#885 Type 2 Diabetes Pro Tip: GLP1, Metformin and Insulin

April 7, 2023Scott Benner

A series for people with pre and Type 2 diabetes.

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

00:00:28 GLP ones can be beneficial.
00:09:44 Insulin and metformin for type 2 diabetes.
00:14:45 Metformin can help with weight loss and may have longevity benefits.
00:18:25 Consult physician before starting medication.
00:27:06 GLP1s can aid in weight loss.
00:34:18 Lifestyle change and satiation matter.
00:39:30 Mindless eating and constant access.
00:43:05 GLP1s can be beneficial for diabetes and weight loss.
00:50:23 Medication can help improve health.
00:55:02 Weight loss medications can have positive impacts on healthcare.
01:00:11 Weight loss lifestyle requires commitment.

Scott Benner 0:00
Hello friends, welcome to episode 885 of the Juicebox Podcast.

Jenny Smith is back today and we're going to do another in the Type Two diabetes Pro Tip series. Today we're going to talk about medications like GLP ones, insulin Metformin, and we're going to touch on a few others, this may end up being a part one of two, because we get pretty far into the conversation about the GLP ones. Now if you don't know what those are, those are ozempic but Jarno, these are once weekly injectables made for type two diabetes. While you're listening today, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. You can get 10% off your first month of therapy@betterhelp.com forward slash juicebox. And you can save 35% on your entire order at cozy earth.com. When you use the offer code choose box at checkout because the Earth is towels sheets. Oh my gosh, Sweatshirts, sweatpants really great stuff cozy earth.com use the offer code juice box at checkout to save 35% off your entire order. This episode of The Juicebox Podcast is sponsored by Dexcom, makers of the Dexcom G six and Dexcom G seven continuous glucose monitoring systems. Whether you have type one diabetes, or type two diabetes, seeing your blood sugar in real time is a game changer. dexcom.com forward slash juicebox. Jenny Hello. Hi, we are back. And we have a number of episodes in our type two Pro Tip series already up and being consumed by people just terrific. Today we're going to talk about medications that people with type two might find themselves using. So I struggled there

Jennifer Smith, CDE 2:21
are so many yes medication.

Scott Benner 2:24
I struggled to ask you if we should begin with what's hot right now in the news, which is like GLP ones or if we should just start with insulin and end with GLP ones. So I think insulin,

Jennifer Smith, CDE 2:38
start with insulin, I

Scott Benner 2:39
think so I want them to understand how it works. And then we can tell you later how these other things might help them as well.

Jennifer Smith, CDE 2:45
Okay, because it's not I would. And that's great, because I think I think I'm the mind of a lot of people with type two is that insulin is going to be in the picture at some point. So I think answering what is insulin? How does it work? What is it supposed to do? etc? is good to start with? I think in terms of where people might start, once they're diagnosed, may not necessarily be insulin, in fact, that may be very far down the road, or maybe not at all. You know, but I think there are lots to discuss. So we can start with insulin because we know insulin right? Yeah,

Scott Benner 3:25
we can talk about that. And we can talk about that. And I do think that, from what I'm learning these GLP ones really could be a situation where if you are in a pre diabetes situation, type two even, it's possible that you could get out of being in that category with the GLP ones at some point. Do you think that's true? Do you think they could keep people at bay for even a lifetime?

Jennifer Smith, CDE 3:52
In fact, in terms of you know, like the GLP ones, and the other ones that we'll discuss and talk about? They should actually from a lot of the new standards that are done by the ADEA. Right, the standards of diabetes care, not only should we be individualizing, management person to person, right? It used to be a chart that was followed start with this go to this move to this but we really do need to and the standards of care suggests to personalize to really in depth talk to the person that you're working with from the clinical standpoint and say, hey, you know, what are your lifestyle factors? Where are your glucose levels, what lifestyle changes have been put into place? Let's look at the meds that one we could use that would be beneficial. And oftentimes the GLP ones and that these newer kinds should actually be more of a front line rather than insulin honestly. And because they have they have a lot more protective. And we'll talk a little bit more about it. Obviously, there are a lot more protective components to some of these newer meds as well. And they're protective in many of the things that we talk about in terms of diabetes complications. So why wouldn't we want to start with some medications that can prove very beneficial in many avenues of type to management, weight management, nutrition intake, glucose management, all of that stuff? Why wouldn't we start with them versus something that might be old school and doesn't fit their need? Really? Yeah.

Scott Benner 5:37
And that makes me think, too of metformin, which is taken in a pill. But that's a drug it's been around with since the 50s. Maybe?

Jennifer Smith, CDE 5:45
For me, yeah. And I think, oh, my gosh, Metformin. I'd, it was like one of the it's like the first, if I remember,

Scott Benner 5:55
there is as much research about Metformin, and insulin and diabetes and weight as there is about longevity. Like there is a ton of metformin research around longevity as well. Yes. Yes, I think we can, that'll seep into the conversation as we go. But let's just start with insulin because, sure, because what if somebody with type two finding themselves here and they're already on insulin? Yes. So I mean, what is it? You need to know? Really? If you have type two, are they going to put you on a Basal insulin?

Jennifer Smith, CDE 6:31
Yeah, yes. Is anything possible with insulin with type two? Yes, absolutely. They could potentially see that when they're looking at glucose levels, especially if you have a CGM, or if you're just doing finger sticks, your fasting glucose level is not meeting target, right under 100 is what we're aiming for. Then, they may start you on just a Basal insulin, with the goal being of overall lowering that background glucose level to get you waking at a fasting target level. Yeah. Right. So yes, Basil could be a first start. If we're talking just insulin in use, and Basal insulin. It's the foundation of kind of management, it's, it's kind of what keeps things stable. If you were to live in a world without food, and without stress, and without anything else, those variables that impact blood sugar, your Basal insulin should hold things stable.

Scott Benner 7:35
Yeah. So in type two, if my average blood sugar is like 120, all day long, for example, and I might inject the Basal insulin once a day, and then I might see my average blood sugar sit lower, hopefully, you know, and, and maybe I see spikes at meals, but they come back pretty quickly on their own. And so just the Basal might help but if that's not the case, then I also might get a mealtime insulin as well to inject to compensate for food.

