Scott Benner 4/13/25 Scott Benner 4/13/25

#1491 Best of Juicebox: Dr. Blevins on GLP Medications Part 2

Dr. Tom Blevins discusses GLP medications. Part 2

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Scott Benner 0:00
Hello friends and welcome to episode 1238 of the Juicebox Podcast

Dr. Blevins is back today to expand on his GLP conversation from a few weeks ago. Today we're going to be taking listener questions Dr. Blevins is going to do his best to answer 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. Hey, if you have type one diabetes or are the caregiver of someone with type one and a US resident, I need you to go to T one D exchange.org/juicebox. and complete that survey that survey helps the T one D exchange to move type one diabetes research forward T one D exchange.org/juice box. If you've ever wanted to help, this is your chance it will only take you about 10 minutes. 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 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 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. 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. Alright everybody. So Dr. Tom Blevins is back, we're going to do another episode around GLP medications. If you have not heard his first one, it's episode 1212. But today, we're going to do all questions from the audience. So Tom, welcome back.

Dr. Blevins 2:35
Scott, good to be here.

Scott Benner 2:37
I'm glad you were so good the first time I'm excited for you to be back again. I'm just going to jump right into questions that came from the audience about GLP meds I don't know that we're gonna get through all of them. But but let's do it. All right, so I'm gonna start right at the top, my seven year old is very overweight doctor suggested possibly giving her one to help her lose weight over the summer. Is this safe for young children and effective she's type one. She lost 40 pounds before diagnosis and is gained 60 back cannot stop eating.

Dr. Blevins 3:06
Yeah, that, you know, that is a tough problem that she's lost because of the high blood sugar to begin with. And now she's gained back everything and then some. And she's she's hungry. And hunger is a is a tough deal as possible. Certainly that insulin induces some hunger or promotes it. And she's overweight. Now, we don't know the details. But you know, here comes the summer, you wanted to lose weight? And the question is about GLP. One's a glucagon like peptide, one meds? And I'll tell you, it's important to look at what what's been done in terms of studies. And all that when I answered this question, and the answer is there is no medicine approved at this point for a seven year old. And for for any purpose for diabetes, or for weight loss, and there's no GLP one approved, the approvals are the one called saxenda, which is liraglutide, the once a day injection, that one is approved for weight loss in the pediatric population down to age 12. So that's not going to go and the bottom line when it comes to approvals here is that we just don't have data. So we don't know, the person who asked the question could talk to their, their doctor and ask about that. That's certainly something they can talk about. But I would be reluctant to go that direction. It's a really good thought. And you'd love to get her to lose weight, that's for sure. But anyway, I'd be very, very cautious about that talk to a doctor. And and work maybe with this might be a time you know, everyone that's listening probably has talked to a dietitian before. Dieticians can be very effective. So it might be a good time to talk to a person like a dietitian to talk about the eating.

Scott Benner 4:58
Is there a possibility of so for spa this, this suggestion is coming from their physician. So, I don't know, I can't make you guess about this. But is there a world where you would ever look at a seven year old in a similar situation and have this thought or you wouldn't go this way? Full

Dr. Blevins 5:13
disclosure? I do. Mainly, I see mainly adults, and I don't really see seven year olds. So I couldn't answer that about a seven year old. But, you know, this is a place where the doctor, doctors can use medicines, as you know, off label. And and they can look at the indication. And and they could use a medicine that doesn't kind of fit the indication it's a clinical judgment call. We don't know about safety for young kids. And would it be less effective, more effective? We don't know, I suspect it would work the way it does for older children. So the answer is we just don't have much data there.

Scott Benner 5:50
Okay. Let me jump to the next question. This is I'm going to jump around a little bit on this list. But just a very simple question does GLP medication cause muscle loss? So if you're paying attention in the space, when GLP has became kind of in the, in the limelight maybe two years ago, I think Dr. Peter Atea, pretty famously said that he is his practice, took a look and said that people were losing muscle. And I think that became one of the one of the concerns out in the in the media and everything now. Yeah, I've been on it for 13 months now. I don't feel like I've lost muscle. But as a matter of fact, I feel stronger now than I did before. But does it cause muscle loss? Or is that just part of losing weight? Or what are we seeing? 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 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.com/juicebox head over there now get the same accurate and reliable meter that we use.

Dr. Blevins 7:44
Great question. And it is a concern. And there there have been people who said oh, these medicines, the GLP ones cause muscle loss. And that's been that's been an inhibitory kind of commentary or idea for many people when they when it comes to using them. But here's what we know, if a person takes a medicine or of any kind or loses weight for any reason, and they're sedentary, they're going to lose fat and muscle both. And probably preferentially even in that situation. If they stay sedentary, they're going to lose more muscle more that is fat than muscle. And typically the first fat loss is the visceral the abdominal fat. And that's what you want to lose as that rapid turnover fat. So that will go first yet if a person maintains a certain amount of activity. And and I would say it's always important for a person to be active walking like 150 minutes a week or whatever a person does. Many people do much more than that, of course, like lifting weights, that kind of thing resistance exercise, those people are not going to have much muscle loss when they use a GLP one or when they lose weight for any reason. This is really a weight loss phenomena. It is true that when a person loses weight, especially a substantial amount that some muscle areas are just not needed as much not having to carry as much weight, so they might lose those muscles a little bit. There have actually been some pretty good studies done that have looked at body composition with GLP ones and the combined GLP one tip Med and remember we're talking about GLP one glucagon like peptide one. And the GI P is glucose glucose dependent insulinotropic polypeptide. Those that abbreviations we use tip for that one and then GLP one, that's a pretty good body composition data that shows that yeah, people can lose a little bit of muscle but mainly they're losing fat. So I'm not worried about muscle loss. When people use GLP ones and less they're completely sedentary. And one of the first things I'm gonna recommend that people do when they take one of these meds I say be active and burn some calories to these medicines reduce calorie intake, but also it's very important that people burn calories and and use their muscles. I

Scott Benner 10:01
have to say, I've been wondering about this question for a while, because Did someone just say something in public? And it just stuck? You know what I mean? Was it like a knee jerk reaction or one of their first things like even would you go back to them now? Maybe? And they'd say, Oh, I've looked further. And I agree more of what I just heard. So I'm glad you were able to answer that. So completely. Thank you.

Dr. Blevins 10:22
Yeah. You know, Scott, I think some of the studies that have been done with body composition will be published, and will become more common knowledge. And it's an important concept. It's an important question. And it's important that we advise people to, you know, do their own thing about reducing calorie intake and also increase muscle activity when they're using these methods. Yeah,

Scott Benner 10:43
I saw a big difference. Just adding like low intensity like dumbbells from my arms, my chest, my shoulders. Yeah.

Dr. Blevins 10:49
I'm glad you said that, too. Because your experience is very important. You're not you don't feel like you've lost muscle mass. And you're, you're doing activities, you're lifting weights, and that I'm not talking about heavy and you're not either. We're not talking about heavy duty weightlifting, we're just talking about lightweight resistance. Yeah, resistance exercise.

Scott Benner 11:07
I'm also very careful to mix a fair amount of beef and chicken into my diet for protein to Yeah, good. Yeah. I'm going to jump off the list for a second. This is actually a question that came in to me through a there's somebody I know personally. So they start zap bound for weight loss. This person does not have diabetes, yes. But they were pretty significantly overweight. And not just hungry, Dr. Blevins but like ravenously, hungry 24/7, like could eat to being stuffed, and someone could offer them a dessert and they go, Yeah, bring it on. Like that kind of thing. Knowing sitting there thinking I'm not hungry. Not only am I not hungry, my stomach hurts. But yes, I'm gonna eat this, but they go on zap bound. It took a couple of months. And the fruit noise did not go away for a couple of months. And I said to them, just keep going. It will. And one day, I get a text. It's working on me all the sudden, like I'm starting to lose weight. I don't feel ravenously hungry all the time, I'm filling up quicker, it took months for to start working for them. And they're having success, they lost 14 pounds, things were getting better. And then all the sudden, the doctor does the blood work. And they have a significantly increased lipase and amylase. So lipase 394, Emily's 204, Doctor pulls them off the med. And those numbers go back down. So my first question is, are those bigger numbers a reason to say oh, my god pancreatitis is coming get off the med or is that just the thing that happens? Well,

Dr. Blevins 12:42
that is a great question. And I'm not sure I have the the perfect answer here either. But we've done quite a number of studies and I can talk about published information. And it is clear that those enzymes can sometimes go up and down. And and while on treatment. The question is what happens in people who are not on those meds at all on a day to day, week to week, month to month basis? And we don't know there really hardly any studies, if any at all. I don't like that. I can cite one that looks at amylase and lipase and as you said those are for the audience. Those are the enzymes from the pancreas. And they tend to be really high when people have pancreatitis. Well keep in mind that pancreatitis is a clinical syndrome of pain, Amin pain, like bad pain, and inflamed pancreas, and very high numbers. So what does it mean when those numbers are high, and a person is not having pain? We don't know. And, of course, I agree those numbers are are depending on the normal range, depending on the normal range in that lab. Those numbers are concerning. And I do understand the concern of the doctor there. And using a medicine that remember these medicines stimulate the beta cells to make insulin they they affect the alpha cells that make glucagon in the pancreas EndyMed that might affect the pancreas could maybe inflame it, but there's really no clear evidence that these meds do that. So I agree with the concern. It's an unknown and this is going to be a clinical thing there with the person who was on the zet bound. That person I know will be talking to the doctor further. And do they want to re reintroduce the medicine that's there? That's a judgment call. Yeah. Is it pre pancreatitis? Who knows? That's a great question. Do I normally measure lipase amylase? Do we always routinely do that? No. Was there a reason in that patient and the person you're talking about to measure at night where they have in some pain? Maybe I don't

Scott Benner 14:44
know Tom. Absolutely no, no pancreatitis Oh

Dr. Blevins 14:47
symptoms at all. One at all. So it wasn't pancreatitis. Almost certainly. And in that one's going to be a call it as you go, and do I recommend that people check amylase and lipase not really Everybody has a different level of caution. Some practitioners may want to check them along the way. And that's their call.

Scott Benner 15:07
Yeah. All right. So here's another one that's not on the list, person using medication for mood stabilization and anxiety, yes, starts using a GLP medication for weight loss. And then it messes up the absorption of their medication. And their anxiety gets significantly worse. Is there a way to manage that they're already on a large dose of the anxiety? medication, the doctor was uncomfortable giving them more. And that's why they took this person off of the off the GLP. But was there a better way to manage that, that you know, if you

Dr. Blevins 15:47
get that's gonna be very much a clinical thing up kind of between the person you're talking about and the doctor would a lower dose of the GLP one work and make it all okay, maybe would timing help of the medicine? Maybe, but not not horribly likely. Because, as you know, these GLP one meds like the ones we use once a week, and they have a very long life. So there's not really a predictable time during the day that the effect would be less on the stomach emptying, would it gradually improve over time, but not hard to know. As you know, the effect on gastric emptying that these medicines have the slowing down of gastric emptying is something that happens, especially early on when you start the medicine and every time you increase the dose, it kind of recreates itself. But as the gastric emptying kind of goes back a little bit more towards normal, after a person has been on the bed for a while. And after a few weeks, it doesn't go back to normal. That's going to be very much a play about your thing. That's what this is why the people say it's the art of medicine, just the science and that's gonna be an art thing. I

Scott Benner 17:00
asked the question here just so people can hear like if you are taking medications by mouth, you might be seeing absorption changes, it is the thing to take care of. You notice that is true. Take note of Alright, let's stay in that vein a little bit. I have gastro problems when I use these drugs. I have a very low carb diet, which helps me keep my numbers in five, five range, but I need to lose weight. Low Carb means high fat some of the time, which can make me sick with the drugs. Is there anything that can be done to help me use GRPs without so much sickness? This episode is sponsored by Medtronic diabetes, Medtronic diabetes.com/juice box. And now we're going to hear from Medtronic champion Jalen. I

Speaker 1 17:44
was going straight into high school. So it was a summer heading into high school was that particularly difficult, unimaginable, you know, I missed my entire summer. So I went, 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, I outside of that I didn't have any type of support in my hometown.

Scott Benner 18:17
Did you try to explain to people or did you find it easier just to stay private?

Speaker 1 18:22
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.

Scott Benner 18:36
Did you eventually find people in real life that you could confide in. I

Speaker 1 18:41
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

Scott Benner 19:02
diabetes.com/juice box to hear more stories from the Medtronic champion community.

Dr. Blevins 19:09
Yeah, you know, this is this a question has many different components in a way and keep in mind that fat does slow down the stomach emptying already. And then you add a medicine on top of it, that slows it down and you get a double slowing and away maybe not double but you get more slowly. And that can lead them to more or not nausea, and even vomiting. And and so one of the strategies of course, when people start a GLP one or GLP one gi P method is to reduce the fat. So those of you out there who are taking these meds, if you have a high fat diet, then you're taking a GLP one cut back because that will help the nausea if you're getting nausea. Low Carb doesn't necessarily have to mean high fat. Low Carb can be accompanied by kind of a lean lean protein type, elite meat type intake, and it can be okay in terms of weight loss. So I would say that, though it's not as simple as I might try to make it here, that the person here doesn't have to go high fat, and I think they could modify down to, and I think low carb, in my mind, is it many different definitions of different definitions of low carb. I think it's low, simple, simple car, but I think vegetables fit very well into a low carb diet. It's the potatoes, pasta, rice bread stuff that I try to get people to avoid more simple carb and other simple carbs to. So I think I think the vegetable lean meat approach would be okay. And so I hope that helps the person. And if they take that approach,

Scott Benner 20:49
I think it might actually, yeah, here's one. I've been on rebel sis. Since mid February. I'm type one, I'm taking it for weight loss, my a one C is six, eight, no side effects. I've gone from 190 to 169 pounds. Now today, my endo said she's really concerned with me using a GLP medication being a type one, and then notes the risk of pancreatic and thyroid cancer. Is that a genuine concern?

Dr. Blevins 21:15
Okay, so a couple things, I'm always going to want to kind of refer back to the idea of the approvals. And I know this is being used off label for this patient numbers, you know that Rob Bell's is not approved and type one, right? We've talked about this before. And Scott, you know, I'll continue to repeat that because it is up to the clinician, and the patient to decide some some of the many of these things is called off label use of a medicine. So that's one thing to say congratulations to the person who has such a great a one C, and weight loss. That's great. So this is gonna be a discussion that's going to be important for the person to have with their Endo, and go back in and say, Hey, tell me more about this. And let's talk about it. And and I certainly don't want to get in the middle of that. I will say that the thyroid cancer issue with GLP ones and GLP one gi P meds, and it's a boxed warning for virtually all of them has to do with a cancer called Med galeri. Thyroid cancer. That's a route that's I'm not going to go as far as say it's rare, but it's really uncommon. And it runs in families many times not always, there's something called multiple endocrine neoplasia syndrome type two runs on and we do see people I'm an endocrinologist, I see people who have immune to and I would never give them GLP one meds because it's contraindicated because their cells in the thyroid called C cells that were stimulated in rodents, when they were given GLP one meds now humans aren't rodents. But we don't know the whole story here in terms of how humans might respond, who have either the cancer or family history, we don't know that we would promote it. So those people shouldn't take it. Most thyroid cancers have absolutely no implication when it comes to GLP. One, there's no sign that GLP one meds can cause the routine, the common kinds of thyroid cancer. So that's something that person needs to talk to their endo about a little bit to try to find out more about that. And if the person has no family history of medi Larry, thyroid cancer, no family history of me and multiple endocrine neoplasia, then they could go in and talk to their endo about that. Pancreatic cancer, there's really no evidence that these males cause pancreatic cancer. So I think the person wants to go back and talk to endo and say this talk about that issue. What are we talking about here? I think that's the best approach. Go back in and talk to the talk to the endo and find out more about the concerns that we know. Yeah,

Scott Benner 23:50
I'm going to read you something then I'm going to ask you a question about how you think about things. So yes, medullary. Thyroid cancer is a rare type of thyroid cancer accounting for about one to 2% of all thyroid cancers in the US, approximately 1000 people are diagnosed with modularity thyroid cancer each year in the United States. So if you're one of those 1000 people, then their odds aren't great. But that's a pretty low number. And that's fair to say, right? 1000 people is a fairly,

Dr. Blevins 24:18
that's pretty low number. Okay. I agree with the concept. I think one to 2% doesn't fit rare, but it's really, really uncommon. I know it's called rare. It's really, most cancers are thyroid cancers are called papillary, or follicular or mixed. Those are the ones that we see if someone has that kind of cancer in their personal history or family history. There is no contraindication to using this method. So you are you're right. You know, one thing to point out is and we don't want to go too far here, but these meds have been around for quite some time. You know, ozempic was approved in 2017. And then true listed He's been out for a long time. And it's been used in millions of people. And we're not seeing a thyroid cancer, med Valarie? Or any other answers signal in it. Now you could say, well, it's not being followed very closely. I mean, how would you know, because there's not a, there's not a study going on here. But people do report these things. There is no signal that showing up. So I think it's very important that a person not take GLP wants to have if a person has a personal history of modularity, thyroid cancer, or that multiple endocrine neoplasia syndrome, but we are right, it's really, really, really uncommon.

Scott Benner 25:35
So my question to you is, because your common sense person, this is one thing I've learned from you. In the short time I've met you and known you, in your own life, medications you might take or as a, as a doctor who's prescribing? How do you think about the problem of Yes, some people die in car accidents, but we need to drive when it comes to medicine? Like, do you know what I mean? Like that bigger, right? Because you hear people all the time, like, you know, I'll post on the Facebook group, hey, you know, we're talking about GLP. Today on the podcast, and 50 people be like, Oh, my God, I've been on GLP. For two years, I've lost so much weight, my one sees down, blah, blah, blah, it's all in one person's like, it makes me throw up and everyone goes, Oh, my God, it makes people throw up. It's a really interesting way our minds work. Like I know, we're, we're risk averse as humans on purpose. And that's a good reason. But But how do you think about it personally, like when you're standing in front of a person, you decide to give them something? And this and whatever else is in that label is out there? How do you make the risk reward decision?

