#541 Dr. Saleh Adi
Dr. Saleh Adi is a pediatric endocrinologist and the Co-Founder and Chief Medical Advisor at Tidepool.org. Dr. Adi speaks with Scott about insulin delivering algorithms and type 1 diabetes Management ideas.
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Scott Benner 0:00
Hello friends, and welcome to Episode 541 of the Juicebox Podcast.
For this episode, I'd like to give credit where credit is due. Steven is a listener who sent me an email. And at the very end of it, it said, Hey, I have a guest suggestion for you. You should have Dr. salia. d on. I did a little research and I found out that the good doctor is a pediatric endocrinologist who is also the co founder of tide pool and their chief medical adviser. So I was like, all right, that sounds like a good idea. But what happened next was nothing short of absolutely inspiring. This conversation is one of my favorites that I've ever had about the management of diabetes, and I hope you enjoy it. Please remember, while you're listening that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before you make any changes to your health care plan. or become bold with insulin. This conversation is going to break right down the middle almost the first half, we're going to talk a lot about algorithms and the future of them with Type One Diabetes. And in the second half, we're going to talk about Basal insulin, and ideas around management just listen to the whole thing. It's a Master's class.
This show is sponsored today by the glucagon that my daughter carries g vo hypo Penn. Find out more at G Vogue glucagon.com forward slash juice box. The episode is also sponsored by the Dexcom g six continuous glucose monitor, you can get started or Find out more at Dexcom comm forward slash juicebox. There are links to all the advertisers in the show notes of your podcast player. We're at Juicebox podcast.com.
Dr. Saleh Adi 2:02
My name is Saleh Adi and I am a pediatric endocrinologist I spent most of my career taking care of children with diabetes, until very recently, a couple of years ago when I decided that it was time for me to retire. And I left my position at UCSF and I have been just hanging out having fun and volunteer into a number of organizations that I've always done before, mostly related to diabetes in children. And here I am so happy to be involved and continue to be in the community this lovely, wonderful community to be part of.
Scott Benner 2:41
It's excellent. How long did you practice?
Dr. Saleh Adi 2:45
I graduated from UCSF program back in 1997. So that's really when I finished training. And first, I was mostly in the lab doing basic science research until about 2003. That's when I returned to San Francisco and focused my career, refocused my career on clinical work with children with diabetes. And I left the basic science world.
Scott Benner 3:15
What What made you What made you switch.
Dr. Saleh Adi 3:20
I had to make a decision. It's either basic science research or clinical work. And I couldn't do both at the same time, I loved my basic science research area. It was it was wonderful. It was a lot of fun, because I thought that this was something that I wanted to do for a living. But I always miss seeing patients and taking care of patients and interacting with human beings. And I realized after trying for a few years that it's really impossible to do both at the same time, you kind of have to choose either 120% research or 120% clinical, otherwise, you can't really get it done doing 50% here 50% there or a combination. And I had to make a decision and I gave up my lab and decided to be a clinician.
Scott Benner 4:08
Well, there's at least one person who's really glad that you did and it's a person who wrote to me and said you have to have salad on the on the program just to talk about basil insulin and I was like, very specifically was such a specific email. So I said big and I went back and forth with the person they said I'm telling you just have him on and I said okay, I'm gonna believe you. Now you're involved with tide pools still, is that right?
Dr. Saleh Adi 4:39
Correct. Correct. I'm still on the board the tide pool and and Chief Medical advisor. And I know just about everyone who works at tide pool and it's been it's been a lovely and fun journey since we established dipole seven, eight years ago.
Scott Benner 4:55
Well, well, you know, maybe I'll dig into it like this. Maybe. Do you remember The moment when tide pool said, we're going to try to bring an algorithm to market through the FDA.
Dr. Saleh Adi 5:07
Ah, yes, yes, I remember that very vividly. It was a board meeting when we discussed it for the very first time, and everyone was so excited about the idea, such a novel idea, and it was very timely. You know, the loop project has been around as a DIY loop people, you know, download the software and the hardware together and make it work. And it had been for such a long time. So controversial. Is it a good thing? Is it a bad thing? It works clearly works for the patients. But how do we make it official? How do we make it safe? And how do we get the stamp of approval from the authorities? I think there was at that time, it was highly controversial. And the FDA was sort of like, we really like this thing, but we can't allow it to just continue to go on like this. It's so non official, and in the hands of people who don't know what they're doing, it can be not so safe. I don't want to say dangerous, because it's probably okay. But the FDA eventually sort of decided to, well, let's take a different route. And I think in combination between the FDA, and jdrf, and the Helmsley Charitable Trust, they decided that, well, DIY loop is a nonprofit, open source project for the good of the community. title is an nonprofit, open source project for the good of the community. That sounds like maybe we can do something together. And they basically approach tight balls and said, Would you work on this project, to make it more formal and get the official approval, and do all the things that we need to do to make sure that it's safe and efficient and effective, and get it done with an FDA approval? And it was like an aha moment, like, of course, this is what we do. So let's pivot and change direction and make sure that we're going to be able to do this right. And that was a moment when it all started.
Scott Benner 7:20
I have a question. And this will I hope, it doesn't sound like I'm I don't even know the word here. How it I don't mean that if it sounds bit poor, I just don't understand this one aspect of it. How do you take something that's floating around on the internet? And take it and say, we're going to package this up and move it through the FDA? Like? Well, I guess the question is, why is that? Okay? It's just because it's it's open source? Is that the idea?
