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Scott Benner 0:00
Hello friends, and welcome to episode 1192 of the Juicebox Podcast.

Today, Dr. Marwan joins the Grand Rounds series. He's a pediatric endocrinologist who also teaches medical students from both Johns Hopkins and Washington University School of Medicine. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan, or becoming bold with insulin. The diabetes variable series from the Juicebox Podcast goes over all the little things that affect your diabetes that you might not think about. Travel and exercise the hydration and even trampolines juicebox podcast.com Go up in the menu and click on diabetes variables. Are you a US resident who has type one diabetes, or is the caregiver of someone with type one and you'd like to help? You can do a lot right from your sofa with your phone in your hand, go to T one D exchange.org/juicebox. and complete their survey when you do that. Your answers to simple questions will help to move type one diabetes research forward. T one D exchange.org/juicebox.

podcast this episode of The Juicebox Podcast is sponsored by the only implantable sensor rated for long term where up to six months. The ever since CGM ever since cgm.com/juice Box. Today's episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. This is the meter that my daughter has on her person right now. It is incredibly accurate and waiting for you at contour next one.com/juice box. This show is sponsored today by the glucagon that my daughter carries. G voc hypo Penn. Find out more at G voc glucagon.com. Forward slash juicebox.

Dr. Marwa 2:16
Hey, thanks for having me. I'm Dr. Bara Marwan I'm a pediatric endocrinologist at Sinai Hospital in Baltimore. I also teach medical students from Johns Hopkins University and George Washington University School of Medicine.

Scott Benner 2:30
Wow. How did we get in contact? Okay, so

Dr. Marwa 2:34
it's through a patient of mine who actually follows you or podcast. She said Dr. Moore, what you need to meet Scott, you need to be in that podcast. So I thank them for that introduction.

Scott Benner 2:49
Oh, that's nice. Okay, so let's go over a couple of things about you. How long have you been a pediatric Endo? Alright, so

Dr. Marwa 2:55
I started fellowship back in 2018, and July, and so been in the field for now almost six years, then and quote unquote, gainful employment since July 2021. So almost three years as an independent practitioner, but six years almost integral taking care of kids with diabetes. I like to start that my my initial training experience was in camp Sweeney. They threw us for a few weeks at camp with the campers suddenly the camp doctor that I have to prescribe and adjust insulin doses. And I was like, Oh my gosh, that's so complicated. How can I even do something like this. So that really was a very good eye opener for me to not just look at it from a medical standpoint, because as a pediatric resident, my exposure to diabetes was mostly through sick kids in the hospital, or just a few brief clinic appointments, but their one on one contact in the camp just helped me really realize what kids with diabetes have to go through every single day. So kind of gave was a real eye opener when I started fellowships six years ago, that's

Scott Benner 4:08
something they do with everyone, or were you just lucky to have that opportunity?

Dr. Marwa 4:12
I think it's common practice for programs to send their fellows, at least in my program at UT Southwestern, this is considered work so we actually do work hours at camp, but I'm not sure how other programs have it. But it's, it's typically a an opportunity that a lot of fellows like to kind of get themselves into,

Scott Benner 4:36
you know, it's interesting, you think about it, the people who you were helping, were probably thinking, Oh, this guy, he knows what he's doing. And you were thinking, Oh, how do I do this?

Dr. Marwa 4:45
Right? And I was like, Oh my gosh, it's so like, I don't know those devices. Can you please teach me what this guy does? what this button does, like I understand basics of what I mean, they all need insulin, but it's like how we're how we're operating it with so many new devices. So many new tools, that was the first time I actually got introduced to like a continuous glucose monitor, for example. So by that, at that point, it still required a lot of calibration and a lot of work, but it was still a very, very fruitful experience, I would say,

Scott Benner 5:17
when you start off, so let's kind of step through this, you leave high school, you go to college, when you're an undergrad, you know, you want to be a doctor. Alright,

Dr. Marwa 5:25
I'm an international graduate. So I, the way we do it in Saudi where I went to medical school is we do a high school and then directly into medical school, and that's called a Bachelors of medicine. It is equivalent to an MD, it's a longer program. So it's six years of medical school and a year of internship. So it's different from the way it's done typically in the United States and Canada where typically you do undergrad and then you do the MCAT. And then you decide to become a doctor and to become an MD and that's like a postgraduate not just straight from high school.

Scott Benner 6:04
So when you pick the you know, when you pick endocrinology, is there a reason that you chose endocrinology is something that interested you about it something you were good at or had a personal connection to, if you take insulin or sulfonylureas you are at risk for your blood sugar going too low. You need a safety net when it matters most. Be ready with G voc hypo pen. My daughter carries G voc hypo pen everywhere she goes because it's a ready to use rescue pen for treating very low blood sugar and people with diabetes ages two and above that I trust. Low blood sugar emergencies can happen unexpectedly and they demand quick action. Luckily, G voc hypo pen can be administered in two simple steps even by yourself and certain situations. Show those around you where you storage evoke hypo pen and how to use it. They need to know how to use Chivo Capo pen before an emergency situation happens. Learn more about why G voc hypo pen is in Ardens diabetes toolkit at G voc glucagon.com/juicebox. G voc shouldn't be used if you have a tumor in the gland on the top of your kidneys called a pheochromocytoma. Or if you have a tumor in your pancreas called an insulinoma. Visit G voc glucagon.com/risk For safety information.

Dr. Marwa 7:28
Big question. So zero personal connections at that point. So I was in the middle of pediatric residency. So basically graduated medical school applied for residency and matched to a US hospital in New York where I was doing pediatrics. But throughout those three years of training, it prepares me to become a general pediatrician. And then I have the opportunity to do three additional years of training in whatever field that I'm interested in. So whether it's being like a heart doctor, a cardiologist or an endocrinologist that comes in, after we do those three years of general, whether it's internal medicine, if you want to be an adult endocrinologist or pediatrics, if you want to do a pediatric endocrinologist. Okay, so my first year in and like as a pediatric resident, I was like, I know that I don't want to do general pediatrics, I think yes, I love taking care of patients in a Well Child setting. But I do like to take care of kids who have chronic diseases. And so whether it's being an asthma doctor or like a, like rheumatoid doctor or a heart doctor, or like I wanted to take it a step further. And so, at that time, I was also doing my master's in public health. And I had, at that point, wanted to be involved in some kind of research. And during that time, the fellows who were in my program wanted a statistician to help them run those numbers and analysis. So I kind of find myself really, with the people with the group of endocrine fellows and the endocrine attendings who were amazing. And they got me involved into the diabetes research. And I was like, You know what, I actually liked that, but I did not know how much I would love it. I was like, Okay, I don't mind being an endo or an asthma doctor. But now it's like, looking back. I don't want to do anything about diabetes and Endocrinology. So I'm glad that it's kind of the stars aligned this way for me. Yeah.

Scott Benner 9:36
What about it captured your imagination.

Dr. Marwa 9:39
I knew I love working with numbers and I'm a caring person. So I think I found that kind of right mix within paediatric endocrinology. But at that point, I was like, Okay, I like to get results right away. So I was thinking maybe I can do a hospitalist job where I can just take care of very sick kids in the house. Fill er the ICU or neonatology. But then, like, I love to also have a work life balance and spend the nights really at home with my family and not really have to spend so many nights of my adult career in the hospital. So that's where a subspecialty like endocrinology came in as a natural fit. It's

Scott Benner 10:22
interesting how many little variables go into your course.

Dr. Marwa 10:26
Right? Yeah,

Scott Benner 10:27
really, it is really something. So once you decide that you're going to, you're going to help kids, you know, in a clinical setting, what do you know about diabetes, I guess, in the beginning, and how do you learn what you know now? Because it's not from medical, because people would be keen to believe that go you go to medical school. So now you understand diabetes? That's not really how it works. So what's the pathway to to really becoming proficient?