Jennifer Smith, CDE 8:05
Correct rapid acting insulin Yes. And, and rapid being that mean rapid. We hate the word rapid when we talk about insulin because it's it's not as fast as like instantaneous action. It takes, you know, 2030 minutes for it to really get going and get moving. But its action profile is really short where Basal insulin you may take once a day, and it has about a 24 hour effect. Rapid insulin is much shorter, it goes in and out. So it clears within about three to five hours is the average right?

Scott Benner 8:41
Yeah. So you you might find yourself just using a Basal insulin which is a once a day background insulin, you might find yourself using a meal insulin along with it. Is there a world where they would give you mealtime insulin but not Basal? No,

Jennifer Smith, CDE 8:57
that's not where there might be. But that's not something that I've seen. Lately, and there are other meds obviously we're going to talk about a lot of the meds. There might be some other meds that are in use and maybe maybe the mealtime management is not going as well. The other meds are helping in one way. But the mealtime navigation, it just needs it needs some insulin to assist, right? That might be a scenario where there is some rapid acting insulin added to kind of assist in that picture. But typically not if you're not using a basil. You wouldn't really only be using a rapid insulin without a beat. So

Scott Benner 9:38
the progression might be basil. If that doesn't help then mealtime. Do people do basil and metformin? Yes, yes. Okay. I'm trying to think of what I would wonder if I had type two diabetes that's that's where my brain is like skipping around to right now.

Jennifer Smith, CDE 9:54
Well, and a big reason as you just mentioned, might you do Basal insulin and like a Metformin I And remember that Metformin is not one that really increases the risk of hypoglycemia or low blood sugar. Whereas insulins job, I mean, it's its main job is to bring your blood sugar levels down, right? Your pancreas has really good management of all of that, it's just part of what your body should naturally be able to do. So your body doesn't naturally drop your blood sugar too low. But when we take an injectable form of insulin, it's dose management. Okay? So it's, it's really, we have to be very careful in adding oral medications, if there is insulin in the picture, that those oral medications are also dosed appropriately taking at the right time, and that they're also not potentially going to be something that's going to increase the risk of low blood sugars because somebody's already taking insulin, right? So Metformin is a very safe one, so to speak. Because obviously, its job isn't to really help release extra insulin from your pancreas, it does help your body to use insulin better, it's an insulin sensitizer to some degree, helps your body to release less glucose, essentially, from your liver. And that helps to keep the glucose levels more stable. Right. So but again, it doesn't help your body make more insulin. Okay. All right. So,

Scott Benner 11:32
so can we should we talk a little bit about Metformin here? Sure. Okay. So I don't know anything about this. Hey, Jenny, Metformin, go,

Jennifer Smith, CDE 11:43
Metformin? Yes. I mean, there's, you know, gluco, fysh, is as another kind of name for Metformin, right, you can take various forms and extended release, which many times people will actually tolerate better, the extended release, it's slower, it doesn't have as, like quick upfront action, Metformin, the nice thing about it is that its side effects are very minimal. Upon starting it, the most common side effect is going to be a little bit of like nausea, or sometimes stomach upset, sometimes a little bit of softer stool. But honestly, those symptoms typically go away. Within about a week or two, after starting it, we also start Metformin at a really low dose to begin with to evaluate tolerance. Many times you may not see much impact from that starting low dose. And so then as tolerance is there, we can increase to more therapeutic doses. And that's done along with the doctors kind of assisting you to titrate that to

Scott Benner 12:54
do a lot of people see a Metformin given by a doctor prior to insulin, right. That's sort of their first step. Usually,

Jennifer Smith, CDE 13:01
that used to be yes, I think with again, some of the newer meds that we'll talk about, sometimes Now, if you've got a really good doctor who is following a lot of the standards of care again, Metformin might be started, but it might also be started again, along with one of these newer meds. The goal being containment of blood sugar sooner than later. Yeah, to really get things as protected for some of those other complications that, you know, we want to try to avoid.

Scott Benner 13:31
Why why do we let me see if you know the answer to this, why do we see what's the phrase I don't want to use it? It's not pejorative for me, but bro science like, why do you see those guys using Metformin in general like they like so what does Metformin do besides, besides help you with your blood sugar, it's also impacting other things, right?

Jennifer Smith, CDE 13:54
Sure, Metformin is one of one of the few oral meds that has been shown in research to have a minor effect on weight, meaning it doesn't, it doesn't increase the risk of gaining weight. If anything, people will lose a slight amount of weight or at least be able to maintain weight. Some of the other medications because of the way that they work can actually not be as beneficial in terms of weight loss, along with lifestyle changes and everything else that somebody with diabetes needs to be making. Metformin is one that can help you to lose a little bit of weight. It's not going to be astounding weight loss, like 1020 30 pounds, but anything taken off can be beneficial. So that's one one positive side effect, I guess, of using the medication.

Scott Benner 14:50
I googled Metformin, longevity. And I hit A Harvard study that says preliminary studies suggest that Metformin may actually slow aging and increase Life expectancy by improving the body's responsive responsiveness to insulin, anti oxidant effects and improving blood vessel health. So I don't know how right or wrong that is. But I do know there's a ton of research about Metformin,

Jennifer Smith, CDE 15:18
longevity, longevity. Well, and when you also, longevity also speaks to me in terms of ability to use long term to not just in terms of the body, but also in terms of safety, safety, right? Because medications, as we know, outside of insulin insolence got a job, it does its job, it gets cleared, you take more of it. It's not like it really does other things in that, like it doesn't impact like your eyeballs and make them grow green spots. Right. We are I hope, not.

