second. And she goes, How old are you? And I said, Guess she goes you're in your? And she's like, I don't want to insult you. And so you just say what you think you know, and she goes mid late 30s. And I went, I'm 52 You're like, yeah, and I was like, This is great. And like, but no, but like, but she was really son. I'm like, even if you were being polite by 10 years, you were still off by seven years. Yeah, that's nice. And I said, this is my point to you. I was like, yes, it sucks now because everybody thinks you look like you're 12. But when you're 52 and someone goes already, you're 3540 years old. You're gonna love this. But the truth is Jessica, that a year ago, she would not have said that to me.

Because you looked old because you were Yeah, healthy. Exactly. Right.

I am at a level of health now. Like forget, I don't care about how I look. It's fun to like joke about everything, except every once in awhile when somebody leaves me a review. And it's like, you're so privileged that you have this like, I know I am calm down. I feel better. I am better. Health wise. It's got I mean, if I still looked like I looked a year ago, and I felt like I felt today am I glad I came back like they came back recently. I would still tell you I'm taking this stuff. Yeah, I mean, so anyway, I have to go but I was gonna I wanted to ask you about low dose Naltrexone and auto immune Have you gotten involved in that at all? I have not. Okay, well, I'm gonna save that for another episode. I'm going to try to find somebody who has been using it or something like that. Apparently, apparently, you know what it is right. I have heard of it, but I've never used it. People are using it for like autoimmune issues now. And for like pain and swelling and stuff like that inflammation. Anyway, look into off to Google it. Yeah. Let's catch up to tell you about it. And then it'll tell you how to build a bomb that it will use on us one day. Thank you for doing this very much. I

appreciate it. Yes. All right. Have a good day.

Yep, hold on a second. A huge thanks to touched by type one. Don't forget to go to touched by type one.org and get your tickets for the big upcoming event in September. Jalen is an incredible example of what so many experience living with diabetes, you show up for yourself and others every day, never letting diabetes define you. And that is what the Medtronic champion community is all about. Each of us is strong and together, we're even stronger. To hear more stories from the Medtronic champion community or to share your own story visit Medtronic diabetes.com/juice box and look out online for the hashtag Medtronic champion. A huge thanks to Dexcom for supporting the podcast and for sponsoring this episode dexcom.com/juice box go get yourself a Dexcom g7 right now using my link, the diabetes variable series from the Juicebox Podcast goes over all the little things that affect your diabetes that you might not think about travel and exercise the hydration and even trampolines juicebox podcast.com. Go up in the menu and click on diabetes variables. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

Hello friends, welcome to episode 1231 of the Juicebox Podcast Welcome back this is another episode in the Grand Rounds series you probably know by now in the Grand Rounds series, we don't use the person's real name and their voice has been changed to protect their identity. Today we're going to talk to Alex. She is a 37 year old medical oncologist from Israel. And we're going to talk about the health care system type one diabetes, and so much more. One of Alex's children has type one was diagnosed just two years ago. There is a lot of spirited conversation in this episode. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan or becoming bold with insulin. When you place your first order for ag one with my link, you'll get five free travel packs and a free year's supply of vitamin D. Drink ag one.com/juice box. Hey, I'm looking for you to give just a little bit of your time. T one D exchange.org/juicebox. Join the registry complete the survey help with type one diabetes research. You just have to be a US resident who has type one or is the caregiver of someone with type one. T one D exchange.org/juicebox. This episode of The Juicebox Podcast is sponsored by the ever sent CGM and implantable six month sensor is what you get with ever since. But you get so much more exceptional and consistent accuracy over six months, and distinct on body vibe alerts when you're high or low. On body vibe alerts. You don't even know what that means. Do you ever since cgm.com/juicebox Go find out today's episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. This is the meter that my daughter has on her person right now. It is incredibly accurate and waiting for you at contour next one.com/juicebox. Alex, what's your job? What do you do for a living?

I'm an oncologist.

oncologist. What is and was your training like to get that job? What did you have to do where I

live? There's six years in medical school, you get into medical school right away, you don't have an undergrad, and then you do one your internship before you get your degree. And after seven years, you're a doctor. And then you have to do your specialties. oncology is five and a half years it's straight through it's been a sub specialty.

It took you from the day you began coming out of out of school until you were I guess certified as a oncologist. 12 and a half years. Yeah.

Kids in the middle. So a bit longer than that. Oh, so

there was a gap of time in there. You took a little time off to wear maternity leave. Yeah. Okay. All right. And now how long have you been practicing?

I finished my residency about two years ago, two years

ago. What would you say? Day to day your job is like what do you what do you do most days?

So after you finish residency, it's mostly working in the outpatient clinic in the hospital. So it's same patients in the outpatient clinic. And then they get therapy in in the daycare center.

So we're talking about like, let's see, okay, clinic, a clinic that does what infusions so

it's in the hospital. And it's always connected to like a big hospital, okay, like the infusion centers. So it's not like an America that they're also like smaller practices that have their own infusion center.

I see. I see. So you see people for chemotherapy? Yeah, yeah. And follow up visits. If I think I have cancer. Are you a person I come to? Or are you in a difficult

situation when you guys send oncologist, you already have a diagnosis, or there's somebody already found that you have cancer, and then you go on colleges to figure out what the treatment plan should be. And for the follow up afterwards,

are you a surgeon as well? Yep. No,

okay. I'm a medical oncologist, medical oncologist. Great.

You said you stopped in the middle there to have some kids. How many did you make? I

have four kids. One was in medical school. One was in the internship year and two during residency. Geez,

I must have made it harder. No.

But everybody starts University later. And it's all because you do either national service or army before you start. So I started at age 21. And I was one of the younger ones.

How long is that army then? Is it one year? No. So

for boys, it's three years and for girls, it's two years. I did national service for two years instead of doing army. I

see national service

means it's like kind of being like a volunteer in different. Okay, organization

go somewhere build a house, they go, Well, something like that. Well, it's more like

working in schools or working like I worked in the Epilepsy Foundation here for one year and I worked in school, the second year Gotcha. To be like at risk kids,

what drew you to oncology what made you want to do that? So

I really believe in patients making their own decisions about treatments and end of life. And I feel like I'm college kind of incorporates that. I also think that in oncology, there is like you have a long term relationship with your patients that you don't have with a lot of other fields.

I see which one of these kids got type one diabetes.

Number two, how old number two on the lottery. She's nine now she was diagnosed when she was seven. Oh,

wow. So a half a year into your practicing. She got type one.

So she actually got it's been more than two years. So she's actually got type one at the end and end of my residency, I say, but I'd already finished like my board certification. So it's a little easier.

Is there other autoimmune or type one in your family? So

until then, we didn't have like, I would have told you that we're all completely healthy. But she was diagnosed with celiac, but at the same time, it was the same blood test. And afterwards, we were diagnosed me, my husband and another kid with celiac. And I have Hashimoto and my husband had psoriasis, which isn't exactly autoimmune miss out on Flim Flam. Ettore. My youngest might have been illegal. So

we're running autoimmune struggle. You didn't know you had Hashimotos.