Dr. Blevins 26:39
Yeah, it's what you said it's a benefit risk equation, it's a benefit risk analysis, you want the benefit, the potential benefit, when you start a medicine, when I run a medicine, I want the benefit, the potential benefit to way exceed the risk in risk is a very, very thing too. I mean, some some medicines have a risk of some really nasty things. Some medicines have risk of some fairly mild things. So nausea can be anything from mild to nothing too terrible. It is true. And I tell people this all the time, or if I'm ever presenting this data, I say, Well, some people can't take it, for sure. And that's true of most myths. And that's when I take them out. I know I'm going to try it. If I'm having a symptom I don't like I'm going to stop it. And I'm going to look for an alternative. Maybe it depends on what it's all about the the condition, and the benefit and the risk. And so people need to know going into taking this type of medicine or any type of medicine, why they're taking it, what it can do for them and the risk, and they need to realize it especially with GLP ones that sometimes people just simply can't take because of nausea. Yeah, if one person has nausea and vomiting, and they stop taking it does that is that a clarion call to say everyone should go off of it? Not at all, not at not at all, the vast majority of people have no problems with it, they might have mild nausea, they may have moderate nausea, or even even notable non nausea, which tends to get better over time. It doesn't always get better over time, though. And I'll tell you, if you look at most studies, I'll just kind of ballpark it anywhere from 4%. Up to 8% of people in the studies had to discontinue the GLP one or GLP one tip meds because of GI symptoms. And as we've talked about before, that would be nausea, vomiting, diarrhea, constipation, I tell people, Hey, you may get nausea, vomiting, diarrhea, constipation, and you don't get to choose, you know, one of those and you may not, you may not tolerate it. Many times we can mitigate the we can reduce the side effects by reducing the dose. And in their other things I could go on and on about that can also reduce the risk of that like lower fat. We talked about that while ago. lower volume in the in the food intake. There's lots of things people can do to modify. But yeah, you're right. If one person has a significant side effect, and they can't take it that does has that's interesting. And that's that's it, and I'm sorry for that person. Of course, it doesn't mean other people should go off of the medicine

Scott Benner 29:12
or not try it out either. Yeah, exactly. My mindset is simple. Like, we're here now. Like, the rules have changed. Like I'm not, I'm not standing in front of you. Me personally, super fit and muscular with no fat on me and no risks of heart attacks. I'm 52. I'm carrying extra weight. A lot of it's in my stomach. You give me this medication. I'm not as hungry, I fill up sooner. I'm losing weight, and I have diarrhea feels like the cost of doing business to me. You know what I mean? Now, it wasn't so bad that I couldn't exist. And of course, if it was that would change it. I want to know too. And this is going to call for speculation but how many people have you stood in front of who experienced the side effects and you think yeah, stop taking this and how many of them do you think tougher out, it'll be okay. And like, it's sometimes it's just the resiliency of the person, not necessarily the medication. I know that I'm not blaming them. But I mean, people do have different tolerances for for trouble. Do you know what I mean? By do?

Dr. Blevins 30:16
You know? The answer is it's highly variable. I had a person in the office yesterday who was having pretty bad constipation, connected to a GLP. One method. And we did a few things. First of all, she didn't want to stop the meth because she's had good results. And just what you said, she's had good results, she understands the importance of the results, she's had her sugars are better, her weights down, everything's better, she feels better. But she has pretty notable constipation. So what do we do we cut back the dose a bit, I gave her some advice about treating constipation in general. And there ways to deal with it. Now some people come and say, is so bad, I can't take it. I go, you're the boss, not me. And let's let's go off of it. Or we might try different GLP one GRP. Med. This is surprisingly, sometimes changing the med can change the symptoms. And you wouldn't think it would be true. You would think that I'll be kind of similar in that way. But there are some there are some differences.

Scott Benner 31:14
My endo told me going from Wiko V to zap bound might help me with loose stool. Yeah, yeah. And she indicated that it's possible my acid reflux, which had gotten much better, could actually even get a little better again, yeah, it has been my finding. If I had known enough about the drug before I started, which I think people should, should know that I was very careful to take magnesium oxide every day, when I started the medication, like, I did not want to be constipated. And I also very thoughtfully, even though I am not a high fat person to begin with, I was extra careful not to eat high fat. Now, I mean, truth is, depending on the dose, I've had, you know, it's funny, I've had French fries in front of me at a table with a bunch of people. And I've reached out and had two or three of them, and you get to the third round, and you just like, I don't want this. And it just it's interesting how your brain works so much differently on this med than then it worked for me that my brain worked without it. Because I could have eaten them. But I was just like, I don't I don't want to do this.

Dr. Blevins 32:18
And that is so cool. Because you just saved yourself a few 100 calories. Yeah, that is that is the way those work, meds work. They do such a nice job with that. Fascinating.

Scott Benner 32:27
Yeah, let me ask you one, it's a little generalized, but just so that this information is in each episode that you do about GLP is this question, what specifically? Is it about a GLP? That helps lower insulin needs for type ones? And is there one that is preferred over another specifically for type ones? Well, the so forget, forget, for a minute. FDA approved, right? We know none of them are for type ones. But what's the mechanism of how a GLP helps lower your insulin needs? Yeah.

Dr. Blevins 32:58
And you're right, none of these were approved for type one. And we are doing a study you as we've talked about before, here in Austin, that's looking at one of these people with type one. And I hope that study pans out to show it's effective and safe. And maybe we'll get one approved, we sure hope so. But the way it could reduce insulin needs would be number one, it does slow down gastric emptying, so therefore, anything that goes in, it's absorbed more slowly. So there's less peaking of the carbohydrate, less less glucose flow from the intestine, at least it's delayed. And so that's a better way to put it. In addition, the medicine can reduce appetite a bit, so fewer calories and fewer carbs in lower glucose and lower insulin need. It can reduce then weight as a result of the decrease in appetite or early satiety. And that improves insulin sensitivity itself, as you know. Now, is there one that's preferred? I don't know. And I'm not gonna I don't think so. I will say that the one called terzetto appetite, which is Mount Yarrow. And set bound has the effect that the GLP one has on slowing emptying and reducing appetite, but also seems to increase insulin sensitivity. And so that that's an interesting phenomena to where everybody's still kind of working their way through that one. So it has that effect. So all of those mechanisms together, or intervene individually can help reduce the need for insulin

Scott Benner 34:41
to follow up questions, so ones for me personally, if it's slowing gastric emptying, meaning I'm probably going to bed with food, my stomach, how is my stomach acid going down? How come it's having that impact for the life of me the first time I lay down at night I thought Oh God, I don't think my dinners like through For me at and I expected more gastric reflux and I got less, what's the mechanism there? Yeah,

Dr. Blevins 35:07
you know, this is going to be something that varies from person to person, these meds can cause a worsening of reflux because they slow emptying. And that's what you'd expect. And some things happen that we can't explain, I will say this, when a person loses weight, they lose visceral, adiposity, visceral fat early on, they don't lose it all, they lose some of it. And that reduces then pressure on the stomach, that's just a mechanical thing that reduces reflux. And so and perhaps a person eats less as as they use the med to. And that might reduce volume. And that might actually reduce pressure in the in the stomach, then the pressure is what leads to the reflux into the esophagus, and the acid feeling. So there are a number of possible reasons that your symptoms are better. One may be the weight loss or reduction adiposity, visceral fat, and the other may be that you're eating lower volumes, and maybe not even notice and you are but the possibly you are I know that that's not have intrinsically any anti acid effect. I'll tell you that. Right. So

Scott Benner 36:15
it's more physical structural implications.

Dr. Blevins 36:19
I think so

Scott Benner 36:20
yeah, it makes sense to me, I'm going to ask a very specific question. This is actually for, like an acquaintance of mine. Yes, at birth, this person lost some of their intestine. So it had to be removed their whole life, they basically eat and then dump, right? Like it just That's how it goes. Right? Did GLP be bad for them? With that structural change? Interesting

Dr. Blevins 36:42
question. And this may also more generally be something people who have gastric bypass his might ask or gastric sleeve to in the answer is, well, first of all, the best answer is, I don't know. The other part of the answer is that person if they wanted to explore that would need to talk with their doctor and find out the you know, the pros and cons and whether it's even possible or feasible. And the answer is, it could in theory, because it slows down gastric emptying that slows down the lower intestine as well in many people. So how that how's that gonna work? I don't know. But it's an interesting thought.

Scott Benner 37:21
It's not a question that makes you like, throw up a stop sign up. Oh, hell no, don't do that. No,

Dr. Blevins 37:26
yeah. Okay. No, that's, it's, this is one of those things, you know, it's a negotiation with the doctor, of course, or that person may have a GI specialist, I don't know. But it's a negotiation, like so many things is, well, what about this? Would it be worth worth? worth trying? And that's, that's where I would take it. Let's

Scott Benner 37:43
listen. That's what I told them, especially when you're, this would be for weight loss for them, not diabetes. I said, My God, they're gonna give you a quarter of like, Wiko V to start, like, I don't think you're gonna get thrown into a giant problem. And if it's a problem, you're gonna live through it and stop, you know, so yeah,

Dr. Blevins 38:00
probably, you know, it's probably the only gi history and there's, there's some I might in general, that I would say as is kind of a contraindication to using them as would be if somebody has established gastroparesis, then adding a medicine that slows down the stomach even more, just, generally speaking, not a great idea. Yeah, most of these is recommended. You don't use them and people have gastroparesis hasn't been studied. And people have gastric sleeve or gastric bypass or a person like the person you're talking about. Know. And could it be tried? Possibly, you'll know pretty quickly. If it's a problem.

Scott Benner 38:37
Yeah, I have a note here to myself, because I knew this would probably come up at some point, talking about the difference between a person with type one who starts to experience digestion issues. Maybe because your pancreas has been impacted the way it has been, you're not getting digestive enzymes, maybe correctly from your pancreas anymore. People don't know that. But the frequency that I hear from newly diagnosed people or my son has stomach issues now that they have type one and they've had it for a year. For some reason, a lot of endos. Don't talk to type ones about using a pancreatic enzyme or a digestive enzyme, excuse me to help with digestion, or maybe add a magnesium oxide to help with elimination, and instead they end up eventually at a gastro who just says, Oh, if your stomach's emptying slowly, you have gastroparesis. The difference between that and someone who's had type one for 30 or 40 years and likely has nerve damage if they have gastroparesis, and I do think there's going to be a section of type ones who GLP aren't going to be a choice for because of actual gastroparesis, that that's affected that is a front what does that nerve called the feel like it starts with an F but I can't think of the name of it all of a sudden, Renick

Dr. Blevins 39:53
is one of the nerves but vagus nerve is there and I mean some people with with Type one do you have that neuropathy? The autonomic type neuropathy? Yeah, which leads to gastroparesis. And some of them don't know, they have gastroparesis. And they might find out if they, of course, it would be off label, if they used GLP, one type method. Yeah. And I've seen that, and they're gonna have more notable, and there could be people who have gastroparesis, who have had diabetes a short period of time, but But it's probably not caused by the diabetes. And so there are certain tests like a gastric emptying study, which is kind of funny study where people may have to intake some food that's got some radioactive stuff kind of mixed in with it. And then it's observed the emptying from the stomach is observed after they eat it. Yeah. But that kind of a test is an objective way to look at gastric emptying.

Scott Benner 40:46
I just want to bring it up. Because there's, there's a lot of thinking to be done around this issue around type one and GLP meds, I think, yeah, I think you're right. Scary. Scrambled eggs aside the gift that they give you for that? Right? Oh, stuff? That sounds kind of awful. Yeah. Would it be better? GLP? Is they mean than taking Metformin? I'm asking because my teenager has major insulin resistance and weight gain.

Dr. Blevins 41:14
Yeah. You know, Metformin, has a little bit of there's data in type one diabetes with metformin, and it can help a little bit, but it's not very consistent. Metformin, primarily seems to reduce a paddock that has liver glucose output. Is it an insulin sensitizer? Can it treat insulin resistance very effectively? The answer is well, in general, it's not a classic sensitizer can it lead to weight loss, and not very often and infrequently, occasionally, though, people get sort of almost like anorectic on Metformin. And we have to take them off. And that is very unusual. So I think Metformin has a potential role, it might be worth a try. It is, of course, it's not approved for type one either, but we try it at times. And so I don't think I mean, that for me might have some effect. What was Scott, what was the other part of that question?

Scott Benner 42:14
They have major insulin resistance and weight gain? Yeah. So I mean, let me ask you a different question about Metformin. And then we'll circle back around. It's one of those drugs that's used a lot by biohackers. Like with the idea of like Metformin fixes everything makes you live on like, is there any studies that tell me that just pop into Metformin is good for my longevity?

Dr. Blevins 42:38
You know, there's a lot of theory here. And Metformin may have some anti inflammatory effect. There are people that feel like it has some effect on reducing dementia. And as an effect on longevity, the data is not in on that one yet. And there's some studies going on. Actually, there's a large study going on to look at that kind of thing, but it's going to take that kind of study clearly can take a while to finish. And they'll hopefully be some stops along the way they will get information but the answer is unclear. Does it lower glucose and sugar? Yeah, it does. And is it good for type two diabetes? For sure. Is it is it a strong met? Not really. It's kind of a weak man, when it comes to lowering glucose. It plays well with virtually every medicine that we have in the type two space. And we do use it off label sometimes in type one.

Scott Benner 43:27
Okay. But GLP is are leaning towards packing some similar ideas with like me right away? What's the one that they want to they were trumpeting like heart disease with GRPs is down and and what else kidney disease. But is that? Is that just the function of keeping weight off and or blood sugars lower? You

Dr. Blevins 43:47
know, it's not really clear. I think that's a lot of it. But you know, that semaglutide which of course would be ozempic will go V rebel says the ozempic component that is looked at people went with type two diabetes and with existing heart disease, and found that there was a reduction in what was called major adverse cardiovascular events, and that would be cardiovascular death, and then also non fatal mi heart attack and non fatal stroke. So is it because of the weight loss? Hard to know? Is it because of the consequences of weight loss? Probably, yes. The lowering of blood pressure or maybe improving lipids, other anti inflammatory or other effects we don't even know about? And maybe so but in people with known heart disease, cardiovascular disease, and type two diabetes ozempic has really good data. And you know, that will go V recently, which is of course, the same thing for the weight loss is semaglutide with GAVI recently was approved to reduce the risk of those major adverse cardiovascular events, and people that have known heart disease and either obesity or overweight. So we know that these meds and other meds are the other meds like Manjaro is at bound, they're being studied in the same way. Trulicity showed improvement, you know, truelist, these Dula glue tie the other GLP. One. liraglutide showed that too, so that that whole area is very good. Usually, though I'll point this out. They're looking at people I've known known known cardiovascular disease, they're not looking at people who have type two diabetes and don't have any known disease. And they certainly have not looked at people with type one. Kidney, yes, there's some good data that shows that these meds and specifically semaglutide might actually have a beneficial effect on the kidneys. Interesting.

Scott Benner 45:47
Let's do one for people who are using now what happens if I go up and down on my dose? Because of the shortage of the medications? Is that gonna hurt me?

Dr. Blevins 45:56
And the answer is, it's gonna be really annoying, and it's gonna hurt your feelings for sure. And I don't know, I don't think it's going to hurt you, you're gonna have to chase the glucose is a little bit when you go down on the dose, or you have if if a person, for example, can get one dose, but they could get the lower dose, the pharmacy has the lower dose, they don't have the dose they're taking? Well, the lower dose is gonna be less effective. The person might have to adjust their glucose, sugar lowering meds a little bit. And, and they may feel differently. And then, you know, in a month or two months, they might get the dose, they were on that as now the higher dose, and they might have to reduce their their meds a bit. Is that going to hurt you? I don't think so. Is it going to annoy the heck out of you? Yes.

Scott Benner 46:42
Yeah. It's almost like somebody's going to reach in and change your Basal rates or something like that without telling you. Right? Right. And even if you're just on it, for I'm seeing people who are just on it for weight loss, they don't have diabetes, and the same things happen. And they call their pharmacy and their pharmacies like, Yeah, we don't have it. And you know, but we have this one, and you go, all right, I mean, some is better than none, if it's lower, but you can't just go from like, for example, you can't just go from five milligrams of zinc bound up to 12. Because that's what they have that'll crush you. Right?

Dr. Blevins 47:14
That can be a problem. And I think some people could probably tolerate that. But we don't know. And the whole idea about going up slowly, is just what you're implying is so that you maintain your tolerability of the medicine, and going up too far too fast, could bring out GI symptoms that you wouldn't have had otherwise. So that Euro it's a funny world right now, where the supply is difficult. I think there's been some improvement recently, you know, we're talking right now, late May 2024. And I think by by later in the year, the supplies gonna be better. I will tell you this, though, I said the same thing last year at the same time, and the supply didn't improve that much demand is so high for these meds, that it's been hard for the companies to keep up with supply.

Scott Benner 47:59
I think there's an indication there, by the way that because the demand is so high and consistently high and grows, that should be some indication that it's working for people, because sure everybody might want to try it. But if you try and it doesn't do anything you're not going to keep you're not going to keep doing it. You know, it's obviously at best, you know, just me guessing out into the world. But I don't imagine there'd be this trouble locating I mean, I've run around looking for this stuff, like a crackhead a couple of times. You know what I mean? Like, right, yeah, yeah. Yeah, hard to find sometimes hard to find and CVS Caremark just announced, they're just not going to carry it anymore through mail order. Because it's so inconsistent their ability to get it. But okay, but that explains the the moving around in in doses, I went, I'm into my second week of 10 milligrams is that bound? And I was I had plateaued on Rigo V, I couldn't I just wasn't losing any more weight on the go V. I got moved to that bound. My doctor, I think, started me at what is it two and a half, maybe with that, I quickly went to five. Yes, I lost six pounds. But after I and then they put me on, I plateaued she put me at seven and a half. And seven and a half just nothin. Like I started to gain those five or six pounds back that I lost with a switch. And now I'm on 10 for two weeks, and I've lost those six pounds again, right? And everything's back to where it was meaning I started to have sugar cravings at the end of when I was on lower dose of set bound. Now that it's higher, the cravings are gone. The weight loss is happening again. It's fascinating to watch, but you really do have to pay attention to do Yeah, I make a diary of it. I do it on the podcast, but I think if I wasn't making the diary, I wouldn't even be able to keep up with what's happening to me. Like I think it's that's my by the way, that's my little bit of help. I think you should make a diary about it if you're on it.

Dr. Blevins 49:55
I think that's a great idea. And I think I'm really glad you said what you did about titrating To increase the dose and then that you had results on the weight loss side, and because sometimes people will start at the lower doses, nothing's happening, this is not working. And, you know, hang in there titrate the dose, you get up to 7.5 of zet bound 10 12.5. Sometimes people attend, don't get results and got to 12.5 and their work. And there's a chance. I mean, they're always people that don't respond to any dose, that's for sure. But usually titrating up is going to allow a person to get some results, and that goes for what GAVI that goes for all of them.

Scott Benner 50:35
But Dr. Blevins, you're sitting here with this grand amount of knowledge and you're articulate about it, you know how to explain it in a way that people can understand. A lot of people don't get that from their physicians, a lot of some of their physicians are making decisions based on what they hear on Access Hollywood, you know what I mean? Like I hear it's making people throw up, you don't always get real thoughtful advice. And even the advice I'm getting is from a, from a very learned, like, level headed person, you know what I mean? And, and I have good communication with her as well. Like if I texted my endo right, now, she texts me back. Well, that's great. Like that kind of like, you know, like, if I said, Hey, I'm doing this and this happen, what do you think I should do? I'm thinking this, I'd get a note back. Yeah, yeah. And not most people don't have that, you know, it is

Dr. Blevins 51:23
important to realize that people who are prescribing, there's that thing in medicine called do no harm, and you don't want to make people sick with your medicine. And so realize that, the audience realize that, you know, you may not tolerate the medicine, and and you're communicating many times back and forth, just got, as you said, by text or by phone, or by, you know, Portal message or whatever. And you can't express exactly what's going on. And, and then the person on the other end is going to read, if the person said, Hey, I can't tolerate this medicine, they can say, Oh, you want to stop it. But there may be some middle middle ground there and actually communicating in person. Yeah. Or, you know, more completely can really make a big difference that

Scott Benner 52:06
knee jerk reactions from happening to Yeah, exactly. Here. Do GLP s reduce inflammation in the body? And has it shown any benefits for other autoimmune issues? Yeah,

Dr. Blevins 52:17
that's a great question. And that's, that's the hotbed of a lot of of research and a lot of discussion, and a number of studies. And the answer is, if you look at the studies that are so far available, you can see some reduction in markers of inflammation. Is that going to translate into some really good treatment for inflammatory conditions? I don't know. I don't think anybody knows. Like, if somebody has rheumatoid arthritis, as a GLP. One help? Who knows? I wouldn't predict Yes, because I don't see how that could happen. But it may be there. There'll be something down the road. That'll tell us more if a person has say osteo arthritis, the bone, bone on bone in their knees, hips. Does losing weight help that? Of course it does. And so, lots to learn here.

