#1277 Grand Rounds: Dr. Tarlow

Dr. Stephanie Tarlow is a type 1 and an endocrinologist. 

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

Scott Benner 0:00
Hello friends and welcome to Episode 1277 of the juicebox podcast.

Stephanie is a 33 year old type one who happens to be an endocrinologist, and she's here today to add to the Grand Rounds series. Nothing you hear on the juicebox podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your healthcare plan. When you place your first order for ag one, with my link, you'll get five free travel packs and a free year supply of vitamin D drink. Ag one.com/juicebox. 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 juicebox at checkout. That's juicebox at checkout to save 40% at cozy earth.com and if you are a type one, or you're the caregiver of a type one and you're a US resident, I need you to go to T 1d exchange.org/juice, box and complete the survey. Completing the survey helps type one diabetes research to move forward. It may help you. You'll find out more about that after you complete the survey, and it's definitely going to help me. T 1d exchange.org/juice, box should take you about 10 minutes.

This episode of The juicebox podcast is sponsored by touched by type one, touched by type one.org and find them on Facebook and Instagram. Touched by type one is an organization dedicated to helping people living with type one diabetes, and they have so many different programs that are doing just that. Check them out at touched by type one.org this episode of The juicebox podcast is sponsored by the Dexcom g7 made for all types of diabetes. Dexcom g7 can be used to manage type one, type two and gestational diabetes. You're going to see the speed, direction and number of your blood sugar right on your receiver or smartphone device. Dexcom.com/juicebox, today's episode is sponsored by Medtronic diabetes, a company that's bringing people together to redefine what it means to live with diabetes. Later in this episode, I'll be speaking with Jalen. He was diagnosed with type one diabetes at 14. He's 29 now he's going to tell you a little bit about his story. To hear more stories with Medtronic champions, go to Medtronic diabetes.com/juicebox. Or search the hashtag Medtronic champion on your favorite social media platform.

Dr. Tarlow 2:47
Hi, juicebox. I am Stephanie tarlow. I'm a physician assistant that specializes in endocrinology and specifically diabetes at OHSU in Portland, Oregon.

Scott Benner 2:59
Do you have diabetes yourself?

Dr. Tarlow 3:02
I do. I've had type one diabetes since I was 12 years old. So this year makes that 20 years. Oh, you're 32 okay, I'm 33 very soon. Oh, happy

Scott Benner 3:14
birthday in July, perhaps Thank you. When my birthday is June, 27 Oh, well, then really, happy birthday.

Dr. Tarlow 3:20
Thank you. Birthday month.

Scott Benner 3:23
Yeah, do you do like a whole thing? No,

Dr. Tarlow 3:25
we typically go out to Eastern Oregon on this little lake for the weekend, which is nice, very

Scott Benner 3:30
nice. Well, I hope you enjoy it. Thank you. I'm gonna find out a little bit about your diabetes first. So 20 years ago, pretty long time ago, actually, Arden is, hold on. Arden's 20 this year she was diagnosed.

Dr. Tarlow 3:44
We were diagnosed the same year, from what I could tell, 2004

Scott Benner 3:48
is that right? Arden's born 2004 diagnosed, 2006

Dr. Tarlow 3:53
got it, yeah, I was diagnosed in 2004 Okay, you

Scott Benner 3:55
got two years on her. So you're winning some sort of thing that I don't think comes with an award, but so, so management back then, I'm very, very familiar with, did you get a pump at any reasonable distance after your diagnosis? No,

Dr. Tarlow 4:10
I was very against the pump and anything on my body. For that matter, I started out with the mph and regular insulin mix syringes for like, the first year. And then I remember going back a year later to have more education and learn about like carb counting in terms of, like, using ratios and varying the carbs per meal with pens. And that was like the biggest game changer, rather than having I remember my parents getting like, low carb ice cream. And I was so devastated, thinking, this is my life. But, you know, there's so much more flexibility with not fixing carbs per meal. That

Scott Benner 4:49
was it. It was just the ice cream. It said low carb on and you're like, oh yeah.

Dr. Tarlow 4:54
It was so sad. I just remember my grandma made everyone like parfaits, and mine was sugar free chocolate. But soft and stuff. I was like, God, this is so sad.

Scott Benner 5:03
You're old enough to feel it too at 12, huh? Yeah,

Dr. Tarlow 5:07
I was very much a kid that, like, would come home from school and grab a sprite, or, like, have a Costco poppy seed muffin. And so that first year was really hard, because I think I was having, like, 45 grams was the amount I was eating for breakfast, lunch and dinner, and so, yeah, that was pretty restrictive. And then it took me a very long time to give myself a shot by myself. Like the nurses in the hospital were incredible. Usually, they make you give it, you know, try to make you give it yourself by the time you leave at 12. And I was just not having it. So it took me until my parents went out of town, and I did not want my friend's mom to come over and give me the shot that I just was like, I'll do it myself finally. But it would be times where we'd be sitting down and I'd be like, Okay, I'm counting to three, and then I just say one, two, and then, like, 30 minutes would go by. And if my dad ever did it before, too, I would just cry and cry and cry. So yeah, I had a really hard time with the needles. Interesting, so I definitely empathize with my patients when they have those needle phobias. How

Scott Benner 6:13
old were you when you finally did it yourself? When that neighbor was the only other answer?

Dr. Tarlow 6:20
I was probably 13 and a half or 14 couple

Scott Benner 6:24
years. You made it a couple years? Yeah, I um, it's interesting. First of all, it's crazy that you got NPH and regular in America 20 years ago. We might bring that up again, but Arden, similar situation like Arden, got a lot of needles, obviously, in the first handful of years, no one even talked to us about a pump. For years, they never even brought it up. I didn't even know to ask about it, and so she probably had. I remember doing the math back then, we probably stuck her 10,000 times between needles and finger sticks, wow, before she got a pump when she was like four and a half, so, like, in the first two years or so, but she was really young, and I've told this story before, but like, you know, there's once in a while you're like, I think this pump site is bad. Like, I'm going to inject to like, you know, like, see, and even that stopped happening because we were just on a really good roll with OmniPod for a long time. And then one day I was like, Hey, we're gonna have to inject. And when I She's like, okay, like, she like, just was like, Okay. And then I got out the syringe, and she kind of coiled recoil, and she goes, what is that? And she wasn't being like, funny. She was like, what is that? I was like, it's a needle to put in the insulin. She's like, whoa, whoa, whoa. And then then it was crazy, because I was like, Oh my God, you don't remember the 1000s of these that you've had. Like, that's crazy, you know? And, but she didn't, and that's

Dr. Tarlow 7:46
super interesting, actually, yeah, yeah. I mean, it makes sense. Like, I think there's a lot of times too, like, nowadays I think we get kids on Dexcom so quick, like, they don't remember that small little period of finger sticking,

Scott Benner 7:58
no, I agree. And then when you go to do it even now, like, I'm like, alright, and check your blood sugar. And she's like, and she's like, Wait a minute. Like, I got the Why am I wearing this thing? And I was like, so but anyway, like, it happened so infrequently that we didn't realize for a long time, like, Arden had a pretty significant needle phobia, and it didn't rear its head until an A 1c check one time. Oh yeah, where she basically, like, spider monkeyed up the corner of a wall in the room when the when the phlebotomist came in and, like, flipped out, and I had to take her out of the room and, like, calm her down and everything. And now she's got this crazy, and I mean crazy in the sense of the word crazy that you're thinking of, like, when she gets her blood drawn, she stares at the needle. Oh, wow, oh my god. And look away. She goes, I need to see it.

Dr. Tarlow 8:46
Okay. Whatever worked. Yeah,

Scott Benner 8:48
yeah. But so anyway, one time before she left for college a couple years ago, I said you are gonna have to give yourself an injection before you leave, because if it comes up at school, we can't be doing this thing that you just described, by the way, by the way, do you prefer Stephanie or Steph,

Dr. Tarlow 9:04
either way, Steph is what most people call me. Okay, so

Scott Benner 9:08
Steph, the thing you just described, Arden, took a syringe with insulin into the bathroom at our house, and she came back about 45 minutes later, and she's like, sweaty and disheveled, and she's like, I did it. And we were like, Uh oh, I didn't know it was this bad. You know what I mean? Yeah, oh yeah. You know what? Actually ended up breaking it for what she started using a GLP, ah, that's cool. She has to do an injection once a week, and she's getting better and better at it all the time. So which one,

Dr. Tarlow 9:42
I might ask, because some of them have, like, the auto inject, which is a pretty cool feature.

