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Scott Benner 0:00
Hello, everyone, welcome to Episode 330 of the Juicebox Podcast. Today's show is incredibly conversational, I don't want to break it up. So I'm going to put the ads right up front here. Today's guest is David Walton. He's the CEO of T1DExchange. And I expected to have a more technical conversation with my guests about what T one D exchange did. But instead, we ended up having a multifaceted conversation around Type One Diabetes that I enjoyed so much that by the time I got to an hour and a half, I realized I had to let him go. David and I are going to speak today about the research that T Wendy exchange is doing with the COVID-19 virus. And then we get into his diabetes, his life, his management style, concepts about how to help people with type one. I just really enjoy talking to David, I think you'll enjoy listening to him talking to me, and me enjoying talking to him. And I guess hopefully him enjoying talking to me. But that's an assumption on my part because I didn't ask him anyway. ads are up front. podcast in the back. Was that party? What is it? What was that thing he used to say about mullets, business up front party in the back. That doesn't apply to this. This episode of The Juicebox Podcast is sponsored by the Contour Next One blood glucose meter and touched by type one. It's also sponsored by Omni pod and Dexcom. Everyone's got a blood glucose meter. And since you have to have one, you should probably have a great one. And you will, if you go to Contour Next one.com and find out more. The Contour Next One meter is multifaceted just like this episode. And not just because it can speak to a contour app on your phone, iPhone or Android By the way, and help you make sense of the data that's coming back from your meter. But because it's easy to use, easy to handle has a terrific test strip that will allow Second Chance testing like if you touch the blood, don't get it right, you can go back in without wasting a test trip. But the accuracy of this thing is just otherworldly. Arden has been using it for well over a year now. maybe longer, and it's absolutely the best meter she's ever had. As far as accuracy goes, and portability. I just love it. Anyway, if you go to Contour Next one.com there's a button at the top where you can find out if you're eligible to get the meter for free. And if you're not, you can still have your doctor write your script for it or pick it up at a anywhere Honestly, I guess pharmacy once people are allowed to go to pharmacies again. Anyway, this meter is worth looking into Contour Next one.com. After that, please check out touched by type one.org. The people that touched by type one are dedicated to helping those living with Type One Diabetes to excel. And they have a dance program for children actually have a dance studio, you got to go check it out touched by type one.org. If you're interested in finding out more about the Dexcom g six continuous glucose monitor, you're going to want to go to dexcom.com forward slash juice box. And to get a free no obligation demo of the Omni pod tubeless insulin pump sent directly to your home. My Omni pod comm forward slash juice box there are links to all the advertisers in your show notes. And they're also available at Juicebox podcast.com.

Not gonna argue with you You went to Princeton? Is that a burden, but by the way we're recording? And by the way, is that a burden?

David Walton 3:52
No, it's not a burden.

Scott Benner 3:55
But does everybody say it to you at some point?

David Walton 3:58
I definitely get it once in a while. You know, interestingly, I have a I have a twin brother and he went to a good school Gettysburg College. But every time I would go visit him there. It would just be nonstop comments from his friends about you know, why didn't he go to Princeton and you know, various jokes and things like that and but I you know, once I acted stupid and silly, he they realized I was just like, everyone took care of that. Hey,

Scott Benner 4:26
you know, you might be the first person I say this to who genuinely understands what I'm saying. My son goes to Dickinson.

David Walton 4:33
Oh, really? Yeah. Yeah, I have a friend whose daughter plays basketball there.

Scott Benner 4:38
Oh, no kidding. Yeah, I am probably a 10 minute ride from Princeton University. So, you and I overlap a little bit but that's gonna be where that ends educationally. Because my son's the bright one, not me. And I think our our overlap around education will probably end right around there.

David Walton 4:56
I actually live about 25 minutes from print. In right now, I'm in Pennsylvania.

Scott Benner 5:02
Oh, no kidding. I grew up in Bucks County.

David Walton 5:05
In bucks. Yeah. Yeah, yeah, I'm in New Town.

Scott Benner 5:08
Oh, okay. Oh, so let's start over. I was born in New Town. My parents moved into lower Southampton, we lived there for quite some time. My wife got a job in Manhattan soon after we got married, put us into the Princeton area just to be near the train. And we've kind of kind of stayed since then. But not right. in Princeton. If you don't mind walking over some water, you've walked over before, how old were you when you were diagnosed?

David Walton 5:39
I was older. I was 24 years old. I had, I was in business school at Penn. And notice the symptoms that ironically, I knew about because I had, in my very first job at a college, I worked in a consulting company that did work for pharmaceutical companies and the diabetes, the dcct, the diabetes control and complications trial had just findings have just been released. And everybody was talking about, oh, we need to do tighter glycemic control. And one of these pharmaceutical companies hired us to help them come up with a program. And we essentially designed like a

kind of a

patient compliance program, it was discovered a reward system for people if they did the things that were beneficial, like testing your blood sugar, and exercise and so forth that it was for type one and type two, okay, this program, but that they would get points and we developed like a point system and worked with lifescan, who had the blood glucose monitoring, they were one of the partners, we were talking to gyms, etc. So anyway, I did market research and heard from doctors talking about both type one and type two and the symptoms for newly diagnosed. And so I learned a little bit about it. And then fast forward. Two years from then, you know, I'm in, I come back for the second semester, my first year, and I'm going to the bathroom more frequently, I can't quench my thirst, I started losing some weight. And I just started dating my now wife, like a week prior. And I'm telling her that this isn't normal. This isn't how I normally AM. And ironically, she had worked for Eli Lilly as a sales rep and a managed care rep and sold insulin. So she knew a bit about it. And she didn't come out and say it sounded like it. But I asked some doctors who are also in this Healthcare Management MBA program about the symptoms. And I said, it sounds like type one, doesn't it? They said no, you're too old for type one. And you're not really a candidate for type two. So then my vision got blurry. And I went into the student center that day, and read off the symptoms to them. And they kind of looked at me and said, well, let's just test your, your blood sugar. We sure and then I was put in the hospital for a couple days. And you know, off we go. There was no family history. Although subsequently, I have a my sister son, at three years old was diagnosed with type one that more recently that that was more recently and

fortunately, my twin brother and I are adopted.

But we met our biological family when we were 18. So we were adopted at birth. Our parents were teenagers, biological parents. They ended up getting married and then had a son and daughter that our full fledged, you know biological brother and sister. And it's my biological sister whose son got developed type one. So I think we have that that genetic predisposition runs

Scott Benner 9:03
through there. You've brought a lot of things up I have to ask you about so a and this is just gonna be odd. I'm adopted. B are your biological brothers and sisters. I don't know how to say this. Maybe you're not going to answer I did. They go to great schools to

David Walton 9:21
my twin brother biological and grew up with me, Brad. So he went to Gettysburg. My both my brother and sister went to Florida State. They grew up in Tallahassee, and my sister still lives in Tallahassee. My my younger brother, ironically moved up to Boston. And so he and his wife and his two kids, they they live now out west work again to end exchanges up in Boston. So I go up to Boston almost every week for a few days. And every once in a while I get to see him because he's out in the suburbs. But there's no other family history there had there was none private My diagnosis, right? And since my diagnosis, just my my nephew again at age three. Yeah. So I joke if you add us together our ages, you're pretty close to the median age of diagnosis for type one. But I was a little bit older and he was a little on the younger side. And I know you've you've got experience with a young young child. I really do.

Scott Benner 10:24
Let me ask you one thing real quick before we move forward if you're on an Apple Computer, right?

David Walton 10:29
Yeah, I turn notifications off on Outlook, but I guess my yahoo email, don't worry,

Scott Benner 10:34
I know what to do. You're in luck, the apple in the top left corner System Preferences, System Preferences. Okay. The speaker that says sound. And then under the sound effects, tab, alert volume play sound effects through drag the alert volume all the way to the left. But leave it open. So you remember to drag it back to the right when you're done.

David Walton 10:59
You're saying on the output volume?

Scott Benner 11:02
Sound Effects? Not output. So there's sound effects out?

David Walton 11:06
Yeah, I'm on sound.

Scott Benner 11:09
No sound effects sound effects at the top. Yep. And then alert volume. There's a slider bar you run all the way. And then that one,

David Walton 11:16
I'll just keep it off. I don't need to be alerted.

Scott Benner 11:19
Like, wow, I wish I would have known that years ago.

David Walton 11:23
I thought I saw this with turning I look off that.

But I my Yahoo emails. Okay, now that email

Scott Benner 11:28
really wants you to know that you're there. While we're taking a break, I'm gonna have my daughter bolus something she's downstairs

Unknown Speaker 11:39
for school.

Scott Benner 11:42
There. Okay, cool. Well, that's interesting, has nothing to do with what you're on. But it is really incredibly interesting. And I just picture you in, you know, in business school trying to impress a new girl and you're just running to the bathroom constantly. That must have been a that must have been a big a big rock the drag up the hill, like I'm cool. I swear I am I gotta pee again. I'll be right back.