Dr. Marwa 10:55
Right. So honestly, if without having a one on one, diabetes training, I don't know how I would have been one because yes, we do study how insulin works. That's something that they teach us in medical school, they we study the different kinds of insulin we study, there is a pump, we study about DKA. They teach us in the hospital, of course, in the emergency room, how to take care of a sick child, but they don't really teach us what goes into the day to day management of diabetes. This is not a common thing that a general doctor, I mean, yes, they know that the kid needs insulin, but that's pretty much where it ends in terms of what they teach us in pediatric training. Not every pediatrician does endocrinology. So yes, a lot of my trainees currently in the hospital, where I'm at, they just see kids with diabetes in the hospital, they never really have that connection with kids who never landed the hospitals to begin with. So I think, again, if somebody wants to really get into diabetes, they need to actually experience then just deal with people who live with it.

Scott Benner 12:03
Okay. Yeah. So it's just the experience just having conversations, watching people struggle or succeed and taking information from that building on top of it. Absolutely,

Dr. Marwa 12:13
yes. And again, staying. I was very, very lucky to have very good mentors in Dallas, where I did my a year of fellowship. I mean, we just was excellent, 16 endocrinologist and I was the only fellow that years. So again, I felt that there's a lot of responsibility, but at the same time, it's that joy of learning something new, and really being able to slowly understand how those doctors think about going about medically making the right decisions. But then after that, I realized there is a there is very limited that doctors do in clinic appointments. And it's like, and this is always a question that I asked myself, like, what's my job as a diabetes doctor? What's my role? I mean, at this point, at least when I was in Dallas, the nurses would pre charge prepare all the prescriptions for diabetes, there is a protocol for when to do the labs and when to do that blood sugar checks. And even in terms of trend management, giving more or less carb ratios are long acting or just making a pump change. Again, that's also mostly handled by our nursing and diabetes educator team. So it's kind of like that struggle is like diabetes is like no other disease is. It's not just that you need the medicine. Pretty much everyone universally, Nellis you need insulin for type one diabetes, but it's more of how can you tailor that treatment to that individual in front of you?

Scott Benner 13:46
What did you decide your job was?

Dr. Marwa 13:49
At that point in Dallas, it was a much more structured way where we had diabetes educators routinely go in with a doctor's for a visit, that all changed. When I actually started here working at Sinai was COVID. Most people were remote. And we were just starting to get people back to the office. And I found myself basically doing it alone. It's like an old man. Like it's an it's a one man show, for the most part for the diabetes care and follow up where I had maybe three or four people helped me in my visit, I kind of took a different approach to what other doctors might do. It was more of a concierge, so to speak, kind of practice in a community hospital, where I, I personally again, it was like, okay, somebody needs to provide that education. If I don't have the nursing Task Force. I don't have that skeleton. Hey, I mean, I still want my kids to get the best care possible. And I'll just go ahead and do my own education. So I was very, very fortunate to have that capacity. It's like yes, we are a smaller house. spittle, and we have lots of hospitals in the area in Baltimore. It's not a big patient load, we get around maybe one new diabetic every single week. That's different from Dallas, for example, when I used to get a diabetic every single day, the the load there was much bigger. So with having a diabetic every week, it was more of a process of how can I make sure that my patients are up to speed with that education process. So for me, my goal was mostly an educator. And I'm like a teacher. And basically having a little curriculum in my mind, even though it's an unwritten curriculum about, okay, this is what you need to learn when you first leave the hospital. This is what you leave, leave to learn, like, a month or two, down the line. Of course, we all are different in how fast we learn. But at least understanding the basics, the concepts, I would like all my patients to learn how to do trade management, of course, not everybody is able to do so. But it's mostly structuring the education. So I think founding my role as a physician educator was very, very fulfilling, I then decided, okay, you know, what I put in all those hours, I was able to put in my diabetes educator exam, I'm now very one of the very few doctors who are certified diabetes educators, and also board certified in advanced diabetes management. So basically, it's just from an A to Z kind of standpoint where I could just cover not just the doctor, yes, I know how to look at prescriptions and look at trends and make those adjustments, but also educate and empower my patients to be able to really achieve what they need. By the time I see them. The next time, of course, what do I use to measure? what's the, what's the variable that I'm tracking? It's like, of course, I track their time and range, and they're a one see that everybody does, but of course, it's not just a one. See, that happens in three months, I always ask myself, there is a lot of room as a window for opportunity between those visits that we could probably work on.

Scott Benner 17:06
What do you feel like a newly diagnosed person needs to understand? First, it feels like you have it broken into steps, right? What are the steps? diabetes

Dr. Marwa 17:16
is a life changing diagnosis, there's a lot of stress. But then at that point, families are very eager to learn. And I found it that really what we teach in that first week, or that first few weeks, really stick with them for a very long period of time. And it's kind of like this is the unshakable truth. So I think the most important things I teach or focus on, I think everyone can learn eventually how to check a sugar level, or how to give insulin injection, this is not my point of focus, our nurses in the hospital can even they're not diabetes educators, they can also teach those basic mechanical skills, what I focus on is the understanding of diabetes targets as like, Okay, this is a prediction game. Even if you're off by a point, upper or lower, you have the numbers to track and to kind of teach a good target, I always say I want to make diabetes, invisible disease. And so I give Dexcom during that first admission, or like any other as mostly Dexcom. To allow for monitoring, I've got I've given some Libras to my type twos, basically a continuous glucose monitor, so that we can continuously monitor and when they can reach out the first few days after because I'm having a patient a week or so I try to not just say, make this change, but explain why I'm making those changes. So it's kind of like slow learning process that hey, this is a an imperfect disease, we do our best we try to come up with a certain dose. But if it doesn't work out, doesn't mean that you're doing anything wrong. This is the nature of diabetes, and let's try to kind of work on improving all the time.

Scott Benner 18:58
You're teaching them the way you learned from your fellows. Correct. Okay, and you're taking the experience that you had at diabetes camp, right for yourself, remembering that you didn't know anything, and you had to go over and over and over again until it started to make sense to you. You're just doing what worked for you. For them. Yes.

Dr. Marwa 19:15
I was like, Okay, it's they're very worried initially about a high number. I always say it was much higher just a week or two ago when it was running at a super high levels. We did not know it. diabetes was a thing. But now we know it, we can see it, we can act we have the tools to respond to it. And so yes, it's always those kind of questions. Can we have a snack after we had a meal or they like we always try to not give concrete answers, but always try to reference Hey, oh, my gauge is your numbers. And this is what I want to try to kind of perfect and so my focus is yes, you need to learn how to perform those skills how to use The Corporate shell. But eventually, if we do the math, and the numbers are not where they need to be, we need to think about how can we make it better the next day. So kind of make it like a process. And not you do this, and we'll fix that kind of thing.