Scott Benner 9:46
So she is using Manjaro now. Okay, that one's like, cap off, unlock, push button. She had a little more trouble with ozempic. Mm. Because it's like, it's push, like, it's a collapse of, like, how does it work? It works like the Jibo kypo pen, like, you have to push it into, like, click on epi pen, vibe, right? And that one is interesting. Like, something between the button and the pushing was really it was just crazy how much she struggled with it, but it was helping her, and is helping her so much with her blood sugars that even she's like, geez, I gotta use this, you know. So, yeah,

Dr. Tarlow 10:28
it's pretty awesome.

Scott Benner 10:30
Do you have people using it in the practice? This episode is sponsored by Medtronic diabetes. Medtronic diabetes.com/juicebox and now we're going to hear from Medtronic champion Jalen.

Speaker 2 10:43
I was going straight into high school, so it was a summer. Heading into high school.

Scott Benner 10:46
Was that particularly difficult?

Speaker 2 10:48
Unimaginable. You know, I missed my entire summer, so I went to I was going to a brand new school. I was around a bunch of new people that I had not been going to school with. So it was hard trying to balance that while also explaining to people what type one diabetes was. My hometown did not have an endocrinologist, so I was traveling over an hour to the nearest endocrinologist for children. So you know, outside of that, I didn't have any type of support in my hometown.

Scott Benner 11:16
Did you try to explain to people, or did you find it easier just to stay private.

Speaker 2 11:21
I honestly, I just held back. I didn't really like talking about it. It was just it felt like it was just a repeating record where I was saying things and people weren't understanding it, and I also was still in the process of learning it, so I just kept it to myself. Didn't really talk about it. Did

Scott Benner 11:36
you eventually find people in real life that you could confide in?

Speaker 2 11:39
I 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 live with type one diabetes?

Scott Benner 12:01
Medtronic diabetes.com/juicebox to hear more stories from the Medtronic champion community. Dexcom g7 offers an easier way to manage diabetes without finger sticks. It is a simple CGM system that delivers real time glucose numbers to your smartphone your smart watch, and it effortlessly allows you to see your glucose levels and where they're headed. My daughter is wearing a Dexcom g7 right now, and I can't recommend it enough, whether you have commercial insurance, Medicare coverage or no CGM coverage at all, Dexcom can help you. Go to my link, dexcom.com/juicebox, and look for that button that says, Get a free benefits check that'll get you going with Dexcom when you're there, check out the Dexcom clarity app or the follow. Did you know that people can follow your Dexcom up to 10 people can follow you. Right now, I'm following my daughter, but my wife is also following her. Her roommates at school are following her, so I guess Arden is being followed right now by five people who are concerned for her health and welfare. And you can do the same thing, school nurses, your neighbor, people in your family, everyone can have access to that information if you want them to have it, or if you're an adult and you don't want anyone to know, you don't have to share with anybody. It's completely up to you, dexcom.com/juicebox, links in the show notes. Links at juicebox podcast.com, and when you use my link to learn about Dexcom, you're supporting the podcast.

Dr. Tarlow 13:34
I do. I use it off label. Actually, I don't know how I was able to get it covered, but for one of my type ones, I was able to get the GLP one in the form of the pill covered, and it just works wonders for their blood sugar. But a lot of times I struggle with insurance. We see a lot of patients on like the Oregon Health Plan, and that coverage is pretty hard to get.

Scott Benner 13:55
What I'm hearing from doctors is this very kind of medically sound like this person I'm dealing with has type one diabetes, but they also have insulin resistance. Oh, for sure. And if they didn't have type one, they very well might be type two. I you know, I don't know. And but what I'm seeing here is that a person without like insulin resistance, who has type one diabetes, is using significantly less insulin than this person is, and I think a GLP would help them. So they're doing a they're they're sending dual diagnoses into insurance. They're like, look, they're type one and they're type two. I don't care what you guys call it on the computer, that's what I'm doctoring over here. These two problems. Yeah. I

Dr. Tarlow 14:38
mean, that's great idea, yeah. Yeah. And

Scott Benner 14:41
they're starting, some people are starting to see it get covered that way. Okay,

Dr. Tarlow 14:45
yeah, that's great to know. Because, I mean, yeah, when I have patients who come in with a car ratio of one to two, you know, that's clearly insulin resistance. That's and that hurts too. It's not like that's and so for those patients who, if they're on a pot. Pump. They're changing their pump every day, and all very much off label use like a u2 100 insulin, if I have to. Yeah, but still, I think adding something like a GLP one would be awesome. And I know they're doing quite a bit of studies right now, like through T 1d, exchange and stuff to get, like, patients on GLP ones with type one. And hopefully we'll get some sort of approval for that too, to make it easier.

Scott Benner 15:24
Yeah, I think I'm supposed to help soon with the T 1d exchange to find people for that study. So I'm excited about it, because I've been doing a lot of interviews. Actually, I have one going up probably next week with this guy, 58 years old, type one, since he was 50, definitely type one, like auto antibodies, like, you know, the whole thing using insulin for ever. Probably had Lada for the first handful of years, but then his insulin needs went up for a couple of years. He started Manjaro, and literally, is not using insulin at all anymore.

Dr. Tarlow 15:56
Wow, that's pretty incredible. Insane.

Scott Benner 15:59
It's insane. I I've interviewed a 15 year old daughter, the mother of a 15 year old girl who's down to like, four units of basal, and that's it.

Dr. Tarlow 16:07
Yeah, I have actually a patient. She's probably like, 12 or 14, and she's on two units of long acting, and we tried to increase her to three, and it was too much. And that's just so interesting. And the and her carb ratios and correction are, like, pretty average for her age, but we just cannot go up on the long acting

Scott Benner 16:26
because of a GLP or just in general. Oh, just in general. But

Dr. Tarlow 16:30
I think that's so weird. People's different insulin requirements, but yeah, no, that makes sense with the GLP, one needing way less. And I try to get that too sometimes for patients with metformin, but it just doesn't have the same

Scott Benner 16:40
effect. Yeah, Metformin is nice, but it's not going to do this. What this stuff is doing? No,

Dr. Tarlow 16:45
it sometimes decreases long, acting a little bit, but nothing to the extent that the GLP ones do.

Scott Benner 16:51
So for a number of years, Arden Zendo, who manages her diabetes now, was her endo for her thyroid when she was still a juvenile. And she kept talking. She kept talking. So the way we did it was chop, oh, I've never said Arden's Hospital in here before. Oh, well, who cares? It's over now. Chop was managing Arden's diabetes. Listen, they're great, but I was managing ardent diabetes, but I noticed that their deafness, for for thyroid, wasn't what I wanted it to be. So we found a concierge doctor to handle art and thyroid B and she also handles my daughter, my wife's and my son's thyroid issues. Right? When Arden reached 18, and chop was like, Get out of here. They said, it nicer. But, you know, I went to this endo and I said, Look, I know you don't take new patients and you don't do diabetes, really. I was like, but would you, you know, would you manage Arden's type one for me, please? She's really nice. And she said, yeah, absolutely. And then she started, you know, she's like, you know, we've been talking for years about Arden taking Metformin, because Arden's insulin to car break show was one to four or one to four and a half, she was starting to have, like, really, like, bad acne that we couldn't get rid of, you know, and then stomach issues and stuff, and heavy periods, stuff that really looked like PCOS, like, that whole thing. And she's like, let's try the Metformin. And we kind of, I almost said dicked around, but you're like, a professional, so I didn't say it, but then I said it anyway, yeah, but we dicked around for a little while with it, because you're like, I don't know. I don't know. And then once she got her as a as an adult, she's like, Scott, let's give her a GLP and see what happens. That's awesome. And I was, I was like, Cool, all right, so holy crap. Stephanie, like Arden's insulin to carb ratio now is like one to 10. Wow. And and her insulin sensitivity went from 42 to like, 65 that's impressive. Yeah, her basal went from 1.2 during the day to point 8.85, and she's using Iaps. So there are times of day when these settings are even lower or sometimes more aggressive, like, you know what I mean. And more importantly, like, we never thought of her as having weight to lose, but she lost weight and she doesn't, and she looks healthy now. It's not like, we're like, oh god, she's looks thin, like, you know what I mean? Like, she she had, she had lost a little too much. We adjusted her GLP dose, and it's moving the other direction now. But her diabetes is incredibly, incredibly stable, and even if she, like, flat out, just doesn't bolus for a meal until the last second. We're seeing, like, 180s that come back, like, in an hour or so and level out.