Scott Benner 53:08
Is AstraZeneca, developing a GLP that you know if I know

Dr. Blevins 53:12
that Boehringer Ingelheim is developing, and also there's some other companies developing company called structure. I'm not aware that AstraZeneca is and I'll just be the first to say, I don't know everything here. And we do a lot of clinical research here. And there may be things going on, I don't know about but I suspect that question was about boy and girl Ingelheim. The bigger answer here is, you know, there are a number of companies that are developing new GLP, one meds GLP, one gi P meds, and even those are dual agonists. And they're triple. And there's a whole wave of new generation meds coming through. And they're going to have different characteristics and they're going to have favorable characteristics we think. So, you know, hold on, and as you might expect, there's a lot of attention in this area in the pharmaceutical research industry. And there'll be more meds coming down the pike. Let

Scott Benner 54:05
me read you this. And I'll tell you what I think cat GPT four o says AstraZeneca is actively involved in developing a GLP medication. They have recently acquired the rights to a promising oral GLP one agonist called AECC 5004 from a Chinese biotech company called Echo gene. So good now, so great, let everyone he

Dr. Blevins 54:24
says AC is a big company. And many of the big companies have have focused a little bit more on on this area. So that is great news.

Scott Benner 54:35
I'm also excited for biosimilars to start popping up because obviously, these things are working for people, it's hard to turn them out. Some of the molecules work better. And you know, for some things, some for others, I think you can only benefit to have options and a fresh set of eyes. Doesn't always hurt either when people are trying to find something that does the job but isn't copying because that's the real problem right now. So people have patents. So you can't like nobody can knock it off as a generic yet there's, that's not going to happen for a while. And so if you want there to be more innovation, you've got to have all these companies looking at this at the same time. So

Dr. Blevins 55:13
that is so true. Yeah. Yeah, you know, this, this thing about these methods and their effect on what you talked about appetite. And one of the people asked a question asked about appetite. And these, these medicines help regulate appetite, which appetite gets people into trouble. And, like, you have three French fries, and you stop, that's great. Most of the time, you know, over the past, if you were me, a few French fries, oh, man, they all that looks good, I'm gonna have that whole basket. And if some cuts, something good tells me to stop that be really good and very healthy. It'd be interesting to see these meds approved just for appetite reduction, although that's probably going to happen, because I don't think the FDA is going to allow that approval for something they're going to want a disease condition. But appetite is frequently the root cause and these medicines reduce appetite, all of them.

Scott Benner 56:01
I'm waiting for Agra companies to start getting involved in trying to put a stop to them. Because you don't I mean, if I made Oreos, I'd be scared. Seriously? Yeah,

Dr. Blevins 56:11
that's a good point. And no carrying. I don't think Oreos have anything to worry about.

Scott Benner 56:16
I'll tell you what, are

Dr. Blevins 56:17
not the only an Oreo, and I'll eat it. What

Scott Benner 56:20
is is there any concern with long term use? Like I mean, for some people, listen, this is me looking online, right? I've seen some people say I lost the weight, I lost the med because of my insurance. And guess what, I'm fine. I didn't get any back. I learned how to eat better. Everything's going well, I'm active, etc. I've seen people say I've lost the med because of insurance. And I didn't change a thing about what I was doing, I put all the weight back on. So some people are going to have to take it forever. Is there a concern a safety concern with that, that you can think of

Dr. Blevins 56:50
Forever is a long time. And we have a lot of data with these meds. And we don't have like 20 year data yet. Trulicity ozempic have been, we talked about this earlier been a long time. And so far, no new signals have shown up like some weird findings. And so they look safe for long term. In general, I would say that for person to maintain the effect of the Med, most of the data says the person has to continue the Med, they might be able to reduce the frequency of administration and the dose to maintain. But they're going to need to continue the Med, they're going to be exceptions to that rule. They're going to be people who can stop and maintain. That is great. And they're going to people, the only people who take it on and on and on and they regain. But in general, if you continue to Matthew, if the effect continues. So we're looking at everybody's looking at the scientific community to look and see if there's anything long term that turned out to be a negative, but so far, so good. So it's not like the duration of time people are on it to the number of people. And they're really millions and millions and millions of people who've been on these meds now and no clear new signals have shown

Scott Benner 58:04
up. Yeah. Do you have a little more time? Are we done?

Dr. Blevins 58:07
Yeah, we can go? How about we could aim for another 10 or so

Scott Benner 58:11
minutes? Okay. I like to know if GLP is used in patients with thyroid concerns, Hashimoto specifically and or hyper cholesterol OMYA. Is that what that is? hypercholesterolemia?

Dr. Blevins 58:23
III, I think is what they're saying.

Scott Benner 58:26
What are their concerns with that?

Dr. Blevins 58:28
The answer is, there's no sign that GLP one meds or GLP. One GRP meds can make Hashimoto as improve, or worse, there's really no evidence there. And there, there is no evidence that these meds would make cholesterol worse. In fact, if you look at most of the data, you would see that the cholesterol levels improve. I could go through each fraction, I'll just say they improve when people are on these meds probably because of the effect on weight loss. There's no sign that there's a direct effect of these meds on cholesterol synthesis or absorption or any of that. But weight loss is magic. When it comes to improving cholesterol.

Scott Benner 59:11
I'm going to ask one for myself. And this is about you specifically, in your practice. You deal with a lot of adults. Yes. If I was your patient, and I came in, I said, Hey, you know, here's where I'm at so far. And you've watched me for the last 13 months. And I said I want to continue to make my my body stronger and give myself the best chance to live longer if I said I don't know anything about this Dr. Blevins but should I be on some sort of a testosterone replacement? Is that a conversation you would have with me or do you not see the value?

Dr. Blevins 59:40
I would definitely have the conversation with you about that. And what I would wind up what do I do? It was I would first of all ask you about any symptoms related to low testosterone. And then I would check your levels. And then if you're low I would I would say you know your About your muscles, your mood, many things in your body will do better if you're normal. Would I put you on testosterone? If I find you to be normal? And the answer is I wouldn't. There's no evidence that putting people on testosterone who have normal levels is going to prolong life or improve things. And, and so it's another one of those benefit risk things. If the benefit, if you're low, the benefit, I think exceeds the risk, there is some risk potentially. So testosterone is not a cure all for everything. And if the levels normal, there's really no evidence that it could could help. And, you know, testosterone given to people who buy either gel injection, pellet, whatever, can have some negative kind of has some side effects and negatives. And like, they can increase the blood count, which could increase the thickness of your blood or viscosity, which could lead to stroke, things like that it gets overstimulate the prostate. That's another possibility. And I've had some people who are given testosterone who get very agitated, and that's not very often but it happens. And then we just we back off, or we stop it,

Scott Benner 1:01:10
you handled it exactly the way my doctor did. So I was just, I'm just, I was just interested in your response. Yeah. And my levels were didn't need addition. But I was in that mindset, I was like, how do I make sure that I'm stronger and fitter and have the best chance of staying alive as long as I can? Okay, so I'm gonna go to what I think is going to be a little bit of a long answer. So we'll finish with this one. Okay. This person says, I want to know the doctor's thoughts on micro dosing. GLP is specifically for people with autoimmune disease. And for people who do not need it to lose weight. My thoughts are that maybe a pharmaceutical version of these peptides, those far too high and too fast for type ones. Maybe micro dosing will negate many of the side effects, and maybe you'll get some of the inflammation, increased insulin sensitivity, and the other benefits that come along with it. I'm super interested in this because I just did an interview last week with CEOs from xirrus and beta bionics because they're working on a dual hormone pump. And I mean, honestly, what are we talking about there? We're talking about micro dosing glucagon in an insulin pump. So Exactly, yeah. So what do you think here about the idea of this possibility with GLP? Yes.

Dr. Blevins 1:02:19
You know, the micro dosing ideas are really interesting idea. And I will I'll be the algo right out and say, I'm not sure exactly what that dose is. But well, I know that means less than normal. And I would think it might be the same frequency or more frequent lower dose? Who knows, but micro dosing less than normal dosing, specifically for autoimmune diseases? And I'll say very quickly, no data? Would I do that before an autoimmune disease? Depends on which one you're talking about? Of course, some are more serious than others the answers for all of them, I guess, so is that independence? The answer is no, I wouldn't do that. I don't know, I don't have data for that. And what I use it for people who don't need to lose weight, well, that would be people who have diabetes, as to who don't need to lose weight, and some people's because it does have an effect on glucose metabolism. So I would use, the concept of micro dosing is interesting data is not available, it's all going to be personal use, and we'll really need I mean, you know, I'm a scientist, we need a study to tell us what to do anecdote is, is going to get people in trouble. And the thought the pharmaceutical dose could be dosed far too high, maybe for certain things, but not for what we're looking at that dose about right for blood sugar, and the weight loss and that, and then maybe people would have fewer side effects of micro dosing, that's true, they also may have no effect. So we really have to have a clear cut target, like, use it in someone who has a particular type of autoimmune, a group of people who have a certain kind of autoimmune condition, and have a placebo control, and use a lower dose and find out. I don't think those studies are being done, but you whoever wants to can suggest that to their people they know in the pharmaceutical industry? And would that increase some of the benefits like inflammation and sensitivity and things like that? I don't know, maybe, I think the current doses are pretty well worked out. These doses are taken from the bench to clinic, and all kinds of doses are looked at, you want a dose that actually has an effect, and it need to have a target like blood sugar or weight loss or something like that. And then you want to be sure that dose actually works. So I think the I think the current doses are effective. The concept of exploring other areas a great idea, and there are studies being done looking at like arthritis, like osteoarthritis, looking at sleep apnea. There's been some positive there already. That's about weight loss, I think. Yeah, and other other conditions, that maybe even some cognitive conditions like my Alzheimer's Could, could these meds help people, people looking at all kinds of things but until we have a good study, I don't think I would jump in and start using it that way. Yeah.

Scott Benner 1:05:03
Do you think you've seen anything? Even just, you know, N of one kind of like returns? Where people have experienced less gambling habits like other addictive natures that you've heard that talked about, but do you actually say it? I

Dr. Blevins 1:05:18
have not had a person come back and tell me that they took it and they were not going to Las Vegas as often, though, I've read about that. And I think it's fascinating cravings. Appetite is a type of craving, gambling as a type of craving alcohol, and alcoholism. I know for a fact some studies are going on looking at that. Do I know results? No. But I've had a few people come back and tell me they were less interested in drinking alcohol about drinks. And there may be something there? If so I sure hope there is. But I want to see a good study, come back and tell me that that actually was true. Yeah. And it may just be it's not, it's not a consistent thing. I've asked some people, do you drink any less? And they say no. So we need something to tell us more about that.

Scott Benner 1:06:05
I've noticed this thing. I'll end with this and ask you if you've seen it, too. I think it's possible that as a society, we've become so used to people's body mass being a larger, that now I'm seeing people use these medications, get down to what looks like a very nice healthy weight. And yet the people around them are shocked and say like, Oh, my God, you're too thin put weight back on, like, bah, bah, bah. And you if you really look at them, like from a reasonable perspective, they're not too thin, they're not to anything, they just look like a healthy human being. It almost feels like that's not what people are accustomed to looking at maybe with you personally or with people in general. But I was wondering if you've seen those kind of more psychological reactions? Absolutely.

Dr. Blevins 1:06:48
That that's true. Change is something that people notice and comment on. And in historically, when people have lost weight, it's because they're sick, and cancer or something like that. And I've certainly had people comment in that direction, or have people tell me, they've, they've been told they look sick, they need to eat? Yeah, their family, their friends, I'd say here, you need to pat yourself, get some get, you know, eat and gain some weight back. Even though what you said is correct. Their weight is now more normal than ever. I would tell people in the audience expect that and understand it, and take it as a compliment. And let people know what you're doing. And if you want to

Scott Benner 1:07:34
don't let it thwart you, I've seen people, it happened to somebody around me recently, they were so pressured by the oh my god, you're losing too much weight, pressure that they started thinking about not doing the medication, I said, Look, between you and me, I need to lose 15 pounds. And maybe more, I don't know, like, I have to tell you like my ability to understand how much weight I needed to lose is completely skewed. Because I started this thing thinking 20 pounds, I'll be great. When I got that 20 pounds. I was like, I don't even look any different. And now, if I said to somebody, somebody says, Hey, you look great. I'm like, thanks, I still have 1520 pounds loose. They go, that's not possible. And I'm like, Well, I can take my shirt off and share it with you if you want. But like I definitely still need to. Yeah, I just don't want people to get thrown off by knee jerk reactions to their visual appearance.

Dr. Blevins 1:08:21
You know what I mean? I agree. Yeah. Yeah, the nice thing about it is people are concerned. And they notice and, and there is a compliment. You know, it's it's people who are concerned, they think, Oh, is there something going on? I care? I want to know, or they may be they just playing nosy, I don't know. But then you could reassure them and say, you know, and now now everybody knows about these methods, almost everybody. And you could divulge or you don't have to you don't want to maybe tell people what you're doing. You could say now that I don't have cancer. I don't have some bad disease. I'm working on weight loss, and, and, or something like that. But yeah, it's a common phenomena. And everybody should just expect it. And it's actually a real big positive, but it comes off as Oh, you look, you've lost too much weight. And of course, the answer is no, you haven't.

Scott Benner 1:09:07
Yeah. And by the way, I don't actually care about the number of my weight. I care about the fat My body's holding. That's yeah, my concern is so exact whatever I end up looking like after I'm carrying a healthy amount of fat on me, is what I'm going to look like. Right. All right. Well, Dr. Bill Evans again, this is terrific. I feel like I could just have a podcast where I chat with you about anything and it would be good. So thank you. I appreciate your time again.

Dr. Blevins 1:09:32
Scott, thank you very much. It's fun. Yeah, I've enjoyed it.

Scott Benner 1:09:35
Great. And we're gonna head back again. Is that right? Yes. Oh, excellent. Great. Great. I'm super excited. Hold on one second.

Jalen is an incredible example of what's 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/juicebox And look out online for the hashtag Medtronic champion. Having an easy to use an 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. We're starting to get a nice grouping of GLP focused episodes. There's a full list of them in the featured tab in the private Facebook group. 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

#1490 Best of Juicebox: Dr. Blevins on GLP Medications Part 1

Dr. Tom Blevins discusses GLP medications.

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Scott Benner 0:00
Hello friends and welcome to episode 1212 of the Juicebox Podcast.

Tom Blevins is an endocrinologist that Texas diabetes and Endocrinology in Austin Texas today Tom is going to come on and share his expertise so that we can better understand GLP medications I'm talking about we go V I'm talking about ozempic, zap bound, mon Jarno and more. Please remember while you're listening 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. You can find out more about Dr. Blevins at Texas diabetes.com If you are a loved one has type one diabetes and you'd like to be involved in research. All you need to be as a US resident and you can head to T one D exchange.org/juicebox. When you complete their survey you are helping with type one diabetes research. You're also be supporting yourself and this podcast T one D exchange.org/juice box. 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 check out the private Facebook group Juicebox Podcast type one diabetes with over 50,000 members. This episode of The Juicebox Podcast is sponsored by Omni pod five Omni pod.com/juice box if you have FUBU the fear of missing out on Omni bod. You don't have to have that any longer. Just go to my link Omni pod.com/juicebox This episode of The Juicebox Podcast is sponsored by the only implantable sensor rated for long term wear up to six months. The ever since CGM ever since cgm.com/juicebox.

Dr. Blevins 2:04
Hello, everyone. My name is Tom Blevins. I'm an endocrinologist at Texas diabetes and Endocrinology in Austin, Texas. I work at a clinic where there are about 12 endocrinologist and we have about 12 to 15 advanced practice providers and we see a large number of people with diabetes, especially type one. And we also see a lot of people with type two diabetes. Of course we treat people with pumps and technology and, and even just regular injections. Happy to be here. Oh,

Scott Benner 2:35
I appreciate that very much. Thank you. How long have you been an endo?

Dr. Blevins 2:39
I've been an endocrinologist since about 1986. I finished training and went to Baylor College of Medicine in Houston and got boarded in internal medicine then Endocrinology and Metabolism ultimately got boarded and lipid ology as well. So I've been in practice for about that long. I think that adds up to be about 38 years.

Scott Benner 2:58
What drew you to it initially? And is that the same thing that you do today. Of

Dr. Blevins 3:03
course, back in the 80s, when I was in training, endocrinology was kind of a different space, a lot of diabetes, a lot of thyroid, I really was fascinated by the conditions. And I saw a big potential to help people. You know, interestingly, I really liked the people I worked with who were endocrinologist and, and that attracted me. Now over time, of course, things have changed a huge amount, which is really fortunate for everyone. And diabeetus has evolved from the days of mph and ultra linty. And all that the huge fingerstick devices, which if you've seen it those made, you're probably too young to have seen those but the old iTunes and the the evolution of technology has been just incredible. And then the evolution of the therapeutic agents as well.

Scott Benner 3:52
And that's why you're here, Tom. So can I call you Tom or would you prefer to be called Dr. Blevins or Thomas? Good Thomas. Good. Okay. So you you mentioned something else though you got boarded in Lippa chronology is that right?

Dr. Blevins 4:06
Lipid ology technology. You know, like lipids, interestingly, you talk to people about cholesterol, and their LDL, the good and the bad and all that and that sounds very basic, but really, there's a huge world underneath that there's a board Believe it or not, it's that's when you study for and there's a society of lipid ology, and I'm a fellow of that group. And there was a lot of work done in Houston and that's where I trained with people like to Debakey was there the the surgeon, and the cardiovascular surgeon, then a guy named Tony Gato came in to be the person that did the lipids to help prevent some of that heart disease that they were treating, then a few other people, very smart people came in and I was fortunate to be able to train alongside them. So lipids, part of Endocrinology, really, that's metabolism.

Scott Benner 4:53
Is there any intersection between that and why you and I are talking today your understanding of lipids? No, no and how you came to, like pay attention to GLP is

Dr. Blevins 5:04
not exactly it's another aspect of metabolism. Yes, and that is what endocrinology is about by specialty the board has actually Endocrinology and Metabolism, then there's not a tight link between glucagon like peptide, one mil. It's a GLP. One meds and lipids are somewhat of a loose link, we could talk about that anytime people lose weight, of course, their lipids get better. And the GOP one meds can can help people do that.

Scott Benner 5:27
I see. So let me tell people a little bit about how I found you. For the people listening to podcast, they probably know that for about the last 13 months, I've been taking a GLP medication strictly for weight loss, I don't have diabetes. And I've lost I think 46 pounds at the moment. Since then I started on we go V I moved on from weego V to zap bound maybe a handful of months ago now. Anyway, I think not this similarly to how most people end up doing things. I was about six or eight months into this. And I thought maybe I should understand better what it is I'm injecting into myself once a week. I mean, it's working fantastically. I feel better, everything about my life seems to be better. But I'd like to learn more about it. And I'm starting to see people with type one speaking openly about the successes they're having. So that led me of course, to where any good research would lead a person to YouTube, where I found you, Tom just doing a sit down talking head describing GLP to people and I just thought you were masterful at it. And I reached out and I'm really grateful that you reach back because I think this is a great topic for people living with diabetes.