Scott Benner 20:14
I think that one of the nicest things I heard you say, Was that what you tell them in the beginning becomes this unshakable truth. So then, you know, to that if you lead them in the wrong way, in the beginning, it's hard to break them free from that as well. Right? And

Dr. Marwa 20:29
I look at it just like I'm building a house, I need to set up a solid foundation. Yeah. Yeah. And how do I mean, again, it's this is what makes the diabetes doctor different from like, say, hematol, like an oncology Doctor, where you're setting up all the plans, for example, for treatment of a tumor, mostly in the hospital. I mean, what our job is, is to empower people to do the tasks of diabetes at home. And that's what makes our job much more again, demand. And what we're asking for is something that is very demanding 24/7 365 kinds of jobs. So it's this is I think, what makes it all a it's also very

Scott Benner 21:10
uncommon in health care. Far too often, we accept the blood glucose meter that someone hands to us, the doctor reaches into a drawer and goes here, take this one. That is that is the one you want. Is that accurate, you have no way of knowing. But if you want accuracy, and you want to be confident in the blood glucose readings that you're getting from your meter, you want that contour next gen. It's incredibly easy to get the same meter that Arden uses, just go to contour next one.com/juicebox That's all you have to do. The contour next gen is easy to use and highly accurate. It features a smart light that provides a simple understanding of your blood glucose levels. And of course, Second Chance sampling technology that can help you to save money with fewer wasted strips. Contour next one.com/juicebox This episode of The Juicebox Podcast is sponsored by the ever since CGM ever since cgm.com/juicebox. The ever since CGM is the only long term CGM with six months of real time glucose readings giving you more convenience, confidence and flexibility. And you didn't hear me wrong. I didn't say 14 days. I said six months. So if you're tired of changing your CGM sensor every week, you're tired of it falling off or the adhesive not lasting as long as it showed or the sensor failing before the time is up. If you're tired of all that, you really owe it to yourself to try the ever since CGM. Ever since cgm.com/juicebox, I'm here to tell you that if the hassle of changing your sensors multiple times a month is just more than you want to deal with. If you're tired of things falling off and not sticking or sticking too much, or having to carry around a whole bunch of extra supplies in case something does fall off. Then taking a few minutes to check out ever since cgm.com/juice box might be the right thing for you. When you use my link, you're supporting the production of the podcast and helping to keep it free and plentiful. Ever since cgm.com/juice. box right? Because you usually things are measured, take the pill at one o'clock take it at five o'clock, I want you to do the albuterol before you have this hat like like it's all very structured diabetes isn't like that at all. diabetes it is but it doesn't feel like it, it feels like it feels like it's always flowing and moving and changing. And I need you to do this all at home and make changes to that. So how long until you empower them to make dosing decisions that are different from what you've written down? Oh,

Dr. Marwa 23:56
it's like a few weeks down the line. Okay, so I think because I'm with them pretty much every day or every other day when they leave the hospital. And so it's a lot of hand holding initially, but then slowly they realize what I would do. And then I start to ask questions in the Socratic manner be like, okay, they would reach out we're having lows when we're intrigued that honeymoon phase and it's like, okay, you see those lows? What do you think caused that? And what insolent change do you want to do? And I always say, this is purely educational. If you don't know the answer, or if you ask the wrong question is okay, and I'll then put in my recommendation myself, or if I see that they put in a recommendation and it really is what I would suggest and I was like okay, yes, this is what I want.

Scott Benner 24:41
This is how I do it online. I when I talk to people I almost always say to them some version of what do you think, you know, where you ask them a question to get them to think in a direction that they're you don't know to go into? Have you ever done that kind of leap like little carrot and stick lead them towards it?

Dr. Marwa 24:58
Oh, yes, absolutely. You I slowly and sometimes I say, Okay, I usually go down. I mean, sometimes I just when I see somebody is just really stuck and frustrated, I'll say, Okay, we'll do a 20% decrease, what do you think that will do? So at least I'll make them do one task out of the process. Yeah. So at least getting them engaged in there. It's more of where's the center of control, I wanted to be with the families, I want them to feel that they're under control of their disease, yes, they get their prescriptions and the guidance from the doctor's office, but it's mostly I want to empower them to really be able to be independent in taking care of that disease. So they don't need a doctor's input, Allah down the line,

Scott Benner 25:41
it becomes crippling if you infantilize them, and don't let them make decisions, then down the road, when you're not as connected any longer. They don't know what to do. And then they just start taking those outcomes as this is how it's supposed to be. And so they don't even reach for more at that point. They just accept it.

Dr. Marwa 25:58
Right? Yeah. And honestly, I feel that my personal anecdotal experience in my practice or care model, is that I really, really value starting a sensor they won and having that hand holding process throughout, because it's a very critical moment. This is when they're very eager to learn. And this is when I can really get somebody to get a buy in with me teaching versus somebody who's had diabetes for five or six years, I might use the exact same skills, it might not stick, because this is not what they've been used to. It's very hard to change someone's behavior once we get to that level. Yeah. So

Scott Benner 26:39
that's insurance, though, right? If they have insurance, then they get one if they you know, but are there people who you want to put on them? You can't get them for? Pretty

Dr. Marwa 26:48
much, at least in Maryland, I know other states might have it differently. But in Maryland, it's universally covered for anyone who needs insulin four times a day. Oh, wow. So I have samples in my office that I give at the hospital. And so the first one is just a free sample. And that buys me 1014 days until I figured out a prescription and prior auth pretty much they're getting continuous numbers since they are in the hospital for that first appointment.

Scott Benner 27:15
Do you see people becoming overloaded with data? Or do they handle it? Well,

Dr. Marwa 27:20
people handle it differently. But I feel that I want them to be overloaded with data. That's the whole point is to make them to let them know diabetes is messy. And let's try to solve this together and trying to just walk them through my thought process about making it less of a messy disease, so to speak. I

Scott Benner 27:42
appreciate that attitude. I really do because I think that everyone should leave the hospital with a CGM, right? Yeah, after diagnosis, it's just so valuable. And you learn so much about how food and insulin impacts things. It makes you just Ultra aware of all the things that would look completely invisible and unknowable if you didn't see the data. Correct? Yeah. So fantastic.

Dr. Marwa 28:05
I honestly, again, it's this so this is kind of the I'm sure that down the line, we'll have more studies to support that. But I think at this point, even without a study, I think I already know that this is the route that probably the future we'll see this model get more generalizable. Right now I have a very busy clinic, a clinics a week, they really don't have time to kind of sit down for academia and research. And then important topics to kind of just review, evaluate, not in terms of control because I think if we resist studying control in a month or two, I don't think that's a good outcome. Because I think eventually mother nature allows honeymoon to kick in and everybody gets a good, relatively good a one see in like few weeks, a few months down the line,

Scott Benner 28:52
some stability happens. And yeah, a year down

Dr. Marwa 28:56
the line or two years down the line, the understanding the level of being able to handle the burden of diabetes. Initially, I had a mom who was very, very worried about how discrepant the numbers are between the Dexcom and the glucose levels. And she was almost going to write off Dexcom in the hospital. But then I was like, Okay, we need to be patient with this. This is a tool. So it was more of that explanation. But eventually now she's like talking about Well, thank you so much for walking us through it because otherwise we might have not even started it. And I've had it here now where I have a patient who was seven years into their diagnosis, they are still refusing to wear a CGM because they had one bad experience. So I think if we just say that this is the way this is the standard of care is to take care of diabetes with a CGM, despite its limitations, and let's walk through it and let's teach you a sugar stick as a backup. I think this is the message that I want us I want them to stick with and not the fact that oh I can take care of Diabetes with finger pricks? Yes, you can, but you're not gonna get the good control that you would get otherwise with a continuous glucose monitor. What

Scott Benner 30:07
do you think about the algorithms? Do you put algorithms on people? So

Dr. Marwa 30:11
algorithms? Do you mean DIY systems?

Scott Benner 30:15
No, we're all them. Omnipod five control IQ, Medtronic 780 G like, do you? Do you give those to people?

Dr. Marwa 30:22
Oh, absolutely, yes. Yeah, that's what I do most of my day is I look at my most of my day is it tech support, so to speak, because hey, somebody just we need to connect them and we need to get their numbers, the algorithms I day one, I tell them, we have this is Basal Bolus. This is how we can do it at the hospital is a backup system, but yet you need to learn. But I always introduce to families that, listen, it's just a transient phase, but most of my kids will need to transition to a pump process of some sort, to get the good control. So I always say this is just the stage to learn, I kind of try to give the analogy of a elementary school student we don't we don't give them calculators until they have mastered how to do addition and subtraction on paper. So like, I always put them in the mindset that this disease requires technology to fix it at this point, we can only do so much with shots, eventually, the goal is to transition them to a pump of some sort of a closed loop system. So you're

Scott Benner 31:29
of the opinion that they should know how to use a manual pump first,

Dr. Marwa 31:32
that manual pump but at least know how to master injections. First, a lot of families asked me in the hospital, can you get a pump right now? And I was like, No, it's mostly educational. I mean, if they already had another sibling on a pump and family has gone through the process training, then yes, I don't mind a week one or two after diagnosis.