Dr. Tarlow 19:33
Wow. Really something. I love that. Yeah, that is beautiful, fantastic. So

Scott Benner 19:37
anyway, I didn't mean to talk about all that I was I have you on here to say I'd like you to be part of the Grand Rounds series, and all I want to hear from you is what works for people with type one diabetes. What are some of the problems you see clinically, or anything really that you want to share that you think benefits doctors listening and patients who are listening? Mm. That's

Dr. Tarlow 20:00
a great question. Yeah, I think what works is trying to find especially so I've worked, I worked with adults for five years before and at Sutter Health in San Francisco, before moving back to Portland, where I'm from, and doing peds. And, you know, I think the biggest thing, especially in that young adult population and then the teen population is really finding a way to figure out what the barriers to care are and connecting with the patient to address those and make them real. Because I think you know, for every single person, diabetes looks so different for someone they might love having lower blood sugars and run themselves in the 60s because they do not want to hide they're terrified of highs. And then the opposite is a patient who's running themselves so high because they're terrified of lows. And so maybe they're not just missing their insulin because they forget. So really trying to, like, understand the reasoning behind I do feel like I have a little advantage, like, when I see a patient's Dexcom or pump report, I can kind of tell what's going on before I walk into the room. And I think a lot of times too in the in these peds kit population, like, you know, you're with parents, and the kid does not want to get in trouble for not doing what they're supposed to. So there's a lot of maybe lying, of yes, I'm taking my insulin, and it's like, you're not. And so I really love, especially on being able to, like, go through, I think, like looking at the pump reports together to show like, well, this day there was only one bolus, and this day you didn't enter your carbs one time. Like, are you not eating all day? And really, really trying to, like, okay, yeah, I guess I realized, like I wasn't doing that the whole time. And I think the biggest thing I try to enforce is like, they're never in trouble. I just have to know what they're doing to adjust in the best way for them if they tell me they're always taking their insulin and they're on shock so I can't tell, and then I end up adjusting their doses. Then they're going to go low all the time, and then they're going to be afraid to take their insulin, so they're not going to do it. So I really think coming to terms with like taking it patient by patient, I don't think there's a one size fits all for every patient, and really, like bonding with the patient and and their family, to develop that trust so that they're willing to tell you, like, what's actually going on in life and with diabetes is like, the most important thing that you could possibly do. I like to, like, let the families know that I have diabetes, so that I think, like the patient understanding that, like, you know, when I was a kid, I used to get in trouble at my endocrinologist with my parents for only checking, you know, two to three times a day. Like, that's a real thing, and it's okay, and you will be fine. But the more you check, or, like, you know, to convince them to wear a Dexcom so they don't even have to worry about that, I think that's all, like, really important for them to see that, like, it's okay to have these problems, and you will get over them and it will be okay. I was

Scott Benner 23:06
really interested, because when I started making this series with Jenny, I could tell, from her perspective, that the most important thing is communication. And she kept saying, like, if you know, if you're the physician, if you're the assistant, if you are you need to understand the person in front of you and their specific situation and not judge them just based on your idea of how this should go. I feel like that's what you're saying. I feel like you're saying, If I don't know these people, if I don't know what's happening or why it's happening, then how do I help them? How do they do better? Right? So, how do you accomplish that, though? Like, how do you get to know them and figure out, is it questions you ask, is it over time? Like,

Dr. Tarlow 23:49
how does that all work? I think it's a mix of both. Like, when I'm first meeting a patient, you know, I let them know. A lot of times I'll be like, Oh, do you wear a Dexcom, or are you wearing a pump? And they'll be like, you know, yes or no. And I'm like, Oh, I wear the Dexcom, and they're not on a pump yet, you know, I'll, I'll say, Yeah, I didn't want to pump for the longest time. But, you know, now, with this technology out there, it's so good. Would you be willing to just like, hear somebody out about it and really just try to, like, level with them that I had that very similar experience, and I'm and I'm on their side, like, I just want what's best for them, and I don't like to use, you know, scare tactics or anything like that. I also think letting the patient talk so, like, I like to find out, you know, what do you feel you're doing well with your diabetes, and what do you think you could do better? And why do you think you're having trouble with this? And like having those open ended conversations, rather than just saying you're a 1c, is too high, you're missing insulin. Adjust your dose, see you next month, or, you know, in three months. I don't think that works. I think making those conversations and I. And letting them know, like, diabetes is a moving target. So I think a 1c is really especially in our society, like associated with a grade, and if you get an A 1c that's high, then you're failing. And I think that's totally wrong. First of all, I prefer time and range anyways. But if you look at a Dexcom report, it's basically a game. We're trying to maximize your time and range, and the best way to do that is to take your insulin and and so like, letting them really see like and going through the report like, look what happens when you take your insulin before you eat, that spike is so much reduced, versus if you take your insulin 1530 minutes into the meal, look at how high you spike. Or if you didn't take your insulin at all and then didn't correct, look at that, you know, like really trying to show them how diabetes works. I think too, like these kids are smart, they're having to act as adults at, you know, whatever age they're diagnosed, they're getting this crazy diagnosis that I think for it's really impossible for anyone to manage on their own, but just letting them know, like, even if they're doing a little bit, they're still doing a great job, but just, you know, pushing them to do more, and really just being on their team, I think developing that trust is what's so huge.

Scott Benner 26:17
Did you have trouble as a kid?

Dr. Tarlow 26:21
I didn't really, I just had, like, a great I think community is, like, so important, and it always breaks my heart a little bit when kids are embarrassed of their diabetes, because no one actually cares. Like, and I think in the way you phrase it too, like people think it's really interesting and cool. And so I was really lucky when I was first diagnosed, a family friend made a diabetes team for me with neon pink shirts. And that was the very beginning of my JDRF walks, which I've done for 20 years with, like, neon shirts, neon green, neon blue. We get the whole school involved. Like it was a big fun yearly event everyone looked forward to. And I think having that community, you know, I was never embarrassed of my diabetes. My friends were amazing with my diabetes, looking out for me, like at basketball tournaments and things like that. And then my parents would nag me to test my blood, and I would always, you know, get in a little bit of trouble when I wouldn't check a lot at the appointment, but my ANCs, I'm a perfectionist, very type A in terms of my management, and, you know, that kind of like the way I was with school work, it kind of just transferred into how I was with my diabetes care. So in that regard, I'm really lucky, like, I also think at 12, there's like, an advantage of being diagnosed at that age, because it's still kind of fresh. So and you, you're a little bit older, so you kind of have a advantage of possibly missing that burnout. So I never really experienced the burnout. Okay, that was helpful, yeah,

Scott Benner 27:53
was your mom helpful with that? Like, wrapping that amazing the community around you kind of feeling,

Dr. Tarlow 27:59
yeah, my parents are my biggest supports and and my sister and my grandparents, like, they just, you know, really connected me and to who I needed to be with, like my sister. She knew someone at the high school who was, like, this football player and like, you know, he's had diabetes for how many, however many years, and he did shock and he came, she had him connect with me and, like, come to my house when I was first diagnosed, and just talk with me. And I remember, like, you know, he was a senior in high school, and I remember calling him, and he was at the beach with his friends to tell him, I get my first injection. And he was like, so proud of me to not meant the world. Yeah, what

Scott Benner 28:41
do you do, though, if somebody comes in the office, they don't have that around them. They like, what if they live somewhere where people are not as kind and, you know, they don't have a mom or a dad who are going to help them, like, open it up, like, you know, they they can still benefit from just having a, I think, just a few friends who are, like, tight and on their side. But, you know, you know what I mean? Like, it's easy to say, like, go out there, but like, I'm not, I'm obviously, I'm not coming down on you, but obviously the place you went out into was like, oh my god, Stephanie's here. Like, what happens if you go out and people are like, we don't care. Leave us alone. You know what I mean?

