Scott Benner 1/21/25 Scott Benner 1/21/25

#1411 GLP Essentials with Dr. Hamdy (Copy)

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Dr. Hamdy, Medical Director of the Obesity Clinic Program and Inpatient Diabetes Program, discusses GLP medications and the important steps to take when using them.

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Friends, we're all back together for the next episode of The Juicebox Podcast. Welcome.

I'm very excited to share this episode with you. I'm talking today with Dr Hamdy. He is a senior staff physician at Joslin Diabetes Center, the Director of International Medical Affairs, the Medical Director of the obesity clinic program and inpatient Diabetes Program, and an associate professor at Harvard Medical School. And he's here today to share his very important message for those of us using GLP meds, please don't forget that nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin 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, if you're a US resident who has type one or is the caregiver of someone with type one, visit T 1d exchange.org/juice box right now and complete that survey. It will take you 10 minutes to complete the survey, and that effort alone will help to move type one diabetes research forward. It will cost you nothing to help.

The episode you're about to listen to is sponsored by Omnipod and the Omnipod five. Learn more at omnipod.com/juicebox use my links to support the show. We're also sponsored today by touched by type one, and they have something great coming up on March 8. Touched by type one is hosting their very first steps to a cure walk. And you can register right now to participate. Touched by type one.org Go to the Programs tab, click on Steps to a cure and sign up today. You can sponsor walk or volunteer. Check it out.

Osama Hamdy, MD, PhD 2:06
I'm Osama Hamd,. I'm the Medical Director of the obesity clinical program at Joslin Diabetes Center and associate professor of medicine at Harvard Medical

Scott Benner 2:16
School. How did we meet each other? Who put us in touch? Do you remember one of

Speaker 1 2:21
our nurse practitioner, Daniel rock,

Scott Benner 2:25
what did she tell you? I'm interested. What made you be willing to do this? Yeah,

Speaker 1 2:30
he told me it is a very popular broadcast, very efficient broadcast. He follow a lot, and he thought that it would be a good idea that we comment on muscle mass and some of the work that we frequently do in that space on obesity. I had been in obesity field for 40 years now, wow, and I created the obesity clinical program at Joslin Diabetes Center as one of the biggest programs. We had been doing several weight management. You know, we did research that cost us almost $16 million to come with the the best weight management, multi disciplinary weight management program for our patients. It's called, why weight, weight achievement, intensive treatment. And then we have another program called diabetes remission outcome program, drop program, which aimed for diabetes remission in early inpatient, was early diabetes.

Scott Benner 3:27
Can I go to the beginning and ask you about how we got to that? Yeah, yeah, we can. You can ask whatever you would like. You know, you've been in it for 40 years. Let me ask you what got you into it, and what was it like back then, versus what is it now, and how did it change throughout the time? Oh,

Speaker 1 3:44
there is major, major change. You know, the whole concept that link obesity to diabetes was not clear in the old days. You know why people with obesity develop diabetes? Who will develop diabetes? Why Some develop diabetes and others are not until we discover the whole idea of insulin resistance, that once you are obese, and especially if you have more fat in the abdominal area and visceral area, you'll become insulin resistant. And this could be the reason why people, when they gain weight, the start to develop diabetes. So my early research back almost 25 years ago, we found that 7% weight loss improves insulin sensitivity by 57% Wow. So I remember I was whispering to my colleagues at that time, telling them that means diabetes is not a chronic disease. Actually, in reality, we can reverse diabetes. But that concept was not there at that time. Concept that this is a chronic disease, whatever you will do, there is nothing that can reverse it. But people who repeated those studies found 7080, even 90% after. Bariatric surgery significant improvement in insulin sensitivity, which means that if you catch it early enough, especially within the first five to seven years, you can actually reverse diabetes. So

Scott Benner 5:12
for type two, how does the bariatric help? Does it help with the weight loss, or does it help with the with something else, too many?

Speaker 1 5:19
The best to answer is that patients with after bioethic surgery, they stop their diabetes medication in frequently. Why they are in the hospital even before weight loss?

Scott Benner 5:32
Why do you think that is the what's the cause and effect? It is a

Speaker 1 5:36
reduction, significant reduction, in the anti hepatic fat, so when they are in the hospital. After surgery, they are not on oral feeding that much. It is all IV fluids or IV glucose. There is significant deficiency in nutrients in the beginning. So the easiest for the body to do is to take the fat inside the liver and use it as as a source of energy. And immediately, with the reduction in the intra hepatic fat, you will, you will start to see improvement. And then later on, when they start to lose weight, that's when you get the maximum improvement.

Scott Benner 6:17
Wow, that's insane. So, so you saw that you saw, give these people bariatric surgery, they what can reverse type two or stop pre diabetes, either or,

Speaker 1 6:29
you know, it depends in at what stage you are doing. If you are in the pre diabetes phase, definitely okay, you will prevent the type two diabetes. But if you're already on type two diabetes, when it is shorter duration, less than five years, definitely remission can occur for how long that remission will maintain. It is not studied significantly right now.

Scott Benner 6:53
So is the biggest hurdle, then, is losing the weight, not

Speaker 1 6:58
losing the weight in precisely it is when you lose weight, when you say lose weight, you lose muscles, you lose fat, but when you are when we are talking here, we are talking about the critical fat in the body. This is the intra abdominal fat and intra hepatic fat, visceral fat, intramuscular and sufficient fat, all this ectopic fat is dangerous. Okay, this is a problem.

Scott Benner 7:25
I hear people talk about all the time how extra fat impacts hormones and causes hormonal issues. Is that, is that something that you're aware of, today's episode of The Juicebox Podcast is sponsored by Omnipod. Before I tell you about Omnipod, the device. I'd like to tell you about Omnipod, the company. I approached Omnipod 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 Omnipod. They bought their first ad, and I used that money to support myself while I was growing the Juicebox Podcast. You might even say that Omnipod 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, omnipod.com/juicebox whether you want the Omnipod five or the Omnipod dash, using my link, let's Omnipod know what a good decision they made in 2015 and continue to make to this day. Omnipod 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 Omnipod, but please take a look omnipod.com/juicebox I think Omnipod could be a good friend to you, just like it has been to my daughter and my family. That's

Speaker 1 9:05
absolutely right, and I wrote about it before. You know adipose tissue is not an inner tissue. This is an endocrine gland. It secrets hormones like, for example, Leptin hormone, the satiety hormone, the major satellite hormone is coming from adipose tissue, from fat tissue. There is another hormone called the bone actin, which actually increase insulin sensitivity. Unfortunately, when people are obese, adiponing is low, and that's why they are insulin resistant. Interestingly, when you lose weight, adiponing start to go up. And to make it even more complicated, visceral fat is different than subcutaneous fat. Okay, those are two different organs in their genetic expression, in their hormonal secretion, in their even relationship to each other. And so the distribution of fat is. More important when it comes to the endocrine function of the devastation.