Scott Benner 15:55
Wondering why your imagination jumped to that. But okay,

Jennifer Smith, CDE 15:57
yeah, I don't know. Yes. Well, I have kids, you know, they've, they're all about monsters and dragons and weird things. So you know, but a lot of medications in many areas, not just diabetes, they have impact. And thus, all the commercials on television, you hear if you have any of these side effects, or you notice any of this and sometimes those commercials, I'm like, Man, I think I'd rather live with this. See the side effects, you know, but Metformin is one that is truly mostly gi side effects. And are there some people that the GI side effects are so much that they don't go away? They get worse, and they actually can't continue on it? Absolutely. It's not as many people but there are some people that it just isn't tolerated. Is there

Scott Benner 16:43
any way to know what that's tied to when they can't tolerate it? Is it people trying to like continue their dieting from prior, like their fueling plan hasn't changed? There's no connection that you can think of?

Jennifer Smith, CDE 16:55
Okay, no, I mean, I'm sure that maybe there are some studies that I've not read or looked at in terms of why some people have symptoms, or that those symptoms are so bad that they just can't even tolerate it going above the starting dose.

Scott Benner 17:10
But yeah, I think when you're sick, or that it's not an answer, for sure.

Jennifer Smith, CDE 17:13
Yeah. And with you know, Metformin that kind of brings up when should you take it, we most often recommend on starting people take it with their meals, right? So on starting, we usually say start taking it with your breakfast meal, or with extended release, usually recommend taking that with your evening meal, right? Because there's a long term action profile of it. Taking it with a meal decreases the chance of that stomach upset. And I even often tell people take it in the middle of the meal, like sandwiches, eat a little bit, take the Med, eat the rest of your meals, it's kind of like plopped between. Right.

Scott Benner 17:51
The break up in your stomach without hitting harshly somewhere.

Jennifer Smith, CDE 17:55
Yes, exactly. I mean, there are some some, certainly some kind of cautions, obviously, with liver or some kidney problems. Those are some reasons that consideration for not using or paying attention to tests for liver and kidney function would be important if it was a med that was started. But those are some of the things that again, your doctor would be able to pay attention to, and know whether or not they should even prescribe it. Yeah,

Scott Benner 18:29
I mean, I think it goes beyond saying but consult your physician, pay close attention, be in contact, you know, do your own research those things. Yes, exactly. You mentioned when to take it. So I'll just add this. It's kind of one of those things. That seems simple, but you might not think of it. If you're gonna start a medication like this. Do it on the weekend. Or when you're not working, you know, if you have off Tuesday and Wednesday, started on Tuesday, right? Yeah,

Jennifer Smith, CDE 18:58
absolutely. Because then you have a visual to any potential side effect that's going to be negative. And you've got time to deal with it before having to go you know, you take it in the morning, you have this big board meeting presentation and your stomach is going wrong. is probably not the best thing.

Scott Benner 19:18
You don't want to be at work going. I think I'm gonna have loose stools.

Jennifer Smith, CDE 19:21
No, not a good idea.

Scott Benner 19:24
At home on Saturdays what I'm saying? Yes, that's all be

Jennifer Smith, CDE 19:29
close to your own toilet. Yes.

Scott Benner 19:30
So we're not going to see like huge effects from Metformin, we will see. I mean, you will see huge effects from insulin. If you make it to insulin like you are going to notice a significant change in your agency, because you're going to be covering what your body can't cover for the Basal side for that long acting insulin and you're going to be yes hitting your meals with a mealtime insulin, you're going to see a significant change on insulin.

Jennifer Smith, CDE 19:57
Insulin is like immediate efficacy. You You are, it's going to work. Here we are, right? I mean here. And, again, I should backtrack and say if your blood sugars have also been significantly high, you may see impact, but it's not like it's going to be so dramatic that you're going from a blood sugar of 300 down to 50. Right? You may have to increase dose slowly, which is actually much more optimal. You don't want major shifts down. If you've been stable at really high blood sugars for a while. You don't want to all of a sudden be sitting at 80. That's, that's not good for your body. So this slow titration even of insulin, yes, you're going to see impact of it. But it may not be as quick as Gosh, I'm floating at Target now.

Scott Benner 20:44
Yeah. Okay. All right, Jay, let's spend the rest of this time talking about Hilah monsters.

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you're ready? Do you know why I said that?

Jennifer Smith, CDE 22:44
I know why you said it. You tell me since All right. Sounds like sounds like you know you studied

Scott Benner 22:50
so there's a Canadian researcher who studied Hila monsters? Is it it's Gila monster healing doesn't matter big lizard right? And I think that I think the story goes that initially he noticed that they don't eat very much and then started to try to figure out why and found GLP one in the in their saliva. Is that right? Am I getting this right okay. And that was a while ago by the way like I know a long time Yeah, yeah, I know we we get wrapped up in like, you know what's going on in social media and you know, famous people are using GLP ones lose weight. No, we can't, you know, whatever. All that that's all just noise. This has been going on for quite some time. I can remember. It's got to be 15 years ago, a doctor tried to give my wife Victoza for weight loss. And it made her very it didn't didn't it didn't work well. Well with her. Yeah. But since then, others have come along so let's see if I can get these GLP ones ozempic trulicity Victoza by EDAA Where's more? I don't know there's one that starts with an A. I'll find it hold on.

Jennifer Smith, CDE 24:18
Those are I would say that those are

Scott Benner 24:21
the Go ahead. Well, they're all GLP ones though. Right? Like with semaglutide Some of them are so GLP ones are some already Jenny you gotta help me here. GLP ones are semaglutide Is that correct?

Jennifer Smith, CDE 24:35
GLP one you tell me you're listening.

Scott Benner 24:39
I don't know if I trust the list because Victoza for an example is often listed as GLP one but isn't it have a different main component?

Jennifer Smith, CDE 24:49
So Victoza and by Edo were the oldest Okay, right. By Yetta was, if I remember correctly, the first on the market in the very early two To 1000s, and it was dosed twice a day. Right? And then everybody was like, oh, but what if we could just take this once a day and they're there came to be Victoza, which was once a day, and then things like trulicity Trulicity is once a week, similar to ozempic, which is once a week, and which just increases the potential. I mean, and you're right semaglutide or however you were saying it whatever is GLP one,

Scott Benner 25:32
so it's a magnetite. I hear some people say semaglutide I don't think that's correct at all.