Dr. Tarlow 29:15
Yeah, I think in, you know, I didn't notice it as much an adult, but when I I was really fortunate growing up. I had a great childhood, and I didn't realize until coming back to work in peds, how not every family is able to give that to their kids. And it was, you know, it's sometimes really hard to see and it's really challenging to work with. At OHSU, we have an incredible program called niche that works with interventionists that are able to actually like, go to patients houses and interact with them. They'll like, pick them up and take them to the gym. They'll text them. So we really try to get the patients who are struggling or have frequent DKA episodes connected with a niche interventionist. I think that's one of the most amazing things about OHSU. And, you know, not. Everyone has that then. So I really try to give resources of, you know, social media is big. I really like beyond type one. I think that's a great connection for people. It's like a social media for people with diabetes. And so I try to connect them with that. And then, you know, I also just talk to my patients, like, what's embarrassing you about your diabetes? Like, what's the worst thing that's gonna happen if someone sees you take a shot, or someone sees a pump on your body? Yeah, so just trying to reason with them. But you know, I do think there's some huge disadvantage that we haven't figured out, a breakthrough where, you know, if niche isn't covered for the patient and their families, like, and I have a 11 year old whose parents aren't involved like, you know, I haven't figured out a perfect way to deal with that family. It's really hard, and sometimes it keeps me up at night because it's just so unfair for an 11 year old to have to figure out diabetes. And so I think again, that goes with, you know, really encouraging and emphasizing to them that, like, every little thing you're doing for yourself is incredible. I say if you're gonna miss a shot, just don't miss your long acting, you know, let that take that always, to keep you out of the hospital, and just doing really many goals with them to get them to where they need to be. Because at 11 year old, 11 years old, if you're managing by yourself, there is no way you are going to be in Target. I just like, That's so unfair and a very unrealistic expectation. Yeah,

Scott Benner 31:26
okay. I mean, especially when what you just said there about, like, explaining to people, like, hey, look, doesn't matter if somebody sees you. Like, that's parenting, that's not medical care. You know what? I mean, like, you're just being a, you know, a big brother, a big sister in that situation, that that's something you would expect or hope that they're getting at home, and if they're not, and now on top of that, the diabetes comes. I hate to say it like this, but can you identify the people who are going to struggle? Is it not hard to figure out who's who?

Dr. Tarlow 31:53
It's not okay. It's really sad. But I feel like sometimes you're you're pleasantly surprised, but I think you know, in certain situations, you can tell who's going to struggle and have a hard time, because this kid has no idea how to count carbs, and as many times as you bring them in for education, like they're 11 years old. And what, you know, what does that look like? So, and it's hard. Like, you know, we like go to school to learn how to interpret these graphs and make and make adjustments. Like, even for families that are the most supportive, like, a lot of families are afraid to adjust settings on their own, I love and encourage them to always do so. But like, for a kid again, managing on their own, they're not going to do that. So we're making adjustments every four months. If they're able to even get to their visits consistently.

Scott Benner 32:44
Do this with me for a second. That idea of like, you just adjusting it every four months is that it's just a shot in the dark, right? Oh yeah, yeah. You're just like, you're just like, the A, 1c, went up the time and range got worse. I'm gonna put in more that. That's pretty much it,

Dr. Tarlow 33:03
yeah. Like, I mean, I'm looking to see where I need to adjust, but yeah, like, I encourage my patients to always reach out to me through my chart, our little online portal, like, much more frequently if they're noticing trends, because every four months, that's that's not enough. And being realistic, but also we don't have the availability to see patients more frequent than that in most cases, when

Scott Benner 33:27
you use a DIY algorithm and you see the difference in basal and insulin sensitivity and bolusing data. I mean, God, sometimes like hours to hours, but day to day. It really does make, or makes me feel, like, what is the point of like this? These, like quarterly adjustments. Like this is ridiculous. Like, if this is what happens to a person who has like a five, five to a six, A, 1c, then no wonder they have, I mean, because we're talking about people with eights and nines and 10s, right? Yeah, yeah, yeah, greater than 14, Oh, yeah. And so no wonder these other people are having this like, because if the variability is hour to hour, day to day, and we're adjusting every 120 days, then this is just meaningless. Like it almost meaningless, like it does fall to them understanding. And then if you get to the point where you you say, like, as your example, goes, like, they can't count carbs, then that's where you have to start talking to them about, all right, listen, you probably eat the same things all the time. Like, you know, every time you count this, you seem to be off. So forget counting it. Like, look, look what happened here. You know what I mean. Like, you use this much insulin, and it looks like two more units would have been appropriate. So next time you eat this, like, let's just make it five and like, see what that like, you have to start giving them that kind of autonomy. But then that gets outside of any real medical like, advice that you would be comfortable giving, right? Like, that's not a thing you could say to somebody.

Dr. Tarlow 34:57
Oh, yeah. 100% and it's so in. Like, you know, you have patients who could care less about their diabetes, and patients who care so much, and each one of them has their own frustrations with it. So like, I just saw a 12 year old on Monday who she's doing excellent on the pump, but her a 1c went up from like six, nine to seven, five, and she asked to go back to injections. And I was like, whoa, whoa, let's see what's going on here. And you know her pump, she's on OmniPod five, so she was getting kicked out of her pump because high blood, you know her, yeah, high blood. And because her, she was getting like 15 more units in basal in auto mode than manual mode. I'm like, we just need to make these adjustments. You are not doing anything wrong. Like, let's, let's talk about why the pump is better. And one thing I really try to stress with patients who don't want the pump yet is, like, when you give shots, you do four times a day and you're feeling good. Like, I just gave four shots a day. I'm doing a great job. But if you think about it, on your pump, it's making adjustments to your blood sugars every five minutes. You cannot beat that. You can eat pizza at bedtime and wake up with a normal blood sugar. Like, you don't have to wake up at 2am and expect to give a correction. Like, that is amazing technology. Stephanie

Scott Benner 36:16
sweat, sweating your ass off, like, Oh my God. What's wrong? Like, feeling nauseous, like all that. Like, what's interesting here to me is that, like, the A, 1c, goes up the tiniest little bit, and then the person is, like, I want out. Like this, this bad number, bad got it better last time. Like that. It's like, that simple, right? Yeah. And then yeah. And then the next thing I want to ask you about is that idea of, like, some people don't care about their diabetes. So like, do you think they don't care, or do you think that they're lost and don't know what to do? Or are there some of both?

Dr. Tarlow 36:49
That's a good question too. I have some patients that I've seen for, what, three to four years now, I guess I've, I've been back and they, we have the same visit every single time they're on the dash. So they're not in auto mode, which, you know, okay, but they're not putting in any boluses. And then they're like, you know, if I have OmniPod five, it's gonna make a difference. So we switch them to OmniPod five. There's still no boluses. You know, OmniPod five, I love it. I wear it. It does not work. If you don't bolus, it's just not going to work. So, you know, there's certain patients that don't want to that just don't want to interact with their diabetes. And I, I don't think it's that they don't care, because I think deep down, they really do, like, it's easier to put up that front than to, like, admit that they're struggling from, you know, a diabetes related depression, a severe burnout. But, you know, we have psychologists that can meet with the patients, but I don't know. I think burnout is one of the hardest things to deal with.

Scott Benner 37:55
Dig into it with me. Stephanie for a second. Like, just pick one of them in your head. We don't want any identifying conversations, right? But like somebody who you think just doesn't bolus for their meals, do they understand the long term implications of what they're doing?

Dr. Tarlow 38:11
I don't know. Does any teenager, necessarily, I think would. I don't know. I think in a in a lot of settings, people do understand the long term effects even teenagers. But I think what's really hard is when you feel fine at 200 I think the body's like a thermostat. If you're constantly running 60, you're not going to feel low. If you're constantly running 240 you're not going to notice these symptoms of running high. And it's really hard to see that in the long run, you are going to have these issues. And I have, I had so many adult patients that I would see, they would be like, God, and now their a one, Cs are like, six, five, but they've had, you know, one amputation, and they're like, if only I just would have been like, okay, it takes two minutes to bolus. Then I would have just done it. Because now they run their blood sugars perfect, because they get it, because they had to experience some sort of, you know, severe complication.