David Walton 12:02
Yeah, yeah, no, I don't normally go 20 times a day. This I'm telling you, this is an aberration, I swear. But thankfully, again, we were in a health care program. And I'm I was, you know, as casual as you could be about, you know, it happening in the diagnosis after I mean, I didn't freak out. I kind of tried to attack it rationally. But I, I was pretty fortunate that I had a little background and I was older. And you know, I was a college wrestler. So you know, I was thinking, wow, what if this had happened earlier, like it would have totally changed probably what I did or how I did it. But ironically, in the in the Penn hospital, I received a call the first day from a woman who I dated prior to dating my now wife. And she said, Hey, I just wanted to let you know, I heard about the diabetes. And if you ever want to talk to someone about it, you know, you can always call me I know what it's like to live with it. I said, What are you talking about? I've never saw you check your blood sugar or given injection, you have type one? And she said, Yeah, I'm pretty private about it. So often would go to the bathroom. And that's where she tested and, you know, right from the get go I it kind of gave me an appreciation for the fact that there's a spectrum of how people kind of deal manage their diabetes, how they think about it. I was diagnosed in a very kind of,

Unknown Speaker 13:35
let's say,

David Walton 13:37
out front manner, people people knew, like, why is Dave in the hospital here? So and I was older, and it was just a different thing versus you know, if someone's a teenager or someone's younger, you also

Scott Benner 13:49
you also did like a group thing. thing to figure out if you had it, you were talking to people and ask

David Walton 13:54
people they could and they knew about it, and there were physicians that kind of thought but maybe not and then just in general I that's often you know, I that's often the way I you know, think through things that I don't know, it's like, let me talk to other people who may know information that will be helpful.

Scott Benner 14:10
Yeah, well, that's a smart way to figure anything out. I'm now fascinated that you dated a person who had type one and you didn't know it, how long were you together?

David Walton 14:19
Less than two months? Okay, like

Unknown Speaker 14:21
totally

David Walton 14:22
as you're as you're being interrogated in the hospital and I think I was I had every resident intern med student, you know, come through because it's an academic, you know, Medical Center teaching hospital. I got asked the same question you know, any relatives this out of the other? I had several people asked me to knowledge Have you been exposed to a virus in the past six months, and I said, I don't really have a virus meter. I don't I don't know if I if I have been or not, but there was one incident with Taco Bell where I was violent. sick with a stomach virus that happened a few months ago that I guess it's, it's possible. I was just attributing it to bad a bad burrito, but perhaps that was a stomach virus. But then I said, Well, is it possible that this this woman I dated, had a virus and I caught it, I had the same reaction she did, like, Oh, that's crazy. You can't catch diabetes, right? Like, well, I'm not necessarily saying I can catch diabetes, I'm saying, could I catch a virus and we both had a reaction to a virus that was, you know, this autoimmune thing. And they, they kind of treated me like I was the dumbest idea they'd ever heard. And granted, it could have had nothing to do with it. But there weren't a lot of other great theories they were proposing. So I just figured I'd throw that out. I want

Scott Benner 15:45
to tell them I went to Princeton. So David, you're it's only April. But if we give an award this year, for the most organic and natural segue, you're going to win. Just so you know. What? Okay, yeah. Why don't we tell people a little bit about what the T one D exchange is doing? By the way? I don't know. Did we even say that you're the CEO of T one, the exchange, it's not important. It'll be in the title. Anyway, you are? And what are you guys doing right now? based around COVID-19? Sure.

David Walton 16:18
So first of all, it is a very, very high level, we do a lot of kind of what we call real world evidence, doing research and gathering data from things like electronic medical records, for people with type one diabetes. And the goal is to help improve care to work collaboratively with hcps, and researchers on that. So we have diabetes centers across the country that participate. Yeah, through that effort, this quality improvement collaborative we have with different centers, this topic came up regarding COVID, from some of the researchers to our team, that, you know, there's just not a lot known out there, you know, people are, you know, the early information that was coming in, you know, a couple months ago, was, oh, diabetes as a risk factor people, people with diabetes are getting COVID-19. And, as, you know, some of these researchers were looking into what data was really available about type one versus just type two, or overall, just having a diabetes diagnosis, there really wasn't much known. And a couple of things came from China and Italy that we saw that suggested it type one was not a risk factor in and of itself. But that later, we, you know, it seems some indications that poor blood sugar management are probably more indicative of or have more of a causal role in getting infected or having a severe reaction to the infection. So we said, well, we are set up to gather information from different centers on, we're not going to be able to do this automatic kind of poll of data from the electronic medical records of different hospitals. What if we set up a different system to gather data on this from like a survey Type Tool and have a point person at each one of these centers? Just document the cases of COVID that have come in? and answered about we have about 30 questions in the survey, that will give us some idea about the symptoms they had about what their blood sugar control had been previously. What type were they using an insulin pump or CGM? If they were using a BGM? How often were they testing? what medications were they on? and gathering this information? We, you know, had a few goals of trying to characterize does it appear people are being diagnosed in any different rate than either people with type two diabetes or just in the general population? If they are when they are being diagnosed? What is it? How is it presenting? Is there any pattern to the symptoms? And how is it progressing our people? What type of outcomes are they having? It is our are there more instances of DK for these, these people. And so the goal was let's get as many centers as possible. We started with the ones that we work with, which was a about 15. But quickly, other centers were interested and we were started talking to people at other diabetes centers and we saw what was going through on Ada websites and newsletters and things. So we've gotten it up now to about 65 centers. Wow. And and the goal is to get up to 150 to 200 cases documented so that we'll have some ability to draw some insights and conclusions that we can disseminate out spread to the to the medical community and to the patient community, about you know, understanding it better Who knows what some of it is going to be? Interesting, what do we find, and then others we might try to, you know, confirm some of the thinking that we do have, which is that just having a type one diagnosis is not, does not put you at higher risk for getting a covid infection,

Scott Benner 20:19
have to tell you, I'm thrilled to hear that because a friend of mine, who is a physician, by the way, went to Penn, really you and I might be friends, we don't know it. And he's been on a couple of times, through the first six weeks of you know, Cronin, we talked very much at the beginning. And then about three weeks later, and he'll come back on again, as things continue to morph and change. But that really was the consensus, you know, that the best defense for a type one against you know, COVID-19 is being healthy, as healthy as you can be. And in all the ways that that means. And that, you know, he couldn't, you know, early on, figure out how someone with Type One Diabetes, just just by virtue of having Type One Diabetes would be more susceptible to it. Anyway, so since you said that it makes me feel comfortable that about what we talked about?

David Walton 21:13
Yeah, yeah, absolutely. And there are some, you know, some other I've heard Dr. Peters talk, and Dr. Mark Clements, who's at a children's hospital in Kansas City and involved with us. And they've essentially said, that's what the research at this point indicates. Right. And again, it is possible that as you get more information, maybe we will learn something about a certain segment or slice. Sure, you know, we're gathering some other information that could characterize this, but from all the, you know, what we've seen so far, and we're still early, we haven't, you know, analyzed all that, you know, we have about 60 cases documented in the system, by clinicians, but we haven't analyzed all that yet. We just started to do the first 25. And there's a manuscript being written as we speak, because, again, some of its doing the work and some of its getting it out there, yes, and helping to disseminate it and provide it so that other people that are looking for it, you know, have access to that knowledge. And a lot of I've had a lot of parents that I'm in touch with just in the community where I live, who know that I work in the arena. I've reached out to some proactively and a couple of others had, I had some inbound questions, you're wondering, you know what the situation is. And that's basically what I've, I've told them, it's like, we'll learn more. But at this point, we don't believe there's a high risk, but the best, the best thing to do is to keep your blood sugar. And it's tightly controlled as possible, because we know infections, like sugar, right? And if you keep your blood sugar controlled, and to the lower side, it likely will will help about a medical provider. So no, but

Scott Benner 22:56
I have some questions that I don't know if you can tell me from what you've learned so far, maybe you haven't. But first thing is about 60 people from about that many locations was where their hot zones are, was it fairly well spread across the 60?

David Walton 23:11
Yeah, so you know, there's a bit of when you look at the the data coming in, we still have some places with a lot of cases in New York as an example that haven't pulled there. They joined later to the effort. So they're just going through their administrative process, that they're that they're center before they submit the cases, but that should be coming within a week or two. Within two weeks, we should have 100 cases, I believe. We know that there's one one hospital in New York, you know, said that they have about 15 cases. Mount Sinai. Mm hmm. But we haven't seen that yet. That was very got that that. But but they're looking to to put that in, but someone had done someone had quickly looked to see through their systems. And so they haven't entered that in but they told us that they think they have 15 cases. Another another one? I believe NYU said they may have eight cases, or there's some

Scott Benner 24:08
hospitals that are on your list that have not reported back at type on case.

David Walton 24:14
Yes, there are some that said we went through and we had no cases. Gotcha. So yeah, so that's what we need to get more of the information. We can draw conclusions about prevalence from what the numbers that we have, but it is interesting we've seen and our centers may have 1000 type one people in that come to their center routinely. So some of them are decent size, we even have some that are bigger than that, that are 2000 or one that's 5000. So we expect to see some cases just if you think about general population and whatnot, you know, one in 200 people has type one diabetes in the us so

Scott Benner 24:55
well, you know what I find doing the podcast and maybe you know a lot of people with type one as well. I see, there's two, you know, listen, everything's not black and white, but you meet people with diabetes who are either very just micro about it, they're very on top of it, they're a onesies are in the fives. If they get into the sixes, they're, you know, they feel like they've done something extraordinarily wrong, which of course, it's a little silly, but that's what they're that's what they're thinking. They're always well within control. And then you'll see other people who, you know, just having this conversation with someone last night, who asked me, could you interview more people who don't have technology, but who are doing well? And I said, Well, that's, you know, subjective, like what is? Well, first of all, and so the person said, you know, I'm looking for somebody, you know, like you who, you know, whose daughter has a one C and the fives very consistently, I wanted to hear from someone who doesn't have a CGM, you know, doesn't have a pump and is doing that too. And I said, Well, I, you know, I can try to find someone like that. I said, but you'll never know if they're achieving that a one see through protracted lows, you know, they don't have that data. And also, when I've interviewed a lot of people who don't have, you know, any kind of technology that's moment to moment, and I asked, How are you doing, they always say, Oh, I'm doing great. But then they'll very frequently Tell me about an agency that's in the high sevens or in the low eights. And then I realized that their threshold for what great means, you know, is subjective. And for them, I don't pass out during the day and I'm not dead. My doctor says I'm okay. So I'm great. And and it's, you know, there's, there's an interesting swing between, you know, how people manage, and I'm not saying one's better than the other. I'm saying that all those people exist, and then they end up in the hospital. It's funny, because I think that people who are in tighter control lose some of their control in the hospital. And I think people who are in looser control probably gain better control in the hospital. And I'm wondering if there's, if that's being tracked, as you said, we know what were your blood sugar's like prior to being in the hospital? And gap? Do you know what I'm getting at?

