Scott Benner 6/28/24 Scott Benner 6/28/24

#1239 Ask Scott and Jenny: Chapter Twenty-Four

Scott and Jenny Smith, CDE answer your diabetes questions.

• What are the methods to help support an elderly parent who has type 1?

• At what point is it justified for me to ask for u200 insulin?

• What do I tweak first and last to smooth out these highs followed by lows? Do I look at my insulin timing first, my basal, my correction factor, my carb ratio?

• How do I extend a bolus like a pro?

• How do you eyeball carbs?

• With all the automated systems, is getting your meal bolus exactly right going to be as important moving forward as it is now?

• How would you go about putting a pump on your child if they are dead set against wearing a pump?

• What is new in insulin choices and how do they work with pumps?

• How do you handle refrigeration of insulin?

• What about hot tubs? Do you get into a hot tub with your pod on? Could your insulin start to deteriorate?

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

Scott Benner 0:00
Hello friends and welcome to episode 1239 of the Juicebox Podcast

Jenny's back everybody and we're doing another episode of Ask Scott and Jenny. That's pretty much it. Although Jenny loses power like 20 minutes into it. So there's a whole kerfuffle. 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. We're always complaining we want things to move forward. We want better research, but they need to know what to research and what people think. And that's where you come in. T one D exchange.org/juicebox. complete the survey help people who are trying to help people by answering simple questions that you know the answers to I promise. T one D exchange.org/juice. Box takes about 10 minutes to complete the survey they're looking for people living with type one diabetes where US residents and people who are caregivers, T one D exchange.org/juice box be part of the solution. When you place your first order for ag one with my link, you'll get five free travel packs and a free year supply of vitamin D. Drink ag one.com/juice box

Today's episode is sponsored by Medtronic diabetes, a company that's bringing together people who are redefining what it means to live with diabetes. Later in this episode, I'll be speaking with Mark he was diagnosed with type one diabetes at 28. He's 47. Now he's going to tell you a little bit about his story. To hear more stories from the Medtronic champion community or to share your own story. Visit Medtronic diabetes.com/juice box and check out the Medtronic champion hashtag on social media. This show is sponsored today by the glucagon that my daughter carries G voc hypo penne Find out more at G voc glucagon.com. Forward slash juicebox. This episode of The Juicebox Podcast is sponsored by the ever since CGM. Ever since it's gonna let you break away from some of the CGM norms you may be accustomed to no more weekly or bi weekly hassles of sensor changes. Never again will you be able to accidentally bump your sensor off. You won't have to carry around CGM supplies and worrying about your adhesive lasting. Well, that's the thing of the past. Ever since cgm.com/juicebox. Jenny, we are going to do a ask Scott and Jenny episode today. All right, I have questions. You have answers. Let's get started.

Jennifer Smith, CDE 2:52
I might hopefully have answers.

Scott Benner 2:56
This first one I know is a near and dear problem to your heart. So I'm going to start with this. I would be interested in methods to help support an elderly parent who has type one. They have a CGM and Ron MDI, they're 95 years old. Wow. Yeah, that's awesome. Yeah, great. Yeah, that's awesome. Yeah, but you talked about this all the time that the devices aren't really designed for people with slower motor skills, eyesight, stuff like that. And obviously, at some point, this woman got back to MDI, but do you have any thoughts about how to help somebody with this?

Jennifer Smith, CDE 3:35
Yeah, without any of the details, you know, there's, there's got to be a lot of assumption this person is helping their parent did you say it is right for an elderly parent, an elderly parent, if the person is living with them, you know, an automated system may be very good to consider. Because at least at that point, you've got some protection from both the end zones that you're trying to aim to stay away from the highs and the lows, you can also navigate some targets that are even a little bit more conservative, if you're really worried. It may give some ability to have them have some time on their own, while you may go to work, or do the things that you need to do. And so you don't always have to be there for you know, things like bolusing, right? There's a whole host of other things to consider if you're looking at nursing home and those types of care situations, which are very difficult, difficult to navigate with any type of technology. But if you're the main caregiver for an aging or an elderly, you know, parent, or loved one, some of it can be a little bit easier with some of the newer technology that we have because you have visibility then to what's going on. Are

Scott Benner 4:49
you thinking islet? Are you thinking like Omnipod five what is your

Jennifer Smith, CDE 4:54
islet could be the easiest again, depending on what I mean this person is older Are the 95 years old, if clearly had I what I'm assuming is a long time with type one, depending on where they are in their ability to consider things appropriately like mental status, you know, if they're already knowledgeable about carbohydrates, then something like maybe Omnipod five, where they could truly just Bolus for their meal and go about it right might be easier than, you know, I start starts to kind of fail and drawing up a syringe or even dialing up a pen and having the dexterity to be able to push the end of the pen in appropriately. All those things are considerations as we age. So a pump may be easier in terms of button pushing, I would say that the eyelet for somebody who has a little bit less ability to count would be a really nice potential option.

Scott Benner 5:53
You might also think if you've known some older people, they don't eat a ton anymore, either. There's not a lot of food being taken in, you know, maybe that like small meal or snack button on the island would help or, or even, you know, there's part of me wants to say like, what about one of those patch pumps that you just squeeze it and give you two units? But I don't even know maybe two units is way too much? There? No it? Yeah.

Jennifer Smith, CDE 6:15
And or because it's squeezable, again, from a dexterity standpoint, not be able to do it might not be able to do it. Or maybe they can't acknowledge how many pushes they've given I, ya know what I mean? I mean, these are all the things to definitely explore.

Scott Benner 6:32
I interviewed in the cold wind series. So it was an anonymous person who was a nurse in a facility for older people. And if you end up in one of those situations, what's going to be is that they're going to come, they're going to give you a predetermined amount of insulin. And they'll check your blood sugar three hours later, and maybe they'll give you some more if it's high enough. And that's pretty much it. Yeah,

Jennifer Smith, CDE 6:55
you will be in most cases, not all, but in most cases of those living situations for the elderly. Typically, technology is not, is not allowed anymore. Yeah, I've had a couple of rare cases where the family members were close enough. And they would be the ones that came in and did the pump site change, or they were the ones that came in and did the sensor change or whatever. But even there is something happens at two o'clock in the morning. Nobody on staff knows what to do with the system kind of left until your family member can get there. Yeah, and there are a lot of rules and regulations and things that have to be put into place. So it is it's a I've told my boys don't bother me at all. They're way too young to even understand you know what that is. But

Scott Benner 7:51
while you it would be nice if one of you didn't get married, and just hung around with mommy, we'll flip a coin later and figure out who it's gonna

Jennifer Smith, CDE 8:00
be nice if one of you has a basement room that's furnish really lovely, and I promise I won't eat very,

Scott Benner 8:07
mommy's writing this five and a half a one c out till the end. Dammit. Right. Okay, well, I mean, it's, listen, it's a tough thing that hopefully we're all going to have to figure out how to deal with and I don't know that it's going to be an easy answer.

Jennifer Smith, CDE 8:21
Right. And I think you know, for this woman, obviously 95 years old, has lived a long, full, hopefully very wonderful life with what sounds like really wonderful family members who want the best to open. And my hope is that, you know, for the younger people with diabetes and technology use that technology just keeps getting better. And at the point that you may need some type of care, it'll be to the degree that there's not much that you really have to do to use it.

Scott Benner 8:52
So that'd be nice. Alright, let's move on to at what point is it justified for me to ask for you 200 insulin, my 11 year old daughter routinely uses over 100 units of you 100 Novolog every day. And she is already on two Metformin pills a day, the large dose of insulin hurts going in especially the long acting to SIBO. On days we go untethered, could switch into a different type of insulin have a difference as to the kids getting such a large Bolus under the skin to that even that isn't is unpleasant. Yeah. Okay. What

Jennifer Smith, CDE 9:28
do you think, in this 100%? Correct, they should be asking for you 200 insulin, also kind of questioning. They're great that the Metformin is in the picture already. I would actually recommend them ask their clinician, how much of an impact do you think this is actually having? Right? Because and that would take some comparison, which sometimes in kids is harder to do because they are growing and so insulin needs will naturally increase as kids To grow anyway. But from pre use to current use of metformin, has insulin really not shifted much? Maybe it's not doing much. And maybe there are other things that could be considered along with you 200 insulin, that'll take care of the volume at the site. Yeah.

Scott Benner 10:20
What else do you think would help? Well,

Jennifer Smith, CDE 10:22
again, things that are being considered in use things like GLP ones. Yeah. I mean, they're, they're, they're, you know, certainly not as tested in the youth. They're certainly something that I have heard and seen being used off label. It really takes an endo team to consider use for something like that. You know, the other consideration, and this is something that's also very near to what I navigate with people every day is evaluating food intake. Right? Yeah.

Scott Benner 10:59
Yeah. You don't know. Because it's not in the question. They didn't say, they didn't say she's using 100 units, and we're eating 300 carbs a day, this could be right. This could be 50 carbs, and and this problem, which would indicate that it might not matter how low carb you go correctly? Are there knowable, physiological reasons why this happens to some people? Or do you just have to say it happens to some people?

Jennifer Smith, CDE 11:25
I think it's easier to say that it just happens to some people, you know, when you're considering type one was never included, or I guess, resistance was never included, along with type one, until maybe 510 years ago, let's say, in general, where we really started to see the potential that someone with type one diagnosed type one, right, could potentially have resistance along with that, not necessarily relative to lifestyle factors or whatever. more prevalent from a woman perspective, especially once they get puberty and they get into, you know, their adulthood where things like PCOS might be in the picture, polycystic ovarian syndrome, right, that definitely impacts resistance, regardless of type one. You know, I think that there are people that are more resistant, there is a reason for it. I don't think that there is a nailed down conclusive, this person with type one is very likely to also have resistance to insulin, right. Thus, we should consider these types of inclusive, sort of, let's call it alternative medications or management, you know, therapies along with just the insulin. Yeah,

Scott Benner 12:44
well, so I mean, people have heard me say it enough, probably. But I will add that, you know, I just paid cash for a GLP bed for Arden today. So it helps her immensely. She was not up to 100 units a day. But truth be told, like in three days, she could use a whole pod. You know, she could use 200 units in three days. And, you know, I've said before that I expect Arden to use 16,000 fewer units of insulin this year because of GLP. A lot less Yeah,

Jennifer Smith, CDE 13:17
it is And didn't you? I can't remember the age of the child. But you didn't you interview a mother?