Dr. Blevins 6:35
Yeah. Glad to be here. Good. Thank you. Nice to work on the on the weight change. Weight loss.

Scott Benner 6:39
Oh, thank you. I appreciate it. The just about three weeks ago, I went to my Endo, who's the one who manages my weight. She was doing my vitals and she kept like mumbling half under her breath and half of my ear like a kid like a kid. These are great. You know about my BP my blood pressure, like just yeah, just just so much stuff that she's like, wow, this is it's incredible. I look like a completely different person. It's my aches and pains are gone and everything else that you would expect to come with weight loss. But then there's also been other benefits. One being that for my entirety of my adult life, without knowing it, I was running around with an incredibly low ferritin level, I was not absorbing iron, and my digestion was always poor and kind of off. And I guess just the slowing of the digestion. My last Burton was 170. And I'm telling you, I've been in the hospital like in the ER with a nine ferritin where I was like almost passing out. And no matter how I supplemented it, I couldn't cut it to come up without iron infusions. It literally is changing my life in ways I don't even think I know yet. Anyway, I sent off a massive list of questions from listeners to you. And you've kind of boiled it down to what you want to talk about here in our first recording. And I think if you enjoy yourself, we're going to do more. So I'm going to try really hard to make you enjoy yourself. But why don't we start right at the top like GLP one. Of course we go V and ozempic GLP one with a GI P that'd be Manjaro. And zap bound. There's others but these are just the ones that are out in the zeitgeist right now. So let's start real basically with what is a GLP?

Dr. Blevins 8:14
Yeah, GLP one that stands for glucagon like peptide one. And, and the gap that you mentioned, Scott is and let me just recommend everybody stick with the gap abbreviation it's glucose dependent insulinotropic polypeptide. Now, okay, stick with gap and actually stick with GLP. One, if you say GLP, I know what you're talking about. Actually, interestingly, people make these hormones in their body, and they make them in the small intestine, and GLP. One is made in cells called the L cells in the small intestine. And when a person eats, carb stimulates the production of GLP one. And gi P has made in the case cells in the small intestine, and in it to is produced after carb, and maybe protein can stimulate it as well. But those normally do is the GLP. One actually goes to the pancreas and can stimulate insulin production. So that's what they do. Normally, this is natural. This is what your body does all the time. So GLP, one stimulates insulin, it also can affect another cell in the pancreas called the Alpha cell. alpha cells make another hormone called glucagon. And glucagon stimulates glucose release from the liver, and actually GLP one that suppresses the alpha cells, it makes them less glucagon the Alpha cell does, and there's less release of sugar from the liver. And so that's those are two things that GLP one does. Now, I'll tell you, I'm going to skip to tip a minute. Tip stimulates insulin production from the beta cell in the pancreas. That's what it does. That's his main role. And we'll talk more about Then a bit, because there's some other things that GeoIP mimicking medicines can do. Like you mentioned mount Jarrow has GeoIP. And of course mount Jaren is up bound to the same thing GLP one does two more things, though, we talked about the insulin to glucagon all that that's good. But what it also does is slows gastric emptying. Meaning this slows your stomach down when you eat. And it slows the emptying of the carb and everything else into the small intestine. Therefore, the carb can't get in as quickly, that lowers the amount of carb that gets in lowers the sugar after you eat is what it does. And what else happens if your stomach slows down. And Scott, you've experienced this, it makes you get full fast and easily, you don't want to eat as much. And so that's one way by which a GLP one time Ed can lower calorie intake, but also it probably has a direct effect on the hypothalamic area that reduces appetite. And gap can reduce appetite a bit as well. And I'm just gonna go ahead and say GeoIP, and meds, that's the amount jarred can also seems that they increase sensitivity to insulin, which is really interesting. And so these meds, do some really good things. It turns out that people with diabetes, type two, make plenty of this stuff. And as far as we know, people with type one, make these two. But the effect in type two is, is reduced of these two hormones. And so therefore, giving people a medicine that mimics that kind of a hormone can really kind of improve things. Of course, people with type one don't make insulin, so you're not going to get that effect. A person with type one would get the lower glucagon, the gastric emptying effect and the appetite effect. I want to just step right in front and say these medicines are not approved to be used in people with type one diabetes at this point, right? They're approved for type two.

Scott Benner 11:59
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Dr. Blevins 14:41
know, the answer is these. Well, to your second question was a good way to enter back into the first part of the question your first part of the question. That is a concern with slowed emptying and suppressed glucagon. And of course glucagon and people type one your alpha cells do make glucagon and go God can help when you get low, of course, and that's what you get by injection, you know, the glucagon injections. And your your alpha cells make that and they help regulate your sugar. So if your sugar gets low, your cells kick out glucagon. Well, if you suppress glucagon, it could increase your risk of low number one. Number two, what you said is right, if the stomach emptying slow down that could increase your risk of of low also. Now back to the first part of your question. These agents have been studied in people with type one. And I'll just briefly tell you, there were two studies a few years ago, we participated in one of them here, we do quite a bit of clinical research here. One thing I didn't mention when I introduce you should have but we do quite a bit of clinical research. And we were really excited about these studies using it was liraglutide, which you know, as Victoza. And that was being studied people type one and there's large studies. And sure enough, in people with type one diabetes, who were treated with, I'm gonna say Victoza because people know this is Victoza. liraglutide is one of the GLP one meds, it's the one you had to give every day, once a day. Yeah, short duration, you have to give it once a day. And we were very excited about this people's agency did drop, you know, around point 3.4. And, and the body weight dropped five kilos or so that's good. But also and the insulin dose reduced, no surprise, but also those people had more hypoglycemia. And also, there was a little bit of an increase in ketoacidosis diabetes related ketoacidosis. And, you know, that kind of caused everybody to pause. And and these big studies were done, and the drug did not get approved for type one. If you look back into those studies, I will tell you this, just just to let you know, the ketoacidosis episodes occurred for typical reasons, it wasn't they didn't look as mysterious when I looked at the studies. And the hypoglycemia was a bit increased. But I think, you know, it's very possible that could have been mitigated with increased change in doses and things like that. Nonetheless, though, those two studies kind of stopped the whole approval process for type one in its tracks.

Scott Benner 17:21
Do you think it needs to be looked at again?

Dr. Blevins 17:23
I do. I really do. And I'll also tell you that another analysis of this whole area, kind of a pooled analysis of, of a number of studies with GLP, one meds and type one showed, certainly there was more gi side effects, we know that's going to be true. And anybody that takes these medicines are competing nausea, vomiting, diarrhea, constipation. I always tell my patients, you know, with these meds, you could get diarrhea, constipation, nausea, vomiting, and usually gets better I tell people you don't get to choose. One of those might have some of those might happen. But if the this pooled analysis showed no differences in ketoacidosis, severe hypoglycemia between the people treated with the Met or the placebo, so yeah, I think it needs to be studied more. I think, anyone that listens to this should, you know, rattle the cage of somebody and say, Hey, we need to study this again and get this so it's approved. Right? That's my opinion. And you know, we're very cautious about this when people talk why and we'll talk about that more.

Scott Benner 18:27
Yeah, no, I appreciate you being candid. I mean, listen, I think people who listen, no, I am getting, I mean, our endocrinologist is giving my daughter GLP. Actually, she's using Manjaro at the moment, which seems to go Jive better with her. I don't know a better way of saying that. Yeah, the decrease in insulin use is insane. Yep. Yeah, I genuinely believe my daughter will use 16,000 fewer units of insulin in the next calendar year, because she's injecting five milligrams of Manjaro a week. Yeah, it's fascinating. And her her excursions, her glucose excursions are flatter. I don't. And now in fairness, she's also wearing a DIY algorithm she's using Iaps. I don't see any more instances of hypoglycemia. As a matter of fact, without the excursions high we're getting fewer Bolus is to bring her back down, I actually think it might be making less hyperglycemia than before, which isn't to say that she had a lot. I've also told you a story and sent you an episode of 15 year old girl who's gone from 70 units a day down to now, seven units a day of total insulin, a type one, my 47 year old brother went from a seven a one C with type two diabetes down into a five a one C without really even changing how he eats and he lost 35 pounds. I mean, I know there are people who are going to have results that aren't like that or that You know, they have some sort of a reason why they have to stop it. But my gosh, like everything I'm seeing just it screams for us to pay attention to this. Yeah, yeah,

Dr. Blevins 20:09
I agree I do, I do want to emphasize that, since it's not approved for people type one, where I don't want to talk about the information for type two interchangeably, it would be using these medicines and a person with type one diabetes, unless they fit certain weight criteria. And we'll talk about that more in a bit. But is off label meaning it's not approved, right. And, you know, insurance, insurance coverage is highly variable, not guaranteed, in fact, likely won't be covered. And so the doctors, your, your treating prescribing doctor can use a medicine off label if, if that doctor or provider feels like it's appropriate, and some will, and some won't. And everybody wants to be very careful, I'm very cautious, for good reason. And these are some great stories like your brother well, and you know, some people do great with these meds, and some people simply can't take them and they can't tolerate them. And I've had a person in this morning to the office who said, you know, I tried a couple of these. And I simply, she simply could not tolerate, and we can we can adjust the dose sometimes and make it work. And we can use a little bit under even recommended dosing to make it work. But they're not for everybody. Yeah, they really are, are wonderful meds for for many, many people. Right?

Scott Benner 21:25
I do wonder if in the future we won't see at boils down to be micro dosing for people with type one sometimes. Because if you're not looking for the weight loss aspect of it, or the hunger aspect of it, although, you know, when you have type one, a lot of people with type one have trouble regulating their hunger and have digestion issues. It's not uncommon, right? But you know, I want to go back before we go forward, you just said, you know, early on, one of the mechanisms of this is the fullness you feel full, go over again, the part where your brain just doesn't tell you you're hungry, because I have both implications. So yes, I get fuller, faster, right, right. That's slower digestion, that's lovely. You can eat through it, by the way, you have to you have to mindfully stop when you feel it. I can eat through it. I should say, I'm sure some people would vomit, or I've heard those stories, right. Yeah, but the part where your brain, like I have to remind myself to eat, I don't get hungry very often. And if I do get hungry, it's almost always in the last two days of the injection when I think the halflife is waning,

Dr. Blevins 22:32
right? Yeah, you know, there's a lot to learn here. We don't know all the answers. But there does seem to be a central effect of GLP. One agonists we'll call them agonist because that's what these meds are they, they stimulate that GLP, one receptor in various places, there does seem to be an appetite suppressant effect, and GeoIP probably does that too. So those two together work well together when it comes to the appetite part. So appetite could be partly regulated by feedback from the GI tract. That may be and so that could be part of it could still be linked to the to the gastric emptying, issue, or change. But also there's a seems to be a central effect. And when I tell people is, you know, you're taking the appetite, I call it Daymond you're putting into a cave, and you're kind of putting a rock in front of the cave, so won't come back out. Because appetite. Everybody has appetite. And, and I'm sure over time, appetite has been a really good thing to keep people eating. And when there's food eat. And when you're not, you're not getting enough calories eat, you know, but appetite these days, kind of throws people into high calorie intake and high carb high anything intake. And so these meds do seem to have an effect a central effect on appetite. Yeah,

Scott Benner 23:48
that's fascinating. I mean, I think not like most people, I felt impacted by it immediately. And my wife's like, Oh, it's a placebo, but I lost four pounds in the first four days. Yeah, recently, I had to go up in my dose, like I was writing the 7.5 milligram dose as long as I could with the Zep pound. And my doctor, I said, Hey, I put a couple of pounds on but I'm not doing anything differently. And she said, Well, I'm gonna move you to 10. Actually, 10 and 12 is where I see the most weight loss. She goes, I just wanted to see how much you could get out of the 7.5. And all of the little things like I was starting to have more sugar cravings. I was hungrier, all that stuff. I swear to you, I shot the 10. Four or five hours later, I said to my wife, oh, I have that feeling of like when I started the first time in my stomach, my body regulated to it. I've been using it for 13 months. So you know, in a day, I felt better. And now it's been four days since I did that. And I've already lost four pounds. Yeah, and I have not I swear to everybody listening. I haven't changed my activity. I haven't changed my hydration. I haven't eaten any differently. I just I'm losing weight now. Oh, it's absolutely fantastic. And to watch it work on my daughter's blood sugar is is magical. She I couldn't get her she's away at college. And so I, as I was switching her to Manjaro, because she was using ozempic. In fairness, we're getting this through a Canadian pharmacy. So everybody understands how it's happening. I had to ship it to her, and it was late to getting to her. And in five days past her injection day, her blood sugar's got completely wonky, we had to make all kinds of adjustments to her Basal or insulin to carb ratio to her insulin sensitivity factor just to get her through the four days. And then she injected it. And I talked to her last night and I said, Listen to me right now put all of your settings back. And we are going to be looking for lows over the next 36 hours just in case now the algorithms getting ahead of it. But as soon as the medication hit her, her blood sugar's all like flattened out and stabilized. Again, it's, it's really, it's crazy.

Dr. Blevins 25:54
That's really interesting, you said a few things are really important. One is it's not approved, so it's not going to get covered, you're getting it from Canada, which which, of course, I as a prescribing Doc, I can't write scripts, and send them to Canada, they have to be, I can write a script that you could take anywhere you want. But and that's one thing. And the other thing is, it's definitely want to be cautious because the you're right, hypoglycemia is possible, and then you treat it with oral carb, and it may not get absorbed quickly. So you know, the stomach slow down. So you got to be really cautious about that. And if a person has had diabetes for a long time, they might have gastroparesis. And that is slowed down empty, and because of some nerve involvement from the diabeetus, and then they definitely would get doubled to slower in and that would be a person who wouldn't want to take it. So we have to be very, the stories are great. And and the results can be really interesting when you're using it. And off label again, I'll say that repeatedly. Because I want everybody to know that's it as a story right now, with type one and vicious I'd be very careful about it and select people properly and can be careful about the and understand the drug itself may make it a little difficult to treat hypose And could create hypose

Scott Benner 27:08
Yeah, and it's going to be such a case by case situation not that everything about diabetes isn't right. But at the same time, like when this becomes more accepted or covered by insurance or everything, it's going to take some real overseeing by people who understand what's going on, because your transition so important. If somebody wouldn't have told me in the very beginning, hey, it feels like your food stops halfway down your chest for the first couple of weeks, you know, which is how I would describe we go via when I first started taking it. I might have panicked if somebody wouldn't have said to me like do not eat crazy. I don't anyway, but but do not eat crazy, fatty or greasy foods you might throw up, I had help moving into it. I had good direction. It's why I was able to navigate it. Because the truth is there's a lot there to navigate. I you know, people ask like what are your implications, and I had diarrhea in the beginning. But I said to myself, I know that when my body regulates this, I have a good chance of this stopping. So I'm going to try to make it through. Because I want the other side of this because Tom, I thought I was gonna have a heart attack. I'm always carrying all my weight and my stomach. I've classically ready to have heart attack, you know? Yeah, yeah. So anyway, we're gonna go back and forth here. But let's talk about the the half life and the dosing. Right. So I don't I'm sure everybody doesn't know what half life means. But you can explain it to them and tell them why it's important with us. Yeah, thank

Dr. Blevins 28:29
you for asking Half Life is you can look at it two different ways. One is the time it takes when you give a medicine for it when you stop it, the time it takes to reach half the level of the dosing. In other words, look at it as the time that it takes to reach the steady state as you give them medicine. So if the half life is a day, that means that takes about a day for the drug when you give a dose to reach 50% of the metabolized, excreted whatever. And, and so it tells you a lot about the duration of the medicine and the body. And then when you're creating dosing frequency, it tells you how often you have to give the dose I mean, if I gave it a medicine that had a half life of a day, would I want to wait two days to give the next dose? No, because you want to give it every day to maintain the level of the Med and we could go on and on about various meds. But the relevance here is that some of these medicines have very long half lives, meaning they can be dosed infrequently, and some of them have shorter half lives they have to dose more often. And for example ozempic would go v semaglutide. And that rebelliousness is the pill version of that that drug has a half life of a week. So it can be given once a week because it stays around for a long time. The medicine like the mount Jarrah And that's also observed bound. Okay, yeah, as you pointed out earlier, that one has a half life of five days. So it can be given once a week to. And we could go on and on about that Victoza has a half life of about 13 hours. So you really have to give that every day to maintain that level. So the beauty of these new meds that we're talking about the ozempic will go V set bound mount Jarrow, those meds can be given once a week, which is very convenient, really in relative to other meds. And so that that makes a difference.

Scott Benner 30:34
It's fantastic. And I know I think Novo is working on a pill, a once daily pill I got, it'll probably be 10 years before you see it. But I think that people are people by people. I mean, researchers, pharma companies, they obviously see what's going on at this point. Like, it's the amount of people who use this don't have side effects that don't stop them and are having insane kinds of, you know, transformations, both health and visually. Yeah, it's gonna be a focus. But you know, it brings me to this point that you put on your list here, like what is overweight and obesity. And I really do want to hear from you. Because what you're seeing right now, in the zeitgeist, right? The way people talk about this is you'll either find somebody who says, well, whatever works for you, that's fantastic. Good for you, which is how I think about it, or you'll hear somebody say, well, work harder, eat better. And sometimes for those people, I say, Okay, fair enough, there are plenty of people who are not getting movement and are not eating well. And they, they're overweight. But I can tell you that from my perspective, I was not eating poorly, right? My entire life. This has been my situation, I used to joke with people. If I ate like you did, I'd gained five pounds. I retain water, like a pregnant lady, I would tell people, right? Like, if you and I went out to dinner and had a normal meal, I'd be three pounds five pounds heavier. The next day, I couldn't tell you why I didn't eat differently than you did. And so can we talk about this a little bit like, you know, just weight and obesity? How you think about it in relation to these medications?

Dr. Blevins 32:07
Yes, you know, there's a lot of data that shows that as people gain weight, certain things happen. And if there wasn't some risk to gaining weight, we wouldn't care. You might not like the way it looks. But it has medical consequences. And that's where a lot of the treatment sort of motivations come from. And it turns out that as people gain weight over their usual ideal weight, then you start seeing things like high blood pressure, high cholesterol, type two diabetes, insulin resistance. And you know, it's well known that people with type two diabetes have insulin resistance, some of that's genetic, some of its acquired, like when people gain weight. And so, you know, it's kind of arbitrary, when you set a cut point to say over a certain amount of weight over ideal, it is a problem because sometimes people would gain five or 10 pounds and things go to pot when it comes to metabolic things like I talked about. But a commonly accepted standard for overweight, that could cause medical issues is a BMI of 27. Now BMI, what is BMI? Everybody, I think when you go to your get a checkup, you get your weight, your height, and those two can be put together into a formula. And his body mass index, BMI, his body mass index, it's an index that takes into account height and weight. So a person who's like, you know, 610 ways to 10, that's probably okay. A person who's five, two that has a weight of up to 10. That's way over. So you takes into account height and weight, BMI. We could go on and on about that, but I'll just tell you the currently accepted standard is a 27. Plus on the BMI over 27, is overweight, and that person is at high risk for things like all those things. I've talked about high blood pressure, high cholesterol, type two diabetes, insulin resistance, and over a BMI of 30 is called obese. And there are other cuts that are higher than that too. But those are the two classics. Again, BMI is calculated by height and weight. If you wonder what yours is, you could go to a table online, when you go see your medical person and you can say what's my BMI because the EMRs calculated pretty much automatically these days. That's an adult's. I do want to talk a little bit about pediatrics a little different. There are various standards for defining obesity in pediatrics. The most accepted one here in this country is obesity and pediatrics is a weight that's over the 95th percentile. So you get out of BMI. You could use BMI a little bit but you get out of BMI. In up we're looking at percentiles that is comparing people to other people their age. There's so much dynamic changes that occur in the pediatric population. So they get older, the height changes, weight changes all that. So obesity and pediatrics is defined as a weight. That's over 95/95 percentile of other comparable people they like age matched. And those that that goes from the ages of two to 19.