Scott Benner 31:52
I was gonna ask you, can you dig down into that a little bit for me, tell me what the benefits are that you see coming from being MDI for a while? Oh,

Dr. Marwa 32:00
so I think understanding the process, diabetes, understanding the relationship between insulin and food, yes, we can also get that in a pump. But I think with shots, it will make more of a physical, like you are actually getting that insulin to see the effect of food. But then eventually, I think, with any pump, there is a chance of technology failure. So I do want them to be very overwhelmed when technology fails, and we have to resort to some sort of either manual mode or MDI. I

Scott Benner 32:43
say, if you could be certain that there wouldn't be any bad sites or mechanical like, I don't know, hiccups, then would you have any trouble with them starting on a pump, then?

Dr. Marwa 32:56
The family knows how to revert to MDI. I wouldn't mind that, okay. Meaning the family should be very well versed with MDI, they should not I mean, it's not like, oh, we just learned about it for a day in a hospital. No, they should have really a full understanding of it. This is how you do the long lasting, this is how you do your rapid and this is how we calculate the doses manually. It will help them understand how we think about insulin doses. Yes, I do prescribe the bionic pancreas against prescribing it that first week of diagnosis, I think it's important to understand how insulin works, and to see okay, what does five units mean to my child to my meal and what it does and how different doses deal with like, again, how do how they affect insulin levels, like just make it more of a an understanding and break the barrier of Oh, diabetes is difficult. And then I want them to feel that, oh, diabetes is not too difficult. And we really know and it's only repetitive and I think this is when somebody's ready for a for an upgrade. And this is why it's like at least I give them a few weeks of MDI.

Scott Benner 34:07
Give an example of something that you've seen go wrong when someone starts off without that understanding.

Dr. Marwa 34:12
I started like I've had that Pharaoh who was so much into technology. And they requested a an ink pen and ink pen is a smart pen that would have a Bolus calculator and would tell me, Okay, how much you program the current ratio is the correction factor. And the pen will calculate is an onboard pretty much like a very old school Bolus wizard, right and we'll log in the insulin doses. So I had it been who requested that they wanted to hospital and I was I was able to actually provide an NPN as part of their discharge prescriptions. I think the problems that happened is that they became I'm so dependent on that recommendation of the pen thinking that this is an absolute recommendation. And it kind of made them not think about how good is this those working? Or is it time for me to make a dose change. And so they would be like, Okay, that's what the pump recommended. Sorry. That's what the pen recommended. That's why we gave it and not really there. Okay, now, this is something that's manmade, that we came up with those programming settings, and we need to continue changing it kind of thing. So

Scott Benner 35:28
is this a situation where month it's given over to the pump, that if they see it, I don't know, if they see a situation that doesn't react the way they expect it to. They don't think about it any more deeply, because they believe that the pump has told them the right thing to do. Happens

Dr. Marwa 35:46
all the time. Yet, I say, this is where I would like people to think beyond just what's happened. And unfortunately, that might sometimes lead to DKA. Because hey, the pumps told us to not give anything when the pump was actually kinked or something. And someone might try pushing an insulin and despite you reading a chai for many, many, many hours, and then the kids just have comes to the to the emergency room with a DKA diagnosis I so so I try to kind of prevent that reliance on technology. And I try to say it's not like it's not a foolproof thing you foolproof is you need to know how to do the shots, right? I need you to know how to give insulin manually, and how to be able to just put a pause on diabetes technology if you need to. Okay,

Scott Benner 36:30
very nice. I appreciate you explaining all that. Oh, of course. Yeah. No, it's fascinating. So I guess my question is, you said you also you teach people how to do their jobs now, like So you've now become a person who, who helps younger doctors learn what to do and what to expect. Right? What do you think are some of the most important lessons that they can learn when they're younger? Those doctors, right.

Dr. Marwa 36:55
So I think just being humbled to diabetes and learn from your patients, because my patients teach me something every single day. Like it's always a new trick, or hack that I did not know about whether it's in technology and how they do things, I've found, really, yes, I learned a lot from my teachers and my mentors and my professors, but my patients, I really, I'm very, very grateful for all the discussions and the interactions we've had together. I think that's the number one thing is be humble and understand that what it is that we're dealing with every day, what we study in textbook is really nowhere close to what this again, what what people would diabetes in their families have to deal with every day. And again, I think my other advice would be to not prejudge a patient or a family. I think a lot of doctors fall into the trap of the judge a diabetic based on their agency or their race of admission for DKA. I think sometimes we as doctors need to step back and look at the full, holistic picture of what's happening. What are the barriers to care, don't look at it as sometimes people used to us from the doctors world, labeled patients as non compliant and just call it a day. And I think this is the easy, lazy way to do things. I would say they are not adhering to the plan of care. What are the barriers and let's break down those barriers. And so this is the process that I try to teach all my training doctors who come here to like, okay, their agency is high this time, what are the barriers and let's try to kind of break them one by one and try to hopefully work on making it better the next time. Whether it is an educational barrier, or the technology barriers supply barrier insurance barrier, no matter what barriers there are, I always say hey, mother, nature's plan for this kid is to have the agency as 17% or higher. So whatever number that's lower, there is some work that had been done and it always celebrate the successes and try to kind of work on improving it the next time. That's

Scott Benner 39:04
excellent. What percentage of the students do you think, learn those lessons? How many out of 10 do we send off into the world to be good, thoughtful, quality endocrinologist, and how many of them just end up writing down noncompliant if they don't get the result they want back?

Dr. Marwa 39:20
So right now in my capacity, I'm training general pediatricians. So I'll be very honest. I'm not training actual endocrinology fellows who are about to be in the chronologist. But I'm trying to teach your pediatricians if they have if they see their kids with diabetes, whether in the emergency room or hospital or their outpatient clinics, kind of what to look for and kind of how to approach a high agency in that scenario.

Scott Benner 39:44
So that's not a fair question for you then on that form, but let me ask you this then, how do we get the overall quality that people see like him? This is happening at your hospital and you know, at your facility, but that doesn't mean it happens everywhere. Like, how do you think we can turn endocrinology into something for type ones that is very specific to them instead of you know, what often happens to adults, for example, is that they end up at an endo that handles mostly type two, and they don't know anything about type one. And they get no direction whatsoever. Like, like, I know, what's the thing you have to learn? And I know, it's not the same as being other kinds of doctors, where there's just rules or, you know, when we take the medication, or when we put in the implant or something like that. Have you thought about that? Have you thought about ways to spread good care to type ones?