Scott Benner 13:23
She's 15 Yeah. I just heard from her again. They're moving her basil down again. So I told you she was at seven units and no boluses On we go v. And I'm going to scroll up to her extra me. So she says she was a little bit older. She's definitely 15 Yeah, she sent me another graph. It is I would say with the exception of three excursions that go to 151 40 and 150. She is stable around 85 or 90, and never gets under her low alarm, which looks like it's set at maybe 460 at now, if I'm guessing, because I can't see the I can't see where the alarm setup. Wait, here's the rest 95% range, standard deviation 15 Oh, excuse me. 100% and range range 65 to 180. Average glucose 95 standard deviation 15. Scott, I thought you might want to see this. We're going to be dropping Basal from seven, down to six, it might go as low as five that's from 70 total units of insulin a day before the week before the week OB so

Jennifer Smith, CDE 14:41
and other considerations to which this you know, this parent doesn't necessarily post but as thyroid be evaluated, and or has it been managed? Well, if there is already a known issue in the picture, all of that can influence insulin sensitivity as well.

Scott Benner 14:57
So I forgot to say that actually A Thank you. Yeah, yeah, TSH mat, if you have thyroid issue, make sure they're managing your TSH under like 2.1. If your TSH is you know above that and somebody's telling you don't worry, it's in range, we're looking at it, you have symptoms, that I think those symptoms need to be medicated and some of those symptoms could be could be what Jenny's talking about here, which is insulin not working correctly. Okay, you have something else on that. Are you good?

Jennifer Smith, CDE 15:27
I don't know the thyroid was the only thing that I really wanted to add

Scott Benner 15:32
to that. Yeah. Okay. All right. Here's one this is going to be this might take up the rest of the time. What do I tweak first? And what do I tweak last? In order of operation to smooth out these highs followed by lows? How do I look at my insulin timing first my Basal like my correction factor, I carb ratio, what do I look at first when I'm seeing eyes, followed by lows. If you take insulin or sulfonylureas you are at risk for your blood sugar going too low. You need a safety net when it matters most. Be ready with G voc hypo pen. My daughter carries G voc hypo pen everywhere she goes because it's a ready to use rescue pen for treating very low blood sugar and people with diabetes ages two and above that I trust. Low blood sugar emergencies can happen unexpectedly and they demand quick action. Luckily G vo Capo pen can be administered in two simple steps even by yourself and certain situations. Show those around you where you storage evoke hypo pen and how to use it. They need to know how to use Tchibo Capo pen before an emergency situation happens. Learn more about YG vo Capo pen is in Ardens diabetes toolkit at G voc glucagon.com/juicebox. G voc shouldn't be used if you have a tumor in the gland on the top of your kidneys called a pheochromocytoma. Or if you have a tumor in your pancreas called an insulinoma. Visit GE voc glucagon.com/risk For safety information.

Jennifer Smith, CDE 17:12
What do we always start with? We always start first with basil. Basil in the right place. And if you're again, we don't know anything about these the system being used here, right? If it's a manual pumping system or MDI, look at the base Basal which you have adjustment, you know, to? If not, then look at where there is stability in a Basal only time period with an algorithm? And is it holding things in a pretty stable place? Maybe it's holding it a little higher than you want, but at least it's pretty stable. The expectation then is the Basal probably not the piece that's the most off. So then you could absolutely go to the factors that you can adjust which are insulin to carb correction factor, maybe active insulin time. Yeah. You know all of those things. But when you're seeing graphs, I think it's also important to make note of where did the Bolus go in? When did the food start to be taken in? What was the content of the meal? Right? Do you need a longer Pre-Bolus? Do you need a shorter? Do you need none? Do you need an extended Bolus? So there are steps to it, which is what they're asking. But if you're using the right carb count as precise as possible, I don't think everything is 100%. But as much as possible, you're doing your Pre-Bolus Strategy, you're getting high and you get stuck high and you have to correct that it's very likely that it's an insulin to carb ratio problem. You started in a great place it went up never came back down, which is the goal of the right amount of insulin for food is to get it down if that's not happening. The insulin to carb. Yeah, if you're starting at a normal place it goes up higher than you want comes down. But you get to target it's not the Bolus then it's the timing right yeah. And then from a correction factor which I always feel like it's sort of like it's like the stepchild in the corners forgot

Scott Benner 19:16
about their correction factor that

Jennifer Smith, CDE 19:18
a lot of a lot of people don't and I think actually they don't mainly because it's also less adjusted by most clinicians it's the factor that's not often shifted enough unless there's a very visible Oh yes, you corrected and it never brought your blood sugar down. Great. Let's shift this but a good visual love you test it you you find out oh, my insulin to CARB is great. It was the it's timing. Okay, well what happens if you start that meal with a higher blood sugar? You take the right amount of insulin, you time it and your blood sugar does come down but it never lands you at Target. Okay, you knew your insulin to carb was right because when you started with a target blood sugar and you Bolus right He brought you to target. This time you're starting high, and it never gets you down. That's your correction factor.

Scott Benner 20:07
Nice. Okay. That's a nice way to think I said nice because it's a clearer way to describe it. Yeah. Yeah. I mean, when I see this question, my first thought if the person was in front of me, I would probably first say, is this been like this forever? Or was this not happening, and now suddenly, it is happening. If suddenly it is happening, then I'm thinking your insulin needs have obviously changed. And I'm always with Jenny basil. First, make sure your basil is keeping you at the level you want. Also, that's a lot to consider too, because your comfort for Where does your blood sugar sit stable, and somebody else's might be different. If you know Arden's blood sugar is held stable at 90 overnight, then when we go to Bolus for something, she's got that consideration of basil happening constantly. But if you're a person who's like, oh, I want my blood sugar to be at 130 overnight, then the truth is, is you're deficient in basil, not a ton, obviously, because you found stability, but it's still not as much as your body really needs, or your or your blood sugar would be lower. And now you have to, so that's okay, if you want to do that overnight, like good on you, like whatever you want to do is fine with me. But then you have to consider that when you're looking at correction factor insulin to carb ratio, all the other implications because you're already late on Basal Correct, yeah, yes. So

Jennifer Smith, CDE 21:26
if you are thinking that way, it's actually great that you brought it up, because if you're thinking, I feel safe and healthy at 130, floating in overnight, coming into breakfast, and then you're frustrated, because during the day, your Bolus is aren't pulling you down to 100. Basil this week, it's likely that your basil is the deficit there, right.

Scott Benner 21:49
The way I've always said it, you'll hear me say it and like the Pro Tip series is that if your Basal supposed to be one unit an hour and you're using point seven, then every hour of the day, you're deficient point three. So after one hour, you're down point nine, you know, or after three hours down point nine and for six hours you down two units almost. And then you go along and you Bolus for something that your carb ratio says it only needs three units. Well, that's great, except in the last six hours, you're you're deficient two units of basil, you make a three unit Bolus for the meal. You're all you've done is replace the basil. And there you go, you're the blood sugar is off to the races. So I mean, Basil first, because I think nothing works. Well. If your basil is wrong, then I try another meal. If and then just like Jenny said, does it shoot up and then come back down? Maybe your Pre-Bolus was too short, you know, does it go up and stay up? Maybe it's not enough insulin, you know, does it take a while and then go up? Maybe there's no fat or protein in your meal? It's pushing you up? You're not considering there's a you know, keep messing with it. You'll figure it out? Well,

Jennifer Smith, CDE 22:53
and I think in this train of thought when you are trying to figure it out, I think it's beneficial to actually truly try to cover a meal that's not necessarily void of fats and proteins, but not terribly heavy in it either. Because if you're really trying to get a handle on, is it the insulin to carb ratio, then really what does our rapid insulin What's it formed to cover?

Scott Benner 23:18
How many times have you thought it's time to change my CGM? I just changed it. And then you look and realize I got it's been 14 days already a week, week and a half. Feels like I just did this. Well, you'll never feel like that with the Eversense CGM. Because ever since is the only long term CGM with six months of real time glucose readings giving you more convenience confidence and flexibility. So if you're one of those people who has that thought that I just did this, didn't I? Why well I don't have to do this again right now. If you don't like that feeling, give ever sent to try because we've ever since you'll replace the sensor just once every six months via a simple in office visit ever since cgm.com/juice box to learn more and get started today. Would you like to take a break? Take a shower you can with ever since without wasting a sensor. don't want anybody to know for your big day. Take it off. No one has to know have your sensor has been failing before 10 or 14 days. That won't happen with ever since. Have you ever had a sensor get torn off while you're pulling off your shirt? That won't happen with ever since. So no sensor to get knocked off. It's as discreet as you want it to be. It's incredibly accurate. And you only have to change it once every six months ever since cgm.com/juice box. Right now we're going to hear from a member of the Medtronic champion community. This episode of The Juicebox Podcast is sponsored by Medtronic diabetes. And this is Mark.

David 24:53
I use injections for about six months and then my endocrinologist at nav recommended a pump

Scott Benner 24:59
Hello Have you been in the Navy? Eight years up to that point? I've interviewed a number of people who have been diagnosed during service. And most of the time they're discharged. What happened to you?

David 25:09
I was medically discharged. Yeah, six months after my diagnosis. Was

Scott Benner 25:13
it your goal to stay in the Navy for your whole life? Your career was?

David 25:17
Yeah, yeah. In fact, I think a few months before my diagnosis, my wife and I had that discussion about, you know, staying in for the long term. And, you know, we made the decision, despite all the hardships and time away from home, that was what we

Scott Benner 25:29
loved the most, was the Navy, like a lifetime goal of yours?