Know that. I knew, but I never considered it if you'd have asked me. Am I healthy? I always said yes. Like, and I gave birth and they said, No. Do you have anything, any medications you take? And I was like, Oh, no. And I'm like, Oh, wait, I do have something because it's just something that's so common. How

old when you were diagnosed with that? 24? Okay, so how old are you now?

37?

Might you laugh?

Because I can never remember.

Like, okay, so you've had it Hashimotos for a while. And even though it's auto immune, if I would have asked you the day your daughter was diagnosed, are there any other autoimmune issues in your family? You might have skipped right over Hashimotos? No,

I asked me like that I would have skipped over. But it's not like I thought about it.

Okay, so it was a surprise. Obviously, when you look at your family line, your husband's in yours. Do you see any other autoimmune? No, no, just the two of you getting together might have been the soup that made

like we didn't even know we both had celiac before. It would have been a cute dating story. But it didn't happen like that.

So can I ask I'm so sorry. This is a weird, like path to go down. But you just ladder running to the bathroom? You didn't know why or was it not affecting No,

once you have one kid who has celiac or person in the family? So you do screening for all the like, first degree relatives? So we all did screening? And my husband is symptomatic. And I think it's just people didn't look for it as much when we were younger. Yeah. So he just like lived with it, because that's the way his body worked.

I take I mean, listen, I think that's a valid answer. I think that's it, people don't understand I'm older than you fairly significantly. And I'll

tell people like You're like one half generation, I guess above are wondering, I

mean, I'm 52. I don't know what that means. But like, all I know is that no one ever considered my health. Like I was either sick, like with a cold or something broke, but nobody talked about nutrition or how your body worked, or what was normal, or what level like that was just not a thing anybody spoke about, you would have been like a majorly hippie if you talked about that in my family in the 70s. You know what I mean? Okay, so you've had this job now for a couple of years, you're obviously on a cold wind episode. So we usually skip ahead a little bit here. Instead of telling fun stories and stuff like that, what makes you reach out and say, I think I have something to add to this cold wind series. Contour next one.com/juice box, that's the link you'll use. To find out more about the contour next gen blood glucose meter. When you get there, there's a little bit at the top, you can click right on blood glucose monitoring, I'll do it with you go to meters, click on any of the meters. I'll click on the Next Gen and you're going to get more information. It's easy to use and highly accurate. smartlight provides a simple understanding of your blood glucose levels. And of course was second chance sampling technology you can save money with fewer wasted test strips, as if all that wasn't enough. The contour next gen also has a compatible app for an easy way to share and see your blood glucose results. Contour next one.com/juicebox And if you scroll down at that link, you're gonna see things like a Buy Now button. You could register your meter after you purchase it or what is this Download a coupon Oh, receive a free Contour Next One blood glucose meter. Do tell contour next one.com/juicebox head over there now get the same accurate and reliable meter that we use. today's podcast is sponsored by the ever since CGM boasting a six month sensor. The ever sent CGM offers you these key advantages distinct on body vibe alerts when higher low, a consistent and exceptional accuracy over a six month period. And you only need two sensors per year. No longer will you have to carry your CGM supplies with you. You won't have to be concerned about your adhesive not lasting, accidentally knocking off a sensor or wasting a sensor when you have to replace your transmitter. That's right. There's no more weekly or bi weekly hassles of sensor changes. Not the ever sent CGM. It's implantable and it's accurate ever since cgm.com/juicebox. The ever since CGM is the first and only long term CGM ever since sits comfortably right under the skin and your upper arm and it lasts way longer than any other CGM sensor. Never again will you have to worry about your sensor falling off before the end of its life. So if you want an incredibly accurate CGM, that can't get knocked off, and won't fall off, you're looking for the ever since CGM ever since cgm.com/juicebox.

It's really interesting, because you know, every doctor kind of has like their traumatic patient, like the patient that you feel like you could have saved, she would have done something different. And I'm not even talking about like negligence and getting sued. But just like human error, I guess it could be either or. So mine is actually patient who died of decay. Who had type one. And I think that it kind of shows are like understood from that how much we don't understand type one. And that was even before my daughter had type one.

You're helping a person with cancer. Yeah,

so it was like on oncology Ward, right. So we're just in colleges, and she was getting a therapy that she wasn't eating. During the therapy. It was hard for her to eat and she was in pain. So they gave her a lot of morphine. And then she kind of started going downhill. And they decide to center up to be in the ward so we could kind of watch her give her fluids. They took off her fentanyl patches. And they said like if she's kind of seems like she's in pain, like just give her a little bit of morphine. And I was the on call resident we did 26 hour shifts. When they called me the middle the night and they said, You know, I think she's in pain. So like I went to see her, give her a little bit more fit. And she looked really off. So I took my tests, but sadly, the blood gases didn't. They weren't good. So I never got that back. And then they call me like two hours later that she died there is that she's not breathing. And we went to resuscitated her. And we didn't really know what happened when they checked her blood from the ICU. So she had a lot of ketones and they couldn't figure out why. And then they finally figured out that she was type one. And what happened was is that she wasn't eating. And she her blood sugar's were running low. So she took off her pump, and she wasn't getting an insulin. And that means that her blood sugar's weren't high, because that's something that we would notice in the hospital. She didn't say that she was that insulin was a medication that she had to get. And she took it off before. So it was like normoglycemic DK, which was something that I didn't know existed before that. So she died a few a few days later. And ICU. This

feeling you have, there's something you could have done? Was it as strong then as it is after your daughter's diagnosis.

Now it was really strong. Then I did a whole kind of mortality and morbidity meeting with the doctors bass, I kind of researched it. And they understood that type one wasn't something that was just like, okay, you know, they have they have type two diabetes, or they have high cholesterol or they have high blood pressure, that it's something that you really need to notice.

How was she in the system without physicians knowing she had type one. So

she was brought up like this, she was getting treatment. She wasn't an inpatient, and then she was sent straight to the ward, just like that we could kind of help her out. Yeah, again, they assume that she had an overdose of morphine

or fentanyl or whatever. Okay.

And she, so nobody really did a full intake. But I will say that even if she would have said to me, yeah, I have diabetes, I would have been like, okay, so you have diabetes. You know, like you ask, what medications you take, and like, I wouldn't have thought to say, Hey, if you have type one diabetes, how come you don't have insulin on your medications?

You think if you knew she had had type one. And you might have checked her blood sugar but then seen it be at a certain number and then

they knew she had diabetes. It checked her blood sugar was normal. Okay.