Scott Benner 39:07
The question is, how to get them there without them being smacked in the face with something,

Dr. Tarlow 39:11
right? And I just, I don't know, I really don't like to use scare tactics. I have before, I think in a certain patient, I have had to do it because nothing else seems to get through to them. I don't know. I haven't seen what, what's happened yet, but it's the time. Yeah, I think, yeah. I'm hoping it worked. Because, you know, there's a point where, like, also, you know, a lot of our kids, they don't have, like, micro albuminuria yet and things, and I think once that becomes positive too, that sometimes not always, gets parents a little more on board to then, you know, prod at the kid to take their insulin. But I think there's a fine balance, too, between parents and. Kids trying to maintain their relationship and not have it hurt so much from a constant nagging of take care of your diabetes. Digi bolus like that also plays a huge impact on families, and that's really hard.

Scott Benner 40:12
Basically, we're talking about smoking. This is, this is right, this, yeah, is smoking. It's, I feel good when I'm doing. It doesn't seem to be a problem. You're telling me that 40 years now, I'm gonna have lung cancer. That doesn't sound like something's really gonna happen to me. If you degrade, you degrade slowly, you don't feel the degradation happen. And then once it's too late, it's too late,

Unknown Speaker 40:39
right? Yeah, it's smoking. Yeah,

Scott Benner 40:41
it's smoking. And so, yeah, so like, if you I guess we, and how did we fix that in the in the population? Because, hold on a second, ready. Hold on a second. Let me go over here to this screen. How many Americans smoke today versus 20 years ago.

Speaker 1 41:03
Hold on, sorry. Oh, you're fine. Yeah.

Scott Benner 41:07
I'm just asking our our computer overlords, for some details here, American adults has significantly declined over the past 20 years. In 2021 11.1% of US adults smoke cigarettes. This represents a notable decrease from approximate 20.9% in 2004 How about that? So okay, so hold on. How did we accomplish this? Public awareness campaigns, increased taxes, smoking bans in public regulations on tobacco, advertising, health warnings on the package, smoking cessation programs, cultural, social shifts,

Dr. Tarlow 41:46
yeah, yeah. And I feel like a lot of those you know, media things were scare tactics. And it's not like, you know, that'd be like, putting on the pump, use or lose land, yeah, no, right, right,

Scott Benner 41:59
yeah. What's this say on my insulin here? Yeah, you're right, so, but is it? Is it highlighting that these people aren't they're not bad people, they're not dumb people. They don't want bad outcomes for themselves. This is just how a human brain works around stuff like this,

Dr. Tarlow 42:20
in a way, yeah, I think, like, out of sight, out of mind, you know, if you're out with your friends and you have to, you have to bolus. Why bolus? Then you're different and you feel fine. So why would I stop skateboarding right now to take insulin for this Slurpee? You know? Yeah, I don't know. I think the biggest thing I always try to emphasize is, like, you don't even know how much better you're gonna feel if you just take your insulin. Like, you're gonna be less tired, you're gonna be way less thirsty, you're gonna focus better. Like, I just really try to frame the positives also, I think too, like, you know, for the patients that aren't gonna do it. We have an option now. We have the island, and that pump is great for patients. Well, you know you have, I think we're learning more and more about it, whereas, like you have to consistently announce meals or consistently not announce meals for it to work the best, but I do think there is, like, a huge advantage to it, like in a completely different direction of the use of this pump. Like I have a family who is not from this country. They do not speak any language that would be on an insulin pump. They eat very different foods, so counting carbs is out of the question. And so we use fixed dosing for shocks right now, and that has resulted in a whole gamut of issues, from hypoglycemic seizure to running really, really high, although they never go into DK, because the parents are amazing, and they always get their insulin, but the amount of insulin really hard to figure out what they're doing at home. And so we're working toward getting them an eyelet because, you know, they will consistently be able to bolus, and the girls are getting old enough that they'll be able to use their pump to do so, yeah, and I think you know that is pretty much going to this technology that is out there is going to change diabetes, especially in this population that doesn't want to think about it, because it does the thinking for them. Like, even if I can get a patient on a tandem pump, if you're not going to bolus on a tandem I would say I could still probably get your a 1c to an eight instead of greater than 14, you know. Like, that's a huge difference in terms of risk reduction.

Scott Benner 44:43
It's good of you to use the numbers, because I think people listening might when they hear high a one say they think, like eight, you know what? I think it's a win. Yeah, for a lot of the people you're dealing with it, it absolutely is right. So I think what I've done here is, I think I built. A community of people who are actively engaged in their health. And so when we stop to talk about some of these other devices, sometimes I think most of them listen and go eyelet, like, what I'm not. I don't want that, you know, I mean, like, and of course, you don't. If your a one sees five and a half and your time and range is crazy and you know, like 90% Yeah, you probably don't want the island, not in its current form. Maybe you would in the future. I don't know what they're gonna do to it, you know, right? But for right now, I keep saying out loud, because I want people to listen. You don't realize that most people with type one diabetes are running around with crazy high a one CS and not, oh yeah, not giving themselves insulin. And you know, and that these devices will help them significantly. You could take a person with a 14, a 1c and give them a seven, oh, my God, right, even if you gave them a nine, what a great thing. And that's why talking to people like you is so interesting, because you actually talk to everybody. Yeah, you see all gamuts of people, right? Like, they're, I'm sure you help people who roll in there every time, they're like, Hey, what's up? Crack their knuckles. They're like, what is it? A five six or a five seven. And then, you know, like, you Josh around a little bit and write their scripts and go, Oh my God, you the best part of my day. And then, like, that kind of thing. Greatly, is that about what happens? Yeah, that

Dr. Tarlow 46:23
was actually my Monday. Okay,

Scott Benner 46:24
and so those people don't need help because, for whatever reason, their brain works with what's happening to them, and they're doing the things they need to do when they need to do it. But what about everybody else? And we don't talk about it because it's uncomfortable, but it's happening to most people,

Dr. Tarlow 46:44
absolutely, yeah, and then you think about it too, and there's people that go above and beyond with their care, and they're still not seeing results. And it's like, well, you know, that's okay, your child is four, they half the time their whole meal. They half the time. Don't half the time they're running around like a crazy person, and the other time they're, you know, yeah, it is so hard. Diabetes is so hard. And I think that's what everyone needs to realize, is everyone is doing the best. Well, most people are doing the best that they can. And I really think if you put any effort toward it, you should be really proud of yourself, because it is so frustrating. You can do the same thing every day and get completely different results, like that is hard, and so

Scott Benner 47:27
I think it's, it's you can say that they're doing the best they can, even if they're not, like, even if you realize, like, look, there's a world where they could do a more, right, but they're not. There's something stopping them, like, what's happening in your mind and your body and your life is not just what you talk about in your endocrinologist office. So like, How come you don't just bullish your meals? Well, you know, I know I should blah, blah, blah, but then you don't know what happens if they get home and there's a drunk parent or a high parent and they're busy, like, just trying to stay out of the way and not get hit or not get yelled at or not get you know, there's a lot of things happening to people that you yeah and so like, they could actually be living a life where dying from a diabetes complication in 30 years is not even in their top 10 problems. So they are, yeah, they are doing the best they can. And yeah, are they doing the best that's available? No, that's not your job, right? Like, how are you going to handle that bigger problem for them? Like, I think sometimes the sadness of it is, is that people who have the bandwidth to take care of themselves sometimes get diabetes, and people who don't have the bandwidth to take care of themselves also get diabetes.

Dr. Tarlow 48:38
For sure, it doesn't discriminate, and it requires as how we know it today, aside from the islet, it requires you to be literate in math, and unfortunately, a lot of our pumps do not have other languages. So I hope you speak and read English like it's really hard, especially for families that are not you know, from, you know, the the typical places that are manufacturing these devices. Yeah, it is interesting. I mean, it's a, it's a disease that affects the whole world. So I don't know how to fix that issue, but I wish that something could be done about that.

Scott Benner 49:15
I was so proud of myself for a piece of time when I put together the Pro Tip series, and then when we, like, made the bold beginnings for people who were newly diagnosed. And I can see, like, Steph, I have 50,000 active members in a private Facebook group. Like, so that's amazing. That group does. I haven't looked in a while, but the last time I looked, it does 125 new posts a day, 8000 likes comments and like hearts like combined, and it adds 150 new people every three days. So Wow. It's fascinating to watch people who either get it or are actively trying to get it, talk to each other, because the community part is, I think the most important part of it. A number of different reasons. And then I end up being in this situation where I look and I go, wow, 50,000 that's insane. Like, really, really amazing. I think I probably run the most active, valuable diabetes group on the planet. I mean, that's incredible. That's definitely, it's only 50,000 people.