Dr. Marwa 40:34
That's a very good question. Because honestly, even my care model, I could not even I will say, share it among peer endocrinologist in just again, in my surroundings. So not everybody is hardwired to kind of function this way, so to speak, because endocrinology is very algorithmic, so to speak, I mean, you have low levels of thyroid, you give thyroid medicines, you check labs in two months. So I think if we put diabetes into the umbrella, this is where a wrong thing happened. And this is where it's very, very hard, because we're all doctors are humans at the end of the day, and we are just as varied as again, the variation of human nature. I mean, some people are more patient than others, some people are more rushed than others. And people like to rush through things. But I think if we were looking at it from a systematic standpoint, then yes, we do have a lot of potential in terms of educating an endocrinologist about type one diabetes when they're in their fellowship. But also, actually, I think, and this is what I always tell my families is that they can share some information with their own doctors about, hey, this is something that I'm interested in. And the doctor needs to also explore those things and needs to be very honest, if that's something that they do everyday or not. And I'll be very honest, not every industry knowledge is fit to kind of tap on diabetes. Again, some people it's that's not their thing, and they shouldn't be forced into that field. I mean, you should have a passion for a topic if you really would like to take care of it. Right? I find it hard to answer that question. Because, again, it's goes into a lot of political. No,

Scott Benner 42:12
no, I expected your answer. I just wanted to just say it, that's all. Because because it is random, like there are people who will just luck of the draw, get get you. And there are people who luck of the draw will get somebody who's not well suited for it. And and then their health follows that path. And they don't even know like, that's the part that's that I think heartbreaking to me is that, you know, I could have got you but I got somebody else. And now my eight one C is seven instead of five. And I'll never know that my whole life. I'll just think that I went to the doctor, they told me the right thing, and a seven is what I'm able to accomplish. And, you know, it makes me wonder so much if we're not going to see a significant change in this through I don't know AI, honestly, over the next 10 years, like how soon until AI is connected to your CGM data, and it knows how many carbs you've taken. And then it starts making suggestions to you about, hey, I think we should change the carb ratio to this or I think we should change your insulin sensitivity to that, like that stuff can't be that far off.

Dr. Marwa 43:18
Right. And I think it's already you're already in the bionic pancreas. Sarah, just to give you as little perspective, I mean, I've had a lot of patients who had, everyone was like, okay, my normal agency is 910. And I was like, This is not normal. I mean, and so, especially in lower like underprivileged communities, and this is most of the kids that I serve here are from underprivileged community, Medicaid, mostly government insurance population and for pediatrics. And like you said, they don't know any better about, oh, really, there is a pump that can do that. And so a lot of doctors would put themselves as basically the judges of how good someone is, and they would think of a pump as a price as like, no, it's a tool I would give a for my criteria to start a pump are very, very low, meaning you just have to have type one diabetes, and you have to care a little bit about getting it better. I mean, it's like you need to charge any pump, you need to keep it on your skin, you cannot just disconnect it, you need to be to have somewhat of a caring thing about your pump. So not your question about AI and technologies. So I always think about that every single day is like, When can I play offense and not defense to diabetes? If I see somebody in the hospital in DKA, or and they're wearing a Dexcom, you don't know how many times I looked at a Dexcom where it was reading 383 90 for like many days, and we are looking at that data. Of course nobody alerted us to look at it otherwise we would have guided the families on what they need to do. But we wait until they land in our emergency room when they are very sick, when we could have kind of picked on those early signs of a deteriorating disease early on, I think it would be interesting to see what the future would hold in terms of not just the corporations, I think this is a very advanced thing, but at least there's something going off and you're spending time before hundreds, maybe it's time to alert the doctor, we don't even have that as an option in most of those data analytics software's that we currently utilize. So there is no way for me to soar with skills, so to speak, I need my help. And unfortunately, some kids go into a mental health crisis. And then diabetes control goes south. And I wouldn't know and this would be the kids that I would expect to control from them the least because they it's again, typically it's something outside of medicine, it's not that they do have a medication, it's mostly something social that impacted their diabetes management.

Scott Benner 45:57
How often do you see people with a three ad for days that they don't do anything about and what do you what do you think that causes them not to react?

Dr. Marwa 46:06
People just become numb to just hey, we were used to being numbers, like the numbers, this highs, like and this is what I mean, like people were not taught the targets they want, they don't know what to expect. And some people just treat diabetes symptomatically I don't feel bad. I feel okay. I don't care what the numbers are. This is the struggle that I always try to make them care. I always say I need to make the height or painless, but I need to make it painful. I need to make them feel that this is not right for my body. And so I think a lot of times there is a fear of dropping low there is like okay, there, we're not even checking. They're not having the alarm set, or nobody's actually looking at that data until they see me in clinic.

Scott Benner 46:46
Right. So for the group of people who are not scared of being alone, they're just not motivated. Right? Do you think they don't understand the impacts on their health? Do you think they don't care? From my perspective, as a person who sees a 135 blood sugar and things? I think we could bring that down? I don't understand staring at a 380 for days, but I'm trying to put myself into the mindset of a person, because it's not just apathy. Right? It's not that they don't care. Like there's other things at play. Right.

Dr. Marwa 47:15
And I think it's that invisibility, feeling that, okay, you know what I mean? Nothing is gonna happen to me, even if I go into DKA, I know that the doctors will fix that for me, kind of thing. So it's especially I mean, again, I'm a pediatric person. So I deal with a lot of children and young adults, I mean, adult children don't think the way we think of things like I wouldn't expect a 16 year old to think about a 401 K. So right, but

Scott Benner 47:40
their parents don't get involved either. Did they do that thing? Or they're like I tried, I told them, but they don't listen.

Dr. Marwa 47:46
Yes, all the time. Again, it's more of we give them the tools we bring into the doctor's appointments. We try we best, but we also have to work three kinds of jobs. And I cannot be there with it to baby my child anymore. Yeah,

Scott Benner 47:58
I see the problem. Okay.

Dr. Marwa 48:00
So this is kind of the struggle that I have to kind of deal with. And this is where I think AI, like on the spa. And this is where honestly, again, sometimes even an Omnipod five algorithm might really not work for that person. So I honestly took a lot of people out of Omnipod, five into some other pumps and vice versa, taking some people to the Omnipod five, some people would do better with a tube, some people would do better without a tube, some people would really like that a we did something different about what we were dealing with every day. And I mean, I've had a kid who really did not pay attention to the Omnipod five, and then the Omnipod five will go into manual mode because it's reached its automated delivery settings, I switch them to bionic pancreas. And today, I saw not great results because the kid was not connected to that to their pump most of the night. So again, it's this is the kind of chart I think, yes, there is a role for technology. But I think we are at a decent stage. from a technology standpoint, it's more the psychology and having the buy in from the people living with diabetes to say, No, I really want to feel better. I really want to make sure that my my numbers are better. I mean, that might sound like common sense to us adults, but for a lot of my kids it's not and some kids do, but some some kids are some of the lessons they just it is a struggle for them dealing with the DS they'd rather not think about it or just take as long as I'm okay I'm not in the hospital I did. I reach my goal. So I tried to be patient try to take it step by step I tried to kind of go focus on little goals and actionable things that they can do to try to kind of prevent a, so to speak of like a major relapse in diabetes, like like a DKA admission, but also to really make sure that we're back to the process of hey, you need to see too You see 100 Most of the time and not 250. And you feel that this is okay. And so trying to change that mindset is a hard thing. I think, again, I am not a behavioral person myself, but my wife does a lot of work with applied behavioral analysis. My parent, my father is a psychiatrist. So again, I was surrounded by a lot of mental health experts in my home. So I got a lot of training there about maybe a behavior prescription so to speak, which so I think is helpful.

Scott Benner 50:34
Yeah, no, I would imagine it would be greatly valuable. Can I ask you, so I find myself like wondering out loud about the eyelet pump, the BT bionics pump. And I think, well, if somebody's not going to do anything, at least if you put them on that they maybe could get an A one C and the sevens with it. But you're telling me that you might be intersecting people who won't put the pump on even? Right?