Is this the first time you're seeing her when when you interact that night? Yeah, yeah. Okay. Yeah, that's crazy. And no one, it just doesn't click for anybody that you can have

click for anybody. It's like it's a went through, like, usually you have a lot of people looking at something and then somebody's going to figure something out before something bad happens. Yeah, so I was just like the last one when the really bad thing happened. But nobody realized that. And if I put it in other perspective, and I'm not taking the responsibility off of me, or like, the doctors in general, I feel like when you're tightline, it's really important. Like you have to know about your disease. And you have to know that insulin is a medication that you take, and that you cannot take off your pump for a day or two, you know, you have to know that you always have to have Basal insulin,

right, retrospectively, do you know how long she had type one for

years and years and years? And I think that that's also people who are older, like I find in the hospital, that people who are like in their 70s or 60s and they have a pump? I feel like they don't know quite as much about diabetes, people who are maybe diagnosed today. Yeah,

I think that's true. I also can see where if loaded on morphine. She was thinking, my blood sugar is low. I can't get too low. I'll take this pump off for a little while. Then

she wasn't actually loaded on morphine. And it was just decay. Oh, it was she was? Oh, I don't think I don't think that the morphine issue was at all an issue. She was going downhill because she was starting to be in decay, I think was misdiagnosed.

I see. I see. I see. Wow, geez. Yeah, listen, for people listening. Please don't take your palms off. Please, please, please. But isn't it crazy that even a person who has been living with it forever doesn't know, I need this insulin? I have to have it. I can't be without a background of insulin. Yeah,

and doesn't even look at it as a medication that they have to put on. Like that they have to tell you about. Yeah, it's just like something that they have in the background. And it's funny, because one funny half, I did that. A few years later, I had a patient who had type one. And I went to visit him in the hospital. And also he had been getting chemotherapy and infusion center and his blood tests were off. And so he also he went off to the war to be an inpatient. And I went to visit and just to see how he was doing because he wasn't doing very well. And I knew he had type one. And this is after my daughter was diagnosed, I was super vigilant. And I said, he said to me, Oh, by the way, I don't have infusion sets here. When am I going to go home? Cuz I haven't had my pump on since yesterday. Wait. And I said what? And he said, Yeah, I you know, I came out and it was an infusion center. And then I didn't know that I was going to be admitted. So I you know, when what am I going to be able to go home because I don't pump on that

lack of urgency. It fries my mind a little bit. Like I have just beaten into my daughter's head that if that pump runs out of insulin, and you didn't expect it to if it falls off, everything in life doesn't matter anymore, you stop what you're doing head directly to insulin and get another pump on. Right? Right. It's one of the non negotiables of our of our, our existence and to hear somebody say Oh, my thing got knocked off a day and a half ago. And

again, the reason that he thought that is because his blood sugar's were normal, because he also he was in liver failure. And he wasn't really eating, and his struggles were normal. So he didn't need to get insulin from the nurse. In other words, whenever they came to check his sugar, it was normal. And he didn't feel like he needed to get insulin as a correction.

DK is not attached to a number and it can happen very, very quickly. Yeah, yeah. Yeah. And so is it fair to say that? Do you meet more people with diabetes? Who understand it? Or who don't understand it? Or is it very age, or generational? First

of all, in general, and cancer, like most patients are older, and type one is relatively rare disease so thoroughly, I meet so many type ones. So it's hard for me to say, but I mean, most of the people I meet are 50 and

getting away from type one for a minute What are like what are your bone chilling stories that have more to do with I can't believe a physician didn't understand this, then it does diabetes.

I think I have other things that like stand out to me that like I'll never forget. And again, the reason I don't forget these is because for me the decay patient was like my trauma. Yeah. And afterwards, it's just a habit type one so I'm super vigilant about type one. Yeah.

In your intake you the things you want to talk about. I'm very interested because of the perspective you set this up at like B Basically a doctor's perspective before and after having a personal experience with the disease. And but your first thing on your on your list is Doctor bashing. So what did you want to say about that? Well,

if I did the doctor bashing, by the way, I'll say one more thing about that patient that I had, that I called endocrinologist for the patient who was having normal blood sugars, but didn't have his insulin pump on. And the endocrinologist said, and I said to him, he's type one. And he hadn't had insulin for two days for almost two days. Like, how much basil Should I give him? And he said, What are you talking about his sugars are normal. And the reason I mentioned this is that even Endocrinol she was an endocrinologist in endocrinologist and training others as a sub specialty. And after he talked to his boss, he did get back to me with the number of units. But even endocrinologist don't see type one very often adult endocrinologists. It's more

about type two for them. Yeah, yeah, it's diabetes.

Yeah. And it's hard. Like, even for that, like, it's hard to see. Like, when there's a situation that's super serious, like I was saying to him, like, they're the situation yet. It's super serious. And I need to know, you know, what I should do? And if it would have been anyone else, they would have been said, okay,

yeah. But he sees that number and just goes, I don't need insulin. Yeah,

yeah. And again, I mean, I hope that throughout his training hall, get trained better. And he probably learned from that patient. But most doctors wouldn't have known to even make the call to the endocrinologist. And yeah, many endocrinologist when they definitely want to have, you know, set him know, talk to your attending physician.

Doesn't that frees you though? Like when I when you see, it's funny, like when you said that? I'm almost stunned, like to the point where I can't think for a second, trying to imagine all these people out in the world who are counting on all of these physicians. And a basic idea like that. I don't care if they were new or not a basic idea, like that's not understood, like what chance do we all have? You know, so

I brought that up before the doctor bashing just because I want to say that I do appreciate that doctors definitely need more education, but I feel like the education they need. First of all, it depends on what your specialty is. In other words, there's a difference between family doctors or pediatrician and an endocrinologist, as opposed to an oncologist or surgeon or orthopedic surgeon, you know, people need to know different things. And I feel like most doctors, they don't need to know the ins and outs of diabetes, they need to know when they need to ask. And others. That's how medicine works. Because the specialties, like once I'm an oncologist, I really don't know general medicine anymore. And even within oncology, I'm a GI oncologist. And I can understand about breast cancer. But even now, and it's been three years since my boards, I can't I don't feel like I can treat it well anymore. Because I don't know the new data that's coming out.

Let me say this before we go any further, because I've been doing this series for a bit now. And I live in two different hemispheres of my thinking on this by first is on the ground level at a human level, you're the one saying you know, you need to know. And then I pull back. And I look at all the stories that have been told to me. And I've tried to incorporate everybody's perspectives. And I think that doctors are in an unwinnable situation, because there's so much to know. And they're just people. So they have to be able to hear all the things you're saying, connect the dots correctly, then reach into their, you know, computer bank of understanding, pull out the right answers, apply them correctly, somehow communicate them well to you, you have to do them correctly, it's pretty much impossible, right? You're asking a person to do the job of a computer, which by the way, is going to lead me to say over and over again, probably over the next couple of years on the podcast. I think that the nature of being a physician is going to be changed significantly by AI. I

disagree. Go ahead. I disagree on that. It's not that I don't think that AI is going to be incorporated into doctors worlds. And like I think in general, everybody's going to learn kind of how to use it in a way that actually benefits people in society. I think that with doctors when you meet it, first of all, a lot of being a doctor is being able to relate information. And also to get the information out to the patient. In other words, the patient. Yeah, they can put some stuff into computer, but they forgot to tell you a lot of really important things, for instance, not telling you that they need insulin, or not telling you that like they came for something and you kind of asked him questions. And then like 15 minutes later, they mentioned something that's super serious, but they didn't even think to tell you that before and it's not something that you would have thought to ask. Yeah, so I think that we're very far from like computers being go through that.