Scott Benner 10:03
How does it impact satiation? Yeah, there is a hormone

Speaker 1 10:07
comes from subcutaneous fat. Subcutaneous fat, okay, there's external fat, not the internal fat. It's called leptin. So Leptin is a hormone, one of the major hormone that induced satiety. Just to consider leptin as a defense lawyer for your fat. You know, anytime you start to lose fat, leptin goes up Shut your appetite. Try to preserve fat as much as you can. And interestingly, leptin has a circadian pattern, so it is mostly secreted between 8pm till 8am that's why we will are eating during the day, and they don't eat during during those hours, right? Exactly, right. So let me give an example. If we will get leptin abnormality or Lipton deficiency, they start to eat significant amount of food in the evening. We call them night eating syndrome. So night eating syndrome affect around 2% of the US population. And the eating average studies showed, in average is three big meals after their supper, three big meals. Each meal is 1250 calories. So you can imagine if that hormone is just deficient. Yeah, wow. Some people are, they are born, but this very rare born nose lipicsy And they are very obese from their

Scott Benner 11:34
younger childhood. For people who would say, just do a setup, go for a walk, like, can you tell them why that doesn't work all the time for people who are or in this situation,

Speaker 1 11:46
you know, your your body, need different types of exercise, and each exercise had its own benefit. It is, you know, walking is aerobic exercise. This is very valuable for your heart, for your cardiac effect. But other types of exercise has measured, measure different, different angle. For example, you you need, you need to stretch your body. And stretching your body, which people can do it just for 10 minutes in the morning, increase blood flow to to the body, reduce energy injury, improve movement across the joints. There is a lot of benefit from stretching, but the most important component of exercise is actually strength exercise. Okay, and you cannot do exercise without doing muscle strength exercise. And the reason, the reason is that as you age, you lose muscle mass over time. So normal people without diabetes lose around 5% of their muscle mass every 10 years from age 30 up, people lose diabetes lose around seven to 8% of their muscle mass every 10 years from age 40 up,

Scott Benner 13:02
do we know why people with diabetes lose more than people without?

Speaker 1 13:06
Oh, yeah, there are that is a very complex metabolic issue. But the bottom line is that from age 40 to age 70, you lose around 24% of your muscle mass. I see by ages 70 up, you lose 15% of your muscle mass during your lifetime. If you live till 40, from 40 till 80, you lose 40% of your muscle mass.

Scott Benner 13:32
Is that something that I can I can't stop it completely, but I can get in the way of it, right, try to to slow it down. Is that the idea?

Speaker 1 13:39
Yeah, yeah, no, you do all the effort to prevent it, right? Because loss of muscle mass is, in my personal opinion, is a crime. You know, if you lose your muscle, or anything that makes you lose muscle, you will be in terrible scenario. This is how frailty occurs. This is how we will get poor quality of life. You can even stand from your chair. It is a problem, but there are three major problems. Just to be clear, there are three major problems when you lose muscle mass. Number one, you will not regain muscle mass. You can't get it back, bye, bye, muscle mass. It is very difficult, because you build the muscle mass over years by three hormones, growth hormone, insulin, sex hormones, okay, when you get older, all those hormones are noose down, so you don't have them, so you cannot build muscle mass that much in your older age, or I will say, from even middle age, there's a first problem. Second problem is, once you lose muscle mass, your energy expenditure start to go significantly down, to a degree that if you return back to eat whatever you used to eat, you gain weight, and that weight is not my. Muscle and fat. It is mostly fat. So every time that you lose weight, you lose muscle, and then you gain fat. If you return the back and then recycling, go care. And this leads to what's called sarcopenic obesity. Sarcopenic Obesity means you lose muscle and then you have more fat, okay, but if you age normally, you lose muscle all the time, until you reach a sarcopenia. In this scenario, I say, Okay, the third drawback, just to complete the drawbacks of losing muscle mass, that quality of life start to go significantly down and by percentage loss in the muscle mass. So if you lose 10% your performance of the muscles start to go down. 20% you start to have reduction in your immunity, and you get infections and and problems. 30% you can get pneumonia with zords. 40% of muscle mass loss means mortality will be significantly higher. So

Scott Benner 16:00
how do we balance in I guess, starting with obese or type two community, people are getting GLP medications. They're having some of them significant benefits as far as weight loss goes, but so I don't imagine you would trade their weight loss. But how do you mitigate the muscle loss in the same situation, like, what else should they be doing that we're probably not telling them about Yeah,

Speaker 1 16:21
this is a very, very important issue, because we have to differentiate, Scott from the beginning, between quality weight loss and quantity weight loss. Okay, the weight loss was in keratin mimetic drugs. This is a group of GLP one and GIP and GIP and all this group is volume weight loss, quantity weight loss, not quality weight loss. Quality weight loss is entirely different. Quality weight loss means you lose adipose tissue. You maintain muscle mass, you maintain muscle performance. And quality of life is much better. But if you lose the adipose tissue and lose muscle mass in the same time and have poor performance, weakness in the muscles and so on, you will you will be in in trouble. And that's exactly what happens with those medication. You know, people are happy with the volume of weight loss, but it is not a quality weight loss. So is it

Scott Benner 17:23
possible? Do you think to use the GLP and be exercising and supplementing at the same time to keep a balance? Yeah,

Speaker 1 17:30
we need a lot of research in that area. But theoretically, that's absolutely right. If you take enough amount of quality protein, if you do a Strengths exercise. Very good quality of strength exercise, especially in the muscle, in the bearing muscle the body, bearing muscles around the size and back and and all this area, I think maybe you will mitigate some of the problem with loss and muscle mass. Yeah,