Jennifer Smith, CDE 25:37
It might I say some magnetite it might be semaglutide. i There are so many ways to say these, these names of things that as long as you know that category and what it's supposed to be doing in your body. Great. So

Scott Benner 25:51
I pointed out that Victoza is liraglutide. So it's not exactly the newer drugs, and I think it is good.

Jennifer Smith, CDE 26:00
It's all formulation. Yeah. Okay. Right. I mean, it's kind of its formulation, I think that's the easiest way. I mean, they have in terms of action, their action profiles are all similar enough. But some are taken, like I said more on a daily basis. And some are taken more on a long term, sort of basis, which I think for some people makes it a lot easier that they don't have to remember something every single day. But in general, these GLP ones, their action profile is to really increase insulin secretion. And to help, again, kind of like Metformin, decrease glucose release, sort of from the liver, specifically in the after meal time period. Yeah. And then they also help to delay sort of stomach emptying and like the glucose kind of break down and whatnot, which helps to increase satiety, which is a huge reason that GLP ones are beneficial for weight loss.

Scott Benner 27:06
So if so, for me, if this was me going into a doctor's office, and I saw I was like, Look, I I have prediabetes or I have you know, I have type two, I'd be pointing to, I'd like to try it was epic, or I'd like to try Manjaro. That's where I would be focused based on what my research is telling me. Do you see a reason why others would be?

Jennifer Smith, CDE 27:29
I've actually, and again, I've been out of specific, we've got a number of type twos, but I've been out of the type twos specific, like prescriptive component for a while, by Yetta. And Victoza were very, very big when I was working more heavily with the type two population. But we didn't have things like trulicity or ozempic, or any of those meds to choose from. Yeah, I think now, the benefit of something like ozempic, especially is that they have clearance for some of those other risk factors that we're trying to decrease, right, especially cardiovascular benefit. So if you're looking for the most bang, let's say, in a medication, and you're potentially high risk for heart disease, or you've heard already had some type of cardiovascular event happen, or you have a strong family history of then you're looking more towards these newer GLP one because of what they've proven in some studies.

Scott Benner 28:39
Now Manjaro Manjaro is a GLP one and also a G I P. In that drug. This is what my, my my thinking and my reading has told me. So apparently a GI p is a gastric inhibitory polypeptide. Jenny's just impressed, I said polypeptide correctly. She was looking at me, she goes, watch him mess this up. And I got it. So they are like their studies. Basically the Manjaro people, I don't know who makes it as it Lily. Is it? I don't know. Let's figure it out. I guess I'll scroll. Lilly Lilly makes Manjaro they're saying that people on average on Manjaro are losing like over 20% of their body weight. Is that right? I

Jennifer Smith, CDE 29:29
think I think the one study I read said like 23% Yeah, that's crazy. It was an enormous amount of weight. Absolutely. Yes.

Scott Benner 29:39
And it's not in an insane amount of time either. Six it is not it's under a year, you know. And so but then ozempic I don't know what their their studies say. But it's something more like is it like 16 or

Jennifer Smith, CDE 29:54
it's less than that? But it's it's substantial. Again, when we're comparing it to something that's The older, like even the bio data and the Victoza and definitely much more beneficial than Metformin in weight loss. It's in the it's in the teens area in terms of percent loss.

Scott Benner 30:13
I have here, New England Journal of Medicine semaglutide group, approximately 70% of participants achieved a weight loss of at least 10%. And approximately when we get the rest of it, and approximately 50% of the people are that go. achieved a weight loss of at least 15%. Furthermore, 1/3 1/3 of participants treated with semaglutide lost at least 20% of their baseline weight. Wow.

Jennifer Smith, CDE 30:41
Which is it's huge, you know, if that is, if that one has been a struggle for a really, really long time for you, and now you kind of are slapped with another now you have type two diabetes as well, right? God, I've already been working on this, and I'm not getting anywhere. And now you tell me I have this to work on as well. It's like, how much more can you load on right? And while lifestyle change is the four front of what we would try to encourage, sometimes people have already done some things, lifestyle wise, and it's helped, but it hasn't helped to the degree of 20%.

Scott Benner 31:24
Right? It goes on to say that these are results that approach those of like three years after bariatric surgery. So you know, people getting their stomach stapled, or whatever they call it. And it's three years later to lose 20%. I'm talking about like, click, click, live my life, I'm losing weight. And I we've touched on this before I and I'm going to do it again. i If I could close my eyes and imagine a world we'd all be out jogging after work and eating a half a piece of chicken with a little bit of broccoli on it and go, Oh, I'll take some sparkling water. That's not happening. So like, as long as that's not happening as long as people are are, in some situation stuck eating processed foods that are just beating the hell out of their bodies, right? Yeah, yeah. We all shouldn't just go okay, well, I guess I'm, I guess I'll die. You know, like, this is, this is crazy how well this works. And it is because it got into the weight loss market. It's got a light shined on it now, because I've been hearing people tell me around diabetes for years whispering in my ear, maybe GLP ones, maybe a GLP. One for type ones, like and it doesn't catch any traction. But I'll tell you what, a couple of people lose 50 pounds on tick tock, and everybody goes, Hey, what the hell? What's happened to her?

Jennifer Smith, CDE 32:47
And how did they do it? And gosh, they didn't have to just sit and eat green beans.