Well, that's incredibly common. Obviously, it's people just not telling the whole story. I've just recently had, I did this thing the other night for myself, right, I took this long standing issue, I've had my life. And I opened up a chat GPT four o window where I was actually speaking to the computer, and it was speaking back to me. And I said to him, Hey, I'd like to have a long form conversation about a health issue I've been having for 20 years. And I don't know that I'm gonna get all the information out. So let's have a back and forth. And then I did that I actually just talked to the it was my phone actually talked to my phone for 20 minutes. First of all, it was one of the more cogent conversations I've had in the last six months, which was upsetting to some degree. And I started thinking like, maybe I should start talking to my phone about what what I thought about the movie I just saw, because maybe it'll be better than some of the friends I have. It went back and forth. It asked questions. I, as I went along, would go, Oh, you know what, I forgot to mention this. And then I added that. And what I realized was that the the AI, it hears everything I say, it's not biased, and it doesn't forget. So even if I mentioned something, and then I make a left, turn in the conversation, and never get back to it, it doesn't forget that I said that, right. I'm almost trying to say that AI has. I feel bad for doctors now. Because now I'm recognizing more and more. We're asking them to know everything, and then be able to recall it. And that's not fair. And I don't see how anybody could do that.

Does that make sense? Right? Which is why like, it's, you know, you've mentioned before in the podcast, but if it sounds like a horse, right? That's what it is? Yeah. Because in the end, like you have to go with what's common first. And it's not that you're forgetting that there can be other things is that your first checking or trying to treat what's common? And then if that doesn't work, then you have to go back and kind of ask more questions and reread the notes and think again,

what is that? A I had a conversation with your husband? 20 years ago, don't you think it would have come up and said, hey, you know, you might have celiac,

I think it wouldn't have been hard for anybody.

They're like, listen, we didn't want to stop eating bread, leave us alone. But you don't I mean, like, I wonder if and I take your point, like, I'm sitting here trying to be very thoughtful about it. And I'm having this very Intel conversation with the AI. Most people are going to go, my head hurts. And then where do you go from there with that, right? Like they might read my doctor,

you have the basic questions that you're supposed to ask to try to figure out. What kind of headache is it? First of all, there's something dangerous, you know, or not, and something that's emergent. And then from there, you keep going to try to figure out what it is based on differential diagnosis that you have in your head.

But I can't teach the AI to differential diagnosis, know that you can definitely listen, I know it's your job, and you still have like, 25 more years, you got to make money. I'm going to plant my flag in this one for the future. So I can come back to it. If I'm wrong. That's, that's fair. I think that doctors jobs are going to shift to be the human eyes, on the algorithms, understanding of what's going on.

I will say the beauty of oncology is that it's as opposed to other like to internal medicine, or I'm not trying to diagnose and I'm trying to figure things out so much. I'm trying to figure out what the patient how they want to be treated, and how to treat side effects that they have and how to treat things that have to do with the cancer. Yeah, so I think that my job is pretty safe.

Because at no point are we going to put a person in front of a computer screen and say here make her feel better. So like, you know, like,

this is your prognosis, what would you like to do now?

Also, I think Modern medicine is insanely good at some things, right? Like the mechanical stuff, like surgery and emergency care. I think it's it's Nexen. It's second to none. It's amazing. You know what I mean? But it's when you get into that diagnostic stuff that's beyond normal. Or when it gets into, I mean, something like type one diabetes care, which is so much more, what would you call it? Like, it's my it's more art than science? Maybe?

You know what I mean? And I think also that type one is really different than other diseases. And it's one of the only ones I think are the only one that I know of that it's really like you at home have to make decisions all the time and to change your dose. And what how much you're giving now how much you're giving afterwards. You can't wait the three months to see the endocrinologist to figure out your trends. It's like you have to change it by yourself. Yeah. And I think in most other like I can't think of anything else that's like that, that it's not the doctor actually designed to give you a medication and telling you when to take it and how much to take it. So type one is really different even in other chronic illnesses or illnesses in general. Why

I wonder then, why do we try we doctors? Why do we try to give static advice for something that's so clearly Ever changing. So I

don't, I think there's two answers to that one, I don't feel like I got static advice, good. When she was diagnosed, it was kind of clear, like even the person who did the pump training for us. So she also had type one. And she said, you'll see like, you'll start changing things in your pumps on your company, see, the things are kind of going wonky for your Basal if you're, you know, you'll make changes. And the doctor was also really clear to him in the beginning, I called him every single day, he said, Call me every morning, tell me what her number was when she woke up, and we'll decide on the Basal dose and, and at that, you know, every night call me and tell me what her what her numbers were throughout the day. So in that sense, he was definitely saying that's ever changing. And he was also taking responsibility for him. And I don't know how he does that with every patient. Yeah. And I think different patients at different points feel more comfortable saying, Can I change about myself or I'm going to for

you, when the phone calls went away, when it was no longer comfortable to call somebody every morning? Like, where did you get the confidence to keep doing that as things changed.

So I think it helps to be a doctor, first of all, okay. In other words, like, I never started with, like, not having confidence, I didn't know, I didn't know about type one, I knew that there was basil on it, there was Bolus, like I knew the basics. But I think that, I mean, it's not as scary to use medications to make changes when it's something that you do for other people every day. And I also think it's like, they gave us the basics. And then when I thought we went on a pump, about a month and a half after we were after she was diagnosed, she was on the Omnipod dash. So I just like I knew what he was going to say. I mean, I knew that I was going to say, Oh, she's going up higher, about nine o'clock. So we'll say oh, so change the basil at seven. So eventually, I said, you still want to keep me keep calling you.

I think the point is, is maybe at the core of everything, I'll say all the time that the people who find the courage and the knowledge to make adjustments to their insulin, without a doctor are the ones who end up succeeding the best, you know, like it just that autonomy and confidence. I mean, obviously, it's a need. But if you it's almost like telling somebody, like you can make your thermostat 68 degrees. But if you want to change it, you're gonna have to wait 90 days, and then drive to where I am. And then talk to me about why you want to change your thermostat. And for you know, what happens if it gets warm or cold during that time and you want to move the thermostat back and forth, you look at it, you go I know, this thing could make me warmer or colder, but I'm not allowed to touch it without going and talking to the person that I really think that?