David 25:34
lifetime goal. I mean, as my earliest childhood memories, were flying, being a fighter pilot,

Scott Benner 25:39
how did your diagnosis impact your lifelong dream?

David 25:42
It was devastating. Everything I had done in life, everything I'd worked up to up to that point was just taken away in an instant, I was not prepared for that at all. What does your support system look like? friends, your family caregivers, you know, for me to Medtronic, champions, community, you know, all those resources that are out there to help guide away but then help keep abreast on you know, the new things that are coming down the pipe and to give you hope for eventually, that we can find a cure.

Scott Benner 26:08
Test it with a meal you've been good at in the past. Yeah, it's very countable links so that you're not guessing at the carbs. And then you'll get a good idea of whether or not your ratio is decent or not. And then you can start adding considerations for you know, higher fats and stuff like that down the road. Right. All right. Well, this next one will just kind of like piggyback right on to this, how do I extend a Bolus? Like a Pro? That was the question? Oh,

Jennifer Smith, CDE 26:35
like a pro,

Scott Benner 26:36
just live with diabetes for a long time and keep trying to extend Bolus this

Jennifer Smith, CDE 26:41
is gonna say lots of experimentation.

Scott Benner 26:44
I mean, I'll start by saying that I used to use a lot of extended Bolus is when Arvind was in school. And I would use them in creative places. The first way I use them that I don't think people would think to use is as a way to Pre-Bolus a meal at school. So Arden would we Bolus in her classroom, she and I together. But you know, you wanted a 10 or 15 minute Pre-Bolus. But at the same time, you're pumping insulin into this kid sitting in the classroom, she's not going to the nurse, she's gonna is she gonna go right to the cafeteria, she's gonna mess around is there going to be a line like, I don't know what's going on. So I wanted some insulin on my side. But I didn't have the nerve to just put it all in. Because what if you know all the what ifs. So what I would do is I Pre-Bolus the time, but I would do something like now, remember, Arden uses Omni pod. So this is kind of like language from their thing. But you can apply it to your own, I would do something like that I'd put in all the carbs or 70 carbs in this meal. And it would say, you know, however much it was gonna give her and I'd say Okay, put 30% of it in now, and the rest of it over a half an hour. So let's say it was a 10 unit Bolus, it wouldn't have been, but let's just say it was three units goes in, that's my Pre-Bolus. This last seven units is getting squeezed in real fast over the next 30 minutes, you get the initial pull from the first three units. And then as you get there, and you sit down, you start eating the rest of that seven units is in there starting to fire up. And that's one way I would use one, you can apply that to anything, just have to reverse engineering, you just have to say, I'm gonna have, you know, a high fat meal. And I know that my blood sugar is going to try to go up 45 minutes after I start eating. So how do I line up these extended pieces of this Bolus to combat the impact of the carbs? And that's to me, that's the whole thing. Like it's just, it's basically an extended Bolus is Pre-Bolus thing, a bunch of different variables through a meal. If that makes sense. That is how I think about it. But you might say it differently. Jenny, you're frozen? I thought you disagreed with me. That's hilarious. Hold on a second. All right. She'll be back in a second. She made such a face. Like as she froze. There wasn't like a real face. It just froze in a weird spot. Keep in mind, Jenny is from a Nordic state. Anything could have happened here. massive snowstorm out of nowhere. She could have been eaten by a Yeti. She's pretty close to Canada. She said, okay, all the power my house just shut off. She just texted me. Hold on. I'm gonna pause. Okay, hey, Tony, what's up? Not much. How are you? Good. So I just listened back to the last couple of minutes of this conversation. We're going to leave the part in that indicates that you lost power at your house. So first of all, let's take a second before we go back to where we were to talk about Will you will you share with people what you said afterwards, like when your power went out?

Jennifer Smith, CDE 29:47
What I share Yeah, embarrassing. My embarrassing

Scott Benner 29:51
information. Yeah, so the embarrassing thing that happened but the other thing too, were like, so Alright, so Jenny's power goes out, and she's texting with me. Oh, yeah, and I'm gonna tell you from my perspective, I thought gosh, I hope I'm not miss reading this but she seems scared I'm gonna offer to call her. But you're Listen, you're an adult, you have children a home, a husband, get car, you know, a job, people know you as thoughtful and like level headed, but tell people your fear.

Jennifer Smith, CDE 30:24
I fear is that, you know, like, all the scary people hiding, like, potentially in the dark room that you like, and I think I texted you when you texted you know, are you okay? You seem kind of scared. I was like, so yeah, I was the teenage kid who sat in the kitchen with my friend's parents talking to them, rather than watching the Friday the 13th movie that all my friends were watching, because I was too scared to watch it. So and I've still never seen any of those movies. So I have would have had to have my power goes out, right? Like, okay, check the power box, is it just mine, right. But in the meantime, I like have to go into the dark, dark room in my basement in order to see. And it's not like around the corner in the dark room. It's like across the room in the dark room against the firewall where the spiders live. And all those things, right? So it means I have to open the box, and maybe somebody's hiding it. I know that this is all gonna think oh my god, Jenny is a crazy person. I really not a crazy person. I'm old enough to not have this be the case in my brain anymore.

Scott Benner 31:34
So I call her because I'm like, I really think she's scared. And I'm like, we know each other really? Well. I got Oh, wait you to be scared. You know, it's like so we're on the phone. And then I immediately like I slip into who I am. So I'm like Jane, listen, go head over to the fuse box. I'll stay on the phone with you. And when this guy attacks, you do your best to describe him so I can tell the cops later. She's like, Oh, great. Thanks.

Jennifer Smith, CDE 31:58
And I did I was brave enough. Yeah, I take the flash went into the room. I'm like, yep, none of the fuses are blown. It's all good. And then I texted our neighbor. And it was like a power outage or a car had hit a pole or whatever. And it was out for a good number of hours. But yes, God saved me in my I have to go into the dark room.

Scott Benner 32:16
I did feel that no. Okay, so now we'll, I'll tell you what, we'll pick up where we left off. And at the end of this, we'll tell the people about the embarrassing thing that happened to you after that.

Jennifer Smith, CDE 32:27
Are you sure? Really because that's kind of embarrassed? No, I

Scott Benner 32:30
know, but we don't want to pile on right now. So we're just gonna say this. I don't know where we left off. We were talking about extended Bolus isn't like how to extend a Bolus, like a pro. So yes, like, I gotta be honest with you. Like, I don't know what we talked about. So if you all feel like we didn't do a good job of that, send me a note. And we'll do extended bonuses again, sometimes, but it's gonna be too disjointed to go back and try to figure out where we are and come in.

Jennifer Smith, CDE 32:53
And I think that we had, I mean, we did something about how to do extended why I think we're talking about scenarios as to why you do an extended Bolus. And even some of our algorithms today that don't even allow an extended Bolus and unless you choose to go back into manual mode to utilize that for what you know what you need to write.

Scott Benner 33:12
Okay, so let's just go on to the next question, which is, what to do if you really don't like to count carbs, and you just want to eyeball it, but your guesses are always right. Laugh out loud. I'm just trying to think of things because honestly, you have answered so many of my questions that I've elicited. Okay, so she wants to know, how do you eyeball carbs? I guess is the is the overarching question. Yeah, you really count. Like do you look on boxes and weigh things

Jennifer Smith, CDE 33:39
I would say a lot more of mine is eyeballing. And also, if there is a packaged item, I don't buy packaged items that I haven't purchased before we're really in what we bring into our house, we're careful about a lot of ingredient stuff. So I tend to buy the same things over and over because I know that they work and because I've done that I already know like how many crackers is this particular brand, so I don't really look at it anymore. I just know it from previous use. But other things you know, like fruits and vegetables and stuff that don't come with a label on them. Those become more of an eyeball and there are some things that I use a food scale for to use carb factors and get a more precise count things that I don't eat all the time and that my guesstimate I'd rather have a little more precision like a sweet potato in winter or something like that. But a lot more of my I would say a lot more of my meals are they're intelligent estimates because it's I've been doing it long enough that it works yeah.

Scott Benner 34:44
Or you can just look at a plate and go this is usually about when I have meatloaf it's usually about 50 carbs because I have potatoes with it and there's carrots here some gravy

Jennifer Smith, CDE 34:52
and or that I've made the recipe before and the recipe had nutrition information. And I can all again it's like a mess. Emory component,

Scott Benner 35:01
I should say that I don't mean that the the, I'm guessing, like, oh my gosh, there's definitely 50 carbs here. I think of it more as like, well, there's the insulin that 50 carbs and the pump will give me his worth of impact from food here. I know that sounds weird, right? Like, I don't actually guess the carbs so much. Although I do count sometimes. But it's more like, like if like, you know, if you had hunks of chicken in there were breading on it. And french fries as an example, I would basically just count the french fries and go, you know, 246-810-1215 1820, and then 510 1520, like here for the nuggets. And then I look and go is their sauce, their sauce five more, you know, is this greasy? Maybe another 10%? Here we go. Like, you know, that might be how I would do it.

Jennifer Smith, CDE 35:46
And that's kind of along the lines of when we do more like advanced estimate counting kind of information for people. They're easy tools, like a woman's fist is about the size of a one cup portion. So again, you're not going to carry measuring cups in your purse, but you do have your hand attached to your body. Yeah,

Scott Benner 36:06
I right hand, I was just wondering how big my fist is, like,

Jennifer Smith, CDE 36:09
it's a woman's fist, not a man's fist. A woman's fist is about a cup. So if you know how much from measuring things like pasta, or rice or other carbs worth a cup portion, and you're out in a restaurant, you can say, well, it looks like they're three of my fists of pasta on this plate, you can estimate that a little bit more precisely based on known factors you've had before. Right? I'm

Scott Benner 36:33
gonna ask a question to kind of piggyback onto this one. Now, I want to say before I start, there are times when I ask questions, because I know the answer to them. And I want to have the conversation. This one I don't know the answer to and I may be pulling this out of my butt. And I might not be right. I'm starting to wonder if with all these automated systems, if getting your meal Bolus, exactly right is going to be it's going to sound crazy, but as important moving forward as it is now. Because if I'm having 50 carbs, and I guess 45, and I start heading up, the algorithms gonna start pushing insulin pretty quickly, right?