Scott Benner 17:59
so you don't know this, but I am 57 pounds lighter than I was two years ago, and from a GLP medication. Now I try to balance that with a significant amount of animal protein, and I do a protein drink every day to make sure my protein is high enough during that what I try to do is light to medium weight training in the beginning, arms, legs, poor, but it was harder in the beginning, because I was so I was so out of shape. Now, the irony here, I guess, is that as far as the amount of calories I take in, obviously I take in less now, because the GLP, it does, obviously, you know, kind of shut down your hunger. But at the same time, I'm not eating that much less, and so I noticed a difference immediately. I don't have diabetes, I didn't have diabetes, but I would have described to you that throughout my entire life, my body never responded to food in a way that made sense. My digestion didn't work well, and I had to, as an adult for years, get iron infusions, because my ferritin would drop through the floor, like every six months. But since the GLP, I don't need the iron infusions anymore. I now defecate like a normal person would, like, I eat, I don't get sick right away. And like, it has changed so many things for me, and I don't know how to put it all into words, like it feels like it's having impacts that weren't intended by the label, and I'm done now, like I don't really need to lose any more weight. I have some mid section fat that I'm still working through, but everything else I've been able to to get rid of. But I'm 53 I have very dark hair, so it might be hard for you to see that right now. I got to the point in my life where I thought everything I've tried supplementing, exercising, eating, right, all the things that people talk about, none of it was happening like, it just it wasn't doing anything for me. And I thought, I'm gonna die if I don't do something like I genuinely thought I'd have a heart attack in the next 10 years. So I thought, well, let me get rid of this weight the best I can. I'll try to mitigate. The the muscle loss, as best I can, and now that the weights gone, I'm upping my activity and being more strenuous and looking towards more building. Because the exact same thing that you're talking about, like, I I just watched my mother, you know, at the end of her life, in her early 80s, like, not be able to get up and sit down and get out of a chair and, like, I don't want that to be how I go out, so I'm trying, you know, but I don't know if I'm doing the right thing. Because, to your point, they came up with the meds, and they were like, here, and people got so excited that everybody started taking them, and nobody really knows what they're doing. So I'm, you know, lucky enough to have a nutritionist that I talked to on the podcast who warned me early on about the protein and the muscle building. Nobody told me about that, you know, so I don't know, like we're in a weird spot right now, I'm wondering what you feel about all that.

Speaker 1 20:50
What you did is, right? You know, you try to lose weight, because, you know, initially, you are talking about the complications of obesity. You know, Obesity is a disease. You know it is not symptom or a sign. Obesity is a disease. And you have obesity, you have many metabolic and you have many mechanical problem and you are at very high risk for cardiovascular disease and diabetes and many other problems. That's why people are basically awful in that scenario. But reality is that many obese people are malnourished. In reality, you know, study among the US population found the US population in general, obese or non obese, 40% of them have micronutrient deficiency. So when you are talking about iron or any other test elements or any of minerals, 40% have macronutrient deficiency. What do

Scott Benner 21:44
you think that is because I don't eat I'm gonna try to hold this up to the camera. I don't eat much differently now than I did then. I was eating protein, I was eating healthy, I was taking supplements. But look, can you

Speaker 1 21:56
see that? Oh yeah, yeah, I can see it different. It's a significant

Scott Benner 21:59
difference in who I am now, and so that person in that picture doesn't eat much differently than I do. I can tell you that if I inject on a Wednesday and eat normally, everything's fine, but if, even if I get to the end of the half life on the medication, I can see myself starting to gain weight having not changed one thing about what I'm doing in day six and seven. Do you think that there's an inflammation component to this for some people? Because we're also seeing people use it for PCOS. We're seeing people use it for a number of different things that it's not on label for, that all seems inflammation related, but I don't know anything. I only know what's happening to me. I don't really know what's happening.

Speaker 1 22:42
You know, the medication does two jobs, okay? And this is a reason for weight loss. The first is chat appetite. It works on appetite center in the brain, chat appetite. And you know, most of the obviously, problem is related to larger abortion, frequent eating, stress eating, night eating, binge eating, all kind of stuff. So when you shut up, per se, you lose weight the second that is slow gastric evacuation. So basically, what you eat is slowly digested over time, because it takes longer duration in the Git to to move,

Scott Benner 23:22
and that's how I'm getting my iron from it now, because it's staying in there long enough for it to be extracted. Is that right,

Speaker 1 23:28
you know, but, yeah, when, when the food is slowly processed, definitely more digestion, more absorption, more rather than it, if there's, you know, a quick evacuation for, for, for that. But you know, once you lose weight, your body adjusts itself in many aspects. But the most important is that once you start to lose weight, the critical and the bad fat is a thirsty fat to go down, okay, the intra abdominal fat, the intra muscular fat, the intra hepatic fat, the intramyocardial all those ectopic fat start to go down. Once that visceral fat and intramuscular fat goes down, inflammation in your body will go way, way down. Okay, because that fat in your ectopic area is a source of the inflammation in your in your body. This was called sub clinical Corona inflammation. Why this happens? You know, when the fat cell gets larger. Let me explain it in a much better way. When the fat cell gets larger and larger and larger, it can, you know, can be a very big volume, the fat cell rupture. Actually, it is, I will not say rupture. It will be what's called fat cell necrosis. You know, the cell membrane of the fat cell get necrotized and so on. This death of the fat cell attract cells in your blood called the macrophages. Macrophages is like janitors. They come and to clean the debris of the fat cell. But. When they come in, there is it inside adipose tissue. We call them adipose tissue resident macrophage. They live in the adipose tissue. And this macrophages start to produce significant amount of what's called cytokines, inflammatory Cyto This is the reason why people get cardiovascular disease, heart attack, stroke, insulin resistance on type two diabetes is basically inflammation originated from macrophages raised in the adipose tissue in the ectopic area in your body. That's

Scott Benner 25:32
crazy. I never would have understood the pathway to that. That's really something. Yeah.

Speaker 1 25:36
So people who studied all this area, myself and many others found that the core problem of all this cardio metabolic issue is poor nutrition, because when you eat poor nutrition, you start to accumulate more visceral fat. Visceral fat attract the macrophages. Macrophages secrete inflammatory cytokines. You get inflammation, and then the three branch, dyslipidemia, hypertension, Corona, kidney disease, cardiovascular disease, until we will end up in ICU, heart attack or stroke.

Scott Benner 26:11
Is it possible that the increase in autoimmune issues like hypothyroidism, Hashimotos, type one diabetes? Could this all just be nutrient fat over generations?

Speaker 1 26:24
No, no, no. This entirely different scenario, type one diabetes and autoimmune disease, Hashimotos and autoimmune disease, those are entirely different. We are talking about the process of people who are gaining weight, and especially if they are gaining weight in this wrong area and the wrong area, the divorce tissue, in the visceral area, it can be just one to two kilograms of fat, but is extremely dangerous fat, okay, so you can, you can be lean and happy and so on, but you, if you have that visceral fat, you are at that major risk, like, For example, go, go to people living in South Asia and in India, the average body mass index, 2223 but if you do acidity scan for them, you'll find significant amount of edible station, okay, in visceral area, in the visceral area, that's why they get Diabetes at younger age you get cardiovascular disease at younger age, by age 4050, the may have heart attack. Yes, it doesn't matter how your body mass index looks like it is where that fat is located.