Yeah, I mean, I only have, you know, my experience with endocrinologist that we're with. And that's definitely not the way you know, like, he never had an expectation that we wouldn't change things. And I think the opposite. He has an expectation that if you have the capabilities to do it that you will don't and he only doesn't do that, or people don't change it. Some people just don't have the capability, let's say to do it or to do it in a safe way or to understand it as well. Maybe, right. Sure.

Well, don't you think you you got the autonomy? Because you were a doctor? No, no, you think that you think this doctor tells everybody the same thing? Yeah, okay. Yeah. Well, you got a good doctor, then. So then that's the next part of this whole Doctor thing. Right.

So it's really complicated, though, to say that because I didn't, it's not that I get a lot of information. And I think maybe this goes back to the doctor bashing is that I think that you have to have realistic expectations, like also, with what you expect the doctors to know what you expect them to explain to you when you're first diagnosed and a little bit afterwards. And that doctors have reasons sometimes. And it's not that they don't know necessarily about why they're not saying things, for sure. And in the beginning, you know, you can't have all that information in the beginning. And we left the hospital without a Dexcom. And I have to say that I don't think it's a good thing to leave the hospital for Dexcom, which I know is a minority opinion. Because I think it did two things. One is that it made me not nervous to not have my Dexcom working because we didn't do it for two months without a Dexcom my daughter felt her lows in school. We don't have a school nurse. She was seven and she could still do it and she could fingerprick herself in class if she didn't feel good. And also I think that it was kind of good to just like get the basics down card counting my daughter after she was diagnosed. She would eat five to six bowls of cereal in the morning. Yeah, because she's starting now one bowl of cereal spikes really high hours afterwards. So I can only imagine what those five to six bowls were doing. And to me I checked her you know, before her snack at school, and then we will just correct and move on. Otherwise we would give the correction get the carbs. And that was it. Yeah. And I think that if I would have seen all that data, and I can only imagine that she was sitting Get the three hundreds for those two and a half hours until she went down to 200. And something when I gave a correction, I think it's okay to wait those few months. And to just get the basics down.

I'll play devil's advocate because it's fun. I think you have the luxury of feeling that way because nothing bad happened.

I don't think that something bad happens from having high blood sugars for a few hours. Definitely not for a few months.

I don't mean high blood sugars. I mean, like, in the first six months of my daughter's diagnosis, she had a seizure. If she was I just

I want to say something about that. Yeah, totally different. Totally different if you have a toddler. I'm talking to older kids. Okay. Like, I think that having a toddler is completely different. You can't communicate with them, for them. Definitely impossible at the Dexcom 100%.

But let me ask you, let's just again, what if on one of those mornings with all that cereal, your daughter had a honeymoon moment and you had pumped in enough insulin to cover seven bowls of cereal and then she went to school and passed out. Do you think you'd be saying it's okay, not to have a CGM? Because it's good. You get to learn. But

what I think is that she checked herself and she knew how to treat her lows and it gave confidence.

Oh, I agree. Listen, everything you said there's value to like, I 100% agree. Like,

I don't think that would happen. In other words, it's she went she started honeymooning, right. Like she had anyone for about a month. And in that month, we didn't have a Dexcom. And it drove me crazy. Because we were at the park and suddenly she wasn't feeling good. And she was 40. Like we had bad loads or, you know, she went to sleep and she wasn't feeling well. So I checked her sugar when she went into bed. And she was 30. It's not that we didn't have loads. I didn't. We didn't have it kind of showed me that. Yes, she would feel her low. And yes, we can deal with it. Despite the fact that I don't know how fast she's falling. Yeah, so we gave us carbs. And we checked her again, after 10 minutes. And then we gave more carbs if we needed to know as seizures are few and far between.

In general, you think so

it's not that nothing bad can happen. But I think that in this in the month, usually after you're diagnosed or definitely in the first few weeks, you're usually your blood sugar was so high that until you start hunting money, you're usually not going to have crazy lows. Okay, so I think it's okay to have at least those two weeks of you know, going home, figuring out what you're doing, and not seeing all the data. And again, it's not that I think that it's good to not have the alarms is that I think that seeing so much data, maybe isn't the best thing when you come out of the hospital.

It's and listen, I'm not arguing with you. I will say that. I mean, call me back in 20 years, maybe is the way I'm gonna say this, but like, I, my, my daughter has had one. She had one seizure when she was six months old. We just didn't know what we were doing. We had a high carb meal, we thought we did the right thing. She took a nap and had a seizure in her sleep. It happened again a couple of years later on activity. So we were at an amusement park all day out in the heat. At the end of the day, she saw a vendor holding like, like popsicles. She asked for one, we Bolus for it. She had a seizure two hours later. I know now, by the way that I you know at the end of all that. All that it was super, like I didn't need to give her any insulin for it. Right. I know that now. She didn't have another one again until the night of her senior prom. On a day when she heard very little food and had very little insulin was wearing life saving equipment and all that other stuff. What I'm going to tell you is I 1,000,000% believe and agree with your message. I really do. And I think that the only reason you're able to deliver it is because you didn't have one of those random things happen to you because I don't think you were a CGM. For most of the time you were it for the moment that you can't plan for that you don't see coming. That's my feeling. And you just haven't had one of those moments yet when I hope you never do. Like but

now we're on the CGM. But again, I think that when you're when you're diagnosed and your sugar's are super high, it takes time for them to come down. So I think that you do have a leeway of at least two weeks where it's okay. You don't have to be stressed about getting a CGM because I see people writing you know, like, don't leave the hospital without one. It's okay to leave the hospital without one. You know you you have to

Yeah, no, I take your point like it doesn't like I do see your sad one

after two months. Yeah, we and we didn't have and I would have wanted to have one even before when just when she was honeymooning and I knew that she was having lows. We were no

I think it's a good conversation to hash them. I also don't think there's a right answer and I think that the right answer is for whatever ends up working for you. What I'm saying is it also has to do a lot with your personality like for some people were like look, all that data would be overwhelming. There are other people would be like I'd find all the data comforting, like so your personality, the situation you're in, etc. But I hear what you're saying, If you can't get one right away, like, please don't act like it's the end of the world, you can test you can be careful, you can put safeguards in. And there's a lot to learn along the way. You know, I'm agreeing with you, and at the same time trying to have a conversation, right? Yeah. Yeah, yeah. Okay.

All right. And by the way, like in terms of Outlook, like if my daughter had a seizure, right, what I freak out or not, then and also afterwards, also, in that sense, like being a doctor, I think, and it's possible, it's my personality, without being a doctor, but like, the way that I look at illness and death, and I'm not saying deaths from diabetes, but in general, fatal illnesses and chronic illnesses. I think it's different than like, you were talking before, about, like how modern medicine is amazing in a lot of ways. And I think that it kind of got us used to thinking that everything is fixable. And that, like illness and death is something that's traumatic and not natural. I think that I have a different perspective on that also. So it's also like, if we need to use glucagon, I hope we don't need to, but I'm not sure exactly what my reaction would be. And if it would be freaking out afterwards for the next 10 years.