David Walton 27:03
Yeah, now a couple of interesting points that you brought up that I could maybe expand on, please. Because here we are, we are collecting the most recent a one see the date and what that was prior to them coming in. So that will give us an indication of where their blood sugar has been, and what their control has been. So that that is part of what we endeavor to look at. You know, we'll get something around that if that, that that role that you mentioned, you know, in terms of the technology, it's, it's funny, I, you know, I came along this, this trajectory, like anyone else, I mean, I feel like I was in a healthcare MBA program. I was very educated.

And I had very good insurance.

I worked at j&j for 11 years. And yet, in my early part of j&j in the early 2000s, my blood sugar control was not that good. And I was only testing with a blood glucose meter, one and a half times a day. I would test every morning, and then either at lunch or dinner, and it was almost, yeah, I've never had an endo say anything different. My Awan sees would go between mid sevens to low eights. But I never broke seven. And, you know, I had moved in a new job, new house, kid, you know, you're busy with life, I was just doing injections and using a blood glucose meter. You know, I decided I'd learned a little more. And I'm like, I really should be doing a little better. My Yo, my endo might say you should test more. But they never said my ANC was a problem was a problem or that I could be doing better. Yeah. It kind of suggested if you tested more, it'll be easier to to stay in tighter control, which is absolutely true. All the data shows that but i was i was a little lackadaisical about it, then that I you know, I decided I want to go on a pump and see because I had a friend who was on a pump. And, and her ex husband worked for a pump company. So I got on the pump. And I saw a little bit of improvement. still didn't break seven on day one. See. Then I joined an insulin pump company in 2006. Right. I was at j&j, they acquired animals. So I went over, and I had to, I was leading strategic marketing, which was looking at new products and what was going on with competitors and all the emerging technology and clinical data. It was a great, very interesting job. And I I, to orient myself, I read through some presentations on advanced pumping by john Walsh on San Diego. And it was a great PowerPoint that went through all the ins and outs of using it and but through that I realized, wait a minute, they have these formulas for how you dose insulin based on your weight and your total daily dose and these rules of 1800 and 500 You divide your total daily dose into those numbers to get your correction factor and your carb, insulin to carb. And I realized mine were seemed really out of whack. I was taking one unit of insulin for 25 milligrams per deciliter to correct and I was taking one unit of insulin for 15 grams of carbs. That's what the educators put me on when I was diagnosed. Nobody ever looked at that no one ever suggested that might not be optimal. What have you, yeah, I start reading this presentation and realize that those numbers don't seem to fit with the way Big Data Analysis would ever suggest, or these formulas and clinical studies that were out there with suggest would be in a kind of a stable adult kind of ratio of those factors. So I just changed them on the fly. I looked at my total daily dose, which is like 53 units of insulin that was in my pump. And I divided it in I just instantly changed my my correction factor to one to 35, I think and my insulin, the carb to one to 10. And next day, when c 6.8. First time I cracked said, Yeah, so I didn't need necessarily the pump to deliver the insulin, but the pump tracked my total daily dose for me accurately. And all I had to do was go through the little cap the history in the pump, and I was able to calculate it. Yeah. And that little formula that had been derived from some people, I think, down in Atlanta, and but it was all over the education and diabetes sources. So for 10 years, I was on the wrong dosing. And it's easier to find issues like that if you're using technology and you're collecting data and then even have have, you know, analytics run without you having to do it, like download reporting now and tools that are out there will do this automatically. But I had a you know, I saw great endos one worked at Stanford, one worked at Novo Nordisk that they didn't. I had no hypose to speak of. So they weren't really acutely concerned about anything, and they wouldn't see a 7.6 for someone with no lows and seems to be doing okay, he's busy. That wasn't, you know, they've got other more problematic situations to deal with. But yeah, that wasn't hitting the target. And I had every other thing at my disposal, great insurance, j&j covered all of our supplies for diabetes. So I, I had no excuse. Once I got in better control. I'm like, Wow, it was positive, that positive reinforcement of, well, now I'm taking the right amount of insulin. And, you know, and I was frustrated, it wasn't brought up sooner. But I was pleased that I finally figured out one of the things that was frustrating me, yeah,

Scott Benner 32:35
no, I'm glad. I'm glad you had that feeling. And you didn't just you weren't angry about it. Because I've I've met people who are so angry after they find out that it's hard for them to get past. You know, I've lived my whole life like this, you know. And I heard, I heard a podcast and my agency went from, you know, 8.9 to 6.9. In three months, how could nobody have told me that? It's sometimes it's hard to get past? Yeah,

David Walton 32:59
no, absolutely. And I also benefited from being around a lot of people with type one, I picked up some tips that after that, so then it was like sustaining that my agencies just got a little bit better. And then we're consistently at those, you know, positive levels. And because of that, that education, and then the technology, and then certainly CGM coming out. And I think I first tried it 2007. And it didn't work very well. It was the first gen of Dexcom. But then 2008 when I tried the next one, this the seven Yep. And that that worked better still had some issues. But you know, wow, the insight of seeing how you spike after breakfast, and you know, all the all the various things that come with CGM. One last point on what you just talked about the hospital though, cuz I think that's a very interesting point that it should be pointed out from some of the data that's coming out. And there was a study done by glide tech on just anybody with diabetes, or any high blood sugar they saw in the hospital, a pure hospital study, that it's clear if you manage blood sugar, and if the healthcare team manages blood sugar, more tightly in the hospital, people do better. In a lot of scenarios, after surgery, getting out sooner, and if they're dying, they have diabetes, and and, you know, they were in for some other condition. If you keep their blood sugar and control, they have better outcomes with that other scenario. That's not what's happening right now. Because of COVID. There are healthcare teams that understandably, are trying to minimize contact with patient and blood sampling and they're busy and, you know, being tapped, you know, the bandwidth is being challenged. Yeah. And what that this One study showed is that, you know, David Kahn off was the author that that People aren't doing as well, there, there are a lot of people. And again, this was a lot of type two diabetes. But you know, we're certainly interested in the type one angle, and we are going to be looking at that potentially with with them. And this is data that comes in from all these 300 hospitals that that they work with. And it's, it's fair to say that there are people that get frustrated when they go to the hospital, if they've been managing their diabetes, well type one. And then they're told they can't use their pump, you know, they can't be doing it themselves. And I know the number of hot there are hospitals that will defer to the patient preference, if they've been self managing all this time. And if what they're in for the hospital for is such that they can be lucid and clear their decision making, then let them keep doing it because they have been doing a great job of 24. Seven outside. So why are we going to change that because we're a healthcare team that doesn't know their body as well as they do and so forth. But that's a, you know, if you can see, it's a challenging problem to know, what's that threshold for a hospital say, No, we've got protocols for our quality, and we don't want to get sued. If something happens, we have to follow certain rules. And, you know, there's it, I can understand both sides of that equation. But clearly, I know people that have gone in to the hospital and said, I'm keeping my pump, you're gonna have to rip it off me, I do a good job with this. I don't want this being mismanaged. And I your point. Some people might be a little over the top with that, but you understand where they're coming from, because you know, they're a little anxious about what's going on. And they know they can do it. But if they pass out, or if they're given, you know, medications that change their thinking that, you know, you've you've got concerns there on the other side. So

Scott Benner 36:50
yeah, we we do a, we do a series inside the podcast called diabetes pro tip. And I do it with Jenny Smith, who works at integrated diabetes. She says, Oh, yeah, she has a CD, she's had type one for over 30 years. And there's, I don't even know, at this point, there's probably like, 20 episodes of it. But we very recently went over emergency room protocols, and how to handle yourself during an illness and injury or surgery. Because it's just so it just it, it's not something that would occur to you, you get into a hospital in a position of thinking, well, these people know better than I do. And you just kind of hand yourself over to it. And it's very infrequently with diabetes, the case, you're often you know, the best arbiter of what's going on. And so I think that's, I think that's incredibly important. Also, I want you to know that when you reached for the word lucid, and I did it exactly the same time, it made me feel like I should have tried harder in school.

David Walton 37:48
One thing my mom, who I grew up with, right, as I mentioned, I was adopted, she was a voracious reader, and a stickler for grammar and vocabulary, right. And just because she read so much the words that she would use around the house, some of it I just picked up, because I didn't like to read that much. Certainly, I, like twin brother, and I played sports constantly, in a way with typical boys. And sitting down and reading was sometimes you know, like, just couldn't be done. But I read in school, certainly, and all that, but she's responsible in part for sometimes I would, you know, use use the dsat words, and then I did some sap tutoring after college, on the side, right, make much more money. And I had to learn extra vocabulary so that I could make sure I knew what I was talking about when I tutored some of these kids when vocabulary was a bigger deal on the LSAT. So yeah, it's it's purely there. The circumstances that exist sometimes explain, you know, explain things more than any other, you know, innate as my grasp of vocabulary is probably the same as anyone else.