Jennifer Smith, CDE 37:07
Correct. Depending on the algorithm, some are more aggressive than others, some will turn that around faster, and you won't have to adjust with extra insulin, some are a little slower, and you just have to wait for enough give to get in the picture to make a difference there. But in the case of looking at that data, then somebody who doesn't really just want to rely on the system catching the five gram difference, or the off count or whatever. Some people are great with that, and others are gonna say, Okay, I'm gonna look at my data, I'm gonna say, well, it looks like the system is always giving a lot after my breakfast meal, I probably need to either count more with precision, or maybe my ratio isn't quite right. So I think there are two ways to think about if people want a little more precision in their dose settings. And then other people were, if the system is going to help them, and they're okay with this part, this type of a Rise Fall, they just let it happen. And then, you know, until the system isn't containing it the way that they were used to, and a setting then may need to be shifted for them because something has changed.

Scott Benner 38:16
If you count the carbs get it right, and then it doesn't work, then your settings might be off. Correct, right, or you're getting some impact from food that you're not giving its full weight to.

Jennifer Smith, CDE 38:28
And I think with and on the same like line of thought I think with depending on the do it yourself systems, right, that are now in heavy use. They are leaning to the adaptation of settings in a way that's much more aggressive than the other adaptive systems that are on the approved list here. Right? So settings are going to adapt based on total daily insulin, or a set of data that says it looks like you're trending to needing a little more coverage, it looks like you're trending to needing a little bit less. And some people have found that they don't even Bolus with some of these systems. Yeah, right. They don't even announce anything. And depending on the system they're using, the system may use this particular piece of the algorithm versus this beta based on the rate of change, and the other settings that they have told it to work with,

Scott Benner 39:25
right? So like if on the pod five, for example, sees like a bigger use of insulin over two days. Then on that third day, it may just start being more aggressive because it expects that's what you need. Also, Arden who's wearing IPS which I think she's going to switch from soon to another branch of it. But that one has dynamic, everything. It's dynamic, Basal dynamic, insulin sensitivity, dynamic card ratio, I have it all turned on and it works pretty well. Okay, and you know what, let me just tack on to the end of this. The other idea about Being on the algorithm is an algorithm is let's say your basil is a unit an hour. If you miss your Bolus a unit heavy, there's a world where the algorithm can still make up for that by just keeping the basil off longer after the Bolus co said, like almost like five units were further food. And oops, I put in six units. I'll just keep the basil off an hour longer and make up the difference there. Basically, I Pre-Bolus the next hours worth of basil with the over Bolus of the food, the mistaken overhauls to the food, there's a lot of different ways to think about timing. Once the algorithms involved, it's giving and it's taking away. Right.

Jennifer Smith, CDE 40:39
And I think that's the it's the more automated use of eons ago, the the term coined by John Walsh was the super Bolus option, right, where you give a lot more upfront, and then you would manually set a temporary Basal decrease or suspend assuming the upfront coverage was to stop a quick rise on the back end, you took away what you added in the front. But now our automated systems can absolutely do without you even exactly

Scott Benner 41:07
what it's doing. Yeah. Okay, this one's not going to be easy. So we'll just jump right into it. Because there's a lot of has a lot of just opinion here, but how would you go about putting a pump on your daughter when she's seven years old, and she's dead set against wearing a pump. I know what the right approach is, she's eight months into new diagnosis. I co parent, our daughter is split 5050. Between me and my ex, he told her, it will be up to her when she wants to wear one. And she's sticking to that. And as you can imagine, that's messed up my plan pretty good. So this is interesting, because I just had a conversation on the podcast the other day, I interviewed a physician whose child has type one. And she shared with me. She said, I agree with you, Scott, I've heard you say this on the podcast before I don't let kids make medical decisions. And I'm like, okay, and she goes on, I get the other part of the conversation too, with autonomy and body positivity and like those other concerns. And she's like, but from my perspective, after she wore it for a little while she was okay. And the getting over the hump is what she thought was the problem. And I was like, it's interesting, because I feel both sides of that. I do too. Yeah, you know what I mean? Like, I wouldn't want to make anybody do what they don't want to do. But you also me how many stories you hear about like kids like, no, no, no, no, no. And five days later, like, this is fantastic. I haven't used the needle in five days. So, you know, I don't know, what do you think about that?

Jennifer Smith, CDE 42:41
I do very much agree with the doctor you talk to, in general, the adult brain isn't really completely adult until like to age 25. So we talk about kids, they're really, they're under informed in a way that they're that it's also because they're not at the level of understanding the depth that an adult truly has in understanding benefits here reach bar. Yeah, kids also, you know, have kids with diabetes who have caregivers who are navigating it with and for them pretty much they can't understand or grasp the gravity of what their parents are doing for them. Right. And some of the navigation as that sounds like this parent is kind of emphasizing is they need some life back to they need some assistance with dosing that can be a lot more precise, and potentially offsetting feeding insulin because it doesn't have to be there in such imprecise doses. Right. And so I also agree in the fact that many times kids adapt pretty quickly. They may really dislike it to begin with, maybe it's a week worth of complaining and annoying. But as you said, less injections, man, for the most part goes over pretty darn well. Yeah,

Scott Benner 44:10
I think there's going to be outliers, obviously. And there's yes, there's a spectrum here of of how the response is going to be for sure. Now, if my kid was having a complete meltdown, and you know, like, running into walls and screaming, I'd be like, okay, hold on, like, let's wait, but, but just the kid who's like, I don't want to do that. Well, of course, they don't. I mean, any you put on a pump every day, if I gave you the choice, would you want to do that? Like, you know what I mean? Like nobody wants to do that. Like, it's hard because you get this diagnosis. And, you know, we're very much fans and telling people like you're going to live a perfectly normal life. I think that's true. It's not gonna stop you from doing anything. I think that can be true. But, you know, most people don't walk around with a couple of things stuck to their arm or their hip or their belly or something like that. Right? There's an adjustment to be made there and a Um, acceptance that has to come. Right? You know what I mean? So I'm not, I wouldn't be a fan of just looking at a kid one day and being like blurting out, like, Hey, we're getting the CGM for you, you're doing it, I don't care what you think. Yeah, I think you gotta like, you gotta parent your way through it and support them. And like, there's got to be love there and compassion. And we're gonna do this together, and I know you're wearing it, but I'm gonna be here. And, you know, I wouldn't be I'm not a fan of just like, do it. But I'm also not a fan of letting an eight year old make a decision about their

Jennifer Smith, CDE 45:33
health. Yeah. And I also think that there is a way of discussing that piece that you want to bring in, in a way that makes sense at their level, at their age level, at their education level, you find the things that are really important to them that maybe they've had an issue with, because they always have to check in, because they have to take an injection, or they, you know, are taking more time out of class, and having to always go to the nurse versus push a couple of buttons and text, right. So there are some things on their level that you, you could explain to the extent that you've complained about this, if we did this, it could take this down a notch, it could improve this, we wouldn't have to get up at two o'clock in the morning and do an injection. If that was something that was in the pit, you know what I mean, you also

Scott Benner 46:28
have to be ready for when they're, I mean, there's downsides of everything. So when a downside of a pump comes up, you have to be ready to deal with that to not just act like it's surprising you like one day, it's gonna get ripped off, like your site will get ripped out, or it's an omni pod, or they'll get popped off or your Dexcom is gonna hit a door jamb or something like that. You don't want to be ill prepared for when something like that does happen, because otherwise the kids going to be like, See, now this is a hassle. And you're going to be left by going like that. I think you have to tell them upfront, like it's not going to be perfect, but Right. We'll try to measure our wins here and see if they're not greater than the ones we're having right now. Right? And then you know, half joking. Money always helps to you can just

Unknown Speaker 47:09
grease the skids crazy. bribery. Yeah.

Scott Benner 47:12
How would you like a Lego at a pump?

Jennifer Smith, CDE 47:16
Really big $600 Star Trek or whatever, right?

Scott Benner 47:19
Do you think a new baseball glove and a CGM would go over. I mean, I very famously, and one of my episodes, older kid wasn't Pre-Bolus in his meals. And he was almost out of high school if I'm remembering the conversation correctly. And he wanted to start a business of chopping trees when he got out of high school and needed a chainsaw. And I said, the mom was like, you know, I'm going to end up having to buy the chainsaw initially, because the kid doesn't have any money. And I do want to help them. He's got a truck gonna get off on this thing. I said, Why don't you sell Pre-Bolus for $1? Like in a jar, and tell him look for the first 600 Pre-Bolus says, I'll pay you $1 For each one of them get to 600 I'm done paying, you can buy your chainsaw. And I don't know if they ever did it or not. But I felt like a genius that day. That's a great idea. Right? Like, everybody gets something you got something to work towards you feel like you're doing something for yourself. Yeah, the moms being supportive, because they were just stuck in a battle. The kid wasn't gonna do it. And, you know, I mean, I'm not saying you should bribe people. But I think what I'm saying is, is you can like wave shiny things in front of kids and make them forget what they care about sometimes. And maybe this is one of those situations if it is now if you have again, some over and above problem. sensory issues. Like you know, I'm not I'm not certainly saying just be like, screw you take the pump. You

Jennifer Smith, CDE 48:40
know what I also in this situation, it is a hard one because it seems like parental they're not really on the same page. It's almost like a give from one parent. I think it was the dad who was like, Yeah, whenever you are ready, whatever kind of again, the you make the decisions child right? Where the mom's like, you know what, this is going to be better most of the time, it's going to help much more of the time. It's going to make things easier, more of the time. And it's hard because they're completely on opposite.