Yeah, I don't know. I also don't think it happens to some people at all. Like, I mean, it didn't happen to Arden. Like she had that seizure a couple of years ago. And, you know, she was shocked for a couple of days, maybe three days, actually, like, she was like, 17 years old, like she slept on our bed for a couple of nights afterwards. And then one day, she just got up, and she's like, I'm gonna go in my room. And I was like, okay, and then we talked and we talked a day or so later, we talked about on the episode where she just said, like, I've thought it through, I didn't do anything wrong. And that seemed to comfort her. For so many days and weeks and months and years, I do the same things over and over again. And I was okay. Yes, there was a variable in here that like, she's like, but it's uncommon, and I don't think it's gonna happen again. So I'm gonna go back to my life. Whereas somebody who's maybe bent towards depression or anxiety that could end up making them scared for a decade, like, and I've seen it happen, you know what I mean? So, it's interesting to talk about blanket statements overtop of such a moving target over top of so many different personalities and experiences and, and that's why there's no like one size fits all accommodation, for sure. Yeah, that's just my perspective. No, I love it. Are you kidding me is fantastic. I need to listen without these conversations. I don't know if you know this. The podcast is boring. And then nobody listens. And then Scott's got to get a real job. And I don't want to do that. So imagine if I worked at a store or something like that, where you came into? I would chat chat. Talking to the customer. Yeah, great. Oh my god, I'd be the most popular cashier. I'd be like, I'd be like, hey, what do you know about this? And then we start talking about something crazy. I heard on a podcast probably. But anyway, so Okay, so on your list now what's the nondiabetic? You? Here's your list, I'll give it to everybody. Dr. bashing, nondiabetic number. Parenting versus body autonomy. I love this one. I want to make sure we get to that. Why don't we do that one next? What do you mean by that? And you say parenting versus body autonomy? Because I have a lot of that. Can I say one more thing about the doctor bashing? You want to do some? He's heard but doctor you want to know, Dr. Bash, but

I didn't say the other. Is that, like, I tried listening to the Grand Rounds, and I couldn't I stopped in the middle of the of the first real one. Okay. And, and I think that, I think, again, that you really have to take in perspective, like what you expect of a doctor and what you expect of yourself. And I really feel like we talked about a little bit in the beginning, but that like, it's, it's your illness, and it's like, I'm freaked out that my daughter is gonna go to the hospital when I'm old and can't go with her. And nobody's going to know, you know, how to advocate for her. Yeah. But in a normal world, or person, that you're not by yourself. And either you can advocate for yourself or have family member advocate for you. Like, I feel like that's really like where the education needs to be. And education for doctors again, like has to be a kind of mentioned before, like, it's, it's how to not miss something that's important. And that's true about every illness, and not only type one diabetes. And it's knowing that you have to call the endocrinologist if you're going into surgery with somebody who came in with type one diabetes, and they're not conscious, and they can't talk to you and say things are, you know, how you're supposed to do their sugars when they're in the ward and they're getting, I don't know, TPN or they're getting glucose in there, you know?

So, I think you being a physician and the nature of your personality, it gives you a certain perspective, obviously, but let me let me ask a couple of questions and see if you see a thru line here. Once a week, three men in a truck come down my street and take my garbage away. If they took To the cans and not the third can do I have to go outside and advocate for them to take all the garbage? I

think first of all that you could say, maybe they didn't take it because one of them had to go to the hospital suddenly. Yeah. But

but you know what I'm saying? Like, it's the I didn't see this once.

I'm not saying that I that the doctors don't have responsibility. I think that the expectation that they'll have so much responsibility or so much knowledge, that that's not realistic. I agree with you. Yeah. And that, therefore, mostly, you have to have it and they have to know, hey, this is something that we have to check out. And it's also knowing a doctor has to be able to ask the patient. Oh, you have type one. You know, how do you get your insulin? Oh, they have a pump and CGM. Okay, during your hospital stay? Do you want to take care of it? Or do you want us to take care of it. And that has to be a conversation that can be had with the doctors. And it doesn't have to do with them understanding it has to do with them understanding what type one the type of disease it is, right? And that a patient who's awake and take care of their diabetes better than they can. And also in the hospital, generally patients, like when kids are sick, or people I just know about kids, I have a kid and I'm not the one that's type one. But it's really hard to manage blood sugars. And it's really hard to manage blood sugars for somebody else. Yeah. And I think that you also have to have grace in the hospital that in the end they are when you're in the hospital, they're trying not to kill you, if you came in for diabetes, they really know how to take care, right? They know how to take care of DKA really well. But if you went in for something that's not connected to diabetes, they're taking care of that thing that they have to take care of. And they're making sure that your diabetes is decent and decent is decent in hospital hospital, not decent in the life.

But how are somebody supposed to know that like, so? If I'm just a family or an adult, and I've been alive for 20 or 30 years, and so far, health care has been one time I got the flu and I went to the guy and he gave me Tamiflu, or I fell in my arm broke and I went to the guy and he fixed my arm. How is all the sudden? How am I supposed to know all the sudden that the All Knowing all seeing magic Doctor Who makes more money than me drives better car than me, went to more school than I did says they know all about medicine. How am I supposed to know they don't know where that they don't have good news

is in Israel, we make very little money. Public health care system. Everybody thinks that they know the best thing for everybody in this country. And they will tell you that and nobody's GCR speaks with respect. So we don't have that problem.

I know a lot of Jewish people, and if I can make everybody Jewish, then I would assume that they can advocate for themselves. But

what about the people? What about the people who were also very nice.

I didn't mean it that way. I just I but but but you know what I'm saying? I'll

tell you how. Because because when you're in the hospital that flick a blip in your month or your year. And then you go you have a primary care doctor care doctor, and you have an endocrinologist, and they're seeing your agencies and they're seeing the endocrinologist is looking at your trends. But even the family doctor sees your agency went up from I don't know 6.3 to seven. Yeah, they're supposed to notice that they're supposed to say to you, hey, what's going on? Maybe you need to go back to the endocrinologist. Maybe we can talk about and figure out what's going on. But that's not for the hospital that's for your you're not supposed to leave the hospital or at the hospital isn't your primary care and diabetes is really something that has to be handled in primary care.

Yeah. But how are people supposed to know that? Because their

doctor sees it. I see people say once see, it's like, I don't have an oncologist. I'm not taking care of it. I see that somebody has an ailment, see, let's say they're coming, somebody had colon cancer, they're coming to me, and they're healthy. Now they don't have cancer. And they're just coming for a checkup. And they did blood tests for me, right? I care about specific things. And I don't care about the diabetes. So when I see that they have an A one C of seven, I write to their family care doctor, that they need to go see it to diabetes clinic. And I asked them is who's you know, who's taking care of your sugar is taking care of your diabetes?