Scott Benner 32:52
Right? Because I work because because they make me choke because my parents. It doesn't matter. Like for whatever reason, like I keep trying to make this point. I don't think you should be embarrassed if you have type two diabetes. I don't think no embarrassed if you're something's going on. I don't believe that a large amount of people are just sitting at home with their hand and one bag of Doritos in their hand and something else and going I don't care if I die. Like I just don't think that's true. Is it true for somebody? Yeah, maybe. But also that person deserves a life too. And I'm not saying you should use the drug and then just eat poorly. I'm totally not saying that. But I'm saying that if this helps, then why not? And my point is, why did it jump into the weight loss category. So for example, right now, Manjaro is only available for type two diabetes, but there's no doubt in my mind that they are very busy right now making, you know, something, something that's going to be for weight loss because those Empik is for diabetes, type two, and they made we go V. Now, you'll hear people say ozempic And we go V are exactly the same thing. They they are right, like at the molecule they are it's just the dose, it's just the dose that they change. So there's a different dosing for diabetes than there is for weight loss. Now what they're learning and what they're seeing is the satiation that you're talking about, like just not being hungry. If you go into any weight loss Facebook group or pay attention online, we go over users as an example are like I am not hungry, like I'm reminding myself to eat right? Yeah. And as a matter of fact, their doctors are telling them when you start taking this, you have to keep eating. Correct. And that might not be easy to do. I talking to somebody personally right now, who describes they're using weego V for weight loss, but this person is prediabetes as well, right? So sure. And And they talk about their entire life. While they're making breakfast. They're thinking about what they're going to eat for lunch. Like, like, and it's not like a softness, this isn't a weak person, you know, seemingly, she's just their mind just, they're always hungry, shall have hunger in a way that you can not like, I don't understand when it's described to me. Like, like, What do you mean? Like we just ate? Or did they? Or they'll make three things at a meal, like, any of those things would be a full meal. And they're like, Well, I'm at this with this and this. And as soon as I get that, Enos, I'm going to be hungry again. I don't care if we found a way to say that's a disease or not, that's a disease. You know, like, if your brains not shutting off, you're that correct? Yeah.

Jennifer Smith, CDE 35:46
And I think in today's I mean, I, it begs to actually, it's a rabbit hole. But honestly, we've lost a lot of connection with our brain, to our stomach and what our body actually needs. And when it needs it. We have we've lost a lot of that because we are bombarded with food on a day to day basis, not only with the commercials, but also with social interactions. Yep. Everywhere we go. Availability, something social. includes food, you can't go to a board meeting that doesn't include some type of probably pastry, along with coffee or tea, right? You can't go to meet a friend at a park and just sit. It's let's go grab something to eat and talk over the food. Right? So I

Scott Benner 36:41
I've never drank coffee in my entire life, right? Cold coffee, calories. Oh my

Jennifer Smith, CDE 36:49
goodness, if you're truly just getting a plain old Cold coffee, nothing in it. It's like hot coffee that you've just cooled down. Okay? It's not caloric, right? Our, our cold coffee culture today? Well, that was a lot of C's. Sorry, see, I have little I have little children. But it is it's it's an entire, you don't just get coffee, you get some type of sweet something in it. And you get Frappuccino wised or you get you know, something to it. That makes it not taste like coffee. But it's a sweet treat.

Scott Benner 37:30
And all of a sudden, it's 300 calories in a glass. Absolutely. Yeah. And that's just, I'm saying, imagine a world where you were you've just got caught in this cycle. Like you said, like you we've been eating like this for years. If you go back to the 50s and the 60s and the 70s. There's scarcity of food, right? And people eat your plate, like because we you know, but they were still just eating. I don't know, some potatoes and beef and beans. It wasn't like but they

Jennifer Smith, CDE 37:58
were eating regular meals at fairly regular times. Now. Life has also gotten very busy, very different in today, comparative to the 50s. Right, right. And the structure of our day has changed very dramatically. We don't have a typical breakfast together, a lunch and a dinner time everybody is home. And you know, somebody's reading the paper at the dinner table. That's that's, I mean, now it's I was just talking to somebody at my kids taekwondo last night, and she's like, sometimes I'm shoving peanut butter and jelly in their mouth and being like, we have to be there in five minutes. And that's what they get for dinner is peanut butter and jelly. And I'm thinking to myself, I understand. But I have so much I could say to you about this, but you're not asking so I'm not going to elaborate.

Scott Benner 38:44
Exactly. So but if people's lives are in I mean, look the us up. I remember, I was 12 years old. And my grandmother and I were driving down the street in the town. She lived in her whole life. And she pointed I swear to you, she pointed at a corner where there was construction. And she said they're putting a 711 there. That's the end of this town. That's what she's holding. And I'll be damned that old lady was right. Because now, Wawa 711, any kind of convenience store that you can think of along the way. They're not one in a town. They're at every corner. And so you just think oh, I'll stop and get and then money's more people have money in their pockets in a way that they didn't before. You know, and it's just it's a terrible cycle. So my point is, I think our brains to your point have been they've been I don't know what the word is. But now you're hungry constantly and you have access to food constantly and is generally speaking not good food

Jennifer Smith, CDE 39:43
and it's an it's a miss I think there's a disconnect between what is hunger feel like and oh, I could grab something quick because I'm not like your brain is thinking further. I'm not quite sure when I'm gonna get to some thing else. So I might as well grab something now because hey, that you know, little place to grab up, you know, a coffee and whatever is here, or this little place to grab a sandwich from is here. And it's not truly remembering to connect with your hunger level. It's a, it's almost just a brain notification of grab it. It's here,

Scott Benner 40:20
I had a situation recently where I knew 45 minutes from now, there was going to be food, but I was hungry. And I almost ate to not be hungry. But I still would have eaten 45 minutes later, because I was gonna be there and I just I stopped myself as like, that's insane. Just be hungry for 45 minutes and then eat. But I don't have that. I don't have that push the way some other people do. Correct. And then the other side of it is the so GLP ones, they're going to tell you the side effects may be nausea, vomiting, or diarrhea. Those are the three that they post when they're telling you, right? Correct. The nausea, I don't understand. But the vomiting is from trying to eat food that your body can no longer kind of process, right because it slows gastric emptying. It's

Jennifer Smith, CDE 41:10
correct. In fact, there are you know, if you are utilizing insulin along with some of these medications, it's really important to pay attention to, to the what the meds can do in terms of satiety. Very important because if you are someone who is using insulin and dosing for the food that you're eating, or you have what we call as a set dose, based on meal time, you know, you always take five units of insulin with your lunchtime, and then you eat your lunch while starting on these meds now, you may not be hungry enough for that five units. Yeah, right. So there's, there's some caution to be put into the mix here. Along with use of these because they do impact your desire for food.