Scott Benner 27:33
So for people in India as an example, is that genetic, or is it food related? Is it more cultural?

Speaker 1 27:40
You know, the accumulation of fat and fat distribution in your body is based on ethnic background and some genetic components, like, for example, in the US, African American women accumulate more visceral fat than white women. In the in the in the same time, white men accumulate more visceral fat than African American. Men in Latin America, men and women accumulate more visceral fat. In South Asia, men and women accumulate more visceral fat. Middle Eastern is the same. Just to give you a very simple example of how this can be a problem. If you look to the women Indians and the Bema Indians, Native American they have the highest tendency to accommodate visceral fat. Do you know among the Bema Indians, the prevalence of diabetes 60% 60% because they accumulate significant amount of disorder of fat. You

Scott Benner 28:36
said something, I make sure I didn't misunderstand it if, if I take that same person, like you said, black women in America. Does that mean that black women on other continents don't have the same issue? Is there something to do with them being here or no? Not necessarily.

Speaker 1 28:51
Distribution of fat is entirely different across the globe. Like for example, if you are in the Mediterranean area, South Italy, South France, Greece, North Africa, we will accumulate fat in their periphery, in the lower area of the body, in the side. This is what is called pear shaped right obesity. This is entirely different than Apple shaped obesity, where the fat is accumulated around central

Scott Benner 29:17
area. Is one better than the other. Of course, yes, pear actually,

Speaker 1 29:20
if you have a pear shaped that fat will be protective. Ah, not even, not even harm. It is protective for your body. I want

Scott Benner 29:30
to get my belly into my ass. Is that what you're telling me?

Speaker 1 29:35
But not by transplantation, yeah, let me. Let me tell you something which is so funny. Yeah, when we did our study of the 7% weight loss and we found that insulin sensitivity improved that much, ballistic surgeons said, Oh, that's easy. Let us go and suck 7% of the body fat. Did that work. I will tell you they actually sucked the. 10% of body fat, 10% and I don't know how they suck the 10% i My brother is a plastic surgeon, and I asked him, how you how we can suck 10% of the body? He said, Oh, we have new techniques and and procedures and so on. But do you know the results? 00, benefit, because the what they removed is a wrong fat. They remove the subcutaneous fat, not the visceral fat.

Scott Benner 30:23
I see, oh, that's so disappointing, because I was going to start saving my mommy. When you talk about, I've heard people talk about before their doctors tell them that they sometimes have fat between and under their organs. Is that visceral fat?

Speaker 1 30:37
Visceral fat is inside the intra proteinal cavity, around the organs, around your intestine, all the entire organ and, of course, in the in the liver and around the stomach and all this, all that fat in the visceral lady, when you open the protein, the muscles and protein, you'll find that visceral fat.

Scott Benner 30:59
So the fat I'm left working on now is more about vanity and not about health or no, what

Speaker 1 31:06
you need? You need to reduce a visceral fat. That's that's the aim. You know, if you need health benefit, there's aim. But if you need to maximize the health benefit, you increase muscle mass, okay,

Scott Benner 31:18
the the way to get rid of this fat now is to build more muscle and

Speaker 1 31:22
build more muscles, okay, okay. And by the way, building muscles is the most important thing they can do in your life, especially in elderly population. Okay, so let us go back to the GLP one medication. Yeah, okay. And, but this is around the numbers about, you know what we have been talking about. If you lose weight by just cutting caloric intake, 25% of the weight loss is muscle. So if you lose 10 pounds, 2.5 pounds will be muscles, right? If you do exercise during weight loss, around 15% of the total loss will be muscles. Okay. So if you do nutrition, hypocaloric diet and exercise, the percentage of in muscle mass from the total loss is only 15% okay. When you inject the GLP one hormones. 40% of the total loss is muscle. Why

Scott Benner 32:23
is it different with the GOP than without it? You know,

Speaker 1 32:26
for, yeah, for many, many reasons. You know, a version of food loss of appetite, protein in general, is nussiating. People don't eat that much protein, macro nutrients becomes, you know, lower there is a lot once you suppress appetite and you are not eating, basically imagine someone in the hospital, sick not eating. They lose significant amount of muscle mass during that period. So 40% this is equivalent to around 20 years of loss in one year, 20 years of age, related loss and muscle mass. So this is not a small amount of loss and muscle mass. Like for example, if you look to the studies that had been done on semaglutide, the step one study, they take group of the population, and they did Dexcom to study body composition, and they found that people lost 17 kilogram in average, 17.57 kilograms are lean mass. Okay, seven kilograms are lean mass. This is around 4140 41% okay, of the that that loss, in a year, you are losing all point 5% of the muscle mass. So if you are aging normally, I told you, you lose around 5% ever, every 10 years, right? So in one year you are, you lost nearly around 20, 20% but lean mass is you have also the defined in mass. Lean mass is soft tissue, organs and muscles. Fat, free mass is different. Fat free mass is bone and muscles and all other tissues. But lean mass and muscles is nearly 50% of the lean mass. So the absolute loss in muscle mass, if you calculate it from that whole equation is around 10% 10% of your muscle mass is lost.

Scott Benner 34:25
But you still said you want people to lose the weight, so, like, Dan, so we have to, you got to keep eating, right? Like, I mean, listen, I've been using it for almost two years, and there are days that you have to just walk into the kitchen and say to yourself, I'm going to eat. I'm going to eat something good for me, because I it can happen. I'm not going to lie to you yesterday, I think at five o'clock yesterday, I thought to myself, Oh, I don't think I've eaten yet today, and I did not know it. I wasn't hungry, like my brain wasn't hungry. My stomach wasn't hungry. I was not hungry that. Doesn't happen to me often, but a number of things happened yesterday. People in my house got sick. Things got tossed around. I find it to be incredibly valuable to tell people like you have to eat like chicken, beef. You know, these things like nutrients, get your nutrition, take your supplements, do everything you can do to keep that going while being active, lifting weights, weight training. That's how I've tried to talk about it so far.