Scott Benner 38:59
I got my vocabulary from Howard Stern. So

David Walton 39:01
I got into the radio interviewing

Scott Benner 39:06
podcast, there are times when I think I'm probably only halfway good at this, because of how much of that show I've listened to. There's just a, I have a timer in my head. And when my timer gets bored, I just, I move it along. And I think that's a helpful thing. Okay, so interesting. I want to kind of just hit one thing, and then I want to ask some more questions. But, you know, I don't know that people think about it, because you get diagnosed, and then you're sort of frozen in that time period, right? That happened to you, you were diagnosed, this was the level of care and then that just became what was and as the world moves forward around you, your care doesn't always move forward with you. And that makes sense. If you're with the same doctor for too long or you're not around other people with type one and you don't say to yourself, like how come that guy gives himself insulin before we go to the cafeteria and I'm doing it after I eat, you know, like, like those small idea. And we also all sort of sit back, traditionally, and we wait for the a DA to tell us what our agency should be. Right? That happens historically, over time. The a DA says, this is your goal. And then technology gets a little better than the a DA says, you know, we've done some research. And the problem is, is the research started 10 years ago. And now they're rolling up in 2020. And telling you, here's what you're able to see should be. But you know, I did some research to it was called, I took care of my daughter and figured out how to use insulin, it turns out, you can keep your Ebensee lower, if you have a handful of, you know, tricks in the bag that you can, that you can use for the lack of a better term. I call them tools on the podcast, usually, but they're just simple ideas around using insulin to keep your blood sugar in a more stable and lower place. And so I understand completely the need for the diligence, you know, looking at that over time to come to a conclusion and tell somebody something, don't get me wrong. I'm not, you know, I shouldn't be listened to like the a DA should be their, their their information is vetted. But that vetting process takes time where my vetting process is faster, right. It's it's Yes, anecdotal at first, but then eventually, it's experiential, and then it then it's provable. And I'm a firm believer that I think it's nice when people in the diabetes community say things like, you know, your diabetes may vary. And, you know, your, your experiences with diabetes may vary. I don't argue with that. But the way insulin works, that doesn't really vary. That's pretty scientific, you know. And so the way you use it, or what you eat, or your activity level, or all number of other variables, variables could be different. But at its core, and I say it constantly, I don't think I'll ever stop saying it. type one. diabetes management is about using the right amount of insulin at the right time.

David Walton 41:49
Absolutely. Like I couldn't I couldn't agree more. I the, and again, I worked at an insulin delivery company, animus I mean, what was the point of wearing this, this pump 24. Seven, it's to give the insulin in a better way. Because if you give insulin and and the optimal fashion, you will have great results. It's just very hard to do. But if you pick up all of these, all of these little tips that you're in scenarios about the you know, the first thing people discovered was CGM. I heard Dr. Bruce Buckingham mentioned this, it's Stanford a lot was

Oh, if you

once you put CGM on someone, the first thing they realize is how much that oatmeal causes them to spike. And they don't, their blood sugar's high for three hours afterwards. So people start switching the bacon and eggs, you know, like the carbs in the morning when you're insulin resistant. That that that hyperglycemia contributes, you know, a decent amount to people's kind of above target glucose throughout the day. That dosing formulas that I mentioned, I mean, those Yeah, not everybody is going to fall, right, exactly the formula, it just so happens, I do. I'm like, literally, it worked out. Right on those that it just it fits and my weight, you know, the amount of insulin I use a day is almost exactly half of my weight in kilograms, which is what one and Joe had mentioned to me that that's a good rule of thumb. And it turns out, I get pretty good control, you know, in the sixes, mid sixes to high sixes, depending. And now with control IQ that I use, it's, you know, I'm more in the mids. And I'm not having to, you know, I love that, and we can talk about that later. But, but that aspect of the of the dosing. I fall Exactly. on that. And so I know there are people that have that don't fall right on that, you know, and that average comes from, you know, distribution, a number of people, but when you're way off of that average for no good reason. Or you're doing a number of things like it certainly should give someone pause to think maybe there are some things that aren't tailored to me that maybe I do need more Now, a lot of people don't take enough bazel insulin and so they're putting a lot of insulin to correct for these excursions they have these highs that because, you know, if you're if you're not taking a bazel it's like you've already kind of lost the battle so hard to recover, to, you know, given how long it takes insulin to work. So,

Scott Benner 44:24
David, you would like this podcast?

David Walton 44:26
Yeah, I definitely agree. But one thing I do want to say about who can who's able to figure that out on their own? You know, there is this, it's no

Unknown Speaker 44:34
one

Scott Benner 44:34
it's because the life man because you're busy living here's how I was able to figure it out, right? I don't have type one. It's for my daughter. And because it's for her I feel an incredible responsibility. Right. And I was and continue to be to some degree, a stay at home dad while she was diagnosed, so I had nothing to do but stare at her and and figure it out and and and go through the the Real defeating moments and realize, like, I can't let this be her life, like, I have to figure this out. Like, it must be doable. Some people are doing it, but nobody could explain it. You know, on a side, I got a note yesterday from someone that said, hey, there's someone with an Instagram account ripping off your ideas for the podcast, but trying to put it in their own words. And it's, it's funny. And so I went and looked, and sure enough, there, it's ripped right out of the podcast, and that's fine, you know, whatever. But my point is, is that they said it in their words, and it doesn't work that way. And so there's something about my specific experience and who I am and how I communicate with people. I'm telling you, those those pro tips, it, you know, the other day, I put a website up for, because people were asking, so I made diabetes, pro tip calm, just so people wouldn't have to, you know, go through the entire podcast podcasts if they were just looking for management, because it's interesting. Some people are very interested in community. And some people are very interested in management, the community, you know, just regular interviews with people with type one, and not even like hooked in people, like, people you don't know, they don't have a podcast, they're not online. They're just people with type one, I try really hard to keep those interviews to people like that, right? Those are the most popular podcast episodes. But the people who care about management are fervent about the management. It's It's interesting how some people want the community and some people want the management. But anyway, I put up this thing just yesterday, I said, hey, I've got this diabetes, pro tip calm now. Here's the link, if you could help me in the comments below, just if the podcast has been valuable to you, could you share here, and you know, so people who are coming on new kid could you know, figure out what to expect. And I didn't even believe some of this, this, there's I'm just looking now, my four year olds, a one C is down from 97259. From the diabetes protests, my husband's is down to five, six. And it just it goes on and on. It's it's fascinating. And so I'm proud that I found a way to talk to people about it, because once I could do it, I thought, well, now how do I replicate it for everyone? You know, like, how do I make it as mass market appeal as possible, the idea of, you know, how we manage, and I just broke it down and kept breaking it down and distilling it until it's just the simplest ideas. So that while you're busy living your life, and you know, you're worried about getting COVID-19 and whether or not you can afford your groceries and how you're going to do it your job. And you know, all the other things that people worry about when they start noticing a trend up in their blood sugar that they don't have to go back to a book or go to a doctor's visit, like what what one sentence, can you kind of say to yourself, that'll bring it back for you. And I tried to do that with all the tools. And I think I have. And and, and it's interesting when I used to wonder out loud, like, why can't doctors do that. But now I realized that my whole life's been about communicating with people. That's not what a doctor's life is about. Like, they know the idea, and some of them are terrific at it, don't get me wrong, but a lot of them aren't. And, you know, like, you know, or a lot of them are just like, oh, David's fine, he doesn't pass out. Because they once he's not too high. There's bigger problems here in the practice. So

David Walton 48:26
I'll go I think on the adult side, you know, you find this more, I mean, think about, you know, an adult endocrinologist. How many people with type two is he seeing and, you know, in general, people with type two diabetes are not as engaged and don't spend as much of their mindshare on their diabetes as those with type one do right. Now, it's obvious with kids, I mean, usually people don't have another condition. If they do, it might be asthma, or it might be something else. But diabetes, and with their parents also there, the amount of collective, you know, mindshare, that's focused on that and the importance of that and so forth. Different so you can imagine these endocrinologist who are just beating their head against the wall because they've got type two diabetes patients with multiple chronic diseases, they're not taking their insulin for getting to take their insulin, they're not taking enough insulin, their numbers aren't getting any better. And then if they're worried about a low because of it, I, my endocrinologist mentioned this to me that, you know, when he's had low blood sugars, and some of his older patients, it's when he has their adult child, ensure that they take their insulin every night. And then they get a low because he's been adjusting their insulin up based on the based on that hazard way they use it the way they use it. And so that's part of their skittishness or like, because they don't want to, you know, do no harm they're afraid to, yeah, give them something where an older person who's not used to hypo, that's the thing that happens with tattoos. That they have many more cardiovascular issues. Heart attacks occur when they're not accustomed to having a low blood sugar, and they end up having it at, you know, when they're 65 to 75 years old, it can be, that can be very dangerous. So having spent some time also in the type two space and looking at smart insulin pen caps to try and track that data, so we could try to attack that problem. It's a huge problem. And it's, it's overwhelming, and certainly for primary care, that's taking care of those. Yeah. You know, it certainly can be that well, the percentages,

Scott Benner 50:32
I see them here, because there's, there is no more popular type one podcast than this one. And I know how many people listen to it, versus how many people have type one diabetes. And the percentage of people who, you know, are looking for this kind of information is still small compared to how many people have diabetes, there's, there's far more people who fall through cracks, for you know, the reasons you mentioned, and many, many more than then who are going to have the wherewithal and the and the drive to figure the rest of it out?