Dr. Saleh Adi 7:49
Well, because it's open source, that means it's available for anyone to take it, we don't have to pay for our task, a tight pool was to actually look at it, look at the software itself, and make sure that there are no bugs, make sure that it's rigorously tested, both technically, as well as clinically. Now, doing it clinically is a monumental task, like the traditional route would be? Well, let's take the software. And let's go and design a randomized control trial, where patients can get enrolled in the project and get this DIY loop software or patients and others randomly chosen to not get the software or that they would get another different software, and do the comparisons, you know, do the study, obviously, collecting all of the data, and then do the comparisons looking at the data back and see. Was this safe? Was it as safe as the other projects out there the other closed loop systems? Was it as effective as other closed loop systems? Or was it better or was it worse? And and doing it in a in a randomized control trial in a very efficient in a very official way? That would have taken a long, long time. And the the way we have chosen to do with that title is there are a lot of people who are using it and officially out there on their own. So why don't we end and they've been using it for years. So we have a ton of data collected on them already. It's just not done in a randomized control manner. But there's a lot of data out there that has been generated for years in real people living their real life. So why don't we just go and look at their data if we can, and enroll them in the study and continue to look at the data moving forward for those who are going to start on this system and then see what we get. We know how to look at data We know how to collect data and see whether there's any evidence of that the system is unsafe, or if there's any evidence that it's harmful. Or if there's any evidence that it's actually really good. And we can show the data. And that's kind of where it all started. And we collected the data, the observational study, and we crunched all the numbers. And I shouldn't say we, I think type poll, I really don't take much credit for it, they've done that tremendous job, and submitted it to the FDA and see if the FDA will be happy with all with this sort of non traditional pathway of looking at the safety of a project of a product. And if the if it's acceptable enough to demonstrate safety and efficacy, because at the end of the day, that's what the FDA wants to see. Is that Is it safe, that if we give it to the people to whom it was intended for, that it's going to be safe, if they use it the way it is right now. And is it effective? Does it really do what people claim it does? When we are clearly looking at data and not based on just anecdotal experiences? I see. And we'll wait to see what the FDA thinks about
Scott Benner 11:21
it's an amazing idea to just say to them, Look, I know, this is usually how it goes. But we have all this data, why don't you let us look at it and send it to you and see if you can't be okay with it. And exactly, it really is a fascinatingly simple, you know, you just don't hear too many people approach things in a common sense way, usually. So it's exciting to hear someone look at something and say, here's, here's the common sense of this here. Why don't we do this, I'll have to tell you that my daughter is 17. She's been using loop for maybe a year and a half or two years now. And I mean, she was doing incredibly well, prior, my daughter's a onesies been between five, two and six to for like eight years. But the amount of sleep that we got back exactly. With loop just at all, and we're using an auto Bolus branch. So it's a it's really wonderful. I mean, it's, it's, I haven't seen all of them, obviously. And on the pod fives not out yet. But this is the best one I've seen so far is is is this exact thing that we're using right now. Also, the idea that you that you kind of came to an agreement with on the pod, I mean, the idea that one day on the pod five can either run its algorithm, or yours is brilliant as well, in offering choice to people. I just think there's a lot of open mindedness going on that, that I like saying,
Dr. Saleh Adi 12:50
I like that term, I think the open mindedness, which would be if we were to coin an official term would be interoperability, if you will. So that was something that typos. And I get the credit to Howard and Brandon, the leaders in title of COVID, adopting that concept from the very beginning, from the very early days, it's just like, we have to open up the space of diabetes and, and get rid of all these silos of every company using only their devices and their software. It has to be open so that people can have a choice, which prompted they want to use which CGM do they want to use which software do they want to use, and put an end, put a combinations together, you don't have to buy all of your kitchen equipments from a single manufacturer, with a single brand you like this oven, you like that refrigerator, in that freezer, etc, you can put it together and you can work together. And this is the same concept. And in you know, I'll give the credit to the FDA, who will really was saying, We love the idea as well. And we want to encourage that. So now it's become a very common thing to ask for it just like when you as a manufacturer, when you create a product, how interoperable it is. And it's desirable to be very interoperable and open to other companies and other softwares to work with. And that also was something that jdrf pushed for very, very strongly as well.
Scott Benner 14:26
Yeah, I think that if you're not, if you're not paying attention, you might think of it as I enjoy this pump over this pump. And that's what makes this my choice. But you have to see that moving forward. You're going to want to choose between algorithms like this, the hardware is one thing but the operating system, you're going to want some impact on to so imagine if you really loved Medtronic operating system, but you wanted to wear it on the pot or you know, I mean, I realized it's probably not going to work like that between companies. But this is that idea. Like you get it on the pod because you like it you get on the pod five and you say I really want to try tide pool. And you can like it mean open minus from the FDA from tide pool, I think on the pod to being a privately held company saying, Yeah, well, let's do this like, that's there's a lot of exciting things in here. And I think people with diabetes are going to recognize in the next handful of years and beyond that the algorithms are going to be as valuable as anything else.
Dr. Saleh Adi 15:24
Absolutely. And the algorithm really is the biggest difference, I think that the mechanics of the hardware are more or less for the comfort and the and with what it's like, you know, what I'm comfortable with. And it's the it's the human factor of the hardware that attracts certain populations, certain people, but also the software, I think it's even more important, because software algorithms with all of these closed loop systems are different from each other, they are different enough, that in my opinion, my humble opinion, that that a certain software algorithm isn't going to work for every patient with Type One Diabetes. It depends on how much insulin they take, it depends on how how much beta cell function they have, it depends on how old they are. It depends on their lifestyle, it depends if they are, I think that an algorithm that's going to work really well, for a young adult who eats three times a day very distinct meals, is not may or may not work for a teenager who eats 16 times a day, and eat five grams snack here, and 12 grams snack there, and 128 grams, you know, breakfast, it may or may not work. But and the same thing, if it works for that teenager, who has completely unscheduled bursts of activities and food and behavior may also not be the best algorithm for a two year old infant who has type one diabetes, that's a whole different animal dealing with type one diabetes in a toddler versus an infant versus a young child versus an adolescent versus a young adult, versus even an older person who's like 60 7080 year old with Type One Diabetes, those are very different people. And we really have to approach them differently. And why I think we have to keep that in mind is that not all algorithms for closed loop systems are going to work for every single person with diabetes. Some of them will work better for others, they may work fine and be safe. And I think it may be more, they may be more effective for different populations of people would they be
Scott Benner 17:49
I found that there's a learning curve to I'm going to use the wrong word here. Because I don't mean it to sound like this. But you have to sort of manipulate what the algorithm wants to do sometimes. And sure, and you can make it fit you. If you understand the bigger picture. Surely, no, you definitely have to and for my daughter, you definitely have to Pre-Bolus food. If you miss on the Bolus, you can't lay back and just say, Oh, the algorithm will fix this because maybe six hours later, your blood sugar will come back down again, you have to be willing to go back at it. And then recognize when to let the algorithm start taking basil away again, like there's there's little tricks to do. I think that's where people have to learn on their own how to do it. But I'm saying that away from food, and away from an active Bolus. There's nothing better than an algorithm like this, the ability at a low number is is astonishing the ability to stop a really frightening low, I don't know that my daughter's blood sugar has gone under 50 in two years. Like it, you know, we've had, we've had times where you're like, Oh, I know this happened. But you but you think back to prior to the algorithm, a 50 would have turned into a 30. In a situation like that, then you go back and look at the data and see that for the past 90 minutes, this thing has been trying to stop this low. And I for people who have not lived long with diabetes, you might not know it, you know, for people who weren't born 20 years ago, you might not know it, but everybody needs to understand that in my opinion, this is the way to go. But settings are still King, no matter what like if your settings aren't right. You might as well be doing it blindfolded with a with an old rusty needle like it you have to have your settings right.