Scott Benner 35:18
Is there an increase over decades in young people being overweight? Absolutely. Is that in your opinion? Like, I mean, is it a little bit of everything? Is it movement? Is it what's in our food? Is that how we eat? Is it how often we eat is? It's an amalgam of these things.

Dr. Blevins 35:39
Yes. I mean, I could expound on that. But you nailed it. Okay. It's, it's the diet, its nature, for sure. Genetics determined things, determined metabolic rate. And you can see overweight and families. But it's also nurture, it's the environment we live in. And activity changes over time. And, and what you know, everybody knows what's going on. But it were glued to the computer, or to the phone or something like that sitting still a lot. In the old days, that didn't happen. And we could talk on and on. But you're exactly right about that. Scott.

Scott Benner 36:18
So is the clinician, how do you think about it? Meaning? Maybe I should back up and ask this question. How many times in your career have you told somebody to lose weight? And they've actually done it?

Dr. Blevins 36:28
I'll answer that is many, many times, I think people understand the concepts of calories and calories in calories out. And you know, I'll say, exercise is always important. You mentioned exercise earlier, and your own particular experience. And 20% of weight loss is related to exercise, unless somebody's an elite athlete, or a very athletic and exercises all the time most people don't. So exercise is important. And reducing calories is important. But I'll tell you, I think people respond and are successful, many times, the problem is the long term part of it, people are successful frequently for a while, and on average, they tend to gain it back, we're all busy, we're exposed to calories all the time. Activity is challenging, sometimes because of scheduling or, or just understanding about the amount that you need. So I think people really handle this way on their own. And so people can lose weight on their own to keep it off and do really well then understand the medical part of it. But for the most part, it's really challenging. A lot of it has to do with the environment that we live in. My

Scott Benner 37:36
take on that is in a world where I can't impact the environment, right? I can't just it's nice to say like, I love turning on a podcast or TV show, you hear a rich person say get out and move around. I'm like, Well, you have $9 million in the bank. That's great. You know what I mean? Like, I've got to get up and sit back down and make this podcast all day or I don't get to pay my electric bill. And that's how this works. Right? Right. When that's the environment? Do you have any moral qualms with giving people medication just to lose weight?

Dr. Blevins 38:06
The answer is no. That's the answer. But you know, when I have a medicine that I think is safe, and, and effective, and I understand, then I'm much more comfortable prescribing, we've gone through all kinds of medicines over time. And some of them, we still have, I mean, GLP ones are not the only medicines approved for weight loss. Right. And, and some of them, I feel comfortable with others. I don't like the side effects. And I don't like the idea of long term, I have increasingly come to think and No, and I think most people in this area are similar, that any medicine we use is going to need to be long term. Right? And for example, I mean, let's just go look at other like type one diabetes, it's not like you can take the insulin for a while and and get off of it. And and, you know, various medicines, thyroid hormone, it's not like you can take thyroid hormone for a month or two and then get off and everything's okay. It's a it's a continuing need for treatment, then people call it chronic, chronic condition. So I think the weight loss medicine is going to have to be that way too. Because like you pointed, as you pointed out, you get toward the end of the cycle of these very effective meds and the appetite comes back and tries to come out from the appetite demon tries to come back. Yeah. And you just have to keep it where it is. And so I think chronic treatment is is is the way to go. With this type med.

Scott Benner 39:31
I've heard people describe a food noise in their head that goes away. My wife got a got hypothyroidism and it took us seven years to talk a doctor into giving her medication for it. And in that time, she gained a significant amount of weight which she's almost completely all lost on we go vino. And she describes and I'm going to have her on at some point to tell it in her words, but she describes it she would open her eyes in the morning and be thinking about food before she was even conscious and Then, as she was making breakfast, she'd start wondering what she was going to have for lunch. And she said, It's all gone. It just doesn't happen anymore, which makes it much, much easier. And then her you know, then it impacts the insulin, and that your body's using, keeping in mind, she doesn't have diabetes, right. And then the weight starts coming off, and then the metabolic stuff gets better. And that's in there. I think to me, for me personally, the most significant part is the way I ended up describing it as my body works better with the GLP. I don't really care what that means. And I by the way, I am now more active than I was before, because a I lost weight b I have more energy, my joints don't hurt like I am more active now than I was prior, it was easier to get going, it was easy to pick up weights and go, Hey, I'm gonna lift these now. It's a nice say, go ahead and lift some weights and go for a walk, etc. Except every time I tried to do something, I ended up getting a knee surgery or something like that. Because in fairness, my body was too big. And every time I tried to use it, I'm older and it would break. And so if we can all basically agree that there's stuff in the food we shouldn't be eating, and maybe stuff we're spraying on the food that we shouldn't be eating. And we're microwaving and plastic. And there's 90,000 Different kinds of oils, three of them apparently could be her one of them could apparently be an Industrial Lubricant, the way it's graded out, right. And we're eating this stuff all the time. And over time, people don't even understand what good food and bad food is anymore. In many situations, to say to people, I threw you in the cesspool, and I could pull you out, but at you should climb out. I don't understand that. Like I really don't like what is it? You're saying to people, if you're fighting against this idea now, is this ideal? It's not. But until GLP is make food come out of the ground tasted like candy and being good for you like lettuce. I don't know what else we're gonna do. Because this is where we are now. That's my opinion of it. Yeah, it's nice to hear other people wanting to be helpful for those who are are stuck in that. Also, there are plenty of thin people who are not healthy either. So you know, they're eating the same crappy food to their bodies just aren't reacting the same way as mine did, if that makes sense. Yeah, I think

Dr. Blevins 42:13
that makes sense. Yeah, your body, it was built for a certain amount of weight, your chassis, your skeleton was built for a certain amount of weight, your internal metabolics worked better with a certain amount of weight. And when we load the body with more things happen to the metabolics. And they also you pointed out, you pointed out they happen to the structural part to the knees. Cancers are higher in frequency. You know, I don't have a study that tells you when you lose weight, your cancer risk goes down. I would think that's probably true. But nonetheless, we know that overweight is related correlated to all kinds of things cardiovascular answer, all of that. And then losing weight is actually really important for some people losing 40 pounds is was needed. Some people lose 10. And they do a lot better. Yeah,

Scott Benner 42:59
time. Listen, I didn't even go to college. I have no background in medical whatsoever. I'm better off now than I was last year. Yeah, that my common sense tells me right? I've joked with people if I grow horn out of the middle of my head, and it literally says Manjaro up it. I'll go at least I'm not going to die of a heart attack. You'd have to show me some really tough health concerns about using this for me to think about. I'd be better off 40 pounds heavier. Yeah, yeah. So here's the thing like that. We don't talk about enough. Maybe you could do these medications. They started being researched in the 80s. I might is that story about the heal a monster in the Canadian researcher. Is that true? That's

Dr. Blevins 43:38
pretty true. Yeah. Yeah, they were started. The research started many, many years ago. And there was something in the heel of monster spirit that was kind of similar. And the one of the one of the early medicines that you probably remember was by Ada, which is exemplified, we don't really use it much anymore. He had a very short half life and had to get given twice a day. It was effective. It caused lots of side effects. It had peaks and valleys and peaks and valleys because they had to be given so often. And yeah, these are not brand new. You nailed it. I mean, epic has been out since 2017. Yeah, by eight it was approved long before that. And then we had a long acting by Ada kind of thing. I extended it that was by durian, you probably remember and one or two came and went because they just didn't have enough uniqueness to actually be used very much. And then along came Victoza. And we use that quite a bit that eventually got approved as the drug saxenda that the same thing for weight loss. And then you know, started people start observing, Oh, these are good for diabetes, but they also cause weight loss. And most of the drugs before that we use for diabetes, including the insulin would be associated with weight gain. And we'd say, Oh, that's good weight gain because your sugars are better, but nobody that I know Who is listening? And there's no weight gains good. Yeah, yeah, they've been around for a while.

Scott Benner 45:06
Yeah, it's tough because you lose weight when you're diagnosed with type one very frequently because you're, you know, drifting away from life and you don't realize it at first and then you reintroduce the insulin. And then you get back to the caloric intake that is normal for you, which for some people is more calories than they needed. And then they start gaining weight. And then they say, Oh, the the insolence making me gain weight. And I always try to tell people like, generally speaking, it's the calories you're taking in that help you gain weight. Now, the the insolence putting it, you know, is storing it for you. And do you agree with that generally? Or is there more to it than that? I

Dr. Blevins 45:40
agree with that. Okay, everybody, you know, people, everyone's different. And everyone, not everyone, but in general, it's still safe to say it's a good concept. Everyone has a different metabolic rate. And they deal with calories differently, frankly, calorie burn his genetic appetite is partly genetic attitudes about food are acquired. But, you know, we grew up in our families and in certain attitudes about food and amount of food. People are told, eat three meals a day, and you know, have a dessert. Yeah, we live life in real time. And we eat and so the calories, it would be kind of interesting if everybody had a custom calorie for their particular body. And that can be calculated. But But still, the environment we live in is so easy to get calories one on but you know, a handful of us has lots of calories, go look that up. I use, I use the net. And as many people do in Siri, I just say, Hey, Siri, how many calories in a handful of walnuts or something and you know, it's like, wow. And I still remember when I was in training, we were asked to have a dietician sit down with us. And I would go over to the hospital every day, and grab lunch. Lunch was, you know, an event. And, and we got time off to do it. And I was having a chili dog with french fries and a regular drink. And the dietitian calculated calories for that. And I thought, oh, it's gonna be like 450. But it was like 1000. And I will tell you that kind of feedback was a reality check. And I never had a chili dog again, I'll tell you because I just it just floored me. So if you look at what you actually eat everyone, you've done this, you do this, then you'll you'll find some interesting things.

Scott Benner 47:21
I'll tell you that I had an experience last week where I started eating something I hadn't eaten in a while. And I enjoyed it, and I ate it. And then I injected the 10 milligrams up from the 7.5. And I reached for it on the counter one day. And I actually thought to myself, Oh, I don't want this, right. Like the idea of it nauseated me. Yeah. And I was like, but But five days prior without two and a half more milligrams of this medication. I was like, Oh, this is good. I like this. It's it's it really is fascinating.

Dr. Blevins 47:52
changes your attitudes. And you know, something, there's nothing wrong with that. That's good. I mean, people, do you ask the question earlier? Is that really? Okay? And the answer is, you know, if it works, and it's, it's safe, and you tolerate it, go for it, it's what you should be doing

Scott Benner 48:06
is overweight and obesity, an issue in the type one community more so than in the regular community?

Dr. Blevins 48:11
You know, I've had people tell me, oh, overweight, it's not a problem. The type one is type two. And I look at them and go, No, that's not true. I know that because of the people I see in my office, people with type one diabetes have the same struggles with appetite, and maybe sometimes more. So as the people with type two and struggles with weight. If you look at stats, I can say, Is it 2050 or 80% of people with type one who are overweight or obese based on that definition I gave you earlier. And most people probably say 20%, I think most of the people in the medical world right now would say 50 or more. It's not at all mean, but if 50% of people with type one are overweight or obese, and I'll just say this type two diabetes, people with type two, have not cornered the market on overweight or obesity. And they haven't cornered the market on insulin resistance. People with type one can have genetics that are insulin resistant. And when you gain weight, you get more insulin resistant, whether you have type one or type two. Yeah, so it's a real it's a common issue. It's talked about more and more. And yes, we really do need some good studies, with I hope, this kind of medicine, looking at people with type one, and I'm going to tell you more about I can tell you now and there's a study that's going on, but we need more studies that look at this and people with type one, we need to find ways to mitigate risk. And we can do it. When

Scott Benner 49:34
you say we need studies. Where does that have to come from? Is it a pharma company that has to say, hey, I want to sell to these people. So I have to prove it works? Is it researchers like Who are we looking for to jump in and carry this load for us?

Dr. Blevins 49:46
Yeah. You know, it's the pharma companies. And there were these studies early on that there was a lot of optimism and we all assumed it was all going to be approved and it wasn't they have to go to the FDA and have to show the adverse events associated with medicines, and everybody has to come to an agreement, it just didn't happen. So the pharma company typically would have to put together a sizable enough study, which is very expensive, and then show effect, and then show, you know, manageable side effects. To get it through the FDA. Currently, there are some studies going on. In fact, I'll just jump in a minute and tell you about one, there's been reluctance to proceed. Of course, most people with diabetes have type two. And then there's just people who are overweight, who don't have diabetes at all. And then there are people with overweight who have pre diabetes. And that's where the numbers are. And that's where they're going for. A big part of me says, We want to go on something, and you have type one diabetes, go to the JDRF, and say, hey, please lobby for this because they have an organization. And they know how to do that. And they're really good at that. If I went to a company, and I said, I want to put 50 People with type one on this medicine, and that I probably could get funding to do the study. That's not nearly enough people, though, to get it by the FDA. So it really has to be a large study. Question is what about these weekly meds? That that's those two studies I told you about? That had the ketoacidosis and the hyperglycemia. Were in the once a day drug alert. liraglutide Victoza? What about the weekly meds we don't know, we need studies. Now there is a study going on right now. And I'll just jump in and say something about it's called car mod c AR mot that's just the name of the study. And accompany is studying a medicine such as we're talking about, specifically, in people with type one diabetes, who are either overweight or obese. This is a phase two study meaning it's going to turn into hopefully, if things look good, into a bigger study phase three. Now that's the kind of study that needs to be done. And that is ongoing. That's not from Novar. Lilly, it's a different company. And we are involved in that study, here. And in fact, if anyone is in the Austin, Texas region that wants to be with type one diabetes, who could be categorized as overweight or obese, we're looking for people for that study. So these studies, please, I've encourage everyone to volunteer for some of these studies, as you have in the past. Every medicine that's approved for type one, type two, anything, has people who volunteered to study jump on in there and help those things get approved, or at least at least get them study. They may not get approved. You never know.

Scott Benner 52:34
Yeah, Tom, I'll I'll get some information from you afterwards, I could probably funnel some people towards you that would help with that. And also, let's take a moment to chide Lilly and Novo who both in their charters say that they're around to help people with type one diabetes. So here's your opportunity, spend a little money and help them you know, the big problem here is there's not enough people to sell it to afterwards. That's the bigger problem. Yeah, there's not enough type ones. For them to think of it as a splash. But my gosh, like you're looking at really impacting people's lives. Because, listen, I think you can hear through the raindrops when Tom's talking. If he was in charge, if you were the Wizard of Oz, you'd give this to people, right? You do the study, come up with the protocol and give it to people with type one. Is that fair to say?

Dr. Blevins 53:19
And the answer is yes, I would. Yeah, I would be very, very careful. I would talk about all the things we talked about with the little part of my head saying, you know, there was a study that showed increased ketoacidosis. But then another larger kind of analysis said, probably not, it doesn't make a lot of sense to me that it would cause that I can I can come up with mechanisms. When you look at the studies, you come up with your own impressions. Yeah. And it looks like those people might have developed it anyway. But and then hypoglycemia, that one, I get that one I really do understand. And I know how to mitigate. And what you said earlier, you're you're looping your your daughter's loop. And I mean, and and even the automated insulin delivery devices from all of the manufacturers, since hypoglycemia, or since the progression towards it, and they back off the insulin. So with those devices that lots of people with type one are using, would there be an issue at all with Hypo? The answer is I don't know it needs to be studied. We

Scott Benner 54:18
live in a world where generally speaking, people with type one diabetes don't know how to accurately adjust their insulin to begin with. And often they see doctors who are not much more help it so then to say that we will I'll inject something in you that's going to lower your insulin needs. Who's going to adjust the insulin, like the user doesn't know how to do it, the doctor doesn't know how to do it, you know, like it's, that's where the rubber is gonna hit the road right there you have, you're gonna have to tell people look, we're gonna enjoy when Arden gave herself the first injection of ozempic We spent the next three days changing her settings. It was that significant and that real quick, and then after we got them right, it was fine. And that was it. So you know, anyway, Yeah, sorry, can I say about the DK thing? Yes, I bet you could have gathered all those people up and just check them for DK and came up with similar numbers without the GLP. But that's my guess based on nothing other than talking to people for years about diabetes?

Dr. Blevins 55:15
Well, I will say in those studies, there was a group on placebo and the group on treatment and the people on placebo, that is the comparison and a scientific study where you actually have people who aren't on and who are on and the people who weren't on didn't have the ketoacidosis. I can't say that interesting. And why did it cluster in that particular group? It on treatment, it tended to be the higher dose, so maybe the nausea from the higher dose sort of covered nausea from something else going on, like ketoacidosis. And people were kind of misled. It's possible that the lower insulin dose needed, made people more prone to have keto ketosis because they had less insulin going in. I don't know.

Scott Benner 55:59
And they were still eating regularly because they weren't being slowed down from eating. I wonder there's a lot in there. Yeah, there's, like you said, I think further study might prove out that that's not something to be overly concerned about?

Dr. Blevins 56:11
Well, it's something to be very careful, definitely. And what you said, is, is very important about adjusting for the first three days, the studies studies that are the one that we're talking about the karma study that we're doing, yeah, we have a very clear kind of direction as to how to adjust insulin right off the bat to be very cautious. And so we don't know if person is going to go on the real thing or not. And we adjust the insulin in a certain way. And so these studies should look not only and they are this one study, looking at not not only the effect, and the side effects, was also looking at a treatment kind of algorithm approach to reducing the insulin.

Scott Benner 56:55
Yeah. Do you have any patients of yours type one who you've given them a scrip? And they're paying cash?

Dr. Blevins 57:02
And I'll say I do? Yeah, yeah, you know, I'm writing it off, it's off label. And what I tell people is, I tell them about all the side effects, I say it's not approved by the FDA. And if you look at the approvals, many times, it says specifically not approved for type one. And, and I tell them that and give them a prescription of I think is appropriate, we we start low, we always start low, and then we increase the dose as as appropriate. It is off label. And I'm gonna say that so many times, and and I tell them, it could bring out some major gi problems, and you may really not like it, and you may not be able to take it, you may have to discontinue it. And we're really cautious. But I do have people who are overweight with type one, and I will point out and we can talk more about this later, that actually there are instances in which it could be covered in people with type one. And that would be the obesity overweight obesity indication. And and that would be the main one actually. Yeah. So if somebody and then also with what GAVI there is an indication for using if a person is overweight, or obese, and if they have a cardiovascular disease, so someone has a history of SEO, and a heart attack or stents or bypass or whatever. And if they're overweight, then there's a really, really interesting study that showed a reduction in major cardiovascular events. And people given them a govi. It wasn't that people type one. But there were a few people type one of the studies, it turns out, and they still fit that indication. I hope that made sense. Does

Scott Benner 58:41
Do you think we'll see an approval one day or a study one day for PCOS? Have you seen the people talking about that the the mass amount of women in these Facebook groups who are getting pregnant before they're losing weight on GRPs?