Scott Benner 49:15
Yeah. Listen, I'm over 50 So I'm going to sound old, but in the entire time I was growing up no one ever wants to ask me what I wanted ever in my whole life. Oh, yes. Didn't ask me what I wanted for dinner. They didn't ask me. I would buy like you got shoes that somebody was like hear these? You didn't get to go. Oh, no, thank you. I prefer they Oh, no. Here's your shit.

Jennifer Smith, CDE 49:37
Absolutely. That's so funny because I thought of that the other day when I was making dinner, and we were talking about it. My older son and I and then I thought about it. I was like When did my parents ever asked me like never know ever. It was just presented. This is what you get to eat tonight.

Scott Benner 49:58
I've had 25 minute Converse. patients sitting in our car outside of our house trying to decide what restaurant to drive to with for people where I didn't think we were gonna come to an agreement, I thought we're gonna have to go back inside. If I was lucky enough to go to a restaurant as a child, I certainly didn't get a say into which one it was.

Jennifer Smith, CDE 50:14
No, we were taken wherever we were going to be taken. And then that was it.

Scott Benner 50:19
Also, while I sat at that restaurant, my father smokes cigarettes at the table. So like, the world's gonna come a long way. But I don't know, listen, this is a tough one, like being a parent. You know? I mean, I think my answer is compassionately act like an adult and bring them into the conversation as much as humanly possible. But get them to where you think, you know,

Jennifer Smith, CDE 50:41
and also expose them, right? It's a concept that's very odd to think about. It's, it's not something that they've maybe touched or felt they might have heard adult level talking about it. They might have heard about it in their endocrine visit. But nobody's let them touch it, see it interact with it. You know, from a mom standpoint, check with check with the pediatric that you that you work with? Do they have a pump exploration day? Would you go there? Because you're also then going to probably see other kids who already have a pump? Yep. And that visibility makes it a lot easier for a child to be like, Oh, I guess I'm not the only one considering this.

Scott Benner 51:25
I can't tell you how many can you show me your pump? posts go up on Facebook that can somebody please show my daughter like this? Or that? Like I've actually I've contacted Arvind recently, and I was like, Can I put a picture of you up with your pump on like this little kid, you know, and then I got a nice note back like, oh my god, like, you know, thank you. She's, she thought Arden was pretty and now she'll do it. Like, you know what I mean? Just like that. Yeah, that's simple, you know, make a difference. Yeah, absolutely. Does. What is new in insulin choices? And how do they work with pumps? Um, there's nothing new that's on now is there like is loom jab and fiasco are the newest and there are a few years old with

Jennifer Smith, CDE 52:01
pretty much the newest and they're just considered more, I guess, ultra rapid acting right. And most people see a difference that use them. Not everybody does. And some people see wider variability. But yeah, I mean, in terms of insulin, they're the more rapid acting I would say the next would probably be the inhalable insulin.

Scott Benner 52:26
A Frezza. Okay, yeah. That's pumped, though. But yeah, that's new, right? That's new. You just said something I'm gonna like, because there's not much to say here like the insulin is what it is right now. There's nothing new they work in there. As far as working in pumps. There's one right a pizza doesn't work in a

Jennifer Smith, CDE 52:44
pizza you cannot use in the tandem, tandem one right tandem.

Scott Benner 52:48
And they'll tell you, you can't use it an omni pod. But Arden's been using an omni pod for like eight years. So. But that aside, you just said something really interesting. Like, don't don't let me lose my thought here. We see people some have luck with it, some don't. At what point do we wonder? Is it the insulin? Or the people's knowledge of how to use the insulin? Like why do we so easily say, oh, that works? For some people, it doesn't work for other people. And we say your diabetes may vary and all that stuff. But what if what's really happening is like you're using it wrong, or your settings are way off. And then you tell me a Novolog doesn't work? Well, if your Basal should have been a unit an hour, and it's a half unit of hour, I could see where you would say but because you see that all the time with like, human algorithm pumps, like, right, this thing doesn't work. And then you look at their settings, and they're so whacked, it would have no chance to work. We never really talked about that. I think out of kindness, really. But you know, all those stories you hear in the space about this thing's better than that thing like says you. And how do I know you use that correctly? Here? Is that a thing you think about while you're helping people?

Jennifer Smith, CDE 53:55
That is interesting. And I think in terms of looking at somebody who is trying one of the newest, more rapid acting, whether it's be asked for loom Jahve, who has been appropriately using the just regular rapid acting insulins, whether it's a pee draw, or Nova log or human law or Novo rapid or whatever, right? They've been appropriately using it, but like they're at the point where that Pre-Bolus is becoming for whatever lifestyle reasons, it's hard for them to maintain that. And I think on many levels, whether it's a kid level, a team level, or even a really busy, you know, adult level in a job that doesn't really give them a long time for a break or whatever, right? And so if they're already trying their best, one scenario that it is working to their advantage is that now that they're using it, we can see the difference in their post meal, blood sugar, even some people who may not have much ability from a previous standpoint, if the medication is going to work for them, we're definitely going to see that that again, that post meal or post food intake is much better contained than it was using the other. Yeah, insulin,

Scott Benner 55:13
I come to that question a lot, because I see people online, and they're at wit's end, and I need a cure this look, this happens to me every day. And I think I think if I was there, I could fix this. Like you don't I mean, like, I know, I can't do it remotely, because you're too far spun off center, and you've got too many preconceived notions about what you think is happening. But I really think there's an answer here that I recognize that person might not be able to get to. But I do think sometimes, like, I think if I was there, I could figure this out. And I might be wrong on some of them. But like, I think in a great number of them, it just is I hate to say, I don't mean user error, but it's the quickest way to make the point, you know, so

Jennifer Smith, CDE 55:55
right. I can give my n of one with fiasco specifically. And honestly, with loom job, yes. worked beautifully for me for about five months. Yeah. And then all of a sudden, I was changing settings to the degree that I had never seen that type of insulin, what I was assuming was resistance. And knowing a little bit, it was pretty soon after fiasco came to market where there was some information essentially, about, it seems to work for some people. For some people, it has a little bit of a waning effect, et cetera. And I was one of those. Yeah, I went back to my long term, used human log, and had to dial everything back back. Why do I insulin right away, it was within 24 hours, I was low and having to dial things back down. loom Jeff just didn't. It was variable like variability. I had never, I'd never seen variability like that before. It was almost like it didn't have the upfront quickness for me. But as soon as it got going, it trashed my blood sugar.

Scott Benner 57:01
Okay, it was bizarre a long time to get going. Then it was like turbo after that.

Jennifer Smith, CDE 57:05
And then it was really, really, really fast for me. So I just stick with my human login, select what works.

Scott Benner 57:13
Alright, let's stick with insulin for one more question. Yeah. How do you handle I'm just going to ask you, I'm not going to I'm not going to read the question. How do you handle refrigeration of insulin? So obviously, you keep it refrigerated when you're not using it. But once you open it, do you keep the open vial refrigerated? Yes. Okay. I do too. Do you have to?

Jennifer Smith, CDE 57:36
Technically no, you have, again, based on what the package insert that nobody reads says 28 to 30 days and then a vial at room temperature should be thrown away. That's what they say. Right. Now, I have long term because that's what I learned to do. Long term, insulin was just kept in the fridge, you took it out when you needed to use it, you put it back in the refrigerator. I travelled for years and years with a ice pack specific bag for my insulin to go in and go places and whatever. And to this day, I still use some type of like insulated pack. The only time I haven't is when we hiked the Inca Trail. And there was no ice ash, there's nothing you could do. There's nothing I could do so but I use the frill. And that worked well because I could get water and at least it kept it cool enough room temperature is what they say. Right? But in general at home or in you know, I keep it in the refrigerator or take it out fill my filled syringe, put that on the counter to get to room temperature and my vials back in the fridge.

Scott Benner 58:41
Have you seen people sharing that article that says that insulin lasts longer than 28 days on refrigerated?

Jennifer Smith, CDE 58:46
I haven't read that article, but I didn't know people are sharing. Oh, yeah.

Scott Benner 58:50
So you but you've seen it as well. Right? Yeah. It wasn't an actual study, wasn't it? I believe it was yes. So I'll just say this. Like, we keep our insulin refrigerated. If we didn't, our house is pretty consistently around 70 degrees, like winter summer, like it's about around where we keep it right. So if we left it out, it wouldn't see any harsh conditions. And there have been stretches of Arden's time where we've done that to like just been like, Oh, it doesn't need to go back in there. And it sits out. I use insulin until it's gone. I don't track how many days it's been open if I'm being honest. So and there's no way you use a vial in 28 days. Right? Right. Yeah. Okay. So you keep using it.

Jennifer Smith, CDE 59:34
How often do you change your Landsat? That's the same question.

Scott Benner 59:38
Like so if you want to follow the rules, God bless you, you should follow the rules. And if you want to try some other stuff, I mean, I think it's up to you you have autonomy, you should you should do some experimenting and see what's my other question around insulin I was gonna

Jennifer Smith, CDE 59:54
say and I think that the reason that I also feel confident in going I'm going beyond that 28 days. And really, I also I mean, I suck all of that insulin. Like down to the last little nibble, right? But I feel confident doing it that way, because I have kept it refrigerated. Okay. If I travel in this is just my strategy when I travel and it has been in like a Freo or something like that when I get home, and thankfully I have I have access to enough insulin that you can do it. Yeah, I just get rid of that vial and I started a new one.

Scott Benner 1:00:31
That's the same for us. We have access to insulin, and I would do the exact same thing. We've gone on like Island vacations where eventually like, a weekend or you're like I couldn't get this thing into ice anymore. And but it keeps working fine while you're there. And then you get home and you're like grommet open and no one yes. Yeah, I mean, okay, what about hot tubs? You get into a hot tub with your pot on? I do. And it's okay afterwards. These are all the things people worry about.