Speaker 1 35:22
You know what? We need to educate our patients who are getting on this medication, yeah, that you need to eat high quality protein and do enough strength exercise to mitigate the loss in muscle mass. So usually we will our average we will eat or the recommendation are 0.8 gram per kilogram of body weight. We recommend at our institute 1.2 to 1.5 gram per kilogram of adjusted body weight. But in general, after barretic surgery, the usual patients eat 1.5 gram per kilogram of your ideal body weight of protein, and it has to be high quality protein, right? High quality protein is not plant protein. High quality protein is mostly animal protein. So we have to differentiate, because the Amino the essential amino acids are very important. This is a building block of your hormones in your body. Insulin is insulin growth hormone, other protein based hormones are all a need for that essential amino acid.

Scott Benner 36:20
So now that we understand this about weight loss type two, like, let's sort of pivot a little bit, because a lot of type ones are starting to use glps for insulin resistance. I know it's off label still, but it's happening, and I'm seeing it more and more, to be perfectly honest. So do you have thoughts about how type one should be managing this?

Speaker 1 36:41
Yeah, it is not of label for obesity. Indication, no, no, of course

Scott Benner 36:46
not. But there are type ones now that are getting it for insulin resistance. So what they're doing is they're going to their doctor, and they're the doctor saying, Look, if you didn't have type one diabetes, you'd have type two diabetes, because I see insulin resistance here, and they're getting it covered. You

Speaker 1 36:59
know, I am among the people who created that term in the old days, double diabetes. Double diabetes, really. So double Diabetes means you are type one by auto immune mechanism. You are taking insulin, and so is a growth hormone. And every time you optimize your insulin, you're basically putting in your body more growth hormone blast. They are exposed to the same environment like anyone else, the environment of this activity and high carbohydrate eating and so on. They gain weight. Then they start to be insulin resistant, and then their need for insulin becomes higher, and the insulin is a growth hormone, makes them gain even more weight. So reality, we did that. We published a very nice article about obesity type two, and we were shocked, 53% of type one. Sorry, obesity type 150. 3% of people whose type one diabetes are actually overweight or obese now. Wow. This is totally different from 2030, years ago. Yeah. Let

Scott Benner 37:58
me tell you this, Dr him, because you don't know my daughter. The reason I come by this podcast, my daughter was diagnosed with type one when she was two years old. Yeah, and today she's 20 years old, almost 21 yes. She also seems as near as we can tell to have PCOS. Yes. It shows its head through acne, through painful, longer periods and insulin resistance. Like at some points in the last two years, my daughter's insulin to carb ratio was one to four, and her insulin sensitivity was as low as, gosh, I think 42 one to 42 and so her doctor put her on a GLP and her insulin sensitivity is now more like one unit covers 8085, her carb ratio is up to, like, almost to 10. It's like eight, between eight and 10. She did lose some weight. She did not have a weight issue, but it did, like, just through hunger. It knocked 20 pounds off of her. And she's tall, she's five seven, but she was probably 571 40 when she started, and she's more like 571 30. Now she got to 120 it was too much like she had lost too much weight. So we were stuck because she was doing Manjaro, just 2.5 and it was working great on her insulin resistance, working great for her PCOS, but it was making her not hungry. So what we ended up doing was we now take clean vials and milk the pen into a vial, and then give her less than the 2.5 and we have found the balance where it controls her blood sugars, helps her with her PCOS, but leaves her hungry still, and that has been like the sweet spot we found for so she gained back 10 pounds. She's at a very healthy weight now, and she probably uses, I'd have to guess, 20 to 25% less insulin than she was using before. And she just looks

Speaker 1 39:53
at that's usually the case. You know, we're an hour why wait program around 30 40% and. Range are type one, and we have significant experience in managing obesity in type one. You know, actually, we published several papers about it, and we have to differentiate between two issue, good. This is a benefit of JP one, or the benefit of weight loss.

Scott Benner 40:15
Yes, okay, yes, I know, and I, I struggle with the same thing. Yeah, the

Speaker 1 40:19
benefit of weight loss is huge. You know, you said that she went from 140 to 130 you mentioned at one point she lost she lost the 20 pounds. If she lost that much, she is now more insulin sensitive, she will use less insulin. For sure, the answer is more efficient, because every time that you become more insulin sensitive, your body responded to insulin is much better way. Yeah, so even less insulin can improve. But the most important is that she should continue to do strengths exercise, especially younger. Younger people benefit a lot from exercise because they they can build the muscles more than what you can do now. You know, from age of 40 up, it's very difficult to build the muscle, but in her age, it is easy to build the muscle. Yeah. So my advice for her is to eat more protein, enough protein, and by the way, protein per se, will improve hair diabetes as well. You know, we know that for years, and it doesn't raise a blood sugar up like carbohydrates, right? I have to

Scott Benner 41:22
tell you, like talking about it technically like this. It makes sense. Everything makes sense. It's the the actual living with it and losing your appetite and then having to eat and like, it seems like a vicious circle, like it's not, it's clearly not a perfect fix. But I've done two interviews this past six, eight months that I found astonishing. One was just with the mother of a then 13 year old girl who had had diabetes, type one for four years. She was using almost 70 units of insulin a day. She has antibodies. She has she's type one, right? But her mom had PCOS, and had used the GLP to lose weight and changed her life. The girl was gaining weight, so the doctor put her on the GLP for weight. But today, I'm still in contact with her. Today, her daughter's not wearing an insulin pump anymore and injects like one unit of basal insulin a day. I'm not saying it cured her. I'm certainly not saying that, but she's having an amazing impact on it. And I also had on a gentleman in his 50s who was type one for like, six or seven years, admittedly, Lata, right? It was a slower onset. He got put on zepbound for weight, which I know is Manjaro. He lost so much weight, they took him off his insulin, and he hasn't been on insulin for a while now, but he's got antibodies, and he is type one. And I expect one day that Lot of will complete its path and he'll end up on insulin. But for the moment, it's astonishing.

Speaker 1 42:48
It's quoted all. What you mentioned is not a surprise for me, Wow, because you remove the type two component, yeah, when they lose weight, the type two component, an insulin resistance component, is gone. They remain was type one. So the need for insulin becomes less and less and less. So to be down to one unit per hour on insulin pump or or sorry, or less, or whatever, not surprising, your body become insulin sensitive after you lose weight. Whether you are type one or type two, if you are type two, you get remission. If you are type one, you remain on answer, but in a very small dose.