Dr. Blevins 58:54
Yeah, yeah. People with PCO, you know, weight loss can improve fertility and people with PCOS and without, and there are studies that have that are done small studies, there are ongoing studies. Are we going to see an approval? I don't know. I don't see a big study being done. And people PCO at this point, I may not be aware of one that's been done possible, but I think it's really an interesting thought.

Scott Benner 59:21
I think a lot of women suffer with it quietly. Yeah. And it's not looked at and it's

Dr. Blevins 59:26
highly connected to overweight. You said it right. It's highly connected to overweight and insulin resistance. And if you lose weight, the insulin sensitivity improves. Ovulation improves. Really interesting. I

Scott Benner 59:36
am going to share a story that I can't tell you who the person is, but I know them very well. And 20 mid 20s female, not you know, growing up heavy than not heavy, mostly not as an adult through college, and then suddenly in the last year, just gained 60 pounds. They're working out crazy eating as clean as they can gaining weight through the whole Then doctor says you have PCOS. We told her, go back to the doctor, see if they'll give you a week. Ovie something like that. We go, here's that bound doctor gave her we go V. She shot it on Saturday morning, over FaceTime with me because she couldn't bring herself to do it. I had to talk her through it. And she got it in and sent me a text 36 hours later that said, I've lost five pounds. I don't know what that means, or how to measure that. But that's insane. Like is that's not water weight. Do you know what he means? Like, it is probably some of it. But she stopped eating in the past for 36 hours and nothing's happened. And she's eating super clean to begin with. And she's active and everything else. Like, I don't think we have the answer yet. But you can't tell me that there's not something happening here. That's not commensurate to the idea of thyroid stimulating hormone, right? Like you My body's making it but it's not using it correctly. Like, there's gotta be something there making those those GLP receptors light up, that's changing people on a metabolic level like it maybe I'll be wrong one day, but in the moment, this is how I'm thinking about it. Yeah, yeah. Well,

Dr. Blevins 1:01:10
I mean, I'll say 36 hours, five pounds. There's a lot of water there. I think I mean, that or something? Or maybe there was a big blowout, diarrhea, I don't know. But, you know, usually on any diet when a person lowers calories. Typically the first week or two, you lose a lot of water weight for various reasons, part of its decreased salt intake and, and part of it is kind of the ketone formation thing and the less calorie in and all that type. I agree

Scott Benner 1:01:41
with you totally, but she was already doing that. Yeah, there was never a moment whether it was either a Gary has just exploded, and she just that diary, like or whatever it was, that still didn't happen to her when she was eating clean, exercising, and, and etc, and so on. Who knows? Like, I have no idea, I can tell you my daughter's acne is almost completely gone. And she was not overweight to begin with.

Dr. Blevins 1:02:04
Yeah, you know, we have a lot. Well, I will, I will say we have lots to learn. And I will emphasize to the audience, these are anecdotal, please, of course, examples of effect, not that everyone's going to get anything like that. And some people are really not going to tolerate it. And I have some people who simply can't take it as too bad. Can we talk about that people don't have and yet some people don't have as much weight loss as we're talking about either. So life is a bell shaped curve in response to a medicine is to Yeah, and we like to we tend to talk about the real yet exceptional examples. But remember, not everyone gets that that result.

Scott Benner 1:02:42
Talk to me about the not tolerating it when you don't tolerate it, what does that look like?

Dr. Blevins 1:02:46
You know, the main thing is Gi, and it's typically just what we talked about that gastric emptying, change, and maybe even some central effect can induce nausea, vomiting, it tends to get better over time, we always start with the low dose and we titrate or increase the dose very gradually, we if we increase the dose, and then a person gets side effects, we back off. And that's very doable. You have to work with your health care person when it comes to that. And, and so diarrhea, and constipation, the medicines typically slow down the GI tract all the way down, but some people can get diarrhea as well. Commonly, those those effects are tolerable or get better. I had a gentleman in this morning who told me he's taking one of the meds and that at the highest dose, he gets really tight in his abdomen and very uncomfortable. And he's backed it off, backed it off, backed off and I encouraged him to continue to and try to find a happy medium because the GI tract is in the balance here. Some people can't take it and if you look at studies for up to 8% of people on these meds discontinue because of the GI side effects. Now they're those effects can be matched with medicine. I don't like to treat the side effects of one medicine with another but it's sometimes temporary use of like anti nausea pills can help. And you can use medicines or anti diarrheal 's to same concept but that typically are temporary but not always. And so people need to be aware of that. It just happens it's not your fault if that happens. I will say this if you have nausea and maybe Anyway remember that high fat slows the stomach down to so if you add fat plus a GOP one, your chance of nausea it goes right up. So one thing to do is cut the fat back about

Scott Benner 1:04:40
Yeah, no I don't eat high fat to begin with. I don't use any oils almost at all in my life. But I was very careful about that. I also if I don't see myself going to the bathroom I add a little magnesium oxide to my supplementing Yeah, I knew how important it was to keep the process rolling once I started this, like, if I don't see myself going, going every day on this, I hydrate, I take the magnesium like I keep things moving. I know there are some, you know, people love to yell in the media about stuff like this, but have people been injured permanently from it at all that you know of like, I mean, and is that got something to do with who they were before they started? And? Or could it because I think the fear is like randomly you're just not going to be able to like, I don't know, digest food anymore. Like you mean like people get when they hear about it, and you hear them panic about it, they say kind of bombastic things like that, is there a call for concern,

Dr. Blevins 1:05:37
you can ask something, when we talked about half life earlier, I mentioned that, that, you know, the week Half Life means that it takes a week to reach 50%, I'll tell the audience, it typically takes five half lives for a medicine to get totally out of your body. So if a medicine has a long half life, it's gonna take a while for it to get out. So if you have a symptom that you don't like, and you're gonna stop the medicine, it's not like you stop it. And that just goes away with this type of medicine because of the long half life. The symptoms of like the slowed gastric emptying are gonna go on for a while, and maybe they'll go longer than that. But there's really no clear evidence that those go on forever. And some people have underlined gastroparesis, and we don't know. And, and we might bring it out, make it worse. And then after they get off the Med, they may they may get diagnosed. And I may say maybe think Well, I have this now because the answer is I think they probably had it before. And there's still a lot to learn, but there's no clear evidence out of studies that there's there's a permanent impairment. Right. Okay. And, you know, there are other side effects too, we could talk about that. That's, I think the main one that people talk about,

Scott Benner 1:06:48
I would, I would never minimize anybody's experience. But either, yeah, but I want to say this, and I want to leave with that. I've interviewed 1000s of people. And I have access to my Facebook group that has 50,000 active people in it. And so when my daughter at 18 years old, was told by a GI doctor, she had gastro precess, even though her a one C had been in the fives and the low sixes for most of her life. I didn't accept that. And we went and looked at other ideas, and added a digestive enzyme to her process of eating, which made all of her stomach pain go away. I shared that on the podcast. And I have to tell you that the amount of people with type one who I hear back from who just said to me, I thought my stomach was gonna hurt the rest of my life. I thought there was something wrong with me, my body was broken, etc, and so on. Now, I've added this, and it's all gone. It just cleared up. So we don't talk enough about when you get type one diabetes, some people get digestive problems, right. I mean, you know, they used to give Amazon out like it was like candy to type ones. But now if suddenly we don't do that anymore, so we, we ignore the possible digestive implications of having type one diabetes. And then when people talk about stomach issues, they send them right to a GI doc, who just jumps right to you have slow gastric emptying, you have gastroparesis. And I wonder if there's not, it wouldn't be helpful if people were better educated about that and spoke more about that to their patients. Do you find yourself seeing those things? Yeah,

Dr. Blevins 1:08:27
I think it was a really good point. And I think gastroparesis should be diagnosed based on you know, commonly some testing to document what's going on. And I think if anyone goes to their GI doc, please, if you're on a GLP one, tell them about that. Because everyone, you know, we we in the endocrine world, diabetes world, we're, we're all up on it. But not everyone is. And I can't tell you how many people now the GI Doc's I work with are really sharp. And they picked up on this very quickly. But I got some calls early on, from people saying, Hey, I just did an endoscopy on somebody who's on that medicine and they're still fluid in their stomach and they haven't eaten anything since last night. We've learned a lot, we've learned that that can happen. Slow gastric emptying can leave contents there for a while. And you need to be aware of that. If you're a GI doctor, and then this thing about symptoms too. I've had people go through major gi workups. And, and they're told Finally, well, everything's okay. Take these medicines, and it might help. And then they come back to my office, I go, Oh, you're on this medicine that probably cause all those symptoms. And Did y'all talk about that? And the answer is, there's been a lot learned and things have gotten a lot clearer. But But these medicines if you slow the stomach down, what happens? Well, you slow the stomach down, you could get fuller. And, and like my patient said earlier, it felt like his stomach was tight. Yeah, and that's no surprise. You can also have that gastric to juice be kind of pushed up the esophagus because there's more pressure and you could get some a soft vaginas. So it's important to kind of understand the implications of that gastric emptying thing.

Scott Benner 1:10:11
I have to tell you my acid reflux has completely gone away on a GLP. Right? Yeah, good. Is that in common?

Dr. Blevins 1:10:18
All things are possible there. They could get worse. I mean, you said it's got better for you. Yeah. And so the various things can happen. Okay. Most people really don't have any don't have an increase in reflex. Some do. And I can understand how it could get better, too. So there you go. And, and a lot of variability from person to person.

Scott Benner 1:10:39
I think we're coming up on our time. Is that right? We could go a little bit longer the longer Can I ask you about? So two things? So first of all, availability? Are you seeing it get better? I know there was a flood somewhere that slowed it down for a little bit? Like do you think that they just can't keep up with this? Do you think that so many people are using it? What Why are we seeing this? Do you think it'll clear up at some point?

Dr. Blevins 1:10:59
Yeah, availability has been a big deal. And I think part of it is related to some manufacturing difficulties. Part of it, the most of it, I think, is due just as pure demand. I mean, these these medicines are in high demand. And we almost need a pipeline, you know, there's so much that is needed and needs to be distributed. And we've seen those Olympic supply became very challenging, and it's improved a little bit in my experience will go the challenging, and maybe getting better, I keep hearing next month is going to be better. And then the next month comes in, it's not better June next month. And then now now, you know mount Jarrow has had some tight supply zapped bound as well. And of course, we as treatment people, like I want I want my people with diabetes, to have availability to the medicines they need. Right. And I like people losing weight, that's great. And so, you know, people that don't have diabetes, and you lose weight, that's important people with diabetes, big deal. So, you know, there's this this kind of back and forth about, you know, people who really needed aren't getting it really needed, what the definition of that, but that would be, you know, I think most people think those people with diabetes, again, we're talking type two, because remember, these are not approved? Yes. In general, for type one.

Scott Benner 1:12:24
I mean, listen, I, they've got to, they want to make money, right, they've got to figure out a way to get on top of it. I think one of them literally just bought a new place and down south somewhere, or they bought they bought somebody else's building and they're they're manufacturing, they're trying to get set up for it. I don't think it's because they're not trying. To me it lends to the idea of doing studies in other populations, because if it's this popular now, and you're not going to be able to stop taking it. And we have no shortage of people who could use it for diabetes and or weight, or hunger or PCOS or whatever we end up using it for like moving forward, find more people to give it to so you can make excuses to build more buildings and hire more people and produce more. I've heard of people getting it through China, like through China through a Canadian pharmacy into that was happening like that for a while. It's insane.

Dr. Blevins 1:13:13
Your your points well taken? Yeah. I think the demand surprised everyone, the potential the benefit has been embraced. And there's a shortage, which I think will cure in the next few months. Of course, I said that three or four months ago, too.

Scott Benner 1:13:29
Do you think that the demand was surprising is an indication that it works?

Dr. Blevins 1:13:33
I do? Yeah, I do. And I think that, that people understand that people with diabetes, that have the under the indication, benefit, a great deal from it. And that's really a big deal, because lowering the agency reduces risk of complications of diabetes, and helps all the metabolic issues that occur with diabeetus. And we know now that at least a few of these are approved for reducing cardiovascular risk. This studies were done in people with known heart disease, of course, but we know that too, there there are benefits all the way around. And but I think that people who don't have those, the diabeetus. And those risks still want it because weight loss is something people want. And for good reason. I can't blame them at all.

Scott Benner 1:14:19
Can I give you my my big theory? Yes. I think that after a generation of people using GLP medications, and basically learning to eat less and eat better, because they're being chemically kind of directed like that, that we might raise a new generation of people who don't eat poorly. I know that's a big idea. It's a generational idea. But how do your kids end up eating poorly? It's because you eat poorly and you maybe don't even know it. I use this example all the time. My mom who's passed now was told she was pre diabetic a few years ago, and she called me and said Scott i They Say I have prediabetes I'm gonna film to change up my diet completely. So that's great mom. And then I visited her a week later, and I opened up a refrigerator and everything she bought, couldn't have been a worse decision. Because she just didn't know the right things to eat, right. And that's the lady who taught me how to eat, right. And then I taught my kids how to eat except I got lucky, at some point and said to myself, we're doing this wrong, my wife and I were like, we both grew up very blue collar very simply, nobody understood, you know, nutrition at all. And what we consider to be good food was just the stuff we couldn't afford, that we got once in a while is a treat. And that made it good food is really interesting, like how we think about what's actually good for us. So that's my big idea. My big idea is if we take a generation of parents, and write their thinking that they might raise a generation of kids who don't get, I can see in three generations, this completely flipping the other way and forcing Agra to move with it. Because if we're not buying it, they're not going to make it. That's kind of how I feel about it.

Dr. Blevins 1:16:05
I like your idea there. I think starting early, with pretty much anything when it comes to kids is going to have long term consequences. And I think dietary, you know, approaches that early ages that are good, make make things happen. I've actually know some your young children who eat nothing but vegetables and all that all day, it seems. And they really, they do like ice cream and that but they don't. It's a treat, it's not a common, it's not something they expect, but they don't like some of the things that are really what we'd consider it to be high fat. And they're just because their tastebuds are there, they're acclimated to things that are different and, and they're healthy. And I do think you start early, whether it comes to when it comes to food or various things, like Stay away from drugs and cigarettes and all that I think you start early and you teach the kids how to how to go, it

Scott Benner 1:17:00
just becomes kind of second nature. Yeah, I do a Pro Tip series about diabetes with a with a CD or excuse me with a nude, a woman who's got type one diabetes, and is a nutritionist and her children eat fantastically, but So does she. Yeah, and that I think it just is what Liz also, I have to tell you, Tom, if you're willing to do this a few more times, I think you and I are gonna have a Pro Tip series on GLP is together because this is fantastic. I can't thank you enough for spending the time and we still have we didn't even get to the listener questions yet.

Dr. Blevins 1:17:30
So there's a lot to talk about. No, I'd love to. Okay, we'd love to. That's

Scott Benner 1:17:33
great. Kate, listen, do you accept new patients at the practice? Or would it not benefit you for us to share your information like that? I

Dr. Blevins 1:17:41
really don't see new patients. I do supervise a lot of people with advanced practice providers. We have excellent group here, who are really experts on diabeetus. But we have we're a single specialty. We have 12 doctors and three offices here. So though, I don't see any patients. The we as a practice, we see new patients all the time. Okay. In the Austin area, people come from various and we do diabeetus all endocrine so, you know, some listing that would include the practice predominantly

Scott Benner 1:18:14
and no, I Well, for sure. What would tell me the website? Yeah,

Dr. Blevins 1:18:19
it's Texas. diabetes.com. Okay. Yeah,

Scott Benner 1:18:24
I'll put it in the show notes as well. And I'm not kidding you. When you get done. You send me the study information that I can share online. I'll put it in a place where a lot of people say it for you. Okay, I'll

Dr. Blevins 1:18:33
do it. Yeah, we'll do that. Thank you. Yeah, I appreciate that. Oh, my God, let's let's put off the Frezza a little bit, because, first of all, we'll probably want to do more GLP. One first, because there are quite a few things we didn't get to your right. And we need to like the muscle mass change all that stuff. Preparing for surgery, all that very practical, that the impressive thing, American diabetes is late June, and there's going to be I know there's going to be a study presented that will make that discussion more useful. Okay. And I can't talk about the results before them. So anyway, when that's okay,

Scott Benner 1:19:08
can I leave this part in you talking about it? Like that? Yes. Okay. Because what I see here on I'm going to keep recording. You're back with me in two weeks. I think we need that one and one more to get through. GLP. Okay, and, and then do a fourth one on a friends. I think that would be terrific.

Dr. Blevins 1:19:25
That'd be great. Okay, cool. Very good. All right.

Scott Benner 1:19:27
Use that link I gave you and grab a couple more recording dates. I'll do okay. All right, Tom. This has been fantastic. No, you're amazing. Thank you. Bye. It's

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 since 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/juice box don't forget to get rid of that food go to Omni pod.com/juice box that's Omni pod.com/juice box check out the Omni pod five get rid of that foo today. If you're looking for community, check out the private Facebook group Juicebox Podcast type one diabetes, but everyone is welcome type two gestational, as long as you're impacted by diabetes. You're welcome in my private group. It's absolutely free and currently has 50,000 members, we add 150 new members every three days. 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 to hydration and even trampolines. juicebox podcast.com. Go up in the menu and click on diabetes variables. If you are 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 dietician 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. 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

#1489 Fox in the Loop House: Part 6

Understanding Insulin Sensitivity Factor

+ Click for EPISODE TRANSCRIPT

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

guys. Kenny Fox is with us again. You can find Kenny at Fox in the loophouse.com and today he and I are going to talk about the loop algorithm and understanding insulin sensitivity factor. 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 Juicebox at checkout to save 40% at cozy earth.com AG, one is offering my listeners a free $76 gift. When you sign up, you'll get a welcome kit, a bottle of d3, k2, and five free travel packs in your first box. So make sure you check out drink AG, one.com/juice, box. To get this offer. Are you an adult living with type one or the caregiver of someone who is and a US resident? If you are, I'd love it if you would go to T 1d, exchange.org/juice box and take the survey. When you complete that survey, your answers are used to move type one diabetes research of all kinds. So if you'd like to help with type one research, but don't have time to go to a doctor or an investigation and you want to do something right there from your sofa, this is the way t 1d exchange.org/juice, box. It should not take you more than about 10 minutes. This episode is sponsored by the tandem Moby system, which is powered by tandems, newest algorithm control iq plus technology. Tandem mobi has a predictive algorithm that helps prevent highs and lows, and is now available for ages two and up. Learn more and get started today at tandem diabetes.com/juice box. The show you're about to listen to is sponsored by the ever since 365 the ever since 365 has exceptional accuracy over one year and is the most accurate CGM in the low range that you can get ever since cgm.com/juicebox, Ken, welcome back. Hey, Scott. What are we going to talk about today? I just, I decided with you, I'm just going to say what are we going to talk about today? And let you

Kenny Fox 2:34
take the wheel. You got it all right. So I think I want to talk about ISF. We covered basal and then meals, and we didn't talk about the carb ratio last time as much. But I think people have a pretty good understanding of I want more insulin for the first few hours of my food, and it can tweak the carb ratio from there. So really, what's left is in terms of main like core settings, we'll talk about ISF, which is insulin sensitivity factor. That one is, I think, one of the more misunderstood variables. I've heard doctors and other folks talk about it in the same way they talk about basal when they don't understand something, when they understand why you're high. A lot of people go to, I don't know, let's just change the basal. Once you get into looping and you can wrap your head around basal changes, it often becomes, well, ISF is even more mysterious. I don't understand this one, so let's change that one. If stuff's not going the way I want, that's a little bit tricky of a situation when you're when you're like that. And so we'll try to demystify that a bit more. Okay. Do you find that same problem when people are not understanding it's easier to see when they first start out, but they start attributing certain problems that from an experienced person don't make sense, but they just start messing with things because they don't under it's the thing they least understand.