Dr. Marwa 50:54
Yes, I mean, not put up on par for quite some time. And again, of course, the huge wall, I'm not getting my shipment from my supplier. It's like the usual frustration, and then okay, we don't know what to do as a backup, because we and then our numbers are just running very, very high. So I think, again, until there is a biologic fix to type one diabetes, which I'm hoping for will happen in the next half decade or two, but And so until we're there, I don't think technology by itself, can everybody fix diabetes, I think there should be also a lot of work on the psychology and the social work services that we provide, and not social work in terms of I don't want someone holding a stick, what am I called a social worker, and told the mother, if you don't follow this plan will take the child away from you. I mean, it should not be confrontational, some social workers just don't understand the complexities of this disease, and they want to try to get a black and white answer. And there are lots of shades of grey, and there are some there. Again, there's this difference between somebody who's just overwhelmed, frustrated, diabetes, fatigue, versus somebody who truly is completely completely negligent of their child. And that's, that's a fine line. And I always find myself thinking about those things. But at least, if I have somebody who reaches out to me, when they have trouble, then we have that open line of communication. And we're able to do really, again, it's a partnership, it's like trying to get to a place where they're in harmony with their disease. And what I mean by Harmony is that they're doing what there's something that they're comfortable doing, and they're seeing the results that they're seeing. I mean, you will be surprised how many times I would be somebody with an agency of 12 per sentence as how things are going, and they feel like things are okay, yeah. But in my mind, things are not okay, we need to fix things.

Scott Benner 52:53
You're dealing with so many different types of people. And yes, and situations on top of that, anywhere from someone who's very interested and able, for a number of reasons, and is probably keeping an agency in the fives to somebody who you're just like, Look, you have to put the pump on or you're gonna end up in the hospital, right? And everywhere in between and parents that can be involved in parents that can't be involved in kids that do care and ones that don't care. That's exhausting. No,

Dr. Marwa 53:21
it is very exhausting. Yes, yeah. I love the experience of it all. Whether it's somebody that I was able to, again, at least move the needle in the right direction, and trying to at least make them leave the office with a positive attitude about Yes, I can handle this. Yes, I can. This is something that I learned from the doctor, I can totally make this better the next time and just celebrate the little victories as we go.

Scott Benner 53:44
Do you have any luck explaining to people that high blood sugars lead to cloudy thinking that they are sluggish and, and generally less healthy, and they wouldn't even know it at this point, they don't care. So

Dr. Marwa 53:56
I deal a lot with kids who are taken care of by caregivers. And so a lot of times I tell the parents, please, for the next few weeks, you need to take away all their independence privileges, and you need to be on charge. Not all your life, but give me a week of very solid control, otherwise, your kid will land at the hospital. Right? So I mean, at least I tried to make such an advice very, like very indirect, but at the same time very actionable to say, Hey, listen, it's like they're sick, and they don't understand that they're sick. Like we need to do ABCD you need to follow it as a protocol. And just remember the day you left the hospital, you were calling us every day or every two days, we have to kind of push a hard reset button on diabetes and get it there. Otherwise, I'll have to do this for you in a hospital setting. And so a lot of times, I was able to call, so to speak, press a hard reset on diabetes.

Scott Benner 54:53
How often do you experience someone who has struggled like this, but eventually just breaks it? out of it. Like, do you see them come around eventually?

Dr. Marwa 55:03
Yes, all the time. And this is what makes it very, very fruitful. I mean, I've had people both type one and type two who had very difficult diseases. Sometimes it's just giving them the right tool. And sometimes just listening to them. Sometimes it's empowering them and seen a lot of people who just again, previous endocrinologist would always be like, okay, noncompliant, you stuck in the 10 11% a one sees, but I think I see a nice slow decline, because, like, they feel that they are now empowered to really do this. And they find that, okay, it's not that bad to follow the doctor's advice. I don't have to be defined as a teenager, I, the doctors might say something that's going to help me. And so trying to kind of work with them, and not to kind of be their dictator, kind of like, I'm not mandating you to do this. But hey, why don't we do this and try to make it something that, like, I use a lot of salesperson tactic. Let me put it this way. And I try to not celebrate victories very early, because a lot of times I see a sharp decline, but then things might go south socially, and then I might see a spike back up. So there is no finish line and diabetes is always how can I make it better, so that the following time we can continue? Where we are. So even for my kids who have very good control? My appointments are still very long, because I like them to stay in that range and not really rebound.

Scott Benner 56:26
Yeah, not to feel like, Oh, I did it. Now I can stop doing it. Right, right. How often do you find yourself without hope for somebody?

Dr. Marwa 56:34
I mean, I think when I feel that the person is not connecting with me, I tell them, Listen, maybe I'm not the right fit for you. Maybe you need another endocrinologist. I mean, I can't force people to like me, or I mean, it's just, but if I feel that I cannot partner with someone, when I feel that there are barriers to I mean, I take a lot of no shows people can sometimes not show up to an appointment, it's fine, I'll try to accommodate another time. But if somebody has not seen me for a year and a half, I put a hard stop and say you need to see a doctor or otherwise I cannot keep on being your insulin dispensing machine. So. So that was my heart stop. But otherwise, pretty much I tried to not give up on someone. Because if I do that, I know that knowing my colleagues in the field, I don't know if someone else will be able to provide them the care and just the hand holding that I might be able to provide. But again, I would like to give them the option and eventually to really be able to self manage, so they don't need the doctor. So yes, I have patients that I need to see every two weeks or every week, two patients that I can see every six months, and I had somebody who canceled that six month appointment, and a year later that he was still 6%. So back to my questions like what's the role of a doctor? It's like, yes, we are the educators, we are the coaches, we are the guides, but we are basically the captains of the chef's we need to make sure that things are getting in the right direction.

Scott Benner 58:03
Have you imagined a magic wand fix for problems like this yet? Like is there? Do you look at people and think if I could just make them believe? Do I feel something that this would all go the right way? Like do you know the path and you just can't get them on it, or you're not certain of what the path is at times as well.

Dr. Marwa 58:22
Sometimes not because especially if it's a complex social disease. So say if somebody is struggling with major depression and diabetes, it's very hard for me to fix that without to Central Health help. And I don't have a psychologist or social worker in my office. So I try to be the social worker, even though I'm not a trained social worker, I tried to be the psychologist even though I'm not a psychologist, I tried to not at psychology in a professional setting, but in a way so to speak good heart, somebody who listens to them and try to acknowledge what they're going through and try to at least in a way, be neutral through what they're going through and be a, so to speak diabetes mechanic. My focus here is diabetes and not a mental health professional. Right? My focus here is, hey, yes, you're going through a lot. But can we? What are the things that you can do for your diabetes so that as a diabetes guard, your diabetes is not going out of nowhere? I mean, whether you're having a good day or a bad day, you number should not have a bad day. That's my mantra there. It's like, it's I would like to make a good day for diabetes, no matter what the psychology is. And this is where technology really helps in that regard. If somebody's into that habit into that routine, then the better what life brings good days or bad days, we'll have a good control of their diabetes. So

Scott Benner 59:44
yes, we can see people being like, I guess, emotionally overmatched by how often do you see people who are intellectually overmatched by it and what do you do about that?

Dr. Marwa 59:54
So is it more that they feel that they're defeated by their numbers and diabetes? Since then it's hard for them to kind of predict what's going to happen.

Scott Benner 1:00:03
I mean, I'm saying, Are there people who just IQ wise just can't keep up with what's going on, they can't juggle all the balls and understand the math. Yeah, I've

Dr. Marwa 1:00:12
had a few families. And again, this is where there is no magic wand, you have to take it step by step and focus on one tool and work with it. I mean, we have had a toddler with diabetes recently. And it was a very big shock for them to have to deal with diabetes every day. Initially, I because the kid was not eating solids. So I did not need to teach carb counting initially, I needed to this this, this is how much you're feeding. This is how much insulin you need to give for that amount of milk, because having and then slowly introduced card counting slowly introduced ratios. And so I'm thinking maybe if it's good, I'll put it on a bionic pancreas. Because I don't know if they'll grasp insulin in a toddler. But again, I want them to understand that any device can fail or cannot give insulin, if the numbers are high, we need to do something about it. Unfortunately, this kid is averaging 350. And they're very sensitive to insulin. And if they get insulin, they get very low. So it's a very, very hard balance.