Dr. Saleh Adi 19:36
Yeah, good. I agree with you more. And I would add a couple of things. One is you know, Scott, I think you know, I totally agree with what you said is that you need to understand how the algorithm works. And not to the details over over the software engineer can level the you know, understanding but at least know what it's trying to do. The more you know, the more you understand how the software is how the algorithm is thinking, the more effective you can make it by manipulating certain things, not necessarily manipulating the code. Again, that's, you know, let's not go there. But more like, you know, thinking along the same lines that the algorithm is thinking. Just like when you're dealing with a child, you can have just to think, the same way that child is thinking. And you can have a really good relationship if you do that. And the same thing for it for a soccer algorithm, you can make it work much better if you know how it works, and know which buttons you need to turn left to right, to make things better. But also understanding that your manipulations can make can make an algorithm work much better. But it can also, in terms interfere with its function to be 100%. Effective? Yes. So you really need to know what what are you doing to make it better? And what are you doing that can potentially make it worse? And that effectiveness of you know, not getting down to 50 for the last two years, if you don't know what you're doing, you might actually prevent it from being that effective.
Scott Benner 21:22
Yeah, it's 100%. True, as as easily as you can assist it, you can fight against it. And exactly when you start fighting against it, it's making decisions based off of things you've told it, and then you're changing the game, but it's still doing what you told it like you can't, you can't just randomly throw in a couple of units of insulin and not somehow explain to the algorithm that this is because of I mismatched my carbs. It's one of the things that that makes loop, I think really great is the little stuff, like being able to go back to a Bolus from 90 minutes ago and say, You know what, I told that thing, it was 45. But it turns out, this is 52 carbs. Like that kind of stuff is huge. We have got it's brilliant. Yeah, we have a series of episodes in the podcast called Fox in the loop house that I think you might really enjoy. Where we talk about how to, you know how to be Dr. Frankenstein a little bit with with the algorithm I am. I have to say I'm super excited to see on the pod five. I know it's gonna work differently than loop. But I do want to understand it. And I want to try to get to the point where I'm a good tactician with that as well. But can I can I ask you a question before we move forward a little bit and talk about stuff? If you don't? If you don't know, you don't know. But I keep thinking. You said something earlier in the like when you almost came on, like the FDA said they couldn't let this thing go on. Meaning like an algorithm that just lives out in the in the world that's giving people insulin, do you think they're going to come after the DIY DIY loop at some point and try to try to scuttle it somehow?
Dr. Saleh Adi 23:05
I think that, you know, again, I think that if they wanted to do that they would have done that years ago. And the fact that they're working together with jdrf and Helmsley and title and the community to make it safe is like they don't want to go after anybody. They want this to actually work and be safe, so that everyone can have it. That's good, not just not just the, you know, the elite software engineers and mathematicians who want to, you know, grab this and, and put things together. They want everyone to benefit from it. Otherwise, we wouldn't be doing it.
Scott Benner 23:43
Right now. It's it's an interesting topic, because I know a lot of people use it, you know, when you consider that it's just something that exists out in the ether. But, you know, when you pull that up against how many people are using insulin, really, statistically, no one's using loop. You can compare it to how many people need insulin. So if you can get it into hands that way, I mean, I know very little about type two diabetes, but it seems to me if you're insulin dependent type two, an algorithm would be genius for you. And
Dr. Saleh Adi 24:16
yes, yes. But I have to say, Scott. It's it's not a bad thing. That loop is not so widely used currently, as it as it is in its current form. Because I do think that it's not for everyone. Like you hinted at, which is like, you really need to know what you're doing. Yeah. You need to put the pieces together. You need to do it right. And then you need to have an understanding of how the algorithm works. Because because you really you do need to make sure that you're not interfering with You're not going to interfere with its performance because you can, because by design loop was designed to allow for a lot of things that the patients can the user can manipulate. And for a good reason, it was a clever design. But there's so many things you can manipulate that if you don't know what you're doing, you're actually going to make it not effective and even unsafe, if you go far enough. So I think it's a it's a good thing. And that's what I'm excited about his title is trying to make sure that there are some, some guardrails in there, that are put together so that you don't end up manipulating stuff that you shouldn't be manipulating.
Scott Benner 25:43
Now, I agree, I think that if you if you could take a macro view of this, that the idea that this happened, and that there were this kind of small band of people who were so fervently, you know, developing the algorithm, and at the same time supporting people, and they even put up barriers for people to get to it. I mean, it's not easy to figure out how to do this. And so it's sort of that it sounds crazy. But I do the same thing with the podcast, like, I don't make it easy to be a guest on the podcast. And because of that, what if you're there, when I turn on the machine, when you say you're going to be there, I know, you really wanted to be on the podcast, and that, believe it or not, weeds out a lot of good next. So because there are people who flake and bail and, and you know, and I can't wait three months to be on or something like that. And I think the same thing about about loopy has to make it a little hard, you can't just hand it out like candy. because like you said, you could you could really not know what you're doing. But these people then help other people, they saw people brought them into the fold, explained it to him kind of created a little user base of it. And it expanded slowly. It's beautiful, really, like you'll look back on this in 20 years and think
Dr. Saleh Adi 26:58
Oh, absolutely, yeah, that's the revolution. You know, yeah, it really started start a revolution, the way we think about the whole field and about the approach of FDA approval in building software. And, and I think it also drove, you know, pushed the world of ABS into this interoperability concept even further. Because it's it's a product that stands on its own. It's just an algorithm data. Loop doesn't doesn't make a pump doesn't make a CGM. It's just a software. So you know, we don't have to build a pump. We don't have to build our own CGM. It's a software that should be able to be used by by anybody who uses either pump, or either CGM.
Scott Benner 27:46
Is tide pool involved in development, or are they? Are they quite simply just taking this specific algorithm and trying to move it through the process? Or do you think you guys will at some point, say, well, let's get some developers in here, and we'll get an auto Bolus, like version of this and things like that?
Dr. Saleh Adi 28:04
You know, I think absolutely right. It's, it's not just, let's take it, take what we have and get it approved, I think it's, you know, obviously, once it's approved, once that virgin one is approved, we're already working on version two. And it's going to have different features, and it's going to have, but we need to get the approval for the first one need to go out there and actually be used. But no title will eventually continue to be involved in the development and, and optimization of loop as a software.
Scott Benner 28:41
That's really I have to say, That's terrific to hear. Because as much as I enjoyed loop, it didn't really it didn't really live up to its promise for us until the auto Bolus branch came. And that that was a that was a step up. And and I'll tell you to, if for anybody listening, as much as I've learned about diabetes over the years and kind of put it into words that people can understand, I've learned a lot from the algorithm as well like seeing it. Take away basil or or up basil or to see like a bad site. Like you can see a bad site because Luke keeps bolusing you're stuck at 120. And Luke just keeps like the auto Bolus branch just keeps Bolus and Bolus and Bolus and I'm like, Oh, this thing doesn't think it's gonna break this. This this line right now like this 120 is sticking and then you learn to see bad sides because of that. You learn. You know how you could have attacked these things differently without the algorithm. I've learned more about using insulin from loop in the last two years, maybe than I have from using it.