Dr. Tarlow 50:21
You know it's you're getting to the people that have internet and know how to use Facebook or

Scott Benner 50:25
have time, yeah, the they have the intellect the time their husband's not chasing them with a knife, like, like, or whatever it is, right? Like, the people who are actually able to go, hey, you know what? It's two o'clock in the afternoon. I've got a couple of minutes. Let me listen to this episode about extending my bolus, like, that's not everybody, not everybody's life. And when I realized that I've just spent so much time in my own head trying to figure out, like, how do you put this together for the other people that this isn't the and I don't know the answer either, I rack my brain's trying to come up with

Dr. Tarlow 51:01
the answer, yeah. I mean, I think one thing that's just like, again, something that is brings is an ease of use of like, interact with the pump as least as you possibly can. But it allows people, I think you can't discriminate, people who might not be technologically savvy, to use diabetes technology like it needs to be offered to all patients. I think that's so important, because it's like a cheat code having a Dexcom and having a pump these days, you know, it's really unfair to not offer it to everybody. And I think that's one thing that's super important is like, you know, making that accessible. So

Scott Benner 51:40
I've been having more episodes about I let and I do it. It's kind of at my detriment, because I know that the core audience for this podcast is like, I don't want a seven, A, 1c, and I'll count my cards. Yeah, I just think it needs to get out there more, and I have the biggest platform, so I'm trying to be more aggressive about it, because of all of the other people, and these are the people you can't market to. You can't sell to them. You can't sell to their doctors, because their doctors are looking at them like, here's another one coming in who's just going to ruin their life, and nothing I can do about it, like that bad attitude exists in their life as well. Every time I've interviewed someone from from beta bionics, I've implored them to go to GPS and talk to them, because I don't even think, I don't even think most of these people are going to endocrinologists,

Dr. Tarlow 52:28
yeah, yeah, yeah. I mean, that's totally true too.

Scott Benner 52:30
Yeah, yeah. I'd like to see them educate GPS about, look, just slap this thing on people and see if they can't get things together a little bit, you know,

Dr. Tarlow 52:39
yeah. And, and, you know, I keep talking about the eyelet, like, I think tandem is an amazing pump. And I really also love OmniPod. It is true, though, there's some cool even if you have an ANC of 6.5 or whatever you have, there is some awesome part of islet that always draws me to it. That's like, I could go on a vacation to Italy, any a whole bowl of pasta and five pizzas and whatever I want, and not have to think about how many carbs that is and how to bolus for that, like, that's pretty awesome. That burden reduction is, is something I think that really you know maybe you're going to get a slightly different, a little bit higher, A, 1c but in the again, going back to risk reduction, like, what's the difference between a six, eight and a seven, one? I don't actually know if it's going to be that significant. So if it improves quality of life that much for someone who is instead, you know, counting one and a half, putting in one and a half carbs, like, for a small like, two almonds or something. You know, I think, what about giving yourself that freedom back?

Scott Benner 53:46
Yeah, no, it's awesome. I actually to go a little farther. I think OmniPod was trying to split the difference with OmniPod five. I think they were trying to be like, Look, this is more aggressive, but it also really doesn't want your involvement all that much. You just have to put in the meals. You know what I mean? Because it's not set up for you to understand how it's working like so it's not, it's not a tinker like device. You know what I mean for sure. Yeah. And so

Dr. Tarlow 54:14
part of it kind of drives me crazy

Scott Benner 54:17
conservative, yeah. And and listen, I don't work there, and I don't know anything. And I want to be clear about that, because people think I know stuff, I would imagine that they're working on that behind the scenes to make it a little more aggressive, like they hear the feedback, right? That's the feedback, yeah. So I like the idea of because they know the thing that we don't talk about, which is a lot of people aren't putting in the effort that's necessary all the time, and what if we could cover that effort with a mechanical device? And I think that's a really noble goal, sincerely,

Dr. Tarlow 54:52
yeah, and I guess going back to some of my patients that don't bull us, and you know, they have five episodes of DKA. When I do tell them about the eyelet, I see them smile about their diabetes for the first time, knowing that that's out there. So when you were asking, like, how do you get through to those patients? I think showing them there is a light at the end of the tunnel, you know, like letting them know you do this, you do this well for two months, so we somewhat know what your insulin requirements are, and then by that time, you'll be ready for your pump training, because we book a little bit far out for pump trainings, right?

Scott Benner 55:29
Training is going to be, what is it? Normal meal, small meal, large meal, something like that, breakfast, lunch, pretty

Speaker 1 55:34
much, basically, yeah, it just, I think those first like four days you have to, they really want you eating like regular meals, so the pump learns what a regular meal is. Yes, to get it like set up. I

Scott Benner 55:46
just did an interview with them that went up the other day. You'd probably really like, I'll have to, I'll

Unknown Speaker 55:51
definitely check that out. Yeah, I

Scott Benner 55:53
and because they're also looking at dual hormone now. So it's episode 1217, by the way, this dual hormone pump, which in my estimation, allows them to even probably try to be more aggressive with the algorithm, if they can catch it on the back end with a glucagon. And so I can't wait to see where that goes to, like, that's all very interesting. I also think AI is going to be really valuable for people with diabetes in the next five years, too.

Unknown Speaker 56:19
Oh yeah,

Scott Benner 56:20
yeah. But again, those are tools. That's a tool that you need to be, like, interested in using. You know what? I mean, like, it's not, it's not a thing that it's just everybody's gonna do it, but maybe one day, like, maybe one day it will get to that point. I find these conversations like intellectually inspiring and emotionally draining, because there's, at the moment, not a real answer for how do I go find a person who can't find a way to bolus for their meals and help them? You know, I keep thinking I'm going to talk to somebody who one day is going to be like, Oh, Scott, I know. And I'm waiting for that to happen, I guess. But, um, you don't have the magic bullet answer either, huh?

Unknown Speaker 57:07
Unfortunately, I do not.

Scott Benner 57:08
And how hard is that on you? You come off like, like, a really lovely person. So at what point are you not going to be able to drag your ass out of bed every day to hear somebody go, No, I don't bolus for my meals. Like, when is it? When are you gonna burn out on helping them? You know what? I mean? I don't

Speaker 1 57:27
know. I don't think I can. Because, like, you know, sure, even working in endocrinology, like, I still have nights where I'm up at 2am feeling terrible and eating four packs of fruit snacks, or my blood sugar is stuck at 300 and so I have to be there to advocate for them and to just let them know it's okay. Like I just feel like getting diabetes sucks, but it gave me a real purpose. And so I don't know I feel like I, I I really hate diabetes, but I love it. You know, does that make sense? No,

Scott Benner 58:08
no, no, I it does. I just, I worry about, like, psychological pressure that comes back to you, like, at what point do you become, like, the cop who just expects that everybody's breaking a law? You know what I mean? Because it'll happen eventually. And, yeah, and it sucks, because for you listen to all the motivation you have, it probably maybe it's never going to happen to you, or maybe it'll take forever to happen to you. But for the people who are just like, Look, I just wanted to be a doctor. Get it. I mean, like, sometimes I ask people, why do you help people diabetes? And, like, I don't know. It made sense to me, and I was like, okay, so they're not there for some bigger reason. And then how many visits do they have to how many doors do they have to open up? And then here my a 1c, is 14, and I don't know, man, I don't know how to I don't want abolish this. I don't want to have diabetes like that, like, until they just go, I don't care. You know what I mean? Like, like, when does it kill them inside? A little bit,

Speaker 1 59:02
I guess I would say one thing that really helps is having an amazing team. And I love our team, like they keep me going to, like, there are definitely days I'm frustrated where I'm like, Oh my gosh, not again. Like we had the same talk last time. And, you know, I think our team just keeps me going as well. Like, yeah, you know, the obviously, the patients, but then having my team to talk through things with, and like, you know, give new ideas of what we're going to try for next time. And even just, like a referral to just go over diabetes basics again with the educator, I think is huge, and so that's important as well. Yeah, I