David Walton 51:04
Yeah. Well, you know, interestingly, throughout, you know, I've worked in health care for 25 years. And before I was in the diabetes field, you know, I was a consultant, working with health plans, and with pharmaceutical companies. And I remember looking at a segmentation, consumer segmentation, and what are the different kinds of types of behaviors and a couple of these different analyses show that there's like this 15 to 20% of the population, that are the proactive segment, they're the ones that are going to go research, they're going to go take control of things. And if you ask them, How do you approach care? Do you? Do you research it and then go ask your doctor? Or do you wait for your doctor to tell you because they're the trusted health care professional, or somewhere in between. And when you look at that, it's, you know, 20%, maybe 25, depending, are in that proactive kind of thing. And I saw it in oncology, they saw another company had done this, and the people who are the passengers and people who are the drivers, and then people that are, you know, something else. And that unfortunately, like a lot of the digital health tools, and a lot of things they get built, get built for the proactive segment. But we only address that only that kind of population takes full advantage, it's very hard to get to some of the other people, or you have to do more to, to, you know, bring them along that journey to educate them, you know, etc. And this, this is one of the the challenges in healthcare across a number of different conditions. But Type One Diabetes is certainly in that, you know, in that same in that same vein, yeah, that there, you know, you can go online and look at influencers and so forth, and you see certain profile of people, and they're, they're the ones that are have this, they want to share with what they know, because they've seen it work. And they're like, why aren't more people doing this, right. But there are a lot of other people just living their life who don't aren't connected to people, they don't know about things. So awareness is some of these things. You know, it's tough, like I've been at dinner tables at a restaurant. And I'm adjusting my pomp and telling someone where my friends about it, like they're asking what I'm doing. And the table next to me, a woman leans over and says, I'm sorry to butt in, but my boyfriend has type one, and he just doesn't want to listen to me. Could you talk, literally

Scott Benner 53:29
asking me to tell him why you should test more and all this. So I, I understand that and I, I try to massage the situation. I mean, this guy does not want to be told by a stranger what to do in a public place. That's not the way to handle it, but she cares about them. And she and she's frustrated, she can't make an impact and, but people are all over the place. And that's because I did a lot of market research at atomists and surveyed thousands and thousands of people at a time and, um, you know, it's, it gave me a real appreciation for that spectrum, just like when I was diagnosed. And I mentioned, you know, the previous ex ex girlfriend who took a different approach to her Type One Diabetes than I did once I was diagnosed. And that's perfectly fine, that people are different. And you know, the way people these different personality types and so forth. It transcends the Type One Diabetes diagnosis, it's not naturally going to change someone. So understanding that people are different and that different approaches are needed to get people into the education circle. For me, I realized that everyone's life is gonna take a different trajectory, and their level of you know, how much they want to put into their health on many different fronts is is personal. And I'm okay with people making those decisions for themselves, as long as they know what their decisions are, are going to bring, like, as long as they understand, it's okay with me. I don't know if that makes sense or not. But if you want to get your car and drive it into a wall as long as you understand the car is going to you know crushing the law and you're gonna die right on you, you've got free will, you can do whatever you want. You know, and so I just want them to know how insulin works. I think once you understand how insulin works, then the rest of the things that, you know, quote unquote, are happening to you, you can start to see causality for and then you can make your own decision, like, do I want to Pre-Bolus? You know, I think Pre-Bolus thing knocks a point off of a one say,

David Walton 55:24
yeah, it's absolutely. And again, I mentioned that Buckingham comment he made in 2007, at an at a conference, it just struck me, you know, at the time, and if, if you were to think about and we actually came up with a list of these for insulin pumping, when I was at atomists, I remember, you know, this concept of so many people say if they just could share what they know, or they wish they knew this earlier, right. So the idea is, let's get more people to understand these things. And so, the basics of Pre-Bolus, the basics of how much it should be roughly for the carbs are to correct based off your weight. And based off, you know, trial and error sometimes helps you but you have to get that right. If you're if you're you know, and I was I was, again, I was taking too little insulin for what I ate, and then I was taking too much to correct it, I had this little yo yo thing going on. But you know, given that it takes insulin a while to work. And I don't know, four hours is probably an average duration. We know some people go five or six, and some might be within three, three and a half. But that's about as fast as the rapid acting's go. Now you have ultra rap backing, I guess that can be a little faster. A frenzy, you know, inhaled insulin, that could be certainly faster to bring down high spikes, but that gets, you know, that's a that's like the Masters level, like the introductory level, you're talking about. Having just, hey, if you if you did a handful of things, like the Pre-Bolus, that right amount, to avoid Lowe's, you know, you did what's necessary, whether that's if you have a pump, you can do something if you don't, you're on injections, you do something else by eating right. But the timing of your when you take your long acting insulin, and there certainly are better ones now than there used to be. So if they're more forgiving, but they used to be that you needed to get that right, you know, you couldn't miss the time window too much. So that would be a problem. So you go through, it's not a list of 50 things. No, right? Here it

Scott Benner 57:25
is, your Basal has to be right, that's First, if your Basal is wrong, nothing else works. And the things you're seeing are ghosts, because they're not real. And you don't you don't know if that low what that's from, you know, when I do a talk in person. And I explained to people that if they're bazel should be, you know, two units an hour, but it's a unit an hour, then they're a unit deficient every hour, then all of a sudden they come along, see a meal. And I said I always say like, let's say that God himself has come down or herself has come down and told you that this is absolutely 60 carbs, and that your carb ratio is 100%. Right, you can definitely trust that you count the carbs, you put the insulin in your blood sugar shoots up. That's because most of your bolus is really just making up for the job that the bazel was supposed to be doing. When you say something like that to people the look of all on their face is is fascinating. Like, why would no one tell me that? And it's because no one knows how to tell you how to adjust your basal insulin. And so I figured, you know, I figured out a way to talk about that. I was like, look I talked about based on some like volume, I'm like, you turn it up until it's as loud as you as you can stand it. And then if that makes you a little too low, then just turn it down a little bit. If you had a pump David, and your anybody and your basal insulin was wrong, I could spend a half a day with you and fix your basal insulin. Yeah, it's not hard.

David Walton 58:48
I, I absolutely believe that. And we, again, design these download reports for clinicians to download the pumps, and then with CGM data as well. I mean, that's often You're the ones who are really good and used to doing data interpretation to help patients out. That's the first thing. The first thing they look for is, are they having a bunch of they're having lows. If they're not having the lows, then it's let's, let's go. And even if you're having lunch, it could be the bezels wrong. But usually people are under bazel. That's fine. So that's your point. It's the number one thing from a percentage of the time it's wrong. Like that's where you go first. You have to get that right. Because then, like you said, Why worry about your attempts at trying to fix your bolusing and all that the timing and the amount are futile, because you're you've got the wrong background that you can't operate. And so I I totally agree.

Scott Benner 59:41
I practice, not on purpose, but I practice for this podcast by talking to people privately. So try to imagine never meeting someone before having a phone call with them that lasts less than an hour and figuring out their issue and pointing them in the right direction. Not being able to see anything except for what they're telling you. So you have to learn how to ask the right questions. And then you have to learn how like what the path is for them, like, where do they start? And eventually, during that conversation, they'll feel a little emboldened and say, okay, so around my meal, and I always say, No, your meal is all wrong. It's not even work. I know, it's frustrating, but everything you've been staring at trying to figure out around your meal. It's all meaningless data. It's not real, because your bazel so far off, and I said, so you're gonna have to forget everything you've seen before and start over again. It's just, you know, I don't know, man, is it frustrating and not uplifting?

David Walton 1:00:36
What you just mentioned it brings up to two thoughts first, I you know, I just was talking to some people at at t Wendy exchange about this, you know, we have new people come in, I've started giving a diabetes one on one presentation that kind of updated an older one we had and put additional content in there for my experiences in industry and so forth. And

you know, it's it's interesting

Unknown Speaker 1:01:03
that

David Walton 1:01:05
Oh, God, I just lost my train of thought, because someone's banging outside my door. You don't hear the banging. I don't hear the banging. You need to

Scott Benner 1:01:11
get out of the building. First.

David Walton 1:01:13
decks getting prepared. Oh, okay.

Scott Benner 1:01:16
You said you redid the diabetes 101 that you guys had?