Dr. Saleh Adi 29:50
And yeah, yeah, yeah. Yeah, because this is forcing you to think it's not just take an injection or take a Bolus and go away. There. Because there's not much else you can do, you have to wait for the effect of the insulin. I think because of the intelligence of the software, it's now doing all kinds of things. And if you're really into it, you can start looking at the data. You're looking at that CGM tracing and seeing like, where is it moving from here? Why is it not moving? How can it move too far it was this wasn't the intended action. And it makes you think, and the more you think about it, the more you understand it, and the more you understand it, the better operator you become,
Scott Benner 30:33
it almost becomes second nature. itself. Yes, it takes.
Dr. Saleh Adi 30:38
And it takes a while, it takes a while. And, and there are people who can learn something to themselves. And they can really make it work so well, if they're doing it themselves. But they can't teach it to somebody else. Just like, I don't know how I'm doing this. I just know how to do it. But there are also people who are really good about learning something and also teaching it to someone else. So I think that's where the role of the clinicians come. They have to really understand the algorithms, and figure out how to teach people at different levels of ability to understand these technicalities. And I'm not really good at that. I don't I still don't know how, you know, functions. 100% there's so many things that I don't know about. And I go back to my friends and colleagues and dipole. And I say, Can you tell me why did it do this? Why did it Why didn't do this. And then I learned one more thing about how it thinks and how it operates.
Scott Benner 31:46
I think that one of the biggest leap that we're all going to have to make is exactly what you just said, which is finding a way for clinicians to simply explain this to someone. I don't know that that's doable. Honestly, like, I think it almost is going to have to be one of those slow matriculation things. We're a generation of doctors lives with it like I did, and stares at it and sees it work, until you can just sort of talk about it in a colloquial way, without it seeming overwhelming.
Dr. Saleh Adi 32:18
Yeah, I think I agree with you, I don't think that it's possible for every clinician to be so immersed in the technology of diabetes, that they're going to understand every single device and every single algorithm, I think there are, you know, a handful of us who really, this is what they do for a living. And it's just best to look at data and look at numbers. And they just love that and they want to understand it. But not everyone's going to have that the ability and the luxury to spend that much time and do all of that. So I think the clinicians have have two different roles in this in this field. One is to know all of the algorithms and the hardware is and what they can and cannot do, and help the patient make the choice. And I stress the word help you cheat, the patient still has to make the choice on their own. Not as a challenge, but more like this, you know, what works for you and what doesn't work for you. But also, but the convention needs to be there for advice. And for sort of direction, I think this one might work better for you. I know you like you know, product B but I think product A might be better for you because of so and so based on experience based on just knowledge from the past and seeing other patients similar to you. So that's one and then the other is, is continuing the education started with simple and then come back, look at the data and say, Okay, how can we make this even better? I really think that closed loop systems should not be accepted to achieve time and range of 70 some percent on the I think they can do a lot more than 75 and 76%. If we if we learn how to operate them, right if we learn how to manipulate them, right. And if we obviously I'm talking like if you Bolus for everything you eat, of course, I mean that's like the essential thing. If you don't do that, then forget it. It's just not gonna achieve 80 90% in time and range. So besides doing that, I think that there's a lot to be done gradually for teaching patients and families and how to use the systems to make it work effectively more effectively. But I also go back to one thing you said earlier, which I think I totally agree with in believing, which is the settings the settings are absolutely key to making any system work effective. If you don't have your setting sites, I mean different systems work differently, obviously. And some will take whatever settings you have and manipulated and increase it and decrease it. And some will just ignore completely what your settings are and just think on their own. But I think for at least for the systems that are based on settings that we put into the pump, then I think that the settings need to be optimized as much as possible. If you don't have settings correct, then the system is just fighting too much, and not being super effective.
Scott Benner 35:35
So I think that leads us pretty well into into the next part of our conversation. I'm very pleased to bring this podcast to people because I think it does the thing. You know, part of what it does is it does the it does the job that manufacturers are not allowed to do because the FDA doesn't allow them to do it. And I say this here so that people understand that a pump company is not allowed to tell you how to Bolus for food. Like they're they're quite literally not allowed to, they can tell you that this is the pump. This is how the pump works. You know, functionally, this is what an extended Bolus is. But I can't tell you when to use an extended Bolus, besides, you know, beyond the example of if you have pizza, they're not allowed to talk about how to use insulin. And that's
Dr. Saleh Adi 36:24
not they're not clinicians, that's the clinicians job 100%. And
Scott Benner 36:27
so a lot of people get frustrated because they get on a pump and they think oh, the thing doesn't work, but they don't know how to use insulin. So at the basis of how I talk about insulin, whether you're using an algorithm or you're not in my mind in this order, it is get your basil correct. Learn how to Pre-Bolus understand the different impacts of different foods and then stay flexible. To me those are the four steps to stability and making decent boluses How do you think about that?
Just briefly before the ad start, let me let you know that that noise you were just hearing in the audio is a person down the street from where I record grinding up the trunk of a tree and that does not last for very long during the episode but I am sorry about it. It was far from here and sounded like it was happening right next to the microphone. Anyway, g vo Kibo pen has no visible needle. And it's the first pre mixed autoinjector of glucagon for very low blood sugar and adults and kids with diabetes ages two and above. Not only is chivo hypo pen simple to administer, but it's simple to learn more about. All you have to do is go to G Vogue glucagon.com forward slash juicebox. g Vogue shouldn't be used in patients with insulin, Noma or pheochromocytoma. Visit g Vogue glucagon.com slash risk. So far, there's been a lot of talk in this episode about algorithms, right an algorithm is a program that will live in the in the case of the Omnipod five, it'll live right in the circuit board of your pod. In the case of tide pool when it comes out. It'll live on your cell phone, if you're using a tandem pump. I think it lives right on the pump. I'm not 100% certain but it no matter which one of those you're using unless it's Medtronic. The one thing that all three of them are going to have in common is that they're getting their data so they can make those decisions that they're going to make from the Dexcom CGM. So maybe now is the perfect time for you to find out about the Dexcom g six continuous glucose monitor. Dexcom is a device that you wear, and it reports your blood sugar back to you in real time. Now for Dexcom users that could mean on the receiver that they'll give you or write back to your Android or iPhone, if that's what you want to do. Users of the Dexcom can have followers up to 10. Actually, people just like me or your mom or dad or brother or sister or school nurse people you trust, who can watch your blood sugar in real time on their phone if you like. or you don't have to share it with anybody. It's up to you. But the option is there. Now what is the Dexcom going to show you it's going to show you the speed and direction of your blood sugar. It's also going to show you what your blood sugar is. You're saying I'm saying the number, say your blood sugar's 124. This speed is it moving at all up or down. And if so how quickly two points per minute, three, four more. It'll tell you that too, with directional hours. So now the arrow is gonna point in the direction if your blood sugar's dropping, let's say and tell you how fast it's dropping so is my 124 dropping it four points per minute to one etc etc. This information is super valuable extremely extremely helpful, and at the core of not only how I make decisions about my daughter, but it's also the way that these algorithms are going to know what to do with your insulin. So just like seeing Arden's blood sugar tells me, I think we need a Temp Basal increase here, we should Bolus a little bit or maybe take away some insulin, whatever it tells us, whatever algorithm you choose, is going to also get that information. Please trust me, if you can afford this stuff, if you have insurance coverage, look into it. dexcom.com, forward slash juicebox, the future is here already. Go find links to the tchibo hypo pen Dexcom. And all the sponsors are available at Juicebox Podcast comm or they're right there in the show notes of your podcast player.