Scott Benner 43:24
So then this double diagnosis isn't just a way to trick your insurance company. It's important to know if you have both of those impacts,

Speaker 1 43:30
we don't have COVID for double diabetes, right? You know, you cannot tell insurance that that person has double diabetes. The insurance understand from ICD 10 that either type one or

Scott Benner 43:41
type two. Your opinion, should there be a double diagnosis code, double diabetes? Yes, we should

Speaker 1 43:45
diagnose double diabetes in in people. But my advocate for that term to be used scientifically, rather than just be used that way. I want to thank you

Scott Benner 43:54
for a second, because I didn't really know where our conversation was going to go today. You've indicated me because I took a fair amount of crap online for putting those two episodes up where type ones used the GLP and then came off their insulin. I got a lot of pushback from that. I mean, I understand why, like, type ones don't want you running around telling people, like, don't take your insulin, which is not what I was, you know, definitely not what I'm saying either. I think it does point out how much over the years, old ideas get folded into new ideas, and then along the way, like something gets lost in translation along the way. Do you know? Do you know what I mean by that? Because you said something earlier that made me feel the same way, and it was around the double diabetes, because I had heard people say that in the past, and then other people come along and they poo poo. It like you're either you're type one or your type two. It's then that becomes the argument. You know,

Speaker 1 44:43
let me Scott, let me make it more complicated. We are looking in the future in precision medicine of diabetes, and there will be no type one and type two. There are five different phenotype clusters. Okay, each cluster is treated in entirely different. Way. So type one will be under a cluster called auto immune, severe auto immune diabetes, or said sa ID, severe auto immune diabetes. This will include type one and ladder the antibodies are positive in them. There is another group that exactly similar in the phenotype, but without antibodies. It's called severe insulin deficiency, diabetes, and this is around 18% of people with diabetes, so they are not making insulin. They are lean people, but if you test antibodies, it's negative, and then you have mild obesity, diabetes. This is a common type that we think that, or most people think that this is type two diabetes. That's actually 22% only of all people with diabetes and the diabetes in mild obesity, diabetes is related to obesity. Take the obesity out of the door, diabetes will go out of the window. And this group significantly benefit from weight loss, whether multidisciplinary weight loss or by pharmacologic or by bariatric surgeon I see, and then you have another phenotype cluster called severe insulin resistant diabetes, or cert this group had the severest insulin resistance their body, all the body is resisting insulin, liver, muscles, a divorce tissue. This group, weight loss can be very beneficial. If you see one of those people, they need 100 units of insulin, even 200 units of insulin, sometimes. And then you have mild age related diabetes. This is the biggest one. When you get older, you get diabetes. This is around 39% of people whose diabetes, wow. Basically, understanding the phenotype clusters in the future can tell us who will benefit from what we call it now, type two diabetes is not all of them, but mild obesity diabetes, which is around 15% 22% and the severe insulin resistance around 15% so 27% 20 37% of people with diabetes will benefit significantly from weight loss.

Scott Benner 47:00
What's the roadblock in making this more well understood in for clinicians,

Speaker 1 47:06
you know, this is a classification that you expect to come in few years from now. Okay, there is a cooking for this classification now, and many countries did phenotype clustering, and it looks like the five phenotype clusters are reproducible in a good way. This will help precision medicine in the future. You know, similar to cancer breast, for example, not all cancer is the same. You know you have genetic based cancer. You have hormonal based you have what you know you can manage it in the very precise way. So

Scott Benner 47:42
we're in the not, maybe the infancy, but we're still in the beginning of understanding diabetes then and the way it gets treated more more over at

Speaker 1 47:50
any point in your history of diabetes, you are beginning to understand diabetes.

Scott Benner 47:55
Damn perfect. That's what I wanted to know. Awesome. And for all the people who give me crap online, ha. Dr hand, he just said that I was right. That's awesome. I'd finally write about something. This is great. Listen. I'll tell you something that maybe you'll find interesting, because you're a researcher. I have so many conversations with so many different people who have diabetes, so I record this podcast sometimes more than once a day, but at least once a day, I've had 1000s and 1000s of conversations with people. Have type one. Who are the parents of type ones with people, have type two. With people, have lot of like, all this stuff. After a while, I step back and I say to myself, like, it's not really the way that we're talking about it. Like, until somebody, until you just said what you said, I have to be honest. Like, I never, I'd never heard it, you know, put technically to me, but that all makes perfect sense to me. After having these conversations all these people, they're not all having the same experience, but we call it the same thing. And you know, it's confusing, and then the human component gets twisted into it, because often type ones don't want to be thought of as diabetic or type two, because type two is so closely related to a thing you did wrong instead of, you know what I mean, like, instead of like it happened to me. And I think that argument is where so much of the the resistance to seeing the differences comes into play. But you really think this will be lay the land in a few years the way, the way you spoke about it, yeah, yeah,

Speaker 1 49:23
absolutely, you know, change. The definition of diabetes has changed over time. Many, many times, sure, oh, at the beginning it was just one diabetes. Then they call it after that fatty diabetes and lean diabetes, and then juvenile diabetes and other tons of diabetes. And then insulin dependent diabetes and insulin non dependent diabetes, and then type one diabetes and type two diabetes. But the future will remove all type one and type two and become the five phenotype clusters. And then once we identify the cluster, and by the way, each cluster develop different complications. Okay. Okay, okay. So I told you there are three mild form, three severe form, and and one mile and two mild form. So for example, severe auto immune diabetes, develop micro vascular complications, diabetes, retinopathy, nephropathy, neuropathy, all those kind of complications, severe answer, resistant diabetes, although they are also severely insulin resistant, they only develop diabetes retinopathy and diabetes neuropathy, okay, mild obesity, diabetes, don't develop that much complications. They can develop maybe cardiovascular complication, if they have this liberty or hypertension, severe insulin resistant diabetes, develop hepatic steatosis and mesh and develop Corona kidney disease at younger age, mild age related diabetes, basically don't develop complication except cardiovascular if they have this liberdemia and hyper and hypertension. So if we know the clusters very well, I can tell you what is a prognosis will look like in each one very soon. I had been using the phenotype cluster for two years or three years now in my practice, and I hope in the future, we can educate primary care physician to identify those clusters and treat them in a proper way. Good luck. That's

Scott Benner 51:15
incredible. I'm so happy you came on. Do you see a world where who are type one who don't have weight issues are going to get in my mind, and this is probably a very simple way of thinking about it, the glps have to start coming in vials, so that doctors can help you with dosing, so that it can help you with the things you need without impacting the things you don't because the like, if you don't need the hunger to go away, But you're seeing a ton of help in other spots, just the PCOS help, right? Which is awesome for people. There are people who have PCOS who don't have weight to lose. So, like, what do they do? Like, how do you imagine that endos are going to mix glps into type one care, I guess is my question.