I'm not being clear. I don't think if I go to a hospital, how am I supposed to know that's not where I get this care? Doesn't that seem like the place where you get that care? If you were a person on the outside was not connected to the medical industry at all. You're not a doctor, you're not. You don't go to

the hospital and you just have a flu, you go to the hospital because you have something serious. So I don't think anybody thinks of a hospital as a place that that's like where you get regular care.

I swear to you I think you're wrong. Though I think that people think I don't think they think of the hospital and the doctor's office and an emergency care center. I don't think they think of them as anything different. I think it's I think they believe it's the place they go where people who know better than them are. And when you get there

better than them about specific issues. Yeah. And again, I find that that's something that that people have to be educated. Yeah.

How are we going to do that? How are we going to do that? By

talking about how about learning about their disease and actually, you know, going on Google and looking, you know, looking for answers asking your doctor questions.

I heard an actor on a podcast the other day told me that straight lines aren't a real thing. I heard another I heard a basketball player telling me that the globe is threat flat, you want them to know about this too, like they don't people don't know about anything they don't know, inside of my sphere, the world I've set up for myself, I'm all knowledgeable. If you take me outside of my sphere, I don't know a damn thing about anything. And so what I'm saying is that people have never been sick a day in their life. Just think that when they get to the hospital, everyone they're talking to knows everything that they need to know. And the where that problem comes in, is that obviously those people don't know everything. But if I think they do, then I take what they say as gospel, I also believe there's nothing else because you don't go to the doctor, and he tells you, hey, you have to take one of these pills every day at 8am on an empty stomach, take it Monday through Friday for the rest of your life, you don't imagine that they left something out.

I think times are changing. First of all, it could be different cultural things. But I think that it's not the same, you know, like they talk about a lot and you know, in medical school, and that people don't come to the doctor anymore like that. Maybe it's people who are older, but not people who are younger. And again, it's not that I don't, I don't think that you need to advocate in the sense of arguing with the doctor on call, or that you need to know what you need them to be aware of. And what things are really important to

dig into this for me, what does advocating mean to you? If I have to advocate for myself? What is it I have to do?

First of all, to me, it's even at the start, the doctor comes and asks how you are so you know, you have to put your type one diabetes, in the front of that conversation, right? When you're sitting in the ER, it's only if you if the doctor is not doing those basic things, right. That's when you have to advocate in a way that's maybe or arguing or standing up for yourself. So in general that in life, you have to stand up for yourself, that's just the way it is, you know, an ER has a million people in it. And in the end, and it's sad, but you have to make yourself heard.

So you just said if the doctor doesn't do what they're supposed to do I have to make them do it. How do I know what they're supposed to do? No,

you don't have to know what they have to do what they're supposed to do in terms of your stomach ache, you need to know your type one diabetes, you need to know your chronic illnesses that if something goes wrong, you can die it. That's, that's you need to know what that means. And then type one, you know what that means, right? You know, you have to be getting insulin, you know that you have to be checking your blood sugar, right?

Is there a world where I should expect a doctor doesn't know that.

Again, I think that in type one, as opposed to type two, that they won't necessarily notice in the same way, if a type two is in the ER, right? For 24 hours, it's not the biggest deal in the world, if they didn't quite get the insulin dose that they were supposed to be getting, right 24 hours, it's not, it's not gonna be the end of the world, I don't think that you can expect that the ER doc is going to notice that your pump is off and that you're not getting your insulin because when you're in the ER you don't, they don't ask you for your like, they don't give you your basic medications, at least not here. That's if you go to the ward. So then you sit down, you know, and you write in all the medications and you have all those orders. But if you're in the ER, you have to tell the doctor if there's something that you need to get that as well. It's not something that just happens.

So I should trust the doctor yes or no,

I think that you should trust doctors. And I think that discussion with the doctor starts from trust.

So let me keep going. So I have type two diabetes, I've been told by a doctor already that it's very important for me to take my insulin every day, keep my blood sugar's in a certain place. And then I go to the ER for, I don't know, I can't fart, whatever. And now I'm in the ER and for a whole day, they don't care that my blood sugars are high. And then they're really, there's

no way that they're gonna let you be riding so high. They'll give you corrections. It happens all the time. You're there for 24 hours. Yeah, you should tell them when it's eight o'clock at night or nine. Whenever you take your long acting, you should say to them, Listen, I actually got my long acting, and then the doctor will put in the orders for that. But you can't expect the doctor to remember that you're tied to and that you're on MDI and that you're supposed to get your land and that you've been in the ER for more than 24 hours. So you have to get some time in that timeframe.

Right? No, I agree that the person should say that I agree that the person should recognize that they need to take their insulin on their own. But also, they may be thinking that you're going to take care of it. And also my my bigger point was is that if, if a doctor has told me, Hey, my blood sugar should be between 90 and 120. That's optimal. And then I get to the hospital and my blood sugar's are 180 to 220 and they go It's okay, while you're here, it's fine. How do I not go home then and think, oh, maybe 180 to 220 is okay, maybe the first doctor was wrong.

I think that I think that there. Obviously there's a lot of space for educating doctors, but I think educating doctors is educating that. In other words like that a doctor should be able to know to say to a patient like when you're in the ER Then as your sugars are higher, you know, when you go home, you'll go back to doing what you usually do or go back to your endocrinologist if it's been working out.

I'm just saying that how how do we not expect that that person who's now been through that hospital experience doesn't leave? They're believing that a higher blood

sugar's Okay, still have a family doctor, they still have somebody who's checking their labs, one every once in a while, and somebody who's been to the ER should definitely their family doctor should know that that happened. So there's always supposed to be somebody who's catching that.

Do you really think that happens, though? Do you think people leave the ER and then call their GP?

I think that's supposed to happen. That's what No, but I think that that's where, like the issue of like, how can you make the healthcare system better? It's not for all doctors to know about type one diabetes, it's to be able to have a situation where, yeah, you go into the hospital, and then you, you know, like, somehow gets sent to your GP or your GP knows, or they tell you, you know, you have to take this back to your GP, you know, you get you got a discharge paper, you know, usually like by us, it says, you know, you know, bring this to your family

doctor, you're ignoring the the human aspect of it afterwards, nobody's going to do that. They think they're okay, now they left the ER, the pain is gone. They farted

there think that the people who think like that are also gonna have a really hard time controlling the type one diabetes, because they're not involved. Well, yeah.

Oh, but that's my point. My point is, is that of the like, I don't know what it is now. 1.8 million Americans that have type one diabetes, a very small percentage of them even use an insulin pump where no one is.

But if you see somebody in the ER, right, who came because of DKA, because somebody like that is probably going to have high sugars when they come right. And they should get an endo consult, and they should get they should get an appointment for them to chronologist.

But what if I ended up with the Endo? Who didn't know that the person needed basil? And even though their blood sugar was lower? Well,

that's I'm saying there is that obviously, like doctors need to, but I think that what you hear here, right, is you're hearing people who have bad experiences, and not as much most of the people who are having a decent or good experience. And that's just the reality of having

I think most people are having bad experiences, and few people are having good experiences. And I think the numbers about people's a one sees, like, bear that out. Like, I think that I do a podcast for a very small section of people. And that most people who have type one diabetes are not even hearing this.