Scott Benner 1:01:19
Well, it's just a terrible thing to have to deal with. For sure. Yeah. Yeah. So my gosh, well, I'm going to put this episode in with my series called Grand Rounds that I've been making this year, where myself and a CDE, who has had type one diabetes for 35 years, we took people's feedback listeners feedback about what they wish their doctors would understand. And we did episodes about that. And now I'm adding on conversations with doctors about how they work in endocrinology. So I can't tell you how grateful I am for you taking the time to do this.

Dr. Marwa 1:01:54
Oh, of course. No, thank you so much for giving me that part in that platform. Because yes, I I heard about the Juicebox Podcast, I think I've listened to one or two a few years ago. But I am very, very grateful to be here today.

Scott Benner 1:02:08
No, I am. I'm very grateful for you taking the time because I'm very interested in this entire dynamic about, you know, different people, different scenarios, different variables, different doctors, and how do we get as many people as possible to lower stable a one sees that allow them to go live their life and not think about diabetes quite so much. You know, if you listen to some people, they'll just say, my doctor socks, and I'm sure some of them do. But I also think that there's I don't want to say culpability, but there's responsibility on both sides. Right. And oftentimes, the doctors don't know when they're falling short. And the patients don't know when they're falling short. And they're very apt to blame each other in that scenario. And I don't think it's that simple.

Dr. Marwa 1:02:55
And this is where I feel that hey, I mean, if it doesn't work out by somebody else, maybe it's not a good fit. I mean, I've had some some of my colleagues who are very, I would say robotic, and the way they approach diabetes, where it's just numbers. I mean, some people just want that kind of doctor, you know, if it's like, make sure that my numbers and my pumps are okay, and I will take care of the rest. And these are typically parents who or families who are already pharmacist or medical professionals or highly educated people. But that's not that does not capture that majority of people who's living with type one diabetes every day. How

Scott Benner 1:03:31
progressive? Are you with other things? Do you aggressively manage people's thyroids for example?

Dr. Marwa 1:03:38
Oh, yes, absolutely. Yeah. I mean, I think once I have a problem I try. It's all in our lap. That's, that's my style. You

Scott Benner 1:03:46
medicate symptoms? Not numbers? Pretty

Dr. Marwa 1:03:48
much. Yes. I, I take numbers into context for sure. Sure. And of course, our numbers. I mean, if numbers don't make sense, or if I feel that medication, won't really hell, then I

Scott Benner 1:04:01
use it just to use I'm not going to use it right. But if you're symptomatic and you have a three TSH, then you're getting Synthroid, for example,

Dr. Marwa 1:04:07
I don't think so. No, I think at least a higher number. So depending on what we, again, I try to be logical and try to see hey, I'm I always tell my families I'm like a hormone judge. Is the thyroid guilty or not guilty? Is the pancreas guilty or not guilty? And then I have to kind of give back whatever hormones the body's missing.

Scott Benner 1:04:31
Once you're confident that it's thyroid, what are your TSH goals?

Dr. Marwa 1:04:36
Oh, just in the target goal. So say if it's if it's in the reference range for a lab, then I'll take it but of course, if somebody is symptomatic and there is room to increase the dose, I don't mind giving up on the deals and give a keeping a trial and error. But I mean, typically teaching is TSH of 10 or higher is what you treat. If somebody who's not known to have died disease. However, I've had someone that I treated as seven or eight because they had some symptoms. And I thought, You know what, it's very plausible that those symptoms might be contributing. Let's give it a try. It kind of helped the symptoms, the constipation, but it now made the kids now irritable. So I'm not sure what tease apart. So I think it's not, it's not a straightforward trade line of thinking. It's more of it's a tool. I mean, medications hormones are out, there are tools for us. And if we could utilize them to really improve someone's health,

Scott Benner 1:05:35
then do so yeah. Yeah,

Dr. Marwa 1:05:37
let's let's do it. Yeah.

Scott Benner 1:05:38
Can I ask you, when you do blood work for people? Do you look at their iron ferritin levels, things like that? Not

Dr. Marwa 1:05:44
typically, for type one, unless if someone has specific like symptoms, or they have anemia, I would okay, but not my typical screening, I typically follow the ADA screening guidelines to the book from that regard.

Scott Benner 1:05:57
I asked, and I wonder because I feel like I see a lot of people with digestion, and then absorption issues. So once you have like, type one, or autoimmune, you can see poor digestion. And a lot of people like you must have kids or like my stomach always heard stuff like that. And then, you know, we've been having a lot of conversations on the podcast, people using different aids like digestive enzymes and things like that, that have been taking away a lot of that pain, where their endocrinologist will sometimes tell them, Well, you just you have gastroparesis. And it turns out that maybe they've just needed some help with the digestion process. And when that digestion gets messed up, oftentimes nutrition uptake gets messed up along with it. And then I'm seeing a lot of people with low ferritin issues, who have type one, I see a lot of different interesting connections, having so many conversations, I have over 1200 episodes that I've recorded over the years, and for instance, to talk to people and say, you know, hey, you know, what other autoimmune do you have in your family? And as I'm asking them, I'll always say, How about bipolar? Do you see a lot of bipolar? And you'd be surprised how many people have a bipolar relative, when there's autoimmune or type one in their family? Little stuff you would never see connection to if you didn't have the opportunity to ask so many different people. Right?

Dr. Marwa 1:07:17
So no, I mean, very, very grateful for all those things. Again, this is kind of I think, this is how science, this is what sparked science and scientific research is like, Okay, you, you look at a connection. And then we kind of put it to the test with a with a scientific research question. And I think there's a lot to be understood, there's a lot we need to learn about what causes type one diabetes, what might be a link with other digestive or autoimmune disorders, and I'm sure there are a lot of unanswered questions that will continue learning. I mean, we already have achieved a lot, but there's still a lot to learn about diabetes. And what's happening. I'm excited

Scott Benner 1:07:55
that people like you were involved. Can I ask a question? Of course, what do you think? Or have you thought about where we're going to see GLP medication to use with type ones in the future?

Dr. Marwa 1:08:07
So I am a very aggressive users of GLP. And type one, probably more than my other colleagues in the field. I feel that if someone has signs of insulin resistance and their insulin daily requirements are much higher, and there is their family history of type two diabetes, I think they have two diseases, they have both type one and type two diabetes for the same person. I have specially for my kids who have type one diabetes and who are overweight and who needs for example, 150 units a day, should I just give you more insulin? Yes, I need to give you more insulin. But I always ask myself, why do you need 150 units a day? And these are the kids who end up typically getting a GLP one prescription along with their insulin type one treatment therapies. So in terms of I think, the question about a GLP. One for people who don't fit this umbrella for people who were type one, they're not overweight, there is no family history of type two, can we give a low dose of GLP? One to kind of hell, just with some endocrine function. I have brought it up with one or two patients who had like who were in honeymoon and they wanted to think about hey, can we prolong honeymoon this way? I'm not sure if you're aware, but the New England Journal of medicines submitted, there was a research that was published. For small clinical study only 12 participants who had longer honeymoon longer see peptide if they took a small dose of semaglutide much slower even the dose that I would start somebody with type two. So for type one, can I give them a small dose of a GLP one agonists to kind of help preserve some pancreatic function, especially if they're in that honeymoon phase. I Think this is a question for science to answer in a few years, I feel that I look up GLP, one agonist as in a ways, getting the effects of exercise into the blood sugar level, but without actually exercising, it's nice how their insulin requirements would come down. And insulin, diabetes will be an easier disease to manage with those medications, plus also the impact of the effects of appetite and lowering the appetite, it might also impact and improve those, those glucose levels.