Speaker 1 51:59
PCOS, by the way, related to type two more than type one. Okay, you know, it's kind of care when anyone but it is mostly related because it's part of insulin resistance, and the best treatment is actually not only weight loss, but also some medication that improve insulin sensitivity, like Metformin. And you know, nearly Most cases of BCS are treated with metformin because it improve insulin sensitivity. There are several other hormone medication that also improve insulin sensitivity, but But mind that BCS, they secrete more testosterone hormone, and actually testosterone make their muscles much better. You know, this is a building a block for building hormone for muscles.

Scott Benner 52:42
If I told you my daughter has a bit of a deeper voice, that wouldn't surprise you, then, like, if she has PCOS,

Speaker 1 52:50
you have to measure the three testosterone level. That's the most important point, and then find the reasons. Maybe the testosterone is not just coming from the others. Maybe some other reasons for higher tests.

Scott Benner 53:03
Okay, okay, this is just the thing that happens. Like I said, I talk to a lot of people, and this comes up a lot with women with who have diabetes, or people who have it in their family, and they're talking about their kids or their, you know, sisters and brothers and things like that. Siblings like, I see the same stuff coming up in conversation. This probably is apropos of nothing in our conversation, but the frequency in which someone with type one diabetes tells me they also have a bipolar person in their family is pretty significant. And I don't know if that has anything to do with anything or if it's just

Speaker 1 53:38
random. Yeah, a lot, you know, if we go to the the whole issue of the causes for obesity and hormonal and neurotransmitter changes and so on, you know, we can spend, you know, 345, hours really, because, you know, I wrote many chapters about obesity in mid e medicine, Even textbook, Sister textbook of medicine, and we are explaining a lot of a lot of stuff, but there is a lot that need to be be done. But let me explain you one, one simple thing. Do you know how many hormone and neurotransmitter controlling your body weight in your brain? I have no idea. 34 hormone and neurotransmitter. 34 and it is a very delicate balance. It's like a web all interlaced with each other. So neurotransmitter that related to mood swings and reward system, there is very small, tiny area in the brain called the ventral tegmental area. You know very, tiny area. They know that very tiny area is called the reward center. Reward center is rewarding you for any behavior that you do, so if you are not addicted to anything to make that area happy. The best addiction and the easiest addiction is addiction to food. Okay, a lot of people start to work on blocking the hormonal aspect in the brain, like endocannabinoid receptors. People kill themselves during the study, really, they get severe depression, and they ended up with committing suicide. You know, the brain is very delicate in relation to all those mental issues and all the psychological issues and body weight in the same part. And that, for that reason, many of the major anti psychotic medications, the major one circle and the bricks and the cost significant to again, significant to again, even we will develop diabetes because, because they work on the appetite center, open your appetite to the maximum, okay, antigenic and the significant amount of food, and again, significant weight. So there is interaction all the time between six hormones. For example, you know, melanocortin pathway, which is responsible for skin. Do you know, if you block that bus way, or you stimulate that bus way, you can change the body weight significantly up and down. You know, there is a lot this is a web interaction in that web has to be very delicate, so we are lucky to have a hormone that's relatively safe and working on the appetite without damaging a lot, but still, psychological issue can occur in that scenario as well. How

Scott Benner 56:37
far do you think we are from glps Being a thing of the past, and what you're discussing being the way that you manipulate your body to do what it should be doing. It

Speaker 1 56:46
has to be on the periphery. It has to be with medication that makes you lose weight and preserve the muscles, okay? And there is actually medication in research now that does a job. It's called the myostatin inhibitor, or active in inhibitor. It actually makes the body fat goes down by 20, 30% and the muscle must go up by four or 5%

Scott Benner 57:08
How come that one didn't take off? It

Speaker 1 57:11
is about, it is about what is called the BMA group map, and it is infusion every month. And you know, one of the big companies now got that medication to combine it with GDP one, wow. What's it called? Again? Pima group app. Pima group app, thank you. And it is a monoclonal antibody. Sorry

Scott Benner 57:29
about that. I'll try it better. I'll just say I'm of the opinion Life is short. My body was not doing what I needed it to do to have a long life. And then I have to tell you, like, I really started doing this, like, these are not things I would have normally done till I saw the end of my mom's life, and I thought, I can't let that be how the end of my life goes. Like I'd have to try something. And this is what was available. My point is, if something better comes along, I would certainly be open minded about it. Can I ask you if you could give me some advice? I've been making this podcast for 11 years now. Can you tell me about a couple of things that are coming along that I should be paying attention to and having more conversations about? Besides what we've talked about now,

Speaker 1 58:14
it is definitely we need to understand exactly how the mechanism for weight loss, because this is not even touch it in our conversation, how we can do a multi disciplinary approach for weight management. And we have been doing it for, as I told you, for very, very long time since 2005 and do you know what b will up till now? Are maintaining weight loss? We publish data on five years, 10 years, and we resented that. And the American Diabetes Association for 15 years, and they are still maintaining 8% weight loss. So actually, multi disciplinary, which is proper nutrition, balanced exercise program and Cognitive Behavior modification and medication adjustment, by the way, for people whose diabetes during weight loss, there must be an algorithm for medication adjustment and then good education. When we do that, it is very expensive, but it works very, very well. And people can maintain weight loss for very long duration, but people just take it very, very simple, I will cut my caloric intake, and I will lose weight. This is a commercial way that commercial weight loss, that can end up with people recycling and recycling and recycle. And when you take GLP one, you are in catch catch 22 if you stop the medication, you will gain all the weight back, right? If you continue the medication, you continue to lose muscle mass. So you have to understand very, very well. And this is advice now that intake of protein is very important with those medication strength exercise is very important, and especially high muscles, quadriceps, same string, gluteal muscles, those are the muscles that get weaker and weaker. So I usually ask my brain. Chance take more protein, more animal protein, in a very efficient way. Or you can even take some shake that has protein, especially the I had a shake liberal diabetes, yeah, and do 2030 minutes of strength exercise every single day. And if you don't do it, don't take the medication you need to do 2030 minutes of strength exercise, especially with your soy muscles. Elliptical, against the resistance. Stationary bike against the resistance, squatting, stretch band under your feet. Rowing machine. Squat is quiet, yes, would a rowing machine help? Rowing

Scott Benner 1:00:35
for rubber? Oh, that's for more rubber and lower

Speaker 1 1:00:37
that's absolutely fine, okay. If it is against the resistance it will be. I'm not all looking for a speed. I'm looking for, yes, muscle action.