Scott Benner 3:47
I think that you get frustrated and they just start turning knobs, pushing buttons. That's fair. I think they don't know why they're doing what they're doing honestly. And listen, in fairness. There are times when I make adjustments and I'm like, I think this might be it, but I'm not 100% certain. I mean, look, can I look at basal and say, you know, at times where there's no active insulin and no food involved, and can I look and say, Hey, her blood sugar has been sitting at 110 at this time of night, for example, really consistently. I'm gonna, like, tweak the basal here and see what happens. Yes, right? But it's harder to see, like, insulin sensitivity stuff and correction factor like that. I think is harder for people to see. Do you not agree that one? Yeah,

Kenny Fox 4:33
yeah, I agree. Because I think basal we can, I think, relatively quickly, wrap our heads around, especially at night. That's a nice one. Sensitivity is a challenging one, also, because when you first get diagnosed, you're talking about making corrections. So you like, here's your long acting or your basal settings, here's a carb ratio to start with, and then here's this correction factor, or this number you'll use to calculate how much extra insulin to give if you end up higher. Then you should be a few hours after eating, or just a few hours after your last dose. What happens is, we take that idea over to an automated system like loop. One of the things loop is doing is it's making those small adjustments. If you're if it thinks you're going to end up a little higher, a little low. It's doing that every five minutes, so you end up needing to use a number that's much larger than the number you might use when the doctor says, Hey, try this out. You know, you consult that number couple times a day. You're not looking every five minutes. You're looking every couple hours to see if you need to make a correction, potentially, and using that number then. So I think that's a one, one big difference between the idea when you use it or shots or MDI, or even standard pumping, versus using it in a system like loop. You

Scott Benner 5:48
know, when people get put on a regular system where they're doing MDI, and someone says, We think that one unit moves your blood sugar, I don't know, you know, 200 points, so your insulin sensitivity is 200 Sure, they probably try that in the beginning, right? They're probably like, Oh, my kids, got a 300 blood sugar. I want it to be 100 I'll put in a unit, because they said it moves 200 doesn't take you long to figure out that, like, higher blood sugars kind of need more insulin, okay? If that's true, and I want to move 50 points, and I need a quarter of unit, that usually works if I'm, you know, I'm 100 and I'm 150 and I want to be 100 a quarter of a unit kind of moves me that way. But you don't really see the full picture or the full value until you're on an algorithm, and that thing isn't making these big, sweeping decisions like that, like, you know, I'm trying to move a number this, you know, 200 points when it's trying to move a number 10 points, when it's trying to move a number 20 points, and there's a fraction of an amount of that insulin, like, there's where it becomes, I mean, another level tool, because you're never going to, as a person with a syringe or even with a manual pump, say to yourself, I want to move just this much, and it's 15 points, and my pump is not even set up to, like, correct that Number. So I don't think it comes into people's minds that often. Yeah, and

Kenny Fox 7:03
you're probably going to wait and see how things settle before you make a decision to add more or take away right insulin. So yeah, that makes sense. You're just not going to make the decisions that fast. One, because you have a life to live. And two, you do need to let stuff kind of play out. And there's so much very variability that in food or whatever else is going on that doesn't make sense for you to try and do, you know, quarter unit or 10th of a unit, two weeks all the time,

Scott Benner 7:27
even if you were a machine in your mind, and you could make sense of that bigger picture, you can't take insulin away in a manual pump. Well, you can, but now you're setting, like, Temp Basal offs and, you know, but if you're MDI, you're you're done, like, the insulin is in, it's in, right?

Kenny Fox 7:41
Yeah, you're not gonna set a 30 minute half hour, 30 minute Temp Basal off, and then come back and check it again, and then you end up a little high. So you're not gonna play with it that often, like a system would. And I

Scott Benner 7:51
think for those reasons, that's maybe the least considered setting sometimes for people, and it ends up being very important. Yeah, I agree. And once you see it work on an algorithm, you level up your understanding of it too. Why would you settle for changing your CGM every few weeks when you can have 365 days of reliable glucose data? Today's episode is sponsored by the ever since 365 it is the only CGM with a tiny sensor that lasts a full year, sitting comfortably under your skin with no more frequent sensor changes and essentially no compression lows. For one year, you'll get your CGM data in real time on your phone, smart watch, Android or iOS, even an Apple Watch predictive high and low alerts let you know where your glucose is headed before it gets there. So there's no surprises, just confidence, and you can instantly share that data with your healthcare provider or your family. You're going to get one year of reliable data without all those sensor changes. That's the ever since 365 gentle on your skin, strong for your life. One sensor a year that gives you one less thing to worry about, head now to ever sense, cgm.com/juicebox, to get started, let's talk about the tandem Moby insulin pump from today's sponsor tandem diabetes care. Their newest algorithm control, iq plus technology and the new tandem Moby pump offer you unique opportunities to have better control. It's the only system with auto Bolus that helps with missed meals and preventing hyperglycemia, the only system with a dedicated sleep setting, and the only system with off or on body wear options. Tandemobi gives you more discretion, freedom and options for how to manage your diabetes. This is their best algorithm ever, and they'd like you to check it out at tandem diabetes.com/juicebox, when you get to my link, you're going to see integrations with Dexcom sensors and a ton of other information that's going to help you learn about tandems. Tiny pump that. Big on control tandem diabetes.com/juicebox the tandem Moby system is available for people ages two and up who want an automated delivery system to help them sleep better, wake up in range and address high blood sugars with auto Bolus.

Kenny Fox 10:16
In our previous talk, we discussed a lot of variables that I think you made a good connection of. It's really applies to however you manage. If you can start to understand those, we start to remove what I kind of call the fog, and you can really see what the settings need to be, because you're like, Oh, well, I'm high because, oh, I forgot to handle fat and protein to my meal or basal was off last night. So it's probably not going to be so great today, things like that. Maybe your pump site is not working as well as it could. So that's going to be once you remove all of those. Then we can talk about sensitivity. And we talk about sensitivity, the number is, I'll use the word points. I like using the word points as well. How many points is your blood sugar going to move given one unit of insulin? And what you need to remember is you need to consider the entire runtime of that insulin, or the duration of it, which should be about six hours, and loop models that so to do an ISF test, you'd have to get kind of high, have really good basal, have no other fat and protein going on. So it's really got to be quite a few hours since you ate last, and then give half a unit, or a unit, and then wait five, six hours, see how far your blood sugar drops. And then you can, if you did a half a unit, you'd have to, you know, double it to get to the right number. And so it's a really difficult test to do, because who really wants to sit still and have really perfect basal for the, you know, first for a 678, hour duration. You know, it's interesting

Scott Benner 11:42
when you talk about it in context of the algorithm, of any of these algorithms, right? Like it makes so much sense, because you know that that those little machines are tracking all of the different boluses and all of their different outcomes and and making sense of them when you try to imagine doing that manually. I mean, you can maybe keep track of a couple like, you know, like I Bolus at 8am for breakfast, then I Bolus again at 10 o'clock for this, and then I had lunch at one. At one o'clock, I'm five hours after the eight o'clock Bolus. Like no one's in their mind juggling all that anymore and all the implications and the different timelines that the insulin is running on it's why all these systems are just so next level. So I would need a computer right now, if you're looking for that kind of control and that kind of consistency, then, yeah, I mean, you need something smarter than you to track it. That's for sure, smarter than me, for sure. We

Kenny Fox 12:35
talk about points, just in case people aren't tracking we're talking about milligrams per deciliter for those using Imperial numbers and millimoles for those that are not. And it's an easier way to say it, because if you start trying to talk about the ratios here in an audio setting, you're not going to be able to track all this stuff. So I have a video that's been up on YouTube about how ISF affects carb absorption, and we're gonna talk about that here in a second. So you guys can go see that a few more visuals. But the big challenge we have when we talk about using ISF, or figuring out ISF in loop is one, you first have to shed the idea that it's the same number that I'm going to use like I would if I checked my blood sugar every couple of hours and was high and wanted to nudge blood sugar down. And two, it's going to be even bigger. If you think, Well, how much will my blood sugar come down if I dose the unit and waited six hours when I really didn't have any of these other things we've been talking about active that's when it's like, Oh, I'd probably come down quite a bit. The ISF number you'd think of would be a fairly large number, which means you'd move a lot of points given one unit of insulin compared to what you'd use in a situation where you're high, you're usually addressing something like food or some other issue where you do need more insulin. I think a lot of people, at least those that listen to the podcast, get a very intuitive sense, after some practice, that even if they don't know what that variable is, they might need a decent amount of insulin to bring it down, or may want to bring it down sooner than six hours. So what loop is looking at is is a much larger number than what you're used to. When I see people bring over their settings from a previous pump set up, it ends up causing a little bit of problem because the number ends up being too small. And it's not a problem always of too much in terms of a correction, like getting high, and the loop just gives too much insulin. That does happen. But I think a more common situation is it's just a little bit too strong, a little bit too small of a number, and it negatively impacts how loop tracks meals. And that's really like the in my mind, the largest or most significant thing that ISF does during the day. But before we dive into that, it's easier to talk about the easier situation, which is night time, like you talked about identifying basal overnight. At night, you're not running around, you're not eating anything. You might have some some hormone stuff going on overnight, but it's not as significant. So what I like to do is all use ISF overnight, and I'll often make it a little bit stronger, so where I get the system to respond the way. I would, which is you have a little bit too much insulin, enough insulin that after six hours would probably make you a little low, but not so much that once your blood sugar starts trending down, Luke predicts, Oh, this isn't going to go well. We're going to go low, and it starts turning off the basal. And so it's kind of like a like a mild crush and catch situation, like you talked about here.

Scott Benner 15:19
Is it easy to go too far with that, to where it can't catch it.

Kenny Fox 15:23
Yeah, I think it, I don't know. It's super easy. If you move things in steps of 5% 10% at a time, and kind of nudge the numbers down, then I think you end up being in a situation where that's not going to be the problem. One thing to look for is if you see, even if your basal is not perfect, but if you see loop giving Bolus is and then start dropping, and it's not turning the basal off to be able to catch it, it just goes down so fast that even though it turned off the basal, it couldn't catch it. And again, there's no obvious basal problem. Then, yeah, you'll need to back it off a bit. Okay, that said, I think for other systems like Android APS or trio that use the O ref based algorithm that's different from loop. I think it works better, from what I've heard, to use a single sensitivity number across all 24 hours. And I think you could do that with loop too, if you had pretty good basal and we go with a number that works across both day and night. I think you can do that, but I'd like to use slightly lower numbers at night, just in case things go wrong, like Tessa has a basal increase need and she starts kind of drifting up. And I want loop to kind of keep it contained, to keep it from getting up over maybe 121, 30, even if it's like a big change in basal needs. And so I just give loop a little more permission to kind of hammer out that blood sugar, but starts to drift high, but if it starts causing any problems and it can't catch the resulting drop, then definitely back it off. It's definitely the safest thing to do is to leave it as a larger number overnight, rather than smaller. You know,

Scott Benner 16:51
you talk about pretty frequently the idea of giving loop the autonomy to make a more aggressive move if it needs to. But I think that could be confusing to people. So like, if they're wearing a regular pump, and their basal, empirically, is one unit an hour, we just know that it is, you know, for the conversation, if they make it 1.25 an hour, they're going to get low pretty quickly in a couple of hours. If you tell loop, you know, if you're saying to yourself, I think my basal is one an hour, but you tell loop it's 1.25 Are you saying that loop is going to push, push, push until it sees a low and then take it away and then next time not push is hard because you've given it like a wider decision tree to use right like, as far as the amount of basal goes. But it doesn't necessarily mean it's going to use all of it.

Kenny Fox 17:36
Basal is tricky. Basal, unfortunately, with the way loop is built. Right now, if the basal is off, if you went with a one and a quarter instead of a one heat at an hour, at some point, you're very likely to go low, because loop is assuming that the insulin on board that it sees of, let's say zero, is going to keep you flat. But if your insulin, if your basal is too high, you're going to just start drifting down and loops like, Well, no, you should be straight, and you keep dropping. It's like, No, you should be straight and you keep and you keep dropping. And then if you look like you're going to drop below the glucose safety limit, then it starts to turn the basal off, and you start to get negative insulin on board. But it's still always like, Well, you said basal was one and a quarter, and we now have negative insulin on board. You're going to go up. And so as soon as you do start coming up, when you treat the low, then it comes back. You end up hit. You end up getting over treated. Yeah, so basal is a tricky one. That's not as safe a one to overstate, there's some work being done right now about trying to adjust how the negative insulin on board affects the prediction so loop doesn't think you're gonna come shooting up and then hammering you with us quite as much insulin and send you back low. But yeah, there's not a lot of forgiveness in the system, as it's designed today, around basal. This is why I like to turn down the sensitivity, because it only comes into play if your blood sugar, you know, is higher than the defined range. Basically, if you're high, if you're low, or you're in range of where you told the system you want to be, then the there's no correction or sensitivity nudges that need to happen so it stays out of the way, so it's a little safer in that sense, that you can hover around your range, and it's not going to just all of a sudden shoot you down low, okay, but if you start creeping up a little bit, it can nudge a little bit with sensitivity number. I just

Scott Benner 19:13
want to make sure people understood that, so you can't just tell that. You know, I know my basal is one, but here take more in case you want to use it a different way. It's not going to work that way. It's going to push you too low. Going to push you too low. Correct with sensitivity, though, if you say a unit moves you 100 points, and you then come back and tell them, like, hey, you know what? Instead, like, let's say a unit moves you a different amount, so that you have a little more autonomy in here. So if you wanted it to have more autonomy, and you were one unit moves you 100 points. Would you want to make it one unit makes you 90 or moves you 110 to make it more aggressive?

Kenny Fox 19:48
More aggressive would be 90, the smaller number. And the nice thing is, loop has other pieces to its prediction, one of them being momentum. So if you're if it does. Does get you with an amount of insulin for the 90 and you start dropping, loop does presume, oh, well, you're moving down. You'll probably keep moving down a little bit. So that tends to push the prediction down a little bit lower, faster. So it's not going to just give the 90 dose and then wait for it to settle. If you start moving down right away, it's going to try to pull back. So that's why it's a little bit safer to do. But more aggressive is definitely a smaller number that you'd pick.

Scott Benner 20:25
Okay, I just listen. I want to be clear. I know that I just wanted to say it out loud so that people could hear it right. Because I get the idea of like, oh, I want to give it a little more, a couple more bullets in its bag if it wants to pull it out and start and start shooting. It doesn't work there. Now this might be, I don't want to get too far off the course here, but if your insulin to carb ratio is, you know, one unit covers 10, you know, you change it to one unit covers nine because you want to be a little more aggressive, that's still a thing that the loop could probably adjust within. Is that fair? Yeah,

Kenny Fox 20:56
we talked about meals before. And so if your blood sugar starts to, let's say nine. One to nine is too much, and you'd have drifting a little lower. There's still kind of speed and momentum pieces that we'll talk about more detail later. But moving here, where loop would be like, Oh, you're running a little lower. We should probably turn the basal off, and then you still have the the time window, the absorption time we talked about, that loop will expect that food. But if the nine is too much compared to the 10, you might run a little lower, but there's a chance that you might not go low, and that loop will maybe give you a little bit too much insulin here and there, but still maybe catch it. And then when that time window runs out, it's like, okay, well, we're done looking for those carbs. So it can cause a problem, but it's less likely I think, okay, I appreciate you

Scott Benner 21:39
going over that with me. Go ahead, please go back to the course you were on when I took you off course.

Kenny Fox 21:44
The sensitivity stuff's good. The other thing to remember about, about the sensitivity is that when actually, when loop doses, let's say automatic Bolus, when it gives the insulin that it thinks you need at nights. And use the example, it's only going to give a fraction of that. So if we're using a one to 100 and you end up drifting up and it wants to give you, let's say the recommendation is as much as a half a unit. It's only going to give a fraction of that. So the default setting would be, like 40% so less than half of that half unit, so like little less than a quarter unit, is what it would give. And then the next time, it will only give 40% of what's left of that recommendation. And if your blood sugar starts to curve and starts or start to come down, that recommendation will kind of disappear or will drop significantly at any given point, loops not really giving all of the whole one to 100 or one to 90 sort of sensitivity calculation, which is good, and this is also a good time to mention that there is a algorithm experiment, piece of loop, like an extra little algorithm, modification you can use that will change how that dosing occurs. It will either do 40% which is the standard automatic Bolus, or this one called glucose based partial application, which we referenced before, but it gives a smaller percentage of that recommendation when your blood sugar is closer to your defined range versus and then as you go higher, it'll give a higher percentage of that recommendation. So even though you're dialing down the sensitivity, it's never really going to give all of the insulin right away. So that's the other reason why you can say, well, if I turn it down a little bit lower than maybe it should if you were to do a full six hour test or something, there's a lot of play in there, because the system is not going to deliver in its confidence, not going to deliver everything. So it has time for your blood sugar to start to level out or start going down, and then take appropriate action. So it's something to remember. We're talking about sensitivity, and why I think it's kind of forgiving, especially at night. Yeah, to dial it down. Okay, thank you. Daytime is the trickiest part, and honestly, probably the more important one. What's interesting that I learned a couple years ago from some people smarter than me is that, if you take the sensitivity and you divide that by your carb ratio, and we'll talk about all the units, it gets a little crazy. You end up with, instead of a nice sensitivities of points per unit and carbs is grams per unit, per unit per gram. I forget which one, but if you divide the sensitivity by carb ratio, you end up getting a points per gram, which basically says, if you have one gram of carbohydrate, how many points is that expected to raise your blood sugar? And so now operates off this assumption that a certain amount of carb is going to raise your blood sugar a certain amount. So if you ever go into loop and you enter 10 grams, and then you see the prediction says you're going to go up to a certain number, let's say 500 that's the assumption, if you don't give any insulin. And I always wondered, how did it come up with that number? Well, it's using your sensitivity divided by your carb ratio. And so with that expectation, when your blood sugar does go up after you enter a meal and start eating, as your blood sugar goes up, loop says, Hey, that rise equates to this many carbs. Now. Says, Okay, let's say it's five carbs. It's going to subtract five carbs from the active carbs, from the carb entries we discussed last time. And so that's how it's one other main piece, how it's subtracting the active carbs, or the carbs being absorbed, as the other term loop uses. It's tracking the meal progress based on how much your blood sugar goes up, is one of those major components. So if you have your sensitivity set to too small of a number, this affects your points per gram. The short version is, without trying to talk about all the units, because you really got to see it on the page, is that when your sensitivity is too small, loop sees a lot more carbs when it goes up. And the picture I like to give is a small child might have a sensitivity of 200 or more, and you give them one Skittle, and their blood sugar pops up maybe 15 points for that Skittle, you grab a middle schooler or high schooler, some bigger person, give them a Skittle and their blood sugar is long gonna pop up a couple points. They just don't go up as high for each gram you give them, or we discussed before. You know, you used to have to save Tessa from a low with just a couple grams, and now it takes quite a bit more if she's going low with any substance. I think that's an important concept to wrap your head around, that the less sensitive you are to insulin, the smaller that sensitivity, the less sensitive you are to carbs as well. There used to

Scott Benner 26:18
be times where I'd be like, just drink a quarter of this juice box. That's all, yeah, take three sips. That'll fix it. Now I'm like, just here. Just drink it. Drink the whole thing, yeah, just drink this, and then we'll see what happens. And we've talked about it already, I think, but just over, like, go over it again, mostly that's body mass, or it's also the amount of insulin you think. Do you think some people are just making more insulin as they're younger or more newly diagnosed, and then that goes away over time too. Like, what are all the variables that you think impact

Kenny Fox 26:47
that? Yeah, that's a good question. I think, I think it's all of those things. I think when Tessa was younger, she probably still had some beta cell function. There's even times, I think recently, it's been a while since I've seen this, but I thought I would try to get an ISF test in while Tessa was sleeping. I just give her some of her like, honey. I give her at night, while she's sleeping, she'd never wake up and her shoot her blood sugar up, and then I could give her some insulin and kind of see how far she comes down, you know, maybe, like, three in the morning or something. And I've seen it where I give her the 345, grams of honey, and she pops up and pops right back down. Like, well, obviously there's some body function here that's taking care of this, because it wasn't loop and it wasn't me, so I think that plays into it, and why, I think it's also difficult to get these tests in. But I'm sure body mass is a big one, right? It's there tends to be a relationship between body mass and how much insulin you generally use and how much basal you often use. I think those are two big pieces, and then there's always, like diet plays into it too. How much you're know you can modify your insulin sensitivity with reducing fat in your diet, as a recent study that was coming out, so reducing the your fat intake will improve or increase your insulin sensitivity. So I think there's a lot of factors that are really hard to nail down, but I think body mass as a good placeholder, at least in my mind, from a little child to a big child or an

Scott Benner 28:04
adult just changes. Oh, there's too much to think about. Again. That's all there is.