David Walton 1:01:20
Yeah. So so we we give that education everybody about? Yeah. So they have some some, you know, baseline understanding about, you know, what's taking place and one of the things we were talking about, and I mentioned was, you know, people counting carbs incorrectly. And Bolus Bolus calculations. So it turns out there are lots of studies that show that people consistently under dose their bolus insulin Yeah. And and the thought and Howard Wolpert when he was a Joslin did a nice study with a 30 gram apple and showed, most people guessed it was 10, or 20, or 15. And that correlated with having a higher agency, and the people that saw it 30 or 35, or 40, which were fewer, their agency was better. And so the idea was, if you're better at carb count, you're more accurate at carb counting, you're going to have a bit it correlated with a better agency, is it? Is it causal? Or is it Who knows? But certainly, it makes logical sense that if you're better at that, but the reason people are consistently under is because they have a fear of hypoglycemia. So are they really? Do they really think it's only 10? Or 20? Or are they nervous about giving too much insulin and getting a low blood sugar. And so we did some research with with a, an insulin maker, about this fear of hypo issue to try to understand some of the aspects of it, and the severity and so forth. And we were going to be doing a broader survey, and there's some things that we're going to be teasing out, but it does, you know, brings up that interesting point about you know, there are there are reasons, sometimes you can think the answer is we just got to hammer people with carb counting, let's give them apps, let's give them flashcards, let's, let's get a picture of the the food they eat and send it to a reference database and tell them what it is, you know, I've seen a couple of these apps that you can scan the photo and or scan the food plate, and it will give a reasonable estimate of the carbs. But it turns out, people may actually have some intuition about what the number is, but they're downvote out adjusting because they're nervous. And so that's the first point. Yep, the second would be the potential and promise of Finally, good closed loop systems, or hybrid closed loop systems in the market. And, and, you know, I'm, I'm a little biased, because I used the tandem with the control IQ. But, you know, this promise that we've been hearing about for at least 15 years since I've been working in the diabetes industry, it's right there talking about closing the loop. And now, some of these issues that do exist, where you can say, Is it an education? You know, can we help people understand this better and train them better on these things? Or can we use technology to handle some of the challenges that just only some people have been able to master themselves? Right? Some people just won't. And there's a spectrum there. And, you know, the power of this with the time and range that, you know, we're seeing with people, and that's the thing I'd point out is my agencies haven't improved that much since going on this, but I have no lows. So you know, I like zero will be my top my time and range will have zero sometimes you'll have 1% I used to be at seven or 8% consistently. And that's that to your point in the beginning about there are some people that keep a when C's down in the fives, but you know, but they've got some real significant blood sugar, low blood sugars at times. I used to have more I never, I've never passed out. I've never had something bad bad but I certainly had a lot more lows and I'd have to, you know, go run, get something to drink and whatnot. That just is much less and that's because of the technology. You know, nighttimes being much better. So that whole issue of what are some of those tips, there are tips that you still would need to do even with these kind of systems. But then there are things like, overnight control can be drastically improved. Because I can't think and do things at 3am when I'm asleep when the system can

Scott Benner 1:05:20
Yeah, I started off all my talks by talking about fear, first, you have to get rid of your fear of insulin First, it just, it has to be, you know, if you're going to be afraid of this, it's not going to work out. I talked about, you know, when you're asleep, it's a third of every 24 hours, basically, right? So it's free a one seat time, think of it that way, you know, and, you know, and then, you know, the Pre-Bolus thing and readdressing blood sugar's when they don't go the way you want. My daughter's not, you know, low, you know, a scary amount. I mean, everybody has a scary low once in a while, but it's not not a monthly occurrence or anything like that. Her a one seat is just cemented at five and a half. And she has no diet restrictions, and only we had Chinese food for dinner last night. And you know, and then she worked out afterwards, like, it's not like, you know, it's a regular life. And her a one C has been between five, two and six to for six years. And it's just doing the things that I talked about on the podcast, and it's being it's understanding them, and they don't get me wrong, like after you have some experience with it, it does become second nature, you know, I don't look at an elevated blood sugar for an hour and a half trying to figure out if this is the right one to put another unit on or not, you know, like, it comes to me pretty quickly. I'm still teaching it to her. But the other part of me believes that closed loop systems are going to keep her from really needing to understand all of the things I understand. And you alluded to it, I'm happy about that as a parent, like if my daughter can, my daughter is not the, you know, she's not the sounding board for the rest of the world. She's a person who's going to try to live her life. And if she can live her life without the burden of knowledge about how insulin works that I have, that would make me happy. You generally mean and and I see it too, like, you know, it's it's obviously here, no control, like who's here, horizons gonna be here. Before you know it. I'm assuming Medtronic will figure out how to make that other thing work better at you know, you know,

David Walton 1:07:24
no, absolutely. The next version of a tronic will be better. You mentioned that those are three closed loop systems. And there are four other ones that are in development, right, and will be out within a couple of years. So that's correct, you know, super excited separation of these different systems. But you I think, the point you made, like, even when you're using the systems they'll handle they'll help take over certain issues or problems or, and make certain things better. But you have to have a base understanding of how it's working, and what to do when, oh, wait a sec. I ran out of a supply or my cartridge, something malfunction, I'm getting an alarm here. And they have they have some technical support, you can call it but there are times where some things have happened where I had to improvise, and not understanding what to do, you know, understanding how insulin work when I was traveling five years ago, and I had an empty vial of insulin in my carry case, and I went to go fill up my cartridge in my pump into Oh, I don't have any insulin. Yeah, this is that you know, what midnight, and places are closed, what am I going to do, and I found a 24 hour pharmacy, and then I go and they can't get the prescriptions not on file. So they could give me regular insulin. And so I got a premix. And I just kind of guesstimate of what I should do based off of what I knew and how much I knew I took for long acting and short acting, I divided it up and turns out it worked reasonably well. But like, if I couldn't have done that, what a scary thought if you were by yourself traveling somewhere in a different city, and you don't have anything like what are you gonna do? These these things happen. I mean, I, everyone's gonna have a moment of absent mindedness or forgetfulness, or, you know, unexpected, you know, something came in and took change your plans and you weren't preparing for that. And, you know, I joke to my wife, you know, going for a walk right after I took a lot of insulin, it's just a walk. But it's amazing how that my blood sugar will go down and I just, It surprises me every time and it shouldn't. It's like I'm just walking. But it's insulin, and I play basketball on the weekends and I you know, lift and workout. I'm relatively active, walking right after insulin. It's amazing how my blood sugar drops. And certainly when I you know, I've ran a couple marathons a way back when I learned how my how to balance the insulin. I take any insulin on board relative to how long I'm running for how hot it is. I'm a big guy. So like, you know, I think it's even more drastic, so I would have to drastically cut back my insulin. Yeah. You know that that was trial error that there wasn't a simple formula I could follow. I talked to people who also ran and but I was a little different and you know, you learn these things, how to tips from other people. So I do think that other people with die with type one can be the best source of information, provided you can kind of take it in the right context. So you'll learn a tip or two from somebody But no, they're like, someone else responds differently to oatmeal or to steak than I do.

Scott Benner 1:10:39
Oh, yeah. Hundred percent or younger people like coffee, half the balls for coffee and other people don't have to for the Exactly. I'm

David Walton 1:10:44
wanting to ask the Bolus, right. I don't drink Starbucks often. But my kids love it. And I get the sugar free. I get you know, and do it that caffeine and why? I have to take four and a half units. If I get a venti

Scott Benner 1:11:01
macchiato. Yeah, we've been we've been doing a great

David Walton 1:11:03
Diet Coke with caffeine, you know, nothing, not profitable, in fact, so it's,

Scott Benner 1:11:07
yeah, sometimes sodas make my daughter's blood sugar go up. And I

David Walton 1:11:11
yeah, and I've heard people talk about that. And like, I drink so much diet soda. And like a lot of people with a one and zero impact like I've, I've looked at this I've watched and see because people will tell me, oh, your body treats diet just like regular nice. Well, your mind doesn't?

Scott Benner 1:11:26
Yeah, you're different, right? Your stuff. We've been doing it, we probably have a half a dozen podcast episodes now about algorithm based pumping. And there's more and more coming because I have to tell you, from my perspective, it's my belief that for the great many people who will never find a podcast like this or find community or talk to somebody or live with another person who has type one diabetes and get a tip from them, you're gonna slap this algorithm on them. And with a, you know, hopefully a little bit of guidance there a one C is going to improve their lows are going to improve, it's going to make their life better. Absolutely. You know, and that that for and there and then there'll be people like me and others that will manipulate the algorithms at times and get it to do more of what we want. And that to me is that's the future. Honestly, I I would give everyone a dexcom if I had the power to do it. Yeah, yeah. Well,

David Walton 1:12:13
I certainly I've heard more and more examples now of endocrinologist putting CGM on right away. Yep. to people and after a diagnosis. And it's it's interesting, because I remember this discussion coming up years ago, and people saying, you know what, you know, pumps are put on sooner than CGM a lot of the time, just because they've been around longer. And there's more familiarity with them. But as the familiarity has increased, and they've gotten simpler and more accurate, that has shifted over the last few years now. So I think if if given a choice, and you told people, you had to have either CGM or a pump one or the other, you have to choose Yeah, I think most people are going CGM. Now,

Scott Benner 1:12:58
my daughter has been using wearing on the pod every day since she was four. And she'll be 16 this summer. And they are sponsors of the show. And I am a huge fan of Omni pod in a million different ways. I know people there and I know good people who are working behind the scenes. And same with Dexcom. And if you held a gun to my head, I'd give my daughter's pumped back if you made me you know if you put me in an either worse situation. I right. I'd rather have a seat. Yeah,

David Walton 1:13:22
no, absolutely. I think, you know, you do have studies like the diamond study that showed you can do very well CGM and injections. Similarly, as you could with a pump. I do think you know, the pump has certain advantages. And then there are certain drawbacks to wearing wine. Well listen, once you see

Scott Benner 1:13:41
the data, in my opinion, then you're gonna want a pump. You're gonna just be like, Oh, I would love to use an extended Bolus here or Temp Basal.