Jennifer Smith, CDE 1:00:57
There all the things people worry about. And when people ask, you know, my best is, what is your blood sugar look like hours after? Is it doing what you expect it to do? You know? And if it is, then that didn't have an impact. If you're rising, or if you Bolus for a meal, and you're not getting the response that you typically should expect? Then change it out. Right? Yeah, it's it's less of a, what should I do? Should I you know, whatever. I mean, hot tubs are hot. You're not going to technically be boiling your insulin, right, but exposed to extreme temperature like that. And if you're completely submerged for a really long time in a hot tub. Sure, it could start to impact. Yeah, absolutely.

Scott Benner 1:01:45
But if you were in there, I mean, Arlen gets in a hot tub. Sometimes she's in there for half hour an hour. I don't think anything of

Jennifer Smith, CDE 1:01:51
it. Like I don't even think I've ever sat in a hot tub for an entire like an hour like I Yes.

Scott Benner 1:01:56
Because you're not a young person. Yeah, kids, you got other things to do. Right? I guess I'm not. Because after 15 minutes, you like, this was nice. I have things I gotta do. My feet up, what is that? Also, you know that a summer, it can be 90 degrees outside, and you can be outside for hours and hours of your pump on or you're not pod on. And the insolence still 98 degrees and you leave it on for days. So Right. All right. Okay.

Jennifer Smith, CDE 1:02:25
I mean, I have I have a lot of questions that come that way, too. You know, we've been, we're going on a beach vacation, or we're going here and it's gonna be really hot and really humid. We're going to be outside. Okay, I can't tell you exactly what's going to happen. Could your insulin start to deteriorate? It could? Sure. Is it going to happen every time? No. What do you do you watch your blood sugars and the response that you would typically expect? And if it looks odd, just change it out?

Scott Benner 1:02:52
Yeah. Yeah. And by the way, are you one day going to get, I don't know dehydrated, your insulin is not going to be as effective. And then you're gonna think Oh, my God, the insolence bed. And like, you know, like, it's gonna happen to you like along the way, the best thing I can say to people is that a lot of the things you're worried about, much like in the rest of life, eventually you won't be worried about them anymore. But you have to go through them enough times to see it happen so that you can kind of leave the fear behind and go, this is just how this works. It's fine. If I leave it out, or I don't leave it out. Now listen, if I didn't air conditioning my house in the summer, and it was always 90 degrees in here. I wouldn't leave insulin out of the refrigerator. I just go back. That's not that mean, just common sense. has to come into play at some point. All right. You know what? I think if I'm not mistaken, we are down to one last question on this list. About that. We've actually gotten through this list. That's That's incredible.

Jennifer Smith, CDE 1:03:49
Yay. Is it a long question? I've got about five minutes.

Scott Benner 1:03:55
Yeah, we're not doing it then. No, you're done. Okay. All right. Yeah, so instead Jedi see you just and let me say, We're gonna delete this out. Yeah, just yourself. Okay. And here's why. Because now instead of we're going to tell the story about what happened. So Jenny's power went out. And then she had to take the kids were,

Jennifer Smith, CDE 1:04:14
oh, I had to go pick them up. At the end of my day, I have to go get it to get the kids from school. Right. And power is still out clearly. And I do have to like preface by saying, I'm still in the state of my, my power is out. I had to totally stop this podcast. I had a whole bunch of emails I still had to respond to in detail. So I'm in this a little bit of like, annoyed, flustered. I go in the garage, and I hit the garage door button and then like, cried I'm locked into the garage because it's the electricity doesn't work. So I tech Scott, and I'm like, Oh, my God, my garage door won't open. He's like, Yeah, pull the string. I'm like, oh my god I'm

Scott Benner 1:04:57
so first of all, she texts me and I was like, oh my I got like, I'm really in this with Jenny Now, like it but it's a first of all your terminology is fantastic because you're like, I'm locked in the garage and I'm like, No, she's not. And then I'm like, Okay, I'm like, oh, Mike, okay, find the the motor and pull the cord down. It'll click, and then you can push the door up on its own. And like, I explained how it all works and everything. But that's not really where the embarrassment is. Right? That's just the thing you never bumped into in your life. Where's the embarrassment?

Jennifer Smith, CDE 1:05:24
Or the embarrassment is the fact that so I tell and I got to school a little bit like, late it was like, two or three minutes later, right? And telling the kids why I'm a little bit late. And my youngest.

Scott Benner 1:05:37
That's your oldest kid, your youngest kid.

Jennifer Smith, CDE 1:05:40
How old are young? My youngest kid who is seven, your seven year old? Go ahead. I seven year old? Yes. Before I even told them. How I actually got out of the garage or what I had to do. I was telling him I'm locked in the garage, bla bla bla. And my little guy is like, well, mommy, did you just have to pull that cord? Oh my god, where were you? 20 minutes ago, when I was panicking. My

Scott Benner 1:06:05
favorite part of the story is but later Jimmy says to me, my kid knew how to do that. Good times.

Jennifer Smith, CDE 1:06:12
I think it was frustration because I have maybe if I had looked around in the garage, I'd have been like, oh, look, there's hard to pull here but

Scott Benner 1:06:22
just I want all you people to remember you're getting your diabetes information from a lady who felt like she was locked in her garage because the power

Jennifer Smith, CDE 1:06:30
thank you for making me feel very,

Scott Benner 1:06:32
you're the one that said you had a couple of minutes left that you could have easily said I had to go. Cool. Thank you.

Mark is an incredible example of what so many experience living with diabetes. You show up for yourself and others every day, never letting diabetes define you. And that is what the Medtronic champion community is all about. Each of us is strong, and together we're even stronger. To hear more stories from the Medtronic champion community where to share your own story. Visit Medtronic diabetes.com/juice box. A huge thank you to ever since CGM for sponsoring this episode of the podcast. Are you tired of having to change your sensor every seven to 14 days with the ever sent CGM? You just replace it once every six months via a simple in office visit. Learn more and get started today at ever since cgm.com/juice. Box. A huge thank you to one of today's sponsors G voc glucagon, find out more about Chivo Capo pen at je Vogue glucagon.com Ford slash juicebox. you spell that GVOKEGLUC? Ag o n.com. Ford slash juice box? You have questions Scott and Jenny have answers. There are now 19 ask Scott and Jenny episodes. That's where Jenny Smith and I answer questions from the audience. If you'd like to see a list of them, go to juicebox podcast.com up into the menu and click on Ask Scott and Jenny. I know that Facebook has a bad reputation. But please give the private Facebook group for the Juicebox Podcast. A healthy once over Juicebox Podcast type one diabetes. The group now has 47,000 members in it, it gets 150 new members a day is completely free. And at the very least you can watch other people talk about diabetes, and everybody is welcome type one type two gestational loved ones, everyone is welcome. Go up into the feature tab of the private Facebook group. And there you'll see lists upon lists of all of the management series that are available to you for free in the Juicebox Podcast, becoming a member of that group. I really think it will help you it will at least give you a community. You'll be able to kind of lurk around see what people are talking about. Pick up some tips and tricks. Maybe you can ask a question or offer some help Juicebox Podcast type one diabetes on Facebook, the episode you just heard was professionally edited by wrong way recording. Wrong way recording.com If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

#1238 Dr. Tom Blevins on GLP Medications - Part 2

Dr. Tom Blevins discusses GLP medications. Part 2

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:00
Hello friends and welcome to episode 1238 of the Juicebox Podcast

Dr. Blevins is back today to expand on his GLP conversation from a few weeks ago. Today we're going to be taking listener questions Dr. Blevins is going to do his best to answer them. 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. Hey, if you have type one diabetes or are the caregiver of someone with type one and a US resident, I need you to go to T one D exchange.org/juicebox. and complete that survey that survey helps the T one D exchange to move type one diabetes research forward T one D exchange.org/juice box. If you've ever wanted to help, this is your chance it will only take you about 10 minutes. When you place your first order for ag one with my link you'll get five free travel packs and a free year supply of vitamin D. Drink ag one.com/juicebox I know that Facebook has a bad reputation, but please give the private Facebook group for the Juicebox Podcast. A healthy once over Juicebox Podcast type one diabetes

today's episode of The Juicebox Podcast is sponsored by the contour next gen blood glucose meter. This is the meter that my daughter has on her person right now. It is incredibly accurate and waiting for you at contour next one.com/juice Box. Today's episode is sponsored by Medtronic diabetes, a company that's bringing people together to redefine what it means to live with diabetes. Later in this episode, I'll be speaking with Jalen, he was diagnosed with type one diabetes at 14. He's 29. Now he's going to tell you a little bit about his story. To hear more stories with Medtronic champions. Go to Medtronic diabetes.com/juicebox or search the hashtag Medtronic champion on your favorite social media platform. Alright everybody. So Dr. Tom Blevins is back, we're going to do another episode around GLP medications. If you have not heard his first one, it's episode 1212. But today, we're going to do all questions from the audience. So Tom, welcome back.

Dr. Blevins 2:35
Scott, good to be here.

Scott Benner 2:37
I'm glad you were so good the first time I'm excited for you to be back again. I'm just going to jump right into questions that came from the audience about GLP meds I don't know that we're gonna get through all of them. But but let's do it. All right, so I'm gonna start right at the top, my seven year old is very overweight doctor suggested possibly giving her one to help her lose weight over the summer. Is this safe for young children and effective she's type one. She lost 40 pounds before diagnosis and is gained 60 back cannot stop eating.