Dr. Saleh Adi 41:05
I love your elements, the four elements. And I think you're absolutely right. First, I would start with a Basal. You know, besides understanding how insulin works, and how long it takes for it to actually start working, and how long does it take to be to peak its action, and how long does it last before it finally gone and has no effect anymore. And different insulins have different dynamics. And understanding how food affects the blood sugar and how the dynamics of digestion and absorption different foods are slower and, and and faster than others. And and and they're different in each person. And they're different in the same person. If you eat something in the morning versus you eat it in the evening, the dynamics of absorption are completely different. So learning all of that all of those individual parameters about that particular patient, then we're we're talking about the algorithms and the software and the hardware, I think, you know, setting the basil correctly is number one, and then figuring out what the right ratios are the incident the current ratio, and the correction ratio, and the insulin duration timing, to factoring all of that into the thought process, not just the mechanics, but also the thought process. And that's really hard. You know, it's it's hard to ask everyone to do this every single time they eat something. So we have to simplify it in the beginning, and then get more sophisticated as time goes by. And it's like you said it's it, it then becomes second nature. It's hard to deal with in the beginning. So I think it's upon us actually the clinicians to make it simple to make it intuitive. And to start with smaller baby steps, and then keep going. And in order to do that, you can't just come to the clinic every three months, and do this lifetime of education about certain things, that the the interactions between the patients, the clinicians and the and the patients needs to be continuous all the time. You grab a teaching moment and you say, Okay, let's talk about this. Let's learn one thing today. And that cannot be again, like every three months, when you come to the clinic, there has to be a channel of communication that's open. And I think this is this is this was one thing that titebond really insisted on from the beginning, from the very early days is just like, we have to make the data visible in an intuitive and simple way, and an actionable way. So that we can collect the data. And we can visualize it very simply that everyone can understand it. Because it's key. You can't you can you can come up with all kinds of ideas and and interventions and trials and say, well, let's do this and see how it works. If you don't collect the CGM data and go back and look at it, you have no idea how your experiment worked or didn't work, or what worked and what didn't work.
Scott Benner 44:15
I've been considering for the future of the podcast. I have a friend of mine comes on the show sometimes Her name is Jenny. She's had Type One Diabetes for over 30 years. She works at integrated diabetes. So she is she spends her day talking people virtually through their blood sugar's and she's just really terrific. And one of my ideas for the future is to do a series for clinicians about how to talk to people about their stuff. And it's cool. Yeah, I think that one of the ideas I've had in the past that I don't know why hospitals don't do instead of seeing people 15 and 20 minutes at a time. What can't you do in a large group setting where you can put together a few hours. So you know, see, see 20 3040 people Time and give their give them a larger instruction, which will, by bringing them all together gives you more time to talk to them.
Dr. Saleh Adi 45:06
Like I think that it means certain things can be done in a group and certain things can only be done in one on one person. Sure. So I agree with you that we can be a lot more efficient if we, if we knew what to teach as a group, and, and the idea of doing classes. But now with the technology that everything can be done remotely via zoom and other platforms, then I think I think we need to take advantage of that. And we're not actually doing that very well. Would it?
Scott Benner 45:39
Would it surprise you to know that literally every day, I get between six and 15 messages from people who are experiencing stability, and a one sees in the fives or sixes who just previously three, four or five months earlier, we're on a roller coaster and had no idea what they're doing just from listening to a podcast?
Dr. Saleh Adi 46:03
Yes, that would that would surprise me. But pleasantly surprised to hear that that within a few months, you can actually get that kind of comfort and stability and feel good about it. It can be as you well know, I don't have to tell you this. But it can be extremely frustrating when you're trying to do something, and it just doesn't work. And I really think that, you know, for a lot of my my own personal experience that I have seen, a lot of people get really frustrated, simply because they've tried everything. And the reason that their experiments are not working is because their settings are not correct. And again, if you don't have your insulin to carb ratio, if you don't have your ISF, if you don't have your Basal rate settings correctly, you can go crazy doing all kinds of things. And this just doesn't make sense, right?
Scott Benner 46:58
You can work as hard as you want to dig a hole. But if you're using a screwdriver, it's not going to go well. And right this is this is what happens over and over. So how do you talk to people about the setting their Basal insulin, because the way I talk about it is so incredibly simplified that I wonder how you would talk about it.
Dr. Saleh Adi 47:19
Basal rate is one of my favorite topics to talk about. Because I believe that the base rate is the key to achieving good results. And it's the most important parameter to look at. Because if you don't get anything else, right, you can get the nighttime when there is no food and no activity, which is the which is the product of nothing else. But basically, there's nothing else going on at night. And if you can figure that out correctly, you get yourself eight to 10 hours of straight line of CGM that is going from left to right. And maybe just maybe changing a little bit or fluctuating, but it's still staying within the target range of 70 to 180, or even 70 to 140. So it's worth studying there. And if you get that right, if you get the base rate right at night, then I think it actually gets you in a very good spot during the day. You don't have to do basil testing during the day, you don't have to go for a whole day without carbs to figure out what your basil rate is. I truly believe that if you get the basil rate correct at night, it gives you a pretty darn good idea what the base rate should be during the day. That's number one. And number two is figuring out the basil rate pattern. There is a pattern of basil of basil insulin requirement throughout the day, but particularly at night. And that pattern is not just a flat one single base rate all night long. What the patient what that is the kids that I dealt with all my career is like when the child with Type One Diabetes requires, you know, point four units of insulin, it doesn't, it's not going to work if you do point four units of insulin the whole night. There's definitely a variability a tremendous variability. And it could be point four in one hour and can be point six or seven in one out and then come back two hours later, and it has dropped down to point two or point three units an hour. And knowing that pattern and following that pattern can really put you in a good spot. And then you can achieve a very good flatline of CGM during the night and it can be extremely satisfying. Not only that you had a very good night but also that when you get up in the morning, you're starting in a good spot to begin with. If you get up in the morning with a blood sugar of 300 it's really hard to get that that fixed For the for the rest of the day, if you start out with a blood sugar around 100, then I think it's going to be a much easier job to actually get it and stay in range for the rest of the day. So Basal rate is the key. Basal rate is the first thing I look at. and nighttime Basal rate is the is where we start. And once we get that, right, we know the basic rate for the day. And then we start working on the incident, the conversation and the eyes.