Scott Benner 1:10:34
The study you you spoke about Do you happen to know was periactin Dona involved in that one? Let me pull it up really quickly, because I'm about to have him on the show. And I've had a mother of a like a 13 year old child, who's had type one for three years more using 70 units a day, but with a background of the family of PCOS. And they gave the child we go V, and they're down to seven units a day, and they're not even shooting Bolus insulin anymore. Yeah,

Dr. Marwa 1:11:08
I think there is a lot of potential. I think we are going out. I think the biggest barrier for me prescribing it off label a lot is insurance. Take comments. But for example, I think if somebody is overweight, and using a lot of insulin units a day, I have been able to convince insurance to to start them,

Scott Benner 1:11:31
have you. Yeah, that's amazing if you're able to get type ones covered, because I'm right now, my daughter has PCOS, and type one. And I'm having to buy ozempic out of Canada just to give her a non therapeutic dose. And you should see how much it's helping her. It's significant her, her insulin sensitivity went from one unit moves her 43 to one unit moves at 93.

Dr. Marwa 1:11:55
Wow. So yes, this doctor didn't didn't Donna, and Donna and Dr. Choudry.

Scott Benner 1:12:01
Yeah, I'm in contact with him right now setting up having him on the show. Wonderful. Yeah, no, I'm excited.

Dr. Marwa 1:12:07
So I think my trick there, I would mention that this is an element of type two diabetes, and I make it that this is, yes, we have a background of type one. But please look at the data, it is suggestive of type two in the intermix of the picture like this is this is part of what we're seeing right now, really. And so I was able to get insurance buy in and a lot of and once I get approval, it's very hard that they come back and deny it again. After that,

Scott Benner 1:12:36
I have to ask you if, if you have any tips and tricks for that, if you'd email them to me, I'd like to share them with my daughter's endocrinologist. Of course, yes,

Dr. Marwa 1:12:44
I think it's with insurance. It's always a game. That's another side of what we have to do behind the scenes to try to make sure that we can write the right things to convince insurance for what we are doing is really sound and really medically reasonable and makes sense. I think

Scott Benner 1:13:01
there's gonna be a lot of application for it. I really do. And there's other stuff coming too, right? Isn't one of the companies is working on a daily pill instead of a weekly injection? I think there's a lot, right, I have to tell you, I don't have type one. But my daughter does. And I've been using a GLP for a year now. And I would tell you that I lost I've lost 50 pounds in a year. But I was never a poor eater or, or a person who wasn't moving. And if I had one way to characterize what I think is happening to me, it feels like I have a GLP deficiency. Because in the first four days on point two, five of weego V i lost four pounds, my digestion changed like everything. I was a person who would have to get iron infusions all the time, because I wasn't absorbing my nutrients. But now I've been on a GLP for a year, my ferritin levels 188 When it was just tested, I haven't had an infusion in like 18 months.

Dr. Marwa 1:14:02
Wonderful. That's great to hear that crazy. Yeah, it's it's amazing again, how those new medications are out there. I mean, we did not speak about type two, but I also treat our adolescent type two diabetes in my clinic. And we I mean, we see it very, very commonly, much more commonly than when I started like, six, seven years ago, we're seeing an app spike in type two diabetes, right? I think when doctors three type two is type one, this is the wrong thing, because we keep giving them more insulin and we kind of playing catch 22. And so I tried to get them out of the insulin cycle by prescribing a GLP one agonist for a lot of my kids, especially now that we have a pediatric indication for three GLP one agonists and I'm sure that more will have more choices for pediatrics as well. As we progress, yeah,

Scott Benner 1:15:00
they're working on it. And a lot of them even for pregnancy, they're looking at it now like to be able to keep people it's Listen, my brother, I'm adopted, so not by blood, but my brother is type two. And I've seen I talked him into pushing for a GLP. And his a once he went from the sevens into the fives, yeah. So,

Dr. Marwa 1:15:22
and these are people who've had it for four years. So why so even though my training is in pediatric one that was all just pediatric endocrinology. I'm now a board certified in advanced diabetes management, meaning I can still take care of adults or diabetes across the lifespan. So I face it sometimes I do help some parents with their own diabetes when they ask me questions about diabetes. And so there was that that girl who came to see me again, PCOS, insulin resistance type two and severe obesity, the mother had the same problems. But somebody told the mother that she had type one diabetes after she had gestational diabetes, because she she was very hyperglycemic. And this mother to think was under the care of her endocrinologist for, again, more than a decade treated as a type one. But I was I counseled her, even though I at that point, it was a very brief interaction. I strongly suggested that she presses for GLP one, and she went down from dealing 150 units from Protandim to down to like 20 units a day for tandem. That's wonderful,

Scott Benner 1:16:34
isn't it? No. Hey, you're a little go getter. Dr. Morrow, I see all the letters after your name, by the way here. Sorry, I see you out there hustling?

Dr. Marwa 1:16:43
I enjoy taking exams, I don't mind them. Well, I think

Scott Benner 1:16:48
your letters are going to be in a different line if you get a couple more of them. So it's probably

Dr. Marwa 1:16:54
I mean, again, so I get all those emails like hey, come certifies like yeah, you know what, why not? I'll get back now that I think it makes me a better doctor or worse doctor, but I think it just it's nice to have show that hey, I to learn to learn, of course, and also to be able to present that Yes. Now, I'm not just an endocrinologist, I also do care about this disease.

Scott Benner 1:17:14
Yeah. No, I love your energy around this. I really do think I appreciate this very much. I might have to ask you to come back on again. One day. This was wonderful.

Dr. Marwa 1:17:21
Thank you so much. I will probably be moving to Saudi Arabia. Oh, okay. We'll be probably like this summer. So my contract here in Baltimore is terminated like is ending. And so I might be coming closer to family that might be the next personal big news. But of course where I am, wherever I am, I'll have access to zoom. I'll be in touch.

Scott Benner 1:17:42
Well, listen, they need it to you. I have a number of people in my Instagram, DMS from that part of the world and they're struggling pretty mightily to understand their diabetes as well. Right. So your help will definitely be valuable anywhere you go.

Dr. Marwa 1:17:57
Well, thank you so much. I appreciate it. And again, that's that's that's really again, and this is what makes being a doctor really fulfilling you know, it's like you're able to impact lives and try to kind of make try to help improve people's lives.

Scott Benner 1:18:10
Well, I hope other doctors heard you and they can. I hope they try to match your enthusiasm. That I guess that's what I hope that's really fantastic. Thank you so much.

Dr. Marwa 1:18:19
Thank you so much. Thank you, thank you.

Scott Benner 1:18:28
If you're a physician and you'd like to be on the Grand Rounds series, please send me an email through juicebox podcast.com. I want to thank the ever since CGM for sponsoring this episode of The Juicebox Podcast. Learn more about its implantable sensor, smart transmitter and terrific mobile application at ever since cgm.com/juicebox. Get the only implantable sensor for long term wear. Get ever since having an easy to use and accurate blood glucose meter is just one click away. Contour next one.com/juicebox That's right Today's episode is sponsored by the contour next gen blood glucose meter. A huge thank you to one of today's sponsors G voc glucagon find out more about Chivo Capo pen at G Vogue glucagon.com Ford slash juicebox you spell that GVOKEGLUC AG o n.com. Forward slash juicebox. The Juicebox Podcast is full of so many series that you want and need afterdark s gotten Jenny algorithm pumping bold beginnings defining diabetes defining thyroid, the diabetes Pro Tip series for type one diabetes variable series mental wellness type two diabetes protip how we eat oh my goodness, there's so much at juicebox podcast.com head up into that menu and pick around. And if you're in the private Facebook group, just go to the feature tab for lists upon lists of all of the series. always free. Always helpful. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com