Scott Benner 42:01
Right? So there's a desire, the lose the desire, which is good news, if you're if you're eating too much, but you're going to have to remind yourself to eat but eat the right things within reason. If you know, do people vomit on it? It's not from what I can tell it's not something that happens constantly. But it could be that if you're eating fatty, or foods or greasy stuff that you might have a bad reaction with it.

Jennifer Smith, CDE 42:26
It could be that and honestly, it's more the digestive like, I haven't heard as much complaint about the vomiting piece. It's much more Justice background like queasiness on starting the Med and getting used to it. And then a fullness factor that I think a lot of people may not, again, with that brain not really connecting that way. It may be a fullness that their body's not used to feeling. So it may be uncomfortable. Yeah. So

Scott Benner 43:03
to wrap back around GLP ones if I have pre diabetes, if I have type two diabetes, if I maybe just have weight to lose them in the I think right now for I think right now for insurance reasons, you have to be technically obese to get like we go V.

Jennifer Smith, CDE 43:21
There are BMI standards that they have to essentially follow in terms of prescription. Not that they can't prescribe. But in terms of coverage. For that medication. You have to meet a certain BMI. Yes,

Scott Benner 43:36
yeah. Okay. But again, I think doctors who are looking out for your health and can think outside of the box can find a way to get you these things. But these GLP ones, I'm gonna tell you right now, I'm pushing someone very close to me pretty hard. Who has type two diabetes? To start it? Yeah, I mean, just try to imagine the that you have type two, and you have weight, that's x in excess of what you should be carrying. And that a year from now, you could lose 1015 22% of your body weight and be helped supporting the insulin production. And what's it doing the liver again, it clears something with glucagon. And it helps to decrease

Jennifer Smith, CDE 44:19
your glucose outlet right from your liver. And so the benefit of that, obviously, is, I mean, your liver and your pancreas. They're what these wonderful organs that are supposed to work together really well. Right? They're supposed to. But when you've got too much being released and your body isn't responding the right way and or your body's not making insulin in the right way. You don't need this assistive piece. That's supposed to be this beautiful, like management strategy that your body would naturally do and it's not happening.

Scott Benner 44:56
Not only that, but you know you hear about a lot now that you just never heard about before. fatty liver disease. But like, right, so if there's a non alcoholic, fatty liver disease and an alcoholic fatty liver, I'm talking about non alcoholic fatty liver disease that stops your liver from working the way it should. And these medications are seemed to be helping with that as well. So there's a lot of good here that comes from this. And

Jennifer Smith, CDE 45:23
there are Yeah, there are an enormous I mean, I think, I think, again, with standards of care being changed, as they have been, especially with the increase in these types of medications that are being shown to be more beneficial. It's, it's really talking, again, advocating for yourself, if you don't have a practitioner who has brought any of this up, and you're hearing this, and you're doing a little bit of your own research, and you're saying, Well, I don't know why nobody talked to me about this, right? I don't know why we're starting with this. It doesn't I've been doing the things that I've been told to do, along with the medication doesn't seem to be helping, why can't we consider this? Right? And that's when you might need to go to your doctor and bring it up. And maybe you can teach them a little bit of something, right?

Scott Benner 46:21
And for those of you who are gonna say like, well, GLP ones, they're brand new I, you know, I just heard they can't even make them fast enough, because the famous people are using them to lose weight discovery of GLP. One was first identified in the early 80s. So there you go. It's been, that's 43 years ago. Yeah.

Jennifer Smith, CDE 46:40
And what's interesting is that our zoo, we have a healer monster at our zoo, and they actually have the information about the saliva, and that there is now a medication that helps people with diabetes. They don't name the medication, but they just note that from the saliva was formed this medication, which I

Scott Benner 47:01
think is the gentleman's name is Drucker and inductee into the Canadian Medical Hall of Fame and winner of the Canadian gardener international award is most well known for his contributions to the discovery of glucagon like peptide GLP, one and GLB to gut hormones that help control insulin and balanced blood sugars. That's, I mean, it just it makes sense. Like, it really, really makes sense. You know, we have a couple of minutes left. Before we started recording, you told me you have you have type one clients who are using GLP ones.

Jennifer Smith, CDE 47:35
I have, I have one client who had tried trulicity, I have another one, who has had very good success with ozempic.

Scott Benner 47:47
Yeah, so and a reduction in insulin use significant 25% a day

Jennifer Smith, CDE 47:53
a reduction in insulin use, I have to go back to their specific charts to see how much we reduced by but it's it's a fair amount, I mean, the person using ozempic, now for several weeks has come down in insulin use by about 10 units overall, and has lost weight as well, which is very significant. And beneficial. Obviously, when you are an insulin user, we have this, we have this management that we have to do in order to make sure we're using the amount of insulin that keeps our blood sugar in the right place, but that we're not getting an overage that then insulin is a storage hormone that allows our body to store more than we actually are using up. So it's it's a fine balance. And I mean, you know, in terms of these other GLP ones, I think the newer ones, again, are more the way to honestly go especially as I mentioned briefly before with the benefit towards cardiovascular benefit and whatnot. We really want to look at that in type two diabetes because again, many people who are diagnosed with type two have actually had mismanaged blood sugars for a number of years before they're formally diagnosed.