Scott Benner 50:26
So you have no way of knowing this because you don't listen to the podcast. But when other people listen to this, they're going to be able to feel me smiling while you were speaking. Because you would love this podcast. That's the first thing I can tell you. And you and I are like we are absolutely kindred spirits. You You really did just speak words that I have spoken almost in the exact same order. You used a couple of different ones. But you said exactly the same thing that I've been telling people for years. I'm so glad to know, I'm so thrilled you you said what you did? Because I agree. I mean, everything like I don't think you need to basil tests, like when I tell people when they ask like, Well, how do you figure out what your basil is? I tell them, I think of it as like an old stereo. I turn it up until my mom yells and then I turn it back down just a little bit. And that's good. And you you always do it overnight, right? Like because overnight, all the a lot of the impacts are gone. Unless they're children and they're growing, you know, but overnight, you get overnight, right? And then the daytime is going to be pretty close to the overnight. Some people need a little more overnight, a little less. But for the most part, if you can figure it out overnight, you can figure out during the day and then that just leads into the rest of it, then you can check on your meal insulin is my meal insulin right? Am I Pre-Bolus Singh enough in and then from there, it's just understanding the different impacts of foods and not getting caught up and saying, well, this is 10 carbs. And my ratio is one to 10. I don't know why this one not like what I tell people is I don't care why it goes up. If If meatloaf and green beans mashed potatoes, you know, comes down to 55 carbs, but you always end up correcting later with two more units. We'll then dammit move the two units into the bullet. Because Exactly. It's what that meal needs like just be done. Stop fighting.
Dr. Saleh Adi 52:18
Right, right. It's it's not it's not let's blame the manufacturer who printed the information incorrectly on the box and says if it says 18 grams, but clearly in your experience, it's 24 just counted as 24 next time doesn't matter what the box says. Yeah,
Scott Benner 52:34
no, this has been terrific because you just made me feel like a genius. I really am thrilled. Well, you are you are. No you didn't need to say that. But it just was so free. You know for your edification. Like, I've just been a stay at home dad for decades. My daughter was diagnosed when she was two. I was just like everybody else. I didn't know what I was doing. I didn't understand how the insulin worked. I felt like I was killing her constantly. And honestly, it was before CGM. I probably was. She had a she had had a couple of seizures from low blood sugars. And I just one day I was like, I gotta figure this out, or she's not going to be okay. And back then I had a blog, and I wrote on it a lot. And writing on the blog helped me figure out things. And then one day, I just said to my wife, I'm like, I have a system. I was like, there's a system here and it works. And I don't think it would just work for Arden. I think it would work for everybody. And I just realized that like one of the more damaging things that we say to people with diabetes is like, Oh, that's diabetes. You can't do anything about that. Yeah, yeah. Yeah. Or I'm brittle. You know, you're, you're brittle, because your settings are probably all wrong. Like Like, like, like your jump, I understand your blood sugar flies all over the place. But now I see people all the time. You know, when they come into the podcast, who look quote, unquote brittle from 20 years ago, but their Basal is just wrong, where they let me ask you this. How often do you find that people mistakenly treat Lowe's by taking away basil instead of increasing basil so that they can make better meal boluses does that Oh, it
Dr. Saleh Adi 54:16
it happens. It used to happen more often than it does now. And it all comes back to miss understanding the dynamics of insulin. Cutting off your basil is not going to treat your low, you're gonna be low for the next hour or so you need to do something else. You can prevent the low by cutting up basil, or by stopping the basil or together an hour before or an hour and a half before. But you can't treat a low by doing that.
Scott Benner 54:47
Yeah, let me let me dig deeper and tell you what I've seen from talking to people. So just let's be accepting of an idea that there's a person in front of you who needs a unit of insulin per hour as basil bye For some reason, they're using point seven. And then they end up having to make super aggressive boluses. At meals, they don't Pre-Bolus usually they fly up, then they crash down. And then they go back to their doctor and say, Look what's happening. And the doctor says, oh, you're having a lot of lows, we should take away your Basal insulin. Now they're point seven ends up point five. And all that does is make them be even more aggressive at meals next time creating more lows. Do you see that? Have you ever seen that?
Dr. Saleh Adi 55:28
Oh, more often than I would like to. And I think that even a lot of people also on their own start adjusting their basil incorrectly. I, I encourage people to look at their data and make small changes. But the first thing that they always think about is it's the base rate that needs to be changed. And sometimes it's it because I think it's really hard to figure out whether the insulin to carb ratio is working or not working. I think it's harder to look at it, I don't think it's really hard. I think it's just harder to assess it. Versus it's the Basal that's too much, or it's the Basal is too little this increase that and all of a sudden there's this imbalance between the basil and the Bolus is. And I think that's also an important thing is to understand for each age group, what should the basil present be compared to the total daily dose of insulin? And that can be an extremely helpful guidance towards where should I be looking? First, there's a big discrepancy. I know that, for example, a 14 year old with Type One Diabetes should have about 40 to 45% base rate. And all of a sudden, I see someone who is 14 year old and only getting getting like 65%, in Basal were clear and 35% in bonuses. And the carb ratio is only, you know, one year for 20 grams, then clearly, there's an imbalance there and I can direct I can straight go to that Basal retinas sake, that's too high, 65% Basal for a 14 year old or for anyone age, that's just too much. I think we need to cut back your Basal. And let's either wait and see what happens to your blood sugars, or we can blindly increase your insulin to carb ratio, because it clearly too low and adequate need to read. We rebalance things a little bit. So it's a very helpful first look to say, where are we in the ballpark of Basal rate? Is it the right percent? Is this something that we need to just generally increase or decrease? Or is it more like it's in the right ballpark? I just need to fine tune it a little.