David Walton 1:13:47
Yeah. So like there's that. Absolutely. But you mentioned earlier about some of your listeners being interested in those that technology is funny, because so there are three people, you know, that I know from high school that we all have type one, only one did at the time, two of us got diagnosed as adults. And you know, I won't name her but you know, she has done very well. She was diagnosed in her mid 30s. Very well, just on when she was on a blood glucose meter and injections, okay. They wouldn't see in the low sixes. She's very athletic. But she did. I talked to her a couple times. And you know, I showed up told him what I did, but I'm like, hey, you're doing great man. I you know, enjoy, enjoy that like you're you've got good results. There's not necessarily need to do anything. But then you know, I think some things changed a little and she got out of the habit Libra and think, Wow, this is so much easier than I thought it would be. And I didn't realize like it's kind of cool seeing my body the way it reacts to certain foods. Like Yeah, let's that's the benefit of CGM. And now you know, she's like an advocate. But she was she, not everyone needs the technology at that point in time, but there There's no doubt that a technology like CGM can absolutely give you insights and help make things easier and more and help you do a better job of controlling. Right. You know, and and she's now a convert. So that's why we're getting up into this. I think the estimates are about 4035 to 40% of type ones might be on CGM.

Scott Benner 1:15:26
It's getting there. You know, it really

David Walton 1:15:28
worth that level. Yeah, depends. Depends on what denominator use, I use 1.6 million. But some people use different numbers. I think that's pretty close. That's what CDC came out with recently. So

Scott Benner 1:15:42
yeah, I hear you, I think it's, uh, I mean, honestly, you'd be hard pressed to see the data coming back, like the, when I make an ad for Dexcom, it makes itself data comes back, you get to see what the insulin impacted what it didn't, how you can next time, do a little sooner, a little later, a little more, a little less, you know, do things like I talked about, you know, there's, there's, some times people have meals, they're like, no matter what I do, if I put too much insulin up front, I just get low later. And so we start talking about bigger ideas like getting the insulin up front through a bolus and extended bolus, you know, even attempt bazel increased it to really force the insulin on the place you need it and then create a I call it a black hole of bazel later, just make a void of bazel later, so that when the the harsh bolus you made tails, it tails right into a black hole where there's no bazel. And then that tail just acts as the bazel instead of a catalyst to drop your blood sugar. Yes, it's Yes. It's not as hard as it sounds. Don't even say if you talk if you have a cup, if you talk it through a couple times and understand the timing that your insulin hits, and you can create those sort of, you know, those really kind of what feel like advanced ideas. And you know, I couldn't do that without a CGM. You think I figured that out before Arden had a dexcom? You're out of your mind. So

David Walton 1:17:04
yeah, yeah. Now that that whole concept of like, you know, the Super Bolus, right, that was the concept of pumping A while ago, that much better now, when you have CGM combined with it that, you know, if you're, if you're high right now, you could take even more Bolus and turn your bazel off and get that to get to, you know, try to really bring this thing down faster, right. And like I said, when it's coming down, it's some of it's replacing the bazel deficit. And so you get that softer landing. And so these different ideas, it, you know, because there's a danger element to it, it's not something you enter into lightly, because if you overdo it, you could have a, you know, a bad low. But how nice to have a warning system and alarms go off, if you are coming down fast, and you are cutting below a threshold. Yeah, I mean, that's, that was the early stage of CGM just having that alarm. Like, and yeah, I'm one of those people that doesn't wake up all the time when my alarm goes off the middle the night, which is why control IQ has has helped on the overnight. But that early experience of finally having something it's an early warning system, immensely helpful. And so if people are fear of hypo, I'd say, you know, CGM can be unbelievable in that regard. Now, you have to be okay, and realize you're gonna have some alarms. And those alarms can be annoying at times. But it's kind of a necessary evil I'd much rather have an alarm than wake up in an you know, profusely sweating you know, and, and anxious, you know, in a panic, not know what's going on. And

Scott Benner 1:18:35
I'm hoping you do the right thing that you don't fall back asleep before you figure out if you're okay, and yeah, all the

David Walton 1:18:41
trip down the stairs as you're going because you're a little a little off balance. And, you know, just all those things like, you realize the way we were acting when the technology wasn't as advanced that let's let's take advantage of technology making my life better and simpler. Oh, you only

Scott Benner 1:18:55
you only have to find one person who's had diabetes for 20 years to tell you a story about the time they woke up in the morning and it looked like a bear attack their kitchen and they don't have any record. no recollection of it whatsoever. You start thinking you're gonna call the cops, somebody's broken into your house, but that was just you looking for frosting. You know? It's it's an interesting, it's a really interesting, David, I have to tell you, I mean, this genuinely. You would love this podcast. It hearing you talk. It was interesting for me because I don't come through academia and I don't have type one diabetes, right. I I had a daughter. She got she got diabetes when she was two. I was immediately the person who was you know, with her constantly. Two years into it. I was just still a wreck and everything wasn't going right. And I really felt like I was killing her most of the time. I'd started a blog in 2007, the very beginning of 2007, which sounds cute now but there were only maybe three diabetes blogs. Then, and I wrote about diabetes for such a long time. And then, kind of Luckily, I guess, I wrote a book about something different. And during my PR tour of all people, Katie Couric told me I was good at communicating with people verbally. And I just assumed that everyone was good at that. But she stopped me and told me, no, she's like, you're really interactive. You're moving these people like, Don't you see like your, the way you're talking? They're following along with you. And it was such a nice thing she said to me, about a year later, when blogging seemed to kind of tail away. And it wasn't the thing any more people didn't like to read, I guess. I didn't want to lose the impact of that I was seeing myself have on other people's lives with type one through the blog. And so I started this podcast, which is now 240 episodes, or 340 episodes deep.

Wow. It's crazy, right. And so

when I start talking about what I was blogging about, I realized I could explain it. And then I was getting feedback from people. And they're like, hey, my agency's dropping from listening to the podcast, and it built and built. And then suddenly, I realized that I had a system that I developed an actual system for managing diabetes that I didn't even realize was a system. So I kept distilling it down into t shirt slogans, like more insulin, be bold, Pre-Bolus, like just little stuff, you know, like, just right down to the basic concepts. And what used to be an email or two a month through the blog, like, hey, this blog is really helpful to me, it's now become about a half a dozen notes through different like emails and social media a day, Hey, I just wanted to share with you, my agency came down a point, my agency is down two points, you know, my variabilities, like, I just had a guy the other day show me his, um, his standard deviation was like, 22, from the podcast, which is just crazy, right? Like, I can't get my daughter to 22. I don't know how he did it. It's amazing. And seeing that this was the way that it's repetition, even though it's not your repetition, someone comes in talks about diabetes, I interject a little bit with what I would do there, they tell a story that makes you more comfortable that diabetes is normal. You hear different ways of managing ideas, suddenly, you start seeing, you know, reflections of your own life in these conversations, you make little adjustments, and before you know it, your life suffer. And that was not my intention, I just didn't want to lose my blog. Like that was really it, and that it's turned into what it is. It fascinates me. Because the truth is, is that it's elevated my understanding of diabetes, it's this podcast is much more helpful to me than it is to the people listening to it, I guess, is my is my point. And I've gotten to the point where I've spoken about it so much and broken down so many people's lives with type one, that, you know, I have experiences where I go to, you know, jdrf events and speak and three days later, someone's sending me a 24 hour graph that's never over 120 and never under 70. And they're like there's, you know, there's ice cream in here. Can you find it? I'm like, No, I don't. You know, and, and not that everyone needs to live like that. And I don't mean to say that my daughter's blood sugar is always at five. Because it's not. We're just very reactive to spikes. And we're able to get them down without creating a low. And but but the point is, is that it's there for people and it and it works and to have you come on I mean this with with the with reverence, I really do have you come on and you don't know me, I don't prep for these things. So five minutes before you and I started talking. I had no idea about you, I jumped onto your bio real quick. I was like I went to Princeton, and Penn Oh, this will be fun. And and for you to say things that so closely mimic the stuff that we talked about on the podcast, it made me feel good. It really did. Like it made goods not the right word it It made me comfortable. You know, because there are times where you're saying like, anecdotally I saw this thing, and you're saying it out loud. And you know, when you're blogging to a couple hundred people or 1000 people, which you know, at some point, it became a million people, you know, the stakes are higher, and you realize your responsibility in this podcast has almost 2 million downloads. And so, you know, like, you start realizing like I'm saying something, I better say it right. And it better be universal, you know?

David Walton 1:24:26
Yeah. And so anyway, you know, interestingly, I mean, I'm proud of my Ivy League degrees, but they really don't help with this nothing to do with my diabetes knowledge. And I would tell people, when I got to enemas I didn't know that much. I knew basics of type one diabetes and you know, someone I'd read articles about new products coming out and whatnot. But you know, I, I had to do research to get up to speed and like, I would go to these conferences and just go to the poster sections where all the clinical research are outlined. It's like mean, ridiculous, hundreds and hundreds of yards of posters, you know, on different aspects of diabetes, and you could spend all day in there reading them. And I immersed myself to understand things because I wanted to feel like I was very knowledgeable since I was making decisions about what product we go with next, and what features should be in that product. But I learned so much from talking to people who've been dealing with it, and the the power of experience, and cause and effect, and like being able to figure out what you can use from what someone did. And you know, some people, like you said, with coffee have different, different experiences and reactions to it. And that's something just knowing that that's the case, and that you can't just jump on something because one person told you that's, that's also an important thing. But when someone has gone and talked to a bunch of people, and then curated that and given you a perspective, that's where it's valuable. So that's the role I would play. I used to get frustrated, like people would say, oh, what do people with diabetes? Think about this, Dave? What do they think? As if not asking me because I surveyed 1500 enemas users? Because you haven't been asking me because I was Dave Walton, the type one right, you know, and that type of thing. You know, happened a fair amount.