Dr. Blevins 3:06
Yeah, that, you know, that is a tough problem that she's lost because of the high blood sugar to begin with. And now she's gained back everything and then some. And she's she's hungry. And hunger is a is a tough deal as possible. Certainly that insulin induces some hunger or promotes it. And she's overweight. Now, we don't know the details. But you know, here comes the summer, you wanted to lose weight? And the question is about GLP. One's a glucagon like peptide, one meds? And I'll tell you, it's important to look at what what's been done in terms of studies. And all that when I answered this question, and the answer is there is no medicine approved at this point for a seven year old. And for for any purpose for diabetes, or for weight loss, and there's no GLP one approved, the approvals are the one called saxenda, which is liraglutide, the once a day injection, that one is approved for weight loss in the pediatric population down to age 12. So that's not going to go and the bottom line when it comes to approvals here is that we just don't have data. So we don't know, the person who asked the question could talk to their, their doctor and ask about that. That's certainly something they can talk about. But I would be reluctant to go that direction. It's a really good thought. And you'd love to get her to lose weight, that's for sure. But anyway, I'd be very, very cautious about that talk to a doctor. And and work maybe with this might be a time you know, everyone that's listening probably has talked to a dietitian before. Dieticians can be very effective. So it might be a good time to talk to a person like a dietitian to talk about the eating.

Scott Benner 4:58
Is there a possibility of so for spa this, this suggestion is coming from their physician. So, I don't know, I can't make you guess about this. But is there a world where you would ever look at a seven year old in a similar situation and have this thought or you wouldn't go this way? Full

Dr. Blevins 5:13
disclosure? I do. Mainly, I see mainly adults, and I don't really see seven year olds. So I couldn't answer that about a seven year old. But, you know, this is a place where the doctor, doctors can use medicines, as you know, off label. And and they can look at the indication. And and they could use a medicine that doesn't kind of fit the indication it's a clinical judgment call. We don't know about safety for young kids. And would it be less effective, more effective? We don't know, I suspect it would work the way it does for older children. So the answer is we just don't have much data there.

Scott Benner 5:50
Okay. Let me jump to the next question. This is I'm going to jump around a little bit on this list. But just a very simple question does GLP medication cause muscle loss? So if you're paying attention in the space, when GLP has became kind of in the, in the limelight maybe two years ago, I think Dr. Peter Atea, pretty famously said that he is his practice, took a look and said that people were losing muscle. And I think that became one of the one of the concerns out in the in the media and everything now. Yeah, I've been on it for 13 months now. I don't feel like I've lost muscle. But as a matter of fact, I feel stronger now than I did before. But does it cause muscle loss? Or is that just part of losing weight? Or what are we seeing? Contour next one.com/juicebox. That's the link you'll use. To find out more about the contour next gen blood glucose meter, when you get there, there's a little bit at the top, you can click right on blood glucose monitoring, I'll do it with you go to meters, click on any of the meters, I'll click on the Next Gen. And you're gonna get more information. It's easy to use, and highly accurate. smartlight provides a simple understanding of your blood glucose levels. And of course, with Second Chance sampling technology, you can save money with fewer wasted test strips. As if all that wasn't enough, the contour next gen also has a compatible app for an easy way to share and see your blood glucose results. Contour next one.com/juicebox. And if you scroll down at that link, you're gonna see things like a Buy Now button, you could register your meter after you purchase it, or what is this? Download a coupon? Oh, receive a free Contour Next One blood glucose meter? Do tell contour next.com/juicebox head over there now get the same accurate and reliable meter that we use.

Dr. Blevins 7:44
Great question. And it is a concern. And there there have been people who said oh, these medicines, the GLP ones cause muscle loss. And that's been that's been an inhibitory kind of commentary or idea for many people when they when it comes to using them. But here's what we know, if a person takes a medicine or of any kind or loses weight for any reason, and they're sedentary, they're going to lose fat and muscle both. And probably preferentially even in that situation. If they stay sedentary, they're going to lose more muscle more that is fat than muscle. And typically the first fat loss is the visceral the abdominal fat. And that's what you want to lose as that rapid turnover fat. So that will go first yet if a person maintains a certain amount of activity. And and I would say it's always important for a person to be active walking like 150 minutes a week or whatever a person does. Many people do much more than that, of course, like lifting weights, that kind of thing resistance exercise, those people are not going to have much muscle loss when they use a GLP one or when they lose weight for any reason. This is really a weight loss phenomena. It is true that when a person loses weight, especially a substantial amount that some muscle areas are just not needed as much not having to carry as much weight, so they might lose those muscles a little bit. There have actually been some pretty good studies done that have looked at body composition with GLP ones and the combined GLP one tip Med and remember we're talking about GLP one glucagon like peptide one. And the GI P is glucose glucose dependent insulinotropic polypeptide. Those that abbreviations we use tip for that one and then GLP one, that's a pretty good body composition data that shows that yeah, people can lose a little bit of muscle but mainly they're losing fat. So I'm not worried about muscle loss. When people use GLP ones and less they're completely sedentary. And one of the first things I'm gonna recommend that people do when they take one of these meds I say be active and burn some calories to these medicines reduce calorie intake, but also it's very important that people burn calories and and use their muscles. I

Scott Benner 10:01
have to say, I've been wondering about this question for a while, because Did someone just say something in public? And it just stuck? You know what I mean? Was it like a knee jerk reaction or one of their first things like even would you go back to them now? Maybe? And they'd say, Oh, I've looked further. And I agree more of what I just heard. So I'm glad you were able to answer that. So completely. Thank you.

Dr. Blevins 10:22
Yeah. You know, Scott, I think some of the studies that have been done with body composition will be published, and will become more common knowledge. And it's an important concept. It's an important question. And it's important that we advise people to, you know, do their own thing about reducing calorie intake and also increase muscle activity when they're using these methods. Yeah,

Scott Benner 10:43
I saw a big difference. Just adding like low intensity like dumbbells from my arms, my chest, my shoulders. Yeah.

Dr. Blevins 10:49
I'm glad you said that, too. Because your experience is very important. You're not you don't feel like you've lost muscle mass. And you're, you're doing activities, you're lifting weights, and that I'm not talking about heavy and you're not either. We're not talking about heavy duty weightlifting, we're just talking about lightweight resistance. Yeah, resistance exercise.

Scott Benner 11:07
I'm also very careful to mix a fair amount of beef and chicken into my diet for protein to Yeah, good. Yeah. I'm going to jump off the list for a second. This is actually a question that came in to me through a there's somebody I know personally. So they start zap bound for weight loss. This person does not have diabetes, yes. But they were pretty significantly overweight. And not just hungry, Dr. Blevins but like ravenously, hungry 24/7, like could eat to being stuffed, and someone could offer them a dessert and they go, Yeah, bring it on. Like that kind of thing. Knowing sitting there thinking I'm not hungry. Not only am I not hungry, my stomach hurts. But yes, I'm gonna eat this, but they go on zap bound. It took a couple of months. And the fruit noise did not go away for a couple of months. And I said to them, just keep going. It will. And one day, I get a text. It's working on me all the sudden, like I'm starting to lose weight. I don't feel ravenously hungry all the time, I'm filling up quicker, it took months for to start working for them. And they're having success, they lost 14 pounds, things were getting better. And then all the sudden, the doctor does the blood work. And they have a significantly increased lipase and amylase. So lipase 394, Emily's 204, Doctor pulls them off the med. And those numbers go back down. So my first question is, are those bigger numbers a reason to say oh, my god pancreatitis is coming get off the med or is that just the thing that happens? Well,

Dr. Blevins 12:42
that is a great question. And I'm not sure I have the the perfect answer here either. But we've done quite a number of studies and I can talk about published information. And it is clear that those enzymes can sometimes go up and down. And and while on treatment. The question is what happens in people who are not on those meds at all on a day to day, week to week, month to month basis? And we don't know there really hardly any studies, if any at all. I don't like that. I can cite one that looks at amylase and lipase and as you said those are for the audience. Those are the enzymes from the pancreas. And they tend to be really high when people have pancreatitis. Well keep in mind that pancreatitis is a clinical syndrome of pain, Amin pain, like bad pain, and inflamed pancreas, and very high numbers. So what does it mean when those numbers are high, and a person is not having pain? We don't know. And, of course, I agree those numbers are are depending on the normal range, depending on the normal range in that lab. Those numbers are concerning. And I do understand the concern of the doctor there. And using a medicine that remember these medicines stimulate the beta cells to make insulin they they affect the alpha cells that make glucagon in the pancreas EndyMed that might affect the pancreas could maybe inflame it, but there's really no clear evidence that these meds do that. So I agree with the concern. It's an unknown and this is going to be a clinical thing there with the person who was on the zet bound. That person I know will be talking to the doctor further. And do they want to re reintroduce the medicine that's there? That's a judgment call. Yeah. Is it pre pancreatitis? Who knows? That's a great question. Do I normally measure lipase amylase? Do we always routinely do that? No. Was there a reason in that patient and the person you're talking about to measure at night where they have in some pain? Maybe I don't

Scott Benner 14:44
know Tom. Absolutely no, no pancreatitis Oh

Dr. Blevins 14:47
symptoms at all. One at all. So it wasn't pancreatitis. Almost certainly. And in that one's going to be a call it as you go, and do I recommend that people check amylase and lipase not really Everybody has a different level of caution. Some practitioners may want to check them along the way. And that's their call.