Scott Benner 57:47
I sometimes believe that that's a holdover from old MDI, clinicians who just pushed up basil to Yes, yes. To ask other problems. Yes, yes. Oh, what was I just gonna say do basil. Oh, I, I have this theory. If this is anecdotal, completely, but I do end up talking to a lot of people, I think a good place to start with children who are pre pubescent, like, you know, no, but nobody's into, you know, any other. Any other real growth yet? point one per hour per 10 pounds. That's where I start in my head. It's not all of it for basil, basil. So if you're 50 pounds, you're around point five. If you're 40 pounds, you're around point four. It's a starting point. It's not always 100%. Correct. But yeah, but when you're, but I find myself frequently put in a position where I'm talking to a person privately, who I don't really know. And I don't know how to like, I mean, they want to they're, they're lost. They're, I mean, try to imagine so that you've, you're, you're a parent of a child, or you're a grown up with diabetes, and you're reaching out to a person on the internet for help, like, imagine how lost you are in that moment, because that's not a good idea. And so then I get a message from somebody. And I say, Well, look, let's just get your basil straight first, then I think everything else will start making sense. Well, where do I start? And then you look, and they have 7000 basil rates, all because they've been chasing ghosts for weeks, you know, trying to, you know, things around. And I'm like, like, let's just start here. And I usually say, if it's a 50 pound kid, and I see for instance, they're at point two, five, they're at point three, five, but they're always in 200. So I'm always like, well, I would maybe move that 2.4, let it sit for a number of hours, see what happens. And then we can move it from there. That's just a jumping in point for me. But
Dr. Saleh Adi 59:39
I never thought of it that way. But it, it may be perfectly reasonable to then I will have to do the math. And if I were to approach it from the way I think about it, I would say you know, a pre pubescent child, let's say an eight year old For example, or a seven year old, would require a total daily insulin of somewhere around point five units per hour. For everything total daily, so a seven year old, let's say if it's a I'm sorry, what did they say? point point five unit per kilo per day? Sorry. I misspoke. point five units per kilo per day. So how many kilogram is that child, let's just say if it's a 20 kilos, that means the total daily insulin should be about 10 units, 10 units for that child who was a seven or eight year old, about 40% of that, or less 35 to 40% of their GDP base rate. So that's about three and a half to four units a day of base rate. Does this jive with your calculation? You don't have to do the math? No, no,
Scott Benner 1:00:55
it's pretty close. It's and like I said, it's not a perfect thing. It's not like you just say to somebody, what's your way? This is it? It's a starting point. It's an exactly, you know, exactly. And that's what they lack. That's what I've learned when you're speaking to people's what they lack is, they're like, I don't know, up, down left, right. I've got seven basil programs. My doctor keeps you know, every time I say, Look, he's, you know, no one says my kid's blood sugar's high at 11 o'clock every night. No doctor says, Do you eat a high fat meal in evenings? Like no one ever says that? They say, oh, we'll turn your basil up an hour before it goes up usually.
Dr. Saleh Adi 1:01:29
Right. Right, right. And the other thing I see a lot is, you know, it's in, you know, if you're, you get up in the morning, your blood sugar is 200. And then immediately jumped was like, well, your base rate is not enough. We need to increase your Basal at night. And I think that that happens a lot. And sometimes it's correct. But oftentimes, it's not. Because what was your blood sugar at bedtime? And what was it at two in the morning, if you went to bed at 202, in the morning, it was 200. When you woke up in the morning at 200. That means your Basal rate is actually pretty darn good. It kept your blood sugar exactly where it was the beginning. And for the whole night, you're a 200, ss flatline. 200 that means your base rate is perfect. You don't need to increase your base out what you need to do is to increase your insulin to carb ratio for dinner, or increase your base or before midnight. So that way, you actually hit the night, hit the bed and hit the night with a good blood sugar and it stays that way. And you wake up.
Scott Benner 1:02:29
Yes, yes, yes. That's the way I think about insulin gwit. When I tell people, I say look, insulin you use now is for later. But more importantly, more importantly, the way to think of it. If you're if you're in the middle of managing in the moment, you have to think of it this way. Insulin from before, is for now. That's it right? Right. Right, right. Same thing, but it's a different way of considering what's happening to me now is from before, like that, that helps you in the moment make a decision. Not you know, if you say well, what I'm doing now is for later, people chase they just keep chasing the insulin. It's it's just it's like a time travel movie. And they're in the wrong timeline. You know, II mean, like they're fighting the dragon, the dragon. The dragon was here three hours ago. You don't find it now, you know, get and I always tell people get low, get steady start over. Like don't because they'll chase for days and weeks. And in it. Yeah. And that's the thing that gets. I think that's where the psychological impact comes in that feeling of I'm working so hard and nothing's going right like and and I want to trace back to something you said earlier, I do completely understand that when people are newly diagnosed, that you want to spoon feed them a little bit and bring them along slowly. But I think the one sentence that never gets spoken to people that they need is this is what we're doing now. But this is going to keep changing. Because exactly they get stuck, especially when a honeymoon ends. I don't understand. I don't understand what's happening. Well, there's not enough insulin here has to be this has always worked hasn't and then I think has no one told you that this was going to increase or how is it he didn't think that you gained 10 pounds. And now you need more insulin, or you know, like little things that just you get you get so you get so micro and you're so close to it. You just kind of can't see the forest for the trees after a while. And if someone doesn't tell you that you have to step back every once in a while. You'll never think to do it.
Dr. Saleh Adi 1:04:29
It's Yeah, no, I agree. Scott, I think this is you know, in pediatrics training, this is drilled in our head, which is the anticipatory guidance, which is to tell the parents what to expect next year, what to expect six months from now, so that they're not all of a sudden, oh my god, what's happening to my child. So it's that anticipatory guidance and then telling them what's going to happen from now. And don't be surprised, and I've always taught people and I can't believe that I get the same response every time just like when they hit puberty, they're going to be on 1.2 units an hour, they're going to be on a current ratio of one to five grams of carbohydrates. Don't be surprised when that happens. And all of a sudden, they just their eyes wide open, just like what they're going to require that much insulin, it's gonna come in just like, no, that's what they need. And we just have to keep increasing it with time. And then the other thing is, no matter what we do, we get the settings right, we get we work really hard at that base rate to get to be just perfect for the whole night. And guess what? It works great for about two weeks, and then two weeks later, just have to start over again.