Scott Benner 59:45
don't know how you don't just, like, blurt out, oh my God, just take care of yourself. I know it's hard to, like, make a person see the future, especially a younger person. I get that right, like, I understand the whole like, I. Something has to happen. Like, listen, Stephan, I've interviewed so many adults who will tell the story of it's just it feels like it's such a personal story to them. But I'm like, Oh my God, I've heard this 1000 times. Yeah, you know, I got diagnosed, and my parents took care of it for a while, and I was doing great, but then I went off to college, and I didn't really pay attention to it, but I don't know, I got through somehow, and they're like, oh, what your ANC is? Like, really high, you know? And then I got out, and I thought, Oh, I'll take care of it as an adult. But I didn't. And then always, the same thing happens to the people who get saved before complications. They meet a person that they want to be healthy for Stephanie, I'm telling you all the time, I met a guy, I met a girl. I had a baby. I wanted to have a baby. Those are the things that snap people back the fastest. Helping themselves is not nearly as easy as helping themselves. For someone else,

Speaker 1 1:00:57
you can only get all like little singles night,

Scott Benner 1:01:01
I like, where your brain jumped. You're like, we just got to get all these people hooked up, and then their diabetes

Speaker 1 1:01:07
will be better diabetes. Singles night for 18 and older. Stephanie,

Scott Benner 1:01:12
that was such a 30 year old thing to say. That was fantastic. Thank you. I was thinking, how do we find something in their life that they care about enough that they need to be healthy for it, or does it have to be a person? Because I listen, generally speaking, I'm an upbeat, hopeful person, but if I was living in a terrible situation, or if I was flat broke, or I didn't have any prospects in my life, I don't know why I'd care that much about my health. Like, what am I getting healthy? Right? You know what I mean, to go live, to go live in an alley, like, you know, I'm saying, like, like, and so, like, there's got to be a thing. Like, I just think it's a very human thing to need a goal.

Speaker 1 1:01:53
Yeah, I mean goal, my patients who are goal oriented athletes, or I have one that wants to be a pilot and have to, like, prove incredible blood sugars. These patients do so well or or, like, in my adult care, the ones that lost their license because maybe they had a car accident with a low blood sugar, you know, those ones trying to prove to the DMV they have good blood sugar, those are incredible blood sugars. So

Scott Benner 1:02:18
I'm right. Then a goal motivates people, yeah, yeah,

Speaker 1 1:02:22
okay, take some take something away or or put it at risk. And I think you see a benefit, but also the pressure of that is crazy,

Scott Benner 1:02:30
definitely. Let me say something crazy to you for a second. Okay, what if you launched a little test thing? Okay? And I'm going to tell you how much it's going to cost, the it's going to cost the $10,000 to run this test. And we're going to take 10 of your people who are like, I don't bolus, I don't do this. Blah, blah, blah, and you tell them that at the end of six months, if they can maintain this range and bolus for their meals, etc. They get $1,000 at the end of six months. You do it with 10 people and see if the goal motivates them to help themselves.

Unknown Speaker 1:03:11
That is an awesome it's not

Scott Benner 1:03:13
a bad idea. I

Unknown Speaker 1:03:14
love that because

Scott Benner 1:03:16
so now we just need to find a donor, 10 grand, somebody call Stephanie. That's all I want, like, because I want to see what happens. Do 10 of those people go, Oh, for $1,000 I can do it. I'll tell you something. This idea comes from a different a couple of different places. It comes from three different ideas that I've lived through. I'm 52 Stephanie. I'm pretty much almost dead, so I've been around a really long time. Okay? 52 the new 30. Yeah, good. Tell my knee. My father three packs a day. When he was managing his smoking, it was two packs a day. In the 80s, his boss, who really liked him, grabbed him and pulled aside and said to him, Ben, don't smoke for a month. I'll give you $1,000 and my dad did not smoke for a month. Now, he did eventually die. He did eventually die of heart failure, but so so I don't know if we needed 1000 every month to keep it moving, but he did it my dad, who would break out into a sweat if he didn't have a cigarette every couple of minutes, stopped for a month for money. Okay. Now my next thought here is an episode I did with a mom whose kid wanted a chainsaw, and I told her to pay him for every time he pre bolus up until the value of the chain saw. Did

Unknown Speaker 1:04:33
it work? Okay?

Scott Benner 1:04:36
I've heard that it worked. My third thing is that I worked in a corporate setting when I was really young, and I would frequently get pulled in to Human Resources meetings because I was seen as a common sense person, even at my young age. And they would ask me over and over again, how do we motivate people? How do we motivate people? And I would sit in those meetings and say, I don't care what anybody else says. It's. Nice to say that, oh, we need education. We need to be able to, like, motivate people. We can do monitoring. Technology will help. We want to support them. I'm like money. People care about money. Give them money. And when they finally went to a bonus system, they got the work out of people they wanted.

Speaker 1 1:05:18
I'm telling you, yeah. I mean, I think it's brilliant. I do think $1,000 is very awesome. I think if it was more like $25 I don't know if we'd see the same effect.

Scott Benner 1:05:29
No, no, you need a number that makes people go, oh, hold up. How much? Yeah, yeah, right, yeah. I'm gonna win $1,000 if I can just pre bolus my meals. Okay? Like, because that's really like Stephanie, between you and I, that's the deal. Good settings, yeah. Pre bullish, your meals. Don't stare at a high. Pretty much done, right? 100% Yeah, it's an A, 1c, in the sixes, Yep, yeah,

Unknown Speaker 1:05:55
okay.

Scott Benner 1:05:56
That's what I think. Like, I think you do that and then you say to them, Look, now you feel better. Now you know how to do it. Now we've made a habit. Now do it for yourself, right? Take your $1,000 and go do something awesome with it, and pre balls tomorrow, because you want to feel this good and be this healthy, because they have brain fog they don't even know about. You know what I mean? Like, maybe you can get them clear. And then, am I making that up? Like, like, high blood sugars? Yeah, I think

Speaker 1 1:06:28
it'd be awesome. I'd also be really curious what happens post winning $1,000

Scott Benner 1:06:33
Oh, I would be too, some people are gonna drop off, but you'll save a few of them.

Speaker 1 1:06:36
Yeah, no, I think it's great. And I think too, just like, you know, it's like brushing your teeth. You don't want to do it. You want to just go to bed and just like, you know, be ready for the day. But once you do it, it's a habit. And I think that's kind of how taking your insulin is too. Once they just do it and see, okay, that took an extra 30 seconds. Yeah, it's really not, I mean, yeah, it's, again, diabetes is hard, and it's not fun to have to be different, but it you know, it's not that much more time. It's not like you're taking 30 minutes out of your day before you eat, like it's an extra 1015, minutes. It's

Scott Benner 1:07:11
not that bad. Plus, if you were to write a research paper afterwards and present it to an insurance company and say, Look, how'd you like to save untold millions of dollars by paying everybody $1,000 a year to manage their diabetes

Unknown Speaker 1:07:26
better. Yeah.

Scott Benner 1:07:27
I mean, be brilliant workplaces. Do it right. They'll, they'll do exercise initiatives like they'll, they'll slap a like a little watch on you and give you a portal to report your your steps or whatever. And at the end of the year, they, if you've done it, they give you $500 and people who don't need $500 do it like, like, you know, you people who are like, people who have been in another step of life. If you said, I'm like, Look, I'll give you a $500 to paint my room, they'd be like, Get the out of here. I don't need your money paint your own damn room. But suddenly, when it's a game, it's a game and it has a prize. Boom, yep. Stephanie, when I was in fifth grade, my teacher did this thing in the last two months of the year where they we set up a city in our room, so everybody had to think up a business, and then we made money like and like, and everybody got money, and they were paid. And then on Fridays, all the businesses set up like a flea market, almost, and you tried to see who could make the most money, like it was just, you know, like a capitalism, you know, class almost, in fifth grade. You know, who won. It was me, you know, how I did it. I had a feeling. Did it with a roulette I did it with a roulette wheel. So I came in, I came in with a roulette wheel, and my teacher goes, Uh, you cannot do gambling as your business. And I was like, oh, okay, so what I was gonna do was I was gonna sell squares on the roulette wheel for a $1 whatever our dollar was, and whichever one it landed on the winner got half the pot. That was my plan. And the teacher goes, you cannot, you can't do that. And so I went home and I was like, damn, because I made my dad build me a roulette wheel out of like, wood. That's awesome. I went home and Pac Man was huge back then, so I made my dad buy me these little five inch paper plates and a can of yellow paint, and I laid them out, painted them yellow, cut a piece of pie out of them so they look like Pac Mans. And you put $1 down on a square, and the winner got a Pac Man.