Probably, but I think that that's also why doctors need to be able to give rules that will keep health decent, and not necessarily the best. But even if it's really, really late, so I'm sorry. No, I don't have a problem.

I love this conversation, by the way. And I really appreciate you having it with me because a spirited conversation like this is the only way to get the idea into people's heads. Because I'm not certainly saying that there aren't great physicians. And I'm not saying that people don't drop the ball in their own care all the time. That obviously happens. I'm just saying from a human point of view, I don't think you can set up a system that relies on the average person to understand what they're supposed to do for themselves.

So I think that in America, the system is much more complicated and not good system, right? Because, you know, everybody, you have your insurance and you have the some other nobody's really talking to each other. But I think it works differently in other countries and that there's something to learn. I

would imagine there's something to learn from everybody. Yeah. For certain. Okay. Okay. Parenting versus body autonomy. This is another one, I have to

say I do want to talk about the diabetic goals, though. Save two minutes for that.

It doesn't have to be just an hour. Do you? Can you go a little over?

Yeah, no, I'm fine. I'm fine. Just like that. Did you ask it that? And like, was there anything else you wanted to say? I

like that you listen, okay. Okay. So parenting versus body autonomy. What made you say that? So

I feel like a lot of people, you know, like, they're like, oh, you know, fine. You know, it's been five years, and my kids ready for a pump now. So what are you guys talking about? Or like, you know, we're definitely no, it's, it's her body and or his body and their decision? And I've heard you kind of say it also, I think, but I really don't agree with that. And I think that parenting as a whole is deciding what's best for your child, in many, many aspects, right? We push them to do the things that we think will be good for them. We choose a lot of things for them. And I think that the issue of going on a pump is that your kid can't know what it feels like to be on a pump, and what it can help with if they didn't try it. Now, when you go on a pump, you have to know that whenever you change something, right, going from a pump to an algorithm pump or going you know, back to MDI is always going to take a while of figuring things out. Because different things work differently. And you can't expect to be on a pump for one month and be like, Oh, it does work or doesn't work. So I think that you have to push your kid out there. It's like I didn't ask my daughter she wanted a pump. I said to her, Listen, I didn't even ask her what pumps she wanted. I looked at the pump Um, so I checked what I thought would be best for her. And then I said, Hey, look at this video online, we're gonna get a pump soon. And when you get a pump, you'll be able, I feel like a pump is really important, you know, and diabetes has a lot of disordered eating and eating disorders, right. And I feel like a pump is really, really important for that. It helps you keep your eating just being natural. When you're hungry, you eat when you're not hungry, you don't eat and if you want another bowl of pasta in same meal, you just give yourself a little bit more insulin. Yeah. And especially like now we change to lume. Jeff, so even more, so it's like, we don't have to Pre-Bolus. And that makes it even more natural, except for unless she's high, and we have to bring her down first. So I don't think I think it's not, I think it's the wrong thing to do.

This is boring. We agree. So this is so boring now, because you and I agree.

We agree that but I feel like I feel like on the Facebook page, but it's a minority opinion. And yeah, maybe to you here, I don't know,

somehow my body my choice got mixed in with it's their body, if they don't want to wear something they don't have to. That would be nice if they didn't have diabetes, like like, and I would agree with you, you know, but

again, if your kid is on a POM for three months, so you've already you know, you've given it a shot, and they don't like it. So yeah, go back to MDI. Because they they understand, like, my daughter understands that if she doesn't want the palm, then she's going to have to do a lot of injections. Yeah. And that will have to do corrections with an injection. And also, especially for little kids. And definitely during honeymooning when you can only give full units. Sometimes she didn't want to eat a snack that was 30 cars when she was a one to three ratio. And like a pump gives you all all these things besides like actually be able to, you know, change your basil and to do a lot of different things and to have an algorithm, like just having a POM. It makes life a lot more normal. And you can't know what that feels like until you've tried it. Yeah,

I listen, I agree. I also think if somebody doesn't want to use a pump, they shouldn't. But I don't know that we make a six year old in charge of that decision. I don't know what Listen, my son doesn't have diabetes, but he's 24. And the other day we were talking about software, he's looking for jobs and stuff. And I asked him a question. And he goes through I don't know, in my head. I'm like 14. And I'm like, exactly. I think the way I've said it over and over again in the podcast is I don't know many other big life changing decisions that you let 10 year olds make. Right? Yeah,

I think like it's not only about like a pump. It's also what we wanted to change the type of ends though, when we wanted to start looping. So she was dead set against it. She liked her PDM she knew how to use it. She didn't want to learn how to press other buttons, and she really didn't want to do it. But again, like I didn't ask her like, Hey, do you think we should try this thing? I said, Sir, listen, I found something I think will be better for us. And we're gonna give it a shot. And we're gonna see how it is. And if you tell me later that you don't like it.

So we'll go back. This is how I do it, too. That's exactly how I do it. I also even now that Arden's older, she's 20. Soon, she'll be 20 in a couple of months. And just recently, she got low at school, and we were texting her and she's like, stop texting me. And I said, answer me, and I won't text you. And she's like, you don't need to do this. And I said, Oh, you don't want me to do this. That's fine. I said, start paying for school yourself. And it'll be fine. I was like, but right now, if you want me to pay for college, when I text you about this, you text me back. That's it small price to pay. Right, Alex? What are we asking for? So you don't have to pay the money. She just has to text me back. Right? And then we had a conversation later where my wife and I explained to her like, look, I understand that it might be it sucks. Like you're sitting down, you're working you're distracted, you know, you already fixed your blood sugar, right? Like it's been taken care of the number just hasn't bounced yet. And now we're bothering you. So the blood sugar, so you got low that sucked. You had to fix the blood sugar that sucked. It took you away from what you were doing that suck. And now all of a sudden, here we come. And it's just it feels unnecessary. Like but you don't know our side of it. I understand your side of it. I understand. It's not perfect. I wish it was I'm sorry. It's like this. But we can't just sit here wondering if you're about to die and not do anything. Right? And so that's what this is. And if you don't want this to be that, then that is to say that you don't want us to parent you anymore. And if that's what you want, then I really don't want to pay for college. If you're if you're that autonomous, that's rock and roll I go get a loan. Okay, listen, and I gotta be honest with you after school's over. I'm gonna look for another reason to be able to like to get her to like tell me she's okay. But be yeah, like I take I

think we kind of split on on the parenting.

I tried to make a bombastic description of what it is but I don't think kids like don't get me wrong if art and push back hard enough I'd say alright, this is obviously something you don't want them we're gonna but we can't stay in this current setup. If that's not Part of it. So we're gonna have to change the set, which I assume is going to happen over time to begin with. But your points more about younger kids, your kid, you know, diagnostics, I