Scott Benner 1:26:19
Yeah, no, I hear I don't like I don't pretend that everyone's life is the same. I don't think that I just think there are basic tenants about how insulin works. And I think that there are a lot of similarities to people's lives. Like, for instance, one thing I tell people all the time, like, well, how am I ever going to know how to bolster all these meals because we don't count carbs. So we Bolus historically? And how do you learn how to do that? Well, some of the truth of that is you don't really eat that many different things. You don't I mean, like you maybe have 10 favorite meals or, you know, there, it's not like one day you're having, you know, truffles, and the next day, you're having chicken and the third day, you're gonna like give me like, you just eat what you eat. And so I started telling people, like, Look, you can look at that plate, and say, I don't care what the carb count says, this serving is, you know, the outcome of this meal taught me that while my pump said this was five units, it was really seven. If I come around and make this meal next week, and don't put seven units in, I'm an idiot, you know, like, like, I don't just why would I count the carbs? Gonna go five units, just like last time? Like it didn't work

David Walton 1:27:22
last time? Yeah, absolutely. My my diabetes educator in, you know, at the Pet Hospital, when I was diagnosed, said, after the carb counting lesson, eventually, you'll probably get to a point where you don't do the calculation, you just immediately gravitate to the end, you go to the end result, which is this food means, you know, this granola bar means 2.5 units, right? or what have you. It's not that you're, you're just going to jump to that know that association and not go through the math directly. And so like I see pepperoni pizza, which I don't eat that often. But when I do it's three and a half units a slice with a combo bolus, which is what you know, or extended bolus 60% up front 40% later done over about two and a half to three hours. Right. And that's how pepperoni pizza works for me if it's the right size, the right not to thicker crust, whatever. What when it deviates from that, yeah, I'll be a little bit off. But generally speaking, I go right into it. Let's pepperoni pizza. Here's what I do.

Scott Benner 1:28:22
And if it goes wrong, you're not flummoxed.

David Walton 1:28:25
know exactly how you'll spend the next six hours. Okay, right. I'll monitor and say, wait with my insulin. Do I need to give a little extra was a little under was just a little heavier in carb than I thought. Yeah, absolutely. All the time. Chinese food. You mentioned pizza and Chinese food were two of the problem. foods for a lot of people to usual suspects. And the Chinese I never eat the rice, but manage the sauces and any kind of you know, reading they put it on certain things. But I try to be mindful that I swear I still always get it wrong.

Scott Benner 1:28:57
Yeah. Oh, it gets in there with the fat man. And it just stretches out over hours and

David Walton 1:29:01
hours. Now you see that stuff in the refrigerator and the next day you realize how much fat is in the corn starch or this whatever is in there to make it taste good? Is this big jello? It just congeals in the refrigerator, you realize that's what the chicken egg carry on was?

Scott Benner 1:29:19
I have to tell you last night, my we were finished. And my wife's like here put this away. And I'm like, throw it away. And she goes, What am I gonna keep that? And I was like, Yeah, I mean, I'm not eating it again. Just so you know, like the heat was the only thing making it palatable.

Yeah. Anyway, David, I've learned I can talk to you forever. And I've kept you much longer than you. Then I told you, you're gonna be on. Here's the funny thing. Did we finish what you want to say about what's he when the exchange is doing for people with COVID-19.

David Walton 1:29:47
We know we talked about COVID. I think the last thing I'll wrap it up with is that so we are going to be presenting results along the way. So think of it as the cases come in. We analyze them so Yeah, the first 25 cases, we started to do some analysis, draw some, just just to characterize here's kind of what we're seeing. But you can't really draw too many conclusions from the first 25. But we'll be communicating this information out on a regular basis. So I think, by the end of the first week, in May, well, probably the first time we just talked about that. But we've got 60 cases, and now we'll have 102 weeks. And then there's going to be a lot more and it'll be growing. And we're working with the researchers, these clinicians, you know, Todd Alonzo, at the Barbara Davis center in Colorado. So it's a, you know, a big, one of the biggest in the in the country in terms of taking care of people with type one. And Mary Pat Gallagher at NYU, that they're kind of leading the research along with this Dr. asagi, the cozy and who's at t Wendy exchange. And he has a wife with type one. He's got a lot of great experience working in the type two diabetes and HIV arenas before he came to us as a consultant, and then as a full time doctor, clinical researcher, so those results will be coming forth. We are talking about additional studies, there's a lot of interest. And I talked about the hospital, we may do something looking at just hospitalizations because of some data that this other company has. They want to work with us potentially. But there are other aspects of the what we've done. So that's our big focus now with COVID. But in general, this collaborative we have, we're focused on improving care. And we work collaboratively with leading diabetes centers. And we're growing that and so we'll be at over 20 centers that do this regularly with us picking out topics like how do you drive CGM uptake? How do you screen for depression more consistently, right? Because these things impact care. And the are collaborative, we help do the data analysis and share it with them and work with them hand in hand on how can we get us all to a better spot. And we're all collectively focused on let's get people in better outcomes with Type One Diabetes. That's our that's our mission. That's that's their, their mission. They just happen to be providers of care at diabetes centers, and we happen to be a not for profit in Boston that works with them and does a lot of data and research as part of it. So I love working at that T Wendy exchange. And, you know, I think we have gotten more focused on near term impact and near term, how can we help other organizations and whether that's a healthcare system or another, not for profit, improve the situation for people living with type one. And, you know, I think we're we've had some, some good progresses here, and more people are interested in joining this collaborative, more centers, and we want to get that bigger, so the knowledge is shared amongst all of them. We don't have situations where like I was describing, I'm on the wrong insulin dosing ratios for 10 years. And that was such a simple fix to take off, you know, at least half a percent, if maybe pi more like point 7% off my agency, right? That those kind of things should be done more routinely. And again, we work with some great centers that do a lot of great things consistently. But part of their interest in the collaborative is they're learning from the others. And so they may have a lot of people using CGM, but they may not be screening people for depression and realizing Wow, so that's how you guys are doing it with your, with your medical record system, and how you're getting counselors and social workers connected with patients so that they can deal with these tough problems and challenges like oh, okay, and so it's a it's witnessing it is it's awesome.

Scott Benner 1:33:40
How do you take once you learn something from, you know, you gather the data, and you you sit down and you make sense of it? And you find a, you know, something that that's fallen through the cracks? How do you? How do you put it into practice? Because that's, that's, that's really, you know, great question. Yeah.

David Walton 1:33:59
And I'll tell you what, so this is I won't go deep into quality improvement methodology, because that'll cause some snoozing potentially with some listeners. But there are things called change packages that we helped create working with the Diabetes Center. So it's kind of like an implementation plan. And here's how you do this now. So like we know with CGM usage, look, there are things you can do to make it easier to start someone on CGM. There are also things you can do to make sure that the reimbursement exists. So in Texas, the Texas Children's Center that we work with, they've done a lot of great things to drive up CGM use, but Medicaid wasn't paying for reimbursing CGM for people with type one, right. And they've actually I think, been pretty successful in working with Medicaid to get one off approvals and maybe get a system wide kind of change for that reimbursement well by sharing some information and approaches used by others, centers and other states that helped their cause. But they took a kind of a leadership thing, like they recognize the importance of it, and we help support them with data. You know, we have a portal that we provide that they can do some reporting themselves and look at things. But we also do analysis and provide them with with things so. But the idea is, there are these change packages that we help roll out that's like the implementation plan to do it. And then there's measurement. And every month, you can see how things are going. So are you seeing the CGM usage going up, just like we they look at a one C, we have several years worth of a one c values for all type one patients at these centers, they can see what's happening there, they can see what's happening in their high risk group of people without a one C of nine or above. And so by tracking it, and really, it, you can't manage what you don't measure. And unfortunately, we've lived through that as a country with with COVID. Diabetes is the perfect example of that, when you do a good job of measuring it, it really helps to manage it. And that's something that we're kind of, we help drive that change with these centers working kind of hand in hand, and we're lucky to have a great starting set of centers, and we're looking to add a lot more so we can have a bigger impact. So you know, 1.6 million people, you know, we've only got about 25,000 patients so far in our, in our system, the data from from those EMR, those centers, we're hoping to, you know, drive that number up over the next couple of years. So we have a much bigger sample to work with. And it's, and we're touching more people at those centers. And then other people can learn from that we'll put publications out, a lot of the researchers that work with us at the Centers are putting abstracts out at the ADA conference, European conferences, trying to even share it learn from people, you know, in Europe and elsewhere. So there's so much that can be done on that knowledge sharing and getting it into the hands of gay I'm working with organizations like ADA, and at CES, the new diabetes educator name. And then patient organizations to like, we'd like to get the word out there. And so we've had good work with jdrf and beyond type one and TCL ID and children with diabetes. You know, a lot of great organizations there. We're all trying to figure out how to help each other kind of just complement each other not overlap too much. And that's a big part of what we're

Scott Benner 1:37:25
doing. Well, I'm really pleased that you came here to share it with me so I appreciate it. Thank you for coming on. I know I kept you long. You know to find out more about T one D exchange you can go to T one d exchange.org. Huge thanks to David for coming on and sharing I'm pretty confident he's going to be back at some point I really enjoyed speaking with him. I want to thank also the Contour Next One blood glucose meter. Of course more information about that can be found at Contour Next one.com there's links in the show notes touched by type one is that touched by type one.org please go check them out. dexcom.com forward slash juice box for more information and how to get started with the Dexcom g six continuous glucose monitor. And of course, a absolutely free no obligation demo of the Omni pod tubeless insulin pump can be sent directly to your door by going to my Omni pod.com forward slash juice box. Have a great day.