Kenny Fox 28:09
There's a lot to think about. So the main thing that I want to use, that I encourage people to try to use the daytime ISF for one, let's just acknowledge that it's really hard to test for, and it's a pain in the butt. So what I like to do is I use the sensitivity during the day. I make one rate that covers the daytime, or at least the hours that you could be entering and eating carbs, and then use that number to help you get to the absorption you want. So we talked about using the ice cream all the absorption stuff in the last episode. So I think most people, especially listen to the podcast, will have a good sense for how much their carb ratio should be. Generally, like, if you're not getting enough in the beginning of your meal, you end up a little high with proper pre bossing. And so you they people tend to adjust that down. I think people end up with a fairly aggressive carb ratio if they're listeners of the podcast. And most people that come to me are in that boat too. And so once you feel like the beginning of the meal is good, but then you're noticing that either the carbs are absorbing too slow, meaning loop gets to the very end of the time window for your food, and it still didn't see nearly enough carbs, or the opposite, you get to the end of the time window, and loop saw way too many carbs being absorbed for that meal, that's going to be a sensitivity problem. So I like to find a sensitivity number that helps us get to where most of the list of cars on that carb screen are absorbing pretty well, all within their expected time frames, not too long, not too short. And just change that one number and dial it in. So if we're happy with how much in summer getting the beginning of a meal, and you adjust the sensitivity to get to a spot where loop says, Yep, that meal is over at the right time. Most of the time, you're not going to get it all perfect, but you're going to get it done pretty well. I think that's a guiding principle that's helped me and helped others when I talk about how to use sensitivity, because you can talk about, you know, how much is it correct and how much is it fixing things? Yes, I think if you get the meals mostly finishing right, and you do a pretty good job of counting the meals and the fat and the protein, that's like the major variable we have to deal with in the day. So if we can just nail that, and I think everything else kind of falls into place. And you know thing, you might go a little higher, a little lower here and there for some other reason, but meals are going to look good, and loop is going to do what you want it to do the vast majority of the time. Yeah,

Scott Benner 30:23
do you think you could go back and do this manually? Oh, like just being on MDI. You mean, I put tests on a manual pump. How much of this do you think you could mimic per success?

Kenny Fox 30:33
I think a fair amount of it, because you've covered most of the core components with Jenny talking about fat and protein. And if you can take care of pretty good carb ratio and expecting the fat and protein and dosing for it, I think you're going to get very similar results to what loop will do with decent settings. I think the biggest thing that loop makes a big difference is protecting against lows. Like you mentioned before, you're not gonna sit there and turn off the basal all the time, right? The other one, someone mentioned to me that was working with they came from the tandem pump, and we did the had the same problem when we were using the tandem you could only extend meals in the tandem pump like they have one extension running. You can do the same with any any pump. You can't extend another Bolus on top of a currently running extension. And that's kind of the for me, kind of the magic with loop, with the way Tessa eats sometimes, is she'll have decent amount of fat and protein for multiple meals in a row and so but they're overlapping each other. You want the insulin to extend and handle that fat and protein over a fairly long period of time, but then she ends up eating again, and the fat and protein impacts not done. Release the dosing for it's not done. And so what loop and other systems like this help with is you can just say, enter a long meal, a pizza icon, you know, the long meal, and then enter another long meal. She gets seconds, enter another long meal, and loop sort of handles that extension in response to blood sugar. And if you get this ISF stuff working well, then, you know, four hours after she's eaten, it's going to, know, a pretty good amount of insulin to give for the fat and protein without giving too much. And that's, I think, what takes a lot of the burden off or managing food with a system like this, is that you don't have to worry about, are we extending? Is this to the extension still going? And do we need to cancel that extension and add more insulin in to cover the last extension, and then also extend into this food. So I think that that really helps a lot with how Tessa eats, just that she makes she doesn't eat frequently, or meals are overlapping with each other with respect to the fat and protein window of time that the impact is there. And so it's just it helps a lot for tracking meals that way or lack of tracking. I don't have to do the tracking. We just enter it and move on so we could do it. But I don't know how well Tessa could do it on her own, whereas, right now, she just enters it and she moves on with her day, and it's usually pretty fine. What about you? What about you guys? You know, our needs a lot different, right? She spreads out her meals, sometimes fairly frequently. Yeah.

Scott Benner 33:00
Kenny. I mean, could I go back and do it again with the same success if you give me a child young enough that doesn't have opinions and, you know, doesn't fight back, you know, when you say, do something right, I could easily do it and probably have better outcomes, but I think I'd be exhausted again. I think

Kenny Fox 33:19
I was thinking the same thing, you lose sleep. I think the sleep I think the sleep part is a part I didn't think about till just now is, yeah, that part is the initial magic sauce for most people, right at any automation system, is it can go to sleep and it morning turns out better than it would have if I had just gone to sleep with a regular

Scott Benner 33:35
just 1,000,000% like the the process seems to be is, you know, you have a diagnosis, or, you know, whatever, you've been at it for a while, and you just aren't having a ton of success. Somebody slaps you on one of these algorithms. And then eventually you're like, oh, it's not perfect, but I'll tell you overnight, I'm sleeping again. And then you kind of like, come back to life a little bit. You can start paying attention a little to what's happening. I do think that if you took it all away, the first thing that would happen is my sleep would get dinged. You know, I am almost 20 years older than I was when she was diagnosed. I would find myself making those concessions in the middle of the night. I'd be like, Oh, it's only 170 I gotta get some sleep. I think you'd slip back into that pretty quickly. Then I think that starts to impact the daytime again. And before you know it, you're starting the day with a high blood sugar, not enough insulin, everything starts shooting up, and you're off to the races, and you can't figure out what the hell is going on. And then you struggle all day with it, which makes you exhausted, which then puts you overnight again, into a bad situation. Try to keep up with it the best you can. If I didn't have to sleep, if I wasn't older, I know more now, like if you put me just in charge of somebody's blood sugar, I think I could manage it with an inch of its life, but I don't know how long I could do that before I dropped over dad. I just think that there are so many people out there who are not using this automation or not using it effectively, and you have no idea how much your life would change if you if you had it. And it was and it was working well for you. I really

Kenny Fox 35:02
like how you talked about that with the last episode of your caregiver series. That was great. You guys really hit that pretty good is the lack of sleep is significant burden on caregivers, especially. But you know, just as much with the people with diabetes, once they're in charge of their own blood sugar,

Scott Benner 35:19
it just runs you down. There's no way to get ahead. After a while, you think, no, it's okay. I'll figure it out. But, man, I don't know. Like, you know you're not a machine. You just can't stay ahead of it forever. So right, yeah,

Kenny Fox 35:31
I think the last thing I'd like to drill home with people is this is the most hard to grasp and see, because it's not as visually obvious a lot of times. And so my sequence of going through to figure out what might be wrong, we use the iob overnight, especially as our guide to say is basal right or basal wrong. We make basal adjustments based on we see inappropriate negative insulin on board, or those other data points we talked about in the first episode. Then if they're running high, then before you make any changes, check the pod site, make sure it's working. And then we lean on food. Are we counting things? Well, are we not forgetting to enter food? Are we adding fat and protein, all that food stuff called Food accuracy? And then if we're doing a pretty good job of counting, then, then you got to mess with the car ratio. You're going to get better results. If you're running high or running low. Once basal is good, yeah, to just make sure you get enough insulin with your food. And then, as a last resort, like if you mess with all that stuff and you tinker with it, or you just don't think any of those things need to change, because everything else looks good. Then you start playing with the sensitivity. You look at the arboration of the carb List screen and how absorption is going on, and you tinker with the ISF. But it's something that I find with a with a kid that I don't have to mess with very often, Tessa or any child, really, when you're starting younger, their sensitivity is only going to go to a smaller number. It's only going to drop as they get bigger. So that's one thing, is that if you can get a pretty good number eye sensitivity number during the day that works, then chances are you don't really have a question of whether or not it needs to go up or down. Most of the time. You're just going to say it just needs to go down if it needs to change at all, because they're just going to keep growing and getting bigger. So it is make it easier until your kids done growing, you know, early 20s or something, and then they then maybe can go up and down a little bit more. But with kids, it's pretty simple. It's only going to go down, and I really only mess with it a couple times a year when all the other stuff's not helping. So don't let the ISF confuse you and wear you down and keep playing with it all the time. Like pick a season where you have your basal dialed in and meals are looking pretty good those first few hours. You're happy with your carb ratio and you're counting. And then play with it and get it dialed in, and then you don't, don't mess with it too often. Couple times a year, revisit it and move it down a little bit. I don't want it to drain anyone's brain too much. People spend a lot of time thinking about the stuff they don't yet understand, which I appreciate. There's a lot of people that come talk to me, but I think you can just let it go a little bit and make some other adjustments, and you'll probably be

Scott Benner 38:04
okay. I'm adept at turning the knobs and making things work out, but if you listen to the voice in my head while I was doing it, you wouldn't hear this, like, quiet confidence of like, Oh, I see this number and this outcome. So I know I'm gonna make this that I've learned over time. Her blood sugar has been too high lately. I think I need a little more insulin sensitivity power. Here. I'm going to take it from where it is and make it a little more aggressive. Yeah, I don't think it's the basal. I know we Bolus well for the food, so I'm going to try this here. But you, if you're a person who isn't sure if their carb ratio is right, doesn't understand the impacts of food, basal is off by a little bit, imagine if your insulin to carb ratio is one to 10, but you have it set to one to 15, and your basal is a unit an hour, but you have it set at point eight, five, and your insulin sensitivity is like, who knows? By then, the basal is off, the carb ratio is off. All your meals are moving you around in ways that you know you can't know. Forget being on an algorithm for a second, you're going to get out of whack. And then how would you even figure out the insulin sensitivity? Like, in my mind, the basal has to be right, no matter. I think basal is always first, right. So always, yeah, your basal is first, right? Excellent, great. You eat foods that aren't high in fat, that you're really good at bolusing for that. You really know the carb counts for you count the carbs. You look at the insulin, you say, you reverse engineer. You say, Look, I know this meal for sure has 50 carbs in it and whatever, like, you know, two units always covers this. So great. So your insulin to carb ratio is one unit for 25 carbs. But that doesn't mean that the next meal you're gonna have is gonna hit the same way as that meal, but it's a great starting spot. The thing again, like Kenny keeps mentioning it, because I don't think people appreciate it enough. But if you don't understand the impacts of fat in your food and how it's pushing blood sugars up or holding blood sugars up, you really are at a loss for figuring this whole thing out. I. Know, as crazy as it sounds, but I think the one thing that throws more people off than anything else is the fat in their food.

Kenny Fox 40:05
Oh yeah, for sure. Like someone I've been working with for the full eight weeks of my session with them, and they were near the end, and their 11 year old was munching on a bunch of nuts, like fattier nuts and cashews or something like that. And they're like, yeah, she didn't really enter those a whole lot, or just the carbs for them, and then they should just ended up high, like, couple hours later. Like, do you think it was the nuts? It's like, yeah, that's like, the only reasonable explanation here, that you just kind of drifted up high and then ended up a little bit higher at dinner time. So it's just one of those things that I think happens the most frequently. Yeah, is the easiest thing to under count. And I think if you get that right, the sensitivity, if it's just in the ballpark of where it needs to be to help loops. Be to help loop see the meal, then you'll be much better off those those things are, are the basics. The basal has to be right, and if it's not, then you know, you can't really go tweaking other knobs too much until you get that dialed in with confidence, which when we covered in the first episode, I think it's one of the key things when people are working with me is I really try to hammer in on that, using the iob and getting the basal pretty right, and having confidence that it's that it's right, and then you can mess with other stuff. That way, you kind of have an order that you go through for this stuff. And I really like your idea of using predictable meals. I've had a lot of situations in the last few weeks where a nice, predictable meal turned out to not do what it normally does, and that told me that either the site was bad or some big setting needed to change that I just didn't like usually carb ratio. Just didn't know. Tesla wasn't feeling well. She said she was feeling fine, but she needed a lot more instant for her food that day. Yeah, and you just, you had to catch it. So predictable, meals are a great way to just calibrate off of I don't know where else you're

Scott Benner 41:39
supposed to start, because this idea of fasting, for a really long time, I don't know who you tell me the kid you're gonna say, Look, tomorrow morning, we're getting up, we're not eating. We're gonna get your basal worked out, like I say, figure out basal overnight. Get it close, adapt it for the morning. Once your basal is good, look harder at your carb ratios over predictable meals. Excellent. We got that. Now let's look at a blood sugar that's went up the foods out of our system, but, you know, it never came back down from 180 great time to check your insulin sensitivity. Go ahead and throw a unit in and or a half unit and see where, where do you land? And don't wait like, an hour or two, like, really, just, you know, wait a few hours, like, where does it land? It's not going to be perfect, you know, if the unit moves you 50 points, and it's about at, you know, you went from 180 to 130 and it's just resting in there. You know, there's a great place to start, to start with, yeah, and if you're on an algorithm, and you're close enough, like you said, then the algorithm there will kind of make up the difference for you, because it'll push a little bit more when it needs to push. I mean, how long do you think Kenny with the service you provide? How long do you think people have to work with you before you before you can get them in a place like that? Yeah, what

Kenny Fox 42:44
I've seen this year with the groups that I've gone through, it's been about week six or so of pretty dense conversation for the first three, four weeks, training and stuff, and then some messaging in between. But after about six weeks, they kind of get how to do the basal they've they're have a good understanding of the carb ratio and even have a good guess when it's sensitivity. If they move through that list by week eight, they're pretty solid. Those last couple weeks are just kind of letting them practice. And we go over some other topics that like. We'll cover some other pieces around the algorithm just to improve their understanding. But it's the core of it is probably about six weeks. And I emphasize that the program is training. It's like educational. It's going to be videos that you can watch, but then we're going to do like group calls. It's going to be a group coaching. You're not going to be left to just watch a video. You're going to have access to someone to ask questions and to if anyone else wants to share, you can see their data. I know people really appreciate me showing Tess data so they can kind of understand, like, it's not all sunshine and rainbows all the time, and how and when I would make changes, and just, you know, real life stuff that comes up. And so, yeah, it's about six to eight weeks. The whole program right now, I'm planning on running it for a full eight weeks. But it's, it's really start to kind of get it after about six you have time to practice. Have something go wrong, have an illness show up, have a pod site go bad, those kinds of things. There are a few people that made it the whole time and just didn't have anything significant that needed to change. And so right after we were done, and they called me and we worked through it, but a lot of it's just practice, and most people have setting changes, even just a small basal change, sometimes every couple days, sometimes multiple times a week. Sometimes you wait a week or two before you have to change anything. I think that's really important for people to see, and if they just don't need a change, it takes a little longer to practice all the stuff that you're learning. Tell people how to find you box in the loop house, com, you can sign up to get my email newsletter, so you'll know when classes open up, they're only going to open up a couple times a year. So you can jump in. You want to do some one on one instead of going through with the group. You can also find that information on my website, Fox and loop house, calm, awesome.

Scott Benner 44:55
I told somebody today, I'm like, Oh, I can't talk. I'm I'm recording. And they said, with who and I. Said Kenny. And the response I got back was more Fox in the loop house. I was like, yes, but that's just funny. I can't believe I tagged you with that. I'm so sorry. Like that I tagged you with that moniker, but, uh, I'm glad people know you that way. It's awesome. Hey, I'm gonna roll with it. It's fine, excellent. Is there anything we missed that we should have talked about here that we didn't? No, that's good. Awesome. All right, thank you, man,

today's episode of The Juicebox Podcast was sponsored by the new tandem Moby system and control iq plus technology. Learn more and get started today at tandem diabetes.com/juice box. Check it out. The podcast episode that you just enjoyed was sponsored by ever since CGM. They make the ever since 365 that thing lasts a whole year. One insertion every year. Come on. You probably feel like I'm messing with you, but I'm not. Ever since cgm.com/juice, box. Okay, well, here we are at the end of the episode. You're still with me. Thank you. I really do appreciate that. What else could you do for me? Uh, why don't you tell a friend about the show or leave a five star review? Maybe you could make sure you're following or subscribed in your podcast app, go to YouTube and follow me or Instagram. Tik, Tok. Oh gosh, here's one. Make sure you're following the podcast in the private Facebook group, as well as the public Facebook page you don't want to miss. Please do not know about the private group. You have to join the private group as of this recording, it has 51,000 members in it. They're active, talking about diabetes, whatever you need to know. There's a conversation happening in there right now, and I'm there all the time. Tag me. I'll say, Hi. 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, if 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 Hey, what's up, everybody? If you've noticed that the podcast sounds better. And you're thinking like, how does that happen? What you're hearing is Rob at wrong way, recording doing his magic to these files. So if you want him to do his magic to you, wrong way, recording.com, you got a podcast. You want somebody to edit it. You want rob you.

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