Scott Benner 49:11
And here, Mayo Clinic along with helping to control blood sugar and boost weight loss, GLP ones and SGL two, two inhibitors seem to have other major benefits. Researchers found that some drugs in these groups may lower the risk of heart disease, such as heart failure, stroke, and kidney disease. Kidney Yep, kidney disease. Yeah. So you have your damage being done that you're not aware of type two, because you're slow to be diagnosed. And this isn't going to reverse these problems. Right? But it will,

Jennifer Smith, CDE 49:45
it's not going to reverse them. But in a side note there again, our body is it's a self healing machine. Your body does as much as they possibly can to get over all the damage that you're putting into it or on it right At some point, it can only do so much. So while these meds aren't necessarily healing, what they are doing is with navigating your glucose levels, getting your weight more under control, maybe now you can actually feel good enough to start moving more. That's going to be preventative. And then it allows your body to do some of the self healing that it can. Yeah,

Scott Benner 50:23
if two things are the one, you just said something that really kind of lit me up. Like, I don't think people know how much they're being held down by their health issues. Like I think they get accustomed to feeling tired or weak or whatever. And you just think this is life. And if you can lift that veil, a little, almost like an antidepressant, if you can lift that veil, little you might be able to see up, you know, you might Yeah, and the other thing you talked about about it doesn't, it's not a cure. But you know, think of it this way, if you stand next to the wall and bang your head on the wall, right, and your heads gonna get sore. If you stop banging your head on the wall, your head will stop being sore, it'll end it will go back to the way it used to be tried to think of the sugar as the wall. And instead of it your head, it's your heart or your kidneys or something and you just keep abusing it, it can't rebound. So you gotta give it a shot to rebound. Jenny,

Jennifer Smith, CDE 51:15
that was that's funny that that was actually a really like was a common joke in our house, my dad, we'd go to him with like a complaint like My knee hurts. Well, when does it hurt? Well, when I do this, my dad be like, Well, don't do that anymore. Like it was just it was a joke. Right? But you brought up the exact the exact? Absolutely, yeah,

Scott Benner 51:34
I mean, listen, you said earlier about somebody sticking peanut butter sandwiches in their kid to run off to a thing to run off to a sport, right? Like think about like, when you're four and five, and you're playing soccer or baseball or doing some peewee thing, everyone's reasonably athletic, like they're not all stars, but they can go out and run around and get exercise. And then what happened and

Jennifer Smith, CDE 51:55
their metabolism is much higher than you as an adult, right?

Scott Benner 51:59
And then But then you sit in school for 12 years. And then some of you sit in college for four or 567 years. And all of a sudden you're like, Oh, I gained 20 pounds, I gained 15 pounds. I did this, you know, like your your life changes. So you're eating more like, you know, at the corner kinds of foods. And then you say, Oh, God, I'm 40 pounds heavier than I was in college. I tried and nothing happened.

Jennifer Smith, CDE 52:22
Right? Yeah. Right. I know. And that's like, your head against the wall. It's this it is. And I think in today's society, the I'm not, I don't love medication. Like I try really hard to avoid medicine, I don't have to use like, if I can do something about it, to fix it. I will write even for a headache, like I drink the water. I take a meditate for a little bit. Whatever I try hard. But I think in today's world, some of these meds are they're the best that we can honestly do in order to get around some of the things that you're trying to work on. But you're never gonna get 100% benefit.

Scott Benner 53:10
Yeah. Oh, Jenny froze. This has never happened before. Jenny, you froze for a second? Oh, never gonna get 100%. I did.

Jennifer Smith, CDE 53:18
Oh, that was the first Oh, yeah, you're never gonna get 100% benefit, as you just said, so many things have changed since a kid was being very active. And now as an adult, they look at and they're like, gosh, I used to do all these things. And now I'm 40 4050 pounds heavier. And I'm slow. And I, you know, I can't run the bases around the T ball field with my kid anymore, because I just so that's where these meds, especially from a lot of the protective features that they're proving and research coming along with them. There is a benefit to using them just just remember

Scott Benner 53:53
that hundreds and hundreds of years ago, one of the signs of wealth was being heavy, because it meant you could afford food. And that sort of mindset has just moved in the wrong direction over hundreds of generations. It just has. And I'm sitting here imagining I'm imagining everybody in the world who who can who could and should for health reasons be 3040 50 pounds lighter, right? 2030 4050 pounds lighter, and it's not happening. Like imagine if the whole world used the GLP, one for a year. And we woke up a year from now and everyone in that situations weighed was 15 or 20%. Lower, the world would change and everyone's mind would be rewired. And you wouldn't be like oh I'm going to stop at Wawa and get a pretzel. You'd be like I'm gonna go home and eat my dinner and it right it's just I'm with you on the mat. I wish like I'm sitting here wishing that this wasn't necessary but I yeah situation we're in.

Jennifer Smith, CDE 54:55
It is and I think if we look at it even deeper level Will, Will medications like this if they're used not only for type two, but some of them are being found in terms of just weight loss avenues, right. So if that's the case, we know the stress on our healthcare system already, with a lot of the conditions that we have, that are utilizing a lot of medications that aren't having positive side effects, right. So if meds like this are being brought in and utilize to the extent that it's decreasing, some of the issues, people are coming in with cardiovascular, kidney, whatever, then, at some point, I would like to be able to see that we've decreased the impact on our healthcare system.

Scott Benner 55:49
And there's no reason that things couldn't switch back in a generation or two as well. Like, if every adult right now whose mind is wired to like, stop and grab food and eat this, before I eat that and all that other stuff. If we all rewired our minds, then our kids would grow up in a different situation and a generation from now you could be going in a completely different direction. So here's what I'm gonna say. If you have type two diabetes, or prediabetes, go to a doctor and say I want to use epic or Manjaro. They're not advertisers of the show. As a matter of fact, I don't know insulin, or drug manufacturers ever tried to advertise on the show? I'm not even kidding. Anybody here, right? I'm saying I'm saying this is a fairly simple thing to do. That has a good chance of leading to a benefit for you. I think it's worth a shot.

Jennifer Smith, CDE 56:37
I think the only caveat to it and is very visible, and your doctor may bring it up as well is coverage, right? That it coverage may be a limiting factor, depending on what your in insurance carrier is, or you know, who you're going through for your medical care. So that is it, we talk about all of the highlights and the things and Hey, go and ask about this. It is a certain consideration that you have to make sure that you have coverage because these meds out of pocket are expensive. Yeah,

Scott Benner 57:09
I'm even wondering big picture for the world, if people who have decent coverage that will cover it or can afford it in cash, which I know it sucks extensively expensive and cash like $1,000. But like if your insurance covers it, and it's 25 $50 a month for you or something like that, maybe just the people who can afford it using it, and then the benefit becoming obvious. Maybe then that moves the insurance coverage along and the medical community along and people that are in a position to push and say, Look, we have to cover these things for people look what it's doing. Right?