Scott Benner 1:05:41
Well, I think something you just said really, really sticks with me because I have a number of episodes on how much is enough. And I preach to people that the amount of insulin you need is the right amount of insulin. Not because they ascribe a number to it, or a percentage jump freaks them out. That's another thing that happens to people I get dumped. They love to say it double That can't be right. Well, it appears to be right. And but people get stuck. And when that drags into adulthood. Suddenly, I've interviewed a lot of adults with type one diabetes, they start getting psychological impairments that are difficult to shake. And one of them one of them is a shame about how much insulin they use. Yeah, that's fascinating, isn't it? Yeah, no. So I I've done my best to, to make sure people understand you know, that you just need what you need. Oh, so my daughter 17. She weighs maybe 130 pounds. She is as fit and healthy as you know, a person could be and her her ratios. Her her carb ratio is like one to four and a half. Wow. And that's just how we have our that's what works for her. Now Could I dump a bunch of basil on her and just make sure she eats you know, three times a day and has a snack before she goes to bed? I could. But my daughter also got up this morning. went to high school has not eaten yet. It's 130. Here. I just got a text from her. When are you done? I want to have lunch. Okay, so that okay, and I'm going back on her CGM. I'm going to go back 12 hours, turn my phone landscape and tell you that at 145 in the morning, she was 118 down to 109. I'm now at three o'clock. She's 90 480-893-8591. It's six o'clock. She said school. She's 92. That's it. She's been between 90 and 85. For the last 12 hours. She has not eaten a morsel in that time. Yeah, and that's good. Basil. Right.
Dr. Saleh Adi 1:07:51
That's what but that's that's both the basil way as well as loop and the algorithm. Right. So so but I think it's, I think you also described something which is very key, it's not looking at what her blood sugar is right now is also what it had been over the last hour or two. Because it's a different it. It's when I tell people is with CGM. It's not a blood sugar of 92 anymore. There are five different 90 two's, there's 92 and two arrows up, there's 92 and one arrow up, there's 92 and straight to the right, and two down. So there are five different 90 twos. And each one of them you think about it very differently. And your decision making is going to be different if you have a 92 up versus down.
Scott Benner 1:08:40
Yeah, no, it's just great. Listen, you're allowed to come back on the podcast whenever you Thank you. It every February if you ever like find yourself sitting around the house, you haven't worked in a while and you're like, people need to know about this, you send me an email, get your right on here. Because right, because I really, I can't tell you how much I appreciate your input and your knowledge, especially over all this time. And and for the people listening to I have to imagine it brings them some sort of solace to have you come on with you know, you got quite a quite a long list of bone a few days in front of you. And you really did just say what I say on this podcast for a while and I hope that helps people feel comfortable because I think that you have to dispense with your fear of insulin first. You know, and there are about 1000 other things to understand. And to your point, you can't get them in a doctor's visit. You know you can't bring people together. I think this delivery system for information is great for people because it's at their pace and on their time. And I honestly think if you if you were diagnosed today, and I've seen it a million times already, and you just listened to this podcast. I think you have an A one C in the sixes ease And I, I swear I don't want to do it on here because it'll seem self serving. But I could show you just endless, endless messages about the same thing, people who are diagnosed and find the podcast in the hospital on day one, and will report to me six months later that they don't even understand what. Like when they hear people having all this trouble. They're like, I don't I don't even understand how they could have this trouble. And I was like, Well, yeah, but you you started listening on day one.
Dr. Saleh Adi 1:10:29
Yeah, it's not easy. It takes it takes knowledge, managing type one diabetes, it takes a lot of knowledge. And, and it's acquired the gradually and slowly over time, because it's biochemistry, its biology, its physiology, its food, science, its activity and exercise, physiology and all of those things. And then and then pharmacology when it comes to insulin. And then now we're throwing, you know, software, stuff over, you know, on top of things. So it takes a lot. And it can be overwhelming if you think of it that way. But just take it one step at a time. And look at the data. You have the data, you have tons of data, everyone has CGM data, everyone has pumped you and Bolus isn't insulin, just download those devices take half an hour to just take a look at it and see what makes sense. And if something makes sense. And if it's something doesn't make sense, ask your child, they actually didn't have significant input and insights into it as well.
Scott Benner 1:11:33
I just realized just looking at my at my daughter's data and talking to you. I saw by what the algorithm was doing that her basil could have been a little stronger today because it was taking it away and then Bolus thing and taking it away and Bolus thing for those 12 hours. So if the basil was maybe a tiny bit higher, it might have been able to get away with takeaway and not Bolus, but in the end, it's working exactly the way I want it to. So Right, right. I can't thank you enough. I I invite you if you're interested. Beyond the hundreds of conversations that are in here with people with type one diabetes of all ages, I have a series called defining diabetes that goes through all the tools and in a short way explains what they are. There's a pro tip series that walks you through how to manage yourself. We just launched a variable series. You know, I think the last episode of the variable series was video games. Because, you know, the adrenaline from playing video games for some kids makes your blood sugar go up. I have a great afterdark series with people who have all different kinds of like real world life problems that people who are bipolar, you know, have serious complications there. You know, all this stuff, people that type one talk about it, I swear to you, you listen to this podcast, you're gonna think I ripped you off. So I can't thank you enough for doing this. I mean, this is really wonderful of you to
Dr. Saleh Adi 1:12:58
know I very much enjoyed and Scott, thank you for having me.
Scott Benner 1:13:01
Yeah, and I'm gonna thank the person who sent me your name, even though I don't remember who that was. So if you're listening, you did this. And thank you very much.
A huge thank you to one of today's sponsors, je Vogue glucagon, find out more about chivo hypo pen at G Vogue glucagon.com Ford slash juicebox. you spell that GVOKEGL Uc ag o n.com. forward slash juicebox. I'd also like to thank Dr. Adi for coming on the show. And I mean it sir. If you're listening, come back whenever you like this is fantastic. Lastly, thank you Dexcom for being a generous sponsor of the Juicebox Podcast if you want to learn more about the Dexcom g six continuous glucose monitor. That's at Dexcom comm forward slash juice box. If you enjoy the Juicebox Podcast, please share it by telling a friend that really is the best way to help the show to grow, sustain. And to continue on. Just tell someone, listen to the Juicebox Podcast, show him how to open up a podcast app if you have to show him where the subscribe button is. That kind of stuff is a huge help. Hey, and if you like the show, you might really love the Juicebox Podcast Facebook page. It's a private group with almost 15,000 people in it now, all talking about stuff like we talked about today. Juicebox Podcast Type One Diabetes on Facebook is the least Facebook place on Facebook. I think you know what I mean by that. And if you're still listening, I'm going to assume you're a real big fan of the show and ask you have you gone to T one d exchange.org forward slash juice box yet and filled out the survey. If you haven't, and you're a US resident who lives with type one or a US resident who is the caregiver of someone with type one. Please do that right now. It'll literally take you less than 10 minutes. There'll be a huge help for people living with Type One Diabetes and you'll be supporting the podcast at the same time. T one d exchange.org. forward slash juicebox. That's it for me. Thanks so much for listening. I'll be back very soon with another episode of the Juicebox Podcast.
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