Scott Benner 1:00:46
You can't see this because I have a green screen, but I'm putting my hand on a bike. My office is making this podcast a bicycle to keep my legs strong. And if I'm being honest with you, a pet chameleon that's over there that you can't see Perfect, that's all to watch you need keep me relaxed. Yeah. Oh, this is, this is fantastic. I really appreciate this. Let me ask you, like, a question that I think people are wondering, we hear so much that it's the food. Like, are foods bad food? Like, you'll hear people say, like, oh, I went to Italy and I ate pasta and it didn't make me sick, but I eat pot. Like, is our food inherently causing this? Or is it just speeding it up? Like, what is it about Americans in general that that puts us in this situation?

Speaker 1 1:01:29
There are two problems in the in the US, you know, and we did tons of research and nutrition. Let me just to make it very clear, high carbohydrate intake, this one big problem, process the food is another big problem. Okay, if we eliminate as much as we can both, you know, process the food, any food you have in a refrigerator, processed or even minimally processed, you have to avoid whole food is a way to go if you need healthy eating. And then carbohies, and you have three major carbo problem, sugar, whatever, added sugar in dessert, in juice, in whatever, any sugar, wheat flour products, bread, basta, beets, bread, so bagels, P and peas, right? Starchy food like potato, rice and corn okay. If you cut those significantly down, you'll find significant with weight loss and soft drinks that has high sugar as well. So usually, when I tell people in my practice do that, say, Okay, what we eat. Vegetables is okay. Fruits are okay, legumes are okay. Bees, beans, whatever. And then dairy products are very, very beneficial all kind of dairies, eggs, chicken, fish, lean meat, Turkey, dark chocolate, even I have no problem, right? Tea, coffee, cinnamon, you know, there is a lot that people can eat, but not just a low nutrition. Sugar, for example, is just empty calories. There is no nutrient. Nutrient effect, right? It doesn't have any macronutrients or any any value. Would you

Scott Benner 1:03:10
think that I should take as low a dose of GLP as possible as long as I'm not gaining weight? Like, does the dose matter? Like, should I not stay on a higher dose if I'm not trying to lose weight? I'm not just talking about me. I'm talking about me. I'm talking about people in general. Like, should they titrate down to where it's working? But not as much as,

Speaker 1 1:03:27
yeah, you got it. You have to be, if you would like, maintenance, and you don't need to regain weight back be on the main the minimal dose that suppress your appetite, and more the state, is suppress appetite. You don't have to have what, you know, 100% suppression, because, you know there is tolerance to this medication. You need more doses and more. By the way, we don't know the ceiling of those medication you know, like, for example, semaglutide, oral revulsus. You know it is in the market, four, seven and 40 milligram, but the company is testing now, 2590 or 100 or 75 milligram. So they are testing, we don't know what is a ceiling for those medications.

Scott Benner 1:04:08
Rebels is an example. They're seeing what's happening with the injected and they're thinking they can maybe get that pill to a point where it's in pill form and helping people.

Speaker 1 1:04:18
It will not work with I don't think that will seem like, look like I guess. But there are other medication coming in the future in oral format, synthetic, non peptide, small molecule, that will cause significant weight loss and improvement in diabetes as well. And this will Bush away all the injectable, yeah, that's good. I don't think that injectable will be the future. They will be only for people with very, very high BMI, but oral will will come in the future. And the prism, how

Scott Benner 1:04:47
long do you think for that next year? No kidding, that's awesome. I actually told my daughter the same thing, as odd as it might sound to some people, my daughter has a fairly significant needle phobia. It's pretty traumatic. Or to have to do this every week like she does Okay, putting on her insulin pump and her CGM and everything, but she's been banned with needles since she was little, and she struggles through it because she sees how much it's helping her. And I kept telling her, I'm like, Look, I think very soon this oral medication, I think it's gonna do the same thing, and you can get off of this. So it's it's comforting to hear you say that too. Thank you. Is there anything I haven't asked you about that I should have? I actually think I could talk to you all day, but I assume you have a life to get back to. It's wonderful that we've met. I'd love to invite you back on if you ever have anything else you want to talk about. This was fantastic, but anything we didn't talk about,

Speaker 1 1:05:34
we need another podcast to talk about nutrition. Yeah, because we didn't, we didn't spend enough, enough time talking about nutrition. Those nutrition, you know, people start to understand the nutrition and the history of nutrition, and how this stuff changed over time, and why we're eating what we're eating right now. But you know, this is very important. Maybe, you know, it's a very, very big topic to discuss.

Scott Benner 1:06:00
I'd be happy to also, let me tell you that. I guess you'll be happy to hear that just this morning with the nutritionist, who's also a CDE and a 35 year type one that I do some podcast episodes with. We were just talking this morning about how the next series we're going to do is about nutrition. We're going to do a whole series about it. I'd love to do an interview with you and fold it into the series, that'd be awesome. Absolutely thank you so much. All right, I'm gonna say thank you for now, because this was absolutely terrific. Ask you to hold on for one second, and then I'll set something up with you for something else. Hold on one second. Thank you

Unknown Speaker 1:06:33
again. Okay, thank you. You

Scott Benner 1:06:44
if you'd like to wear the same insulin pump that Arden does, all you have to do is go to omnipod.com/juicebox, that's it. Head over now, and get started today, and you'll be wearing the same tubeless insulin pump that Arden has been wearing since she was four years old, touched by type one is hosting their very first steps to a cure walk. And you can register right now to participate. Touched by type one.org Go to the Programs tab, click on Steps to a cure and sign up today. You can sponsor walk or volunteer. Check it out.

Are you starting to see patterns, but you can't quite make sense of them. You're like, Oh, if I Bolus here, this happens, but I don't know what to do. Should I put in a little less, a little more? If you're starting to have those thoughts, you're starting to think this isn't going the way the doctor said it would. I think I see something here, but I can't be sure. Once you're having those thoughts, you're ready for the diabetes Pro Tip series from the Juicebox Podcast. It begins at Episode 1000 you can also find it at Juicebox podcast.com up in the menu, and you can find a list in the private Facebook group, just check right under the featured tab at the top, it'll show you lists of a ton of stuff, including the Pro Tip series, which runs from episode 1000 to 1025 I want to thank you so much for listening and remind you please subscribe and follow to the podcast wherever you're listening right now, if it's YouTube, Apple podcast, Spotify, or any other audio app, go hit follow or subscribe, whichever your app allows for, and set up those downloads so you never miss an episode, especially an apple podcast, go into your settings and choose, download all new episodes. The episode you just heard was professionally edited by wrong way recording, wrongway recording.com, you.

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#1410 iLet User Experience

Dakota moved from Omnipod 5 to iLet to lessen his carb counting burden.