Unknown Speaker 1:09:38
And I was allowed to do that. By

Scott Benner 1:09:40
the time the eight weeks was over, I had everyone's money. Stephanie, okay, that is awesome, yes. And I'm telling you, what it taught me about people is can be valuable in helping people with their diabetes. And I'm going to tell you right now, if I get afforded I would have already done this. I would have already started. A community thing where you can go into a portal and just track your a one, CS and your variability and stuff like that, and found ways to incentivize people to work harder for their stuff, like I would have, I would have already tried it, but I got the funding, so I'm putting it on you.

Speaker 1 1:10:15
Okay, someone reach out to me and give me the funding. Okay?

Scott Benner 1:10:18
That's all because you don't need money. You just, you just need the prize, not like the the job needs money, right? And then you any prize. How

Unknown Speaker 1:10:25
about a timeshare in Hawaii?

Scott Benner 1:10:28
Stephanie's like, I could probably get my eight 1c down for a vacation.

Speaker 1 1:10:33
Can I participate? I'm gonna stop bullets for a little bit

Scott Benner 1:10:37
every six months. This woman named Steph wins.

Speaker 1 1:10:42
One time, I'll be Steph, one time, I'll be Stephanie. You'll

Scott Benner 1:10:47
be able to trick them. That'll be lovely. Okay, I want everybody to think about this and do this. So here's what I would do. I'd give them the Pro Tip series in the podcast or the bowl beginning series. I would tell them, like, look, listen to this. Put these things into practice. Ask me questions, if you have any questions, and at the end of it, if we can, I don't know, in the first three months, if you can lower your A, 1c, and improve your variability to this level, then you win 500 and then if you can just do it for three more months, and you know, and then get to the goal that we set together, you Get another 500 and that's it. I mean, honestly, the truth is, is that it would be way cheaper to pay people for good health than it would be to spend the next 150 years wringing our hands going, I don't understand why Ben smokes so many cigarettes. How do we help him? Because you're not going to figure that.

Speaker 1 1:11:36
Yeah, when you put it that way, it's like, so it sounds so easy. It's like I know how to get to all these kids now. I'm just gonna offer them 1000 people or PlayStation games. I do really think that would work. Oh,

Scott Benner 1:11:47
my God, are you kidding me? What about just a bucket of PlayStation gift cards or something like that? Seriously, no kidding. Like, like, come in here. On boy, here's how I would do it. I go, Look, I want to first give you one of these for free for doing nothing but being you. You're a terrific kid. I love you. Now, if you want another one, when you come back in three months, you're going to pre bullish your meals, and we're going to bring your A 1c down a little bit. You do that, get to get another gift card for your PlayStation, and then we'll find another thing for you to do, and before you know it, you'll have tricked them into taking care of themselves. Yeah, exactly. I'm a genius. No one, no one listens to me. Stephanie, that is great. No one listens to me. But people care about one thing, money, okay, like, all right, I'm in I understand what to do. All right, we're good. You have anything I didn't ask you that you want to

Speaker 1 1:12:38
bring up? No, I think that was pretty much everything that sounds it was great talking with you. No,

Scott Benner 1:12:42
I had a good time. Do you think they will name a day after me one day, if this works? Yeah, you think so?

Unknown Speaker 1:12:49
I do. I think

Speaker 1 1:12:52
they do. I think we'll have an annual day for you at, OHSU, honestly,

Scott Benner 1:12:57
I want that. I want that I want to become, I want to I look at, can I be serious for a second? Not that I wasn't serious about the other stuff. I found a way to help so many people. And Stephanie, all it did was leave me with a feeling inside that there were a lot of people I didn't help. So I'm very happy with all the people who come to me and say, This saved my life, and oh, my god, I'm so healthy because of you. And thank you. And people who joke about, like, do you know there are nine states in America that have a juice box license plate because of the podcast? Like, I'm not even kidding. That's really cool. I'm not even kidding about that, okay, like, and that stuff. I don't want people to think I'm like, dead inside. Those things are all very cool and make me feel great. Five stars. I love it. I'm a T, 1d and I love this podcast. Thank you, Scott. I'm not alone. When I was diagnosed, I felt like I was the only one who knew the true meaning of diabetes. My mom introduced me to the podcast, and I realized that there are millions of people who don't who understand the feeling the same way as I do now. I love listening, and I feel comfortable listening my pets even like it. You know, these go on forever, okay, like I'm being serious, like those reviews and notes, they happen every day. They go on forever, and it's fantastic. But in my heart, it's not enough people. And I know there's a section of society I'm never going to touch, and so I want to find a way to find them too before, yeah, and

Speaker 1 1:14:21
I guess, just to add on to that, just to getting you know again, family, patients with families who are able to do these things, but I couldn't recommend enough getting involved with your local JDRF walk when it's in town, it's such a feeling of community. And also really consider going to diabetes camp. It is such a once and well, you'll go every summer after that, but it is such a unique and like special experience to be around. Even for me as an I didn't go as a kid because I was afraid of overnight camps. And going now as a provider like it is so fun and. A cool experience that I just can't even put into words. So yeah, I can't recommend that enough.

Scott Benner 1:15:05
Dr Marwa, who's actually part of the Grand Rounds series, said that during his training, part of his training was to go to diabetes camp, and that a big piece of his understanding about people's lives with diabetes comes from being at camp.

Speaker 1 1:15:19
Yeah, oh, yeah. Like the freedom at the Gales Creek camp, which is what we have here in Oregon. The counselors, they carry all the diabetes supplies for the kids, so the kids can just run and be free. And I think that is, like, the coolest thing ever. Yeah,

Scott Benner 1:15:35
no, he just, he learned about bolus thing and what people understood and what they didn't understood. He actually got to see insulin work like live in people's bodies, and he said it was a huge help when he was learning to be an endocrinologist. Yeah. Nice, amazing. Okay, all right. Well, Stephanie, thank you so much for doing this. I

Unknown Speaker 1:15:51
really do appreciate it. Yeah, thanks.

Scott Benner 1:15:53
Hold on one second. Jalen

is an incredible example of what so many experience living with diabetes. You show up for yourself and others every day, never letting diabetes define you, and that is what the Medtronic champion community is all about. Each of us is strong, and together, we're even stronger. To hear more stories from the Medtronic champion community, or to share your own story, visit Medtronic diabetes.com/juicebox and look out online for the hashtag. Medtronic champion. A huge thanks to a longtime sponsor, touched by type one. Please check them out on Facebook, Instagram and at touched by type one.org if you're looking to support an organization that's supporting people with type one diabetes. Check out. Touched by type one. Today's episode of The juicebox podcast is sponsored by the Dexcom g7 which now integrates with the tandem T slim x2 system. Learn more and get started today at dexcom.com/juicebox, are you starting to see patterns? But you can't quite make sense of them. You're like, Oh, if I bolus here, this happens, but I don't know what to do. Should I put in a little less, a little more? If you're starting to have those thoughts, you're starting to think this isn't going the way the doctor said it would. I think I see something here, but I can't be sure. Once you're having those thoughts, you're ready for the diabetes Pro Tip series from the juicebox podcast. It begins at Episode 1000 you can also find it at juicebox podcast.com up in the menu, and you can find a list in the private Facebook group. Just check right under the featured tab at the top, it'll show you lists of a ton of stuff, including the Pro Tip series, which runs from episode 1000 to 1025 thank you so much for listening. I'll be back very soon with another episode of The juicebox podcast. If you're not already subscribed or following the podcast in your favorite audio app like Spotify or Apple podcasts, please do that now. Seriously, just to hit follow or subscribe will really help the show. If you go a little further in Apple podcast and set it up so that it downloads all new episodes. I'll be your best friend, and if you leave a five star review, ooh, I'll probably send you a Christmas card. Would you like a Christmas card? The episode you just heard was professionally edited by wrong way recording, wrong way recording.com, you.

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