Jennifer Smith, CDE 57:43
Absolutely. I mean, if they're not having to end result pay for all of these major procedures and things that are very, I mean, I've ever looked at the cost of like a heart procedure not covered. They're enormous. Just I can't even imagine paying for that out of pocket, but add some end result being that somebody now doesn't have to have that done on our whole insurance sort of industry. It's a rock that once it gets rolling the right way, hopefully it does gather the right kind of grasp.

Scott Benner 58:17
They'll just make money on something else is like, hey, we'll do this instead. And it'll actually help you. I honestly think that what people are complaining about now about all the like social media, people using it and everything, I think that's gonna end up being a good thing. You know, I get that it pisses people off, because they're like, oh, there was a shortage of the drug. And there are people who have diabetes that can't get it now. And I mean, I don't know how true that is that that's actually happening, or if it's just a news story. But what I think is that it normalizes it. And I think that's the one thing around weight that we really lack is somebody being willing to stand up in front of a camera and go, Hey, look at me, I weighed 300 pounds, and I'm gonna stick this on my side. And I'm going to come back every week and show you again and watch that person. You know, shrink down is it's

Jennifer Smith, CDE 59:01
sure. I mean, the you know, the one show that I can't remember what is it the biggest loser right? I don't even know if that's still on anymore. But that was kind of what what this is it was a weight loss, lifestyle weight loss, that really did have major turnaround impact. It did. But they had coaches, they were like, stuck in this place with like, you will exercise this much you will eat all this food, you will make these changes, like, you know, people don't have that in their own home, though.

Scott Benner 59:36
Many of those people reverted when they got away from that that situation too, which is hard to keep up with, right? Because there's no that somebody's yelling at you every 20 seconds do this, do that and you're like, Um, how about I just go to work instead? You know, but but it was I thought that show was a great example of like, wow, you could actually extra small size yourself out of like significant.

Jennifer Smith, CDE 59:54
Absolutely. You can but you can also see the work that it takes and when Again, busy life's life that we have now, you can see the work that that takes and what you would have to do with the other things in your life to get it going the right way.

Scott Benner 1:00:12
Well, and I want to say to for weight loss, there's no one saying that you just stick this drug in and you don't do anything like you still need correct, move and do all the things that you're supposed to do, but you're gonna get an incredible boost from it. And I think the last thing that I want to say is, like I just talked about, like watching like weight loss people like be influencers online, I'd love to see somebody with type two, like, forget the shrinking of your body. Like I'd love to see someone with type to stand up with a camera go, Look, I'm going to inject this and watch my a one C go down, watch my variability, get tighter, like watch my health improve over and over again. I think that would be really, really

Jennifer Smith, CDE 1:00:48
would be. Yeah, absolutely. I I agree.

Scott Benner 1:00:51
Absolutely. Johnny, thank you. We've done

Jennifer Smith, CDE 1:00:55
I know we've and we've only really touched like the tip of the mountain of like, you know, there's so many other medications. So I don't know if we'll want to do anything brief later at some point about the other meds because there are other medications and I know that they are still being used. And I think some minimal explanation might be helpful,

Scott Benner 1:01:15
run through them, and we'll go back and hit them again. But tell people what we're going to hit when we do it again.

Jennifer Smith, CDE 1:01:19
Yeah, I mean, we didn't really hit on like the DPP fours. I mean, we commented, but there are the DPP four inhibitors. Let's see the SDLT twos, we didn't really get into talking about them. We did mention them, right. And there's a host of oral combination meds that are often in combination with metformin. I, they work all different kinds of ways. But honestly, the main categories are the DPP, fours, the stLt twos, we've also got some that are, I think, less use. Now, the TZ D is some that I haven't seen used in a really long time. They're called Alpha glucan. Alpha glucosidase inhibitors, if they're like starch blockers, essentially.

Scott Benner 1:02:06
Are these things gonna go by the wayside though, as the these GLP ones become more prevalent? Do you think? Maybe, no,

Jennifer Smith, CDE 1:02:15
maybe? I mean, honestly, in terms of in terms of use, they are still out there. How much use they're getting along with these newer meds? I don't, I don't know. I'd have to look honestly and do some research to be able to tell how much these newer ones are really taking

Scott Benner 1:02:34
over? Yeah. Well, listen, Jenny. I've never seen anyone and Tiktok say, Hey, I took a DPP four and look at me now. Well, that's an indication but you know,

Jennifer Smith, CDE 1:02:46
no, and there they are. I mean, the DPP fours are usually used in some type of combination with other things, too. So they're not just taken alone. But I think definitely, at least the DPP fours in the stLt twos would be good to chat about Yeah, okay. I

Scott Benner 1:03:05
just want to point out that he'll monsters are very dangerous and don't try to kiss wanting to get their saliva. That's all Yes.

Jennifer Smith, CDE 1:03:09
Don't don't have one as a pet, although I'm sure people do have.

Scott Benner 1:03:13
I saw one eat a goat. While I was looking this up online. I was like, oh my god, so just please, I don't know. Yeah, stay away.

Jennifer Smith, CDE 1:03:23
Leave the lizards in the desert. All right, Jamie. Okay, bye.

Scott Benner 1:03:33
Thank you so much for listening today. thank Jenny. Jenny can be reached at integrated diabetes.com. She does great work for people living with diabetes. Check her out. And thanks to Dexcom for sponsoring this episode of The Juicebox Podcast dexcom.com forward slash juice box, check out the G six the g7 Find out if you're eligible for a free 30 day trial of the G six all on my link dexcom.com Ford slash juice box when you click on the links. You're supporting the show. Alright, thanks so much for listening. I really hope you're enjoying the Type Two diabetes Pro Tip series. If you are, please share it with someone who you think might also benefit or enjoy it. I'll be back very soon with another episode of The Juicebox Podcast.