Scott Benner 15:07
Yeah. All right. So here's another one that's not on the list, person using medication for mood stabilization and anxiety, yes, starts using a GLP medication for weight loss. And then it messes up the absorption of their medication. And their anxiety gets significantly worse. Is there a way to manage that they're already on a large dose of the anxiety? medication, the doctor was uncomfortable giving them more. And that's why they took this person off of the off the GLP. But was there a better way to manage that, that you know, if you

Dr. Blevins 15:47
get that's gonna be very much a clinical thing up kind of between the person you're talking about and the doctor would a lower dose of the GLP one work and make it all okay, maybe would timing help of the medicine? Maybe, but not not horribly likely. Because, as you know, these GLP one meds like the ones we use once a week, and they have a very long life. So there's not really a predictable time during the day that the effect would be less on the stomach emptying, would it gradually improve over time, but not hard to know. As you know, the effect on gastric emptying that these medicines have the slowing down of gastric emptying is something that happens, especially early on when you start the medicine and every time you increase the dose, it kind of recreates itself. But as the gastric emptying kind of goes back a little bit more towards normal, after a person has been on the bed for a while. And after a few weeks, it doesn't go back to normal. That's going to be very much a play about your thing. That's what this is why the people say it's the art of medicine, just the science and that's gonna be an art thing. I

Scott Benner 17:00
asked the question here just so people can hear like if you are taking medications by mouth, you might be seeing absorption changes, it is the thing to take care of. You notice that is true. Take note of Alright, let's stay in that vein a little bit. I have gastro problems when I use these drugs. I have a very low carb diet, which helps me keep my numbers in five, five range, but I need to lose weight. Low Carb means high fat some of the time, which can make me sick with the drugs. Is there anything that can be done to help me use GRPs without so much sickness? This episode is sponsored by Medtronic diabetes, Medtronic diabetes.com/juice box. And now we're going to hear from Medtronic champion Jalen. I

Speaker 1 17:44
was going straight into high school. So it was a summer heading into high school was that particularly difficult, unimaginable, you know, I missed my entire summer. So I went, I was going to a brand new school, I was around a bunch of new people that I had not been going to school with. So it was hard trying to balance that while also explaining to people what type one diabetes was. My hometown did not have an endocrinologist. So I was traveling over an hour to the nearest endocrinologist for children. So you know, I outside of that I didn't have any type of support in my hometown.

Scott Benner 18:17
Did you try to explain to people or did you find it easier just to stay private?

Speaker 1 18:22
I honestly I just held back I didn't really like talking about it. It was just it felt like it was just an repeating record where I was saying things and people weren't understanding it. And I also was still in the process of learning it. So I just kept it to myself didn't really talk about it.

Scott Benner 18:36
Did you eventually find people in real life that you could confide in. I

Speaker 1 18:41
never really got the experience until after getting to college. And then once I graduated college, it's all I see. You know, you can easily search Medtronic champions, you see people that pop up and you're like, wow, look at all this content. And I think that's something that motivates me started embracing more, you know, how I'm able to type one diabetes, Medtronic

Scott Benner 19:02
diabetes.com/juice box to hear more stories from the Medtronic champion community.

Dr. Blevins 19:09
Yeah, you know, this is this a question has many different components in a way and keep in mind that fat does slow down the stomach emptying already. And then you add a medicine on top of it, that slows it down and you get a double slowing and away maybe not double but you get more slowly. And that can lead them to more or not nausea, and even vomiting. And and so one of the strategies of course, when people start a GLP one or GLP one gi P method is to reduce the fat. So those of you out there who are taking these meds, if you have a high fat diet, then you're taking a GLP one cut back because that will help the nausea if you're getting nausea. Low Carb doesn't necessarily have to mean high fat. Low Carb can be accompanied by kind of a lean lean protein type, elite meat type intake, and it can be okay in terms of weight loss. So I would say that, though it's not as simple as I might try to make it here, that the person here doesn't have to go high fat, and I think they could modify down to, and I think low carb, in my mind, is it many different definitions of different definitions of low carb. I think it's low, simple, simple car, but I think vegetables fit very well into a low carb diet. It's the potatoes, pasta, rice bread stuff that I try to get people to avoid more simple carb and other simple carbs to. So I think I think the vegetable lean meat approach would be okay. And so I hope that helps the person. And if they take that approach,

Scott Benner 20:49
I think it might actually, yeah, here's one. I've been on rebel sis. Since mid February. I'm type one, I'm taking it for weight loss, my a one C is six, eight, no side effects. I've gone from 190 to 169 pounds. Now today, my endo said she's really concerned with me using a GLP medication being a type one, and then notes the risk of pancreatic and thyroid cancer. Is that a genuine concern?

Dr. Blevins 21:15
Okay, so a couple things, I'm always going to want to kind of refer back to the idea of the approvals. And I know this is being used off label for this patient numbers, you know that Rob Bell's is not approved and type one, right? We've talked about this before. And Scott, you know, I'll continue to repeat that because it is up to the clinician, and the patient to decide some some of the many of these things is called off label use of a medicine. So that's one thing to say congratulations to the person who has such a great a one C, and weight loss. That's great. So this is gonna be a discussion that's going to be important for the person to have with their Endo, and go back in and say, Hey, tell me more about this. And let's talk about it. And and I certainly don't want to get in the middle of that. I will say that the thyroid cancer issue with GLP ones and GLP one gi P meds, and it's a boxed warning for virtually all of them has to do with a cancer called Med galeri. Thyroid cancer. That's a route that's I'm not going to go as far as say it's rare, but it's really uncommon. And it runs in families many times not always, there's something called multiple endocrine neoplasia syndrome type two runs on and we do see people I'm an endocrinologist, I see people who have immune to and I would never give them GLP one meds because it's contraindicated because their cells in the thyroid called C cells that were stimulated in rodents, when they were given GLP one meds now humans aren't rodents. But we don't know the whole story here in terms of how humans might respond, who have either the cancer or family history, we don't know that we would promote it. So those people shouldn't take it. Most thyroid cancers have absolutely no implication when it comes to GLP. One, there's no sign that GLP one meds can cause the routine, the common kinds of thyroid cancer. So that's something that person needs to talk to their endo about a little bit to try to find out more about that. And if the person has no family history of medi Larry, thyroid cancer, no family history of me and multiple endocrine neoplasia, then they could go in and talk to their endo about that. Pancreatic cancer, there's really no evidence that these males cause pancreatic cancer. So I think the person wants to go back and talk to endo and say this talk about that issue. What are we talking about here? I think that's the best approach. Go back in and talk to the talk to the endo and find out more about the concerns that we know. Yeah,

Scott Benner 23:50
I'm going to read you something then I'm going to ask you a question about how you think about things. So yes, medullary. Thyroid cancer is a rare type of thyroid cancer accounting for about one to 2% of all thyroid cancers in the US, approximately 1000 people are diagnosed with modularity thyroid cancer each year in the United States. So if you're one of those 1000 people, then their odds aren't great. But that's a pretty low number. And that's fair to say, right? 1000 people is a fairly,

Dr. Blevins 24:18
that's pretty low number. Okay. I agree with the concept. I think one to 2% doesn't fit rare, but it's really, really uncommon. I know it's called rare. It's really, most cancers are thyroid cancers are called papillary, or follicular or mixed. Those are the ones that we see if someone has that kind of cancer in their personal history or family history. There is no contraindication to using this method. So you are you're right. You know, one thing to point out is and we don't want to go too far here, but these meds have been around for quite some time. You know, ozempic was approved in 2017. And then true listed He's been out for a long time. And it's been used in millions of people. And we're not seeing a thyroid cancer, med Valarie? Or any other answers signal in it. Now you could say, well, it's not being followed very closely. I mean, how would you know, because there's not a, there's not a study going on here. But people do report these things. There is no signal that showing up. So I think it's very important that a person not take GLP wants to have if a person has a personal history of modularity, thyroid cancer, or that multiple endocrine neoplasia syndrome, but we are right, it's really, really, really uncommon.

Scott Benner 25:35
So my question to you is, because your common sense person, this is one thing I've learned from you. In the short time I've met you and known you, in your own life, medications you might take or as a, as a doctor who's prescribing? How do you think about the problem of Yes, some people die in car accidents, but we need to drive when it comes to medicine? Like, do you know what I mean? Like that bigger, right? Because you hear people all the time, like, you know, I'll post on the Facebook group, hey, you know, we're talking about GLP. Today on the podcast, and 50 people be like, Oh, my God, I've been on GLP. For two years, I've lost so much weight, my one sees down, blah, blah, blah, it's all in one person's like, it makes me throw up and everyone goes, Oh, my God, it makes people throw up. It's a really interesting way our minds work. Like I know, we're, we're risk averse as humans on purpose. And that's a good reason. But But how do you think about it personally, like when you're standing in front of a person, you decide to give them something? And this and whatever else is in that label is out there? How do you make the risk reward decision?

Dr. Blevins 26:39
Yeah, it's what you said it's a benefit risk equation, it's a benefit risk analysis, you want the benefit, the potential benefit, when you start a medicine, when I run a medicine, I want the benefit, the potential benefit to way exceed the risk in risk is a very, very thing too. I mean, some some medicines have a risk of some really nasty things. Some medicines have risk of some fairly mild things. So nausea can be anything from mild to nothing too terrible. It is true. And I tell people this all the time, or if I'm ever presenting this data, I say, Well, some people can't take it, for sure. And that's true of most myths. And that's when I take them out. I know I'm going to try it. If I'm having a symptom I don't like I'm going to stop it. And I'm going to look for an alternative. Maybe it depends on what it's all about the the condition, and the benefit and the risk. And so people need to know going into taking this type of medicine or any type of medicine, why they're taking it, what it can do for them and the risk, and they need to realize it especially with GLP ones that sometimes people just simply can't take because of nausea. Yeah, if one person has nausea and vomiting, and they stop taking it does that is that a clarion call to say everyone should go off of it? Not at all, not at not at all, the vast majority of people have no problems with it, they might have mild nausea, they may have moderate nausea, or even even notable non nausea, which tends to get better over time. It doesn't always get better over time, though. And I'll tell you, if you look at most studies, I'll just kind of ballpark it anywhere from 4%. Up to 8% of people in the studies had to discontinue the GLP one or GLP one tip meds because of GI symptoms. And as we've talked about before, that would be nausea, vomiting, diarrhea, constipation, I tell people, Hey, you may get nausea, vomiting, diarrhea, constipation, and you don't get to choose, you know, one of those and you may not, you may not tolerate it. Many times we can mitigate the we can reduce the side effects by reducing the dose. And in their other things I could go on and on about that can also reduce the risk of that like lower fat. We talked about that while ago. lower volume in the in the food intake. There's lots of things people can do to modify. But yeah, you're right. If one person has a significant side effect, and they can't take it that does has that's interesting. And that's that's it, and I'm sorry for that person. Of course, it doesn't mean other people should go off of the medicine

Scott Benner 29:12
or not try it out either. Yeah, exactly. My mindset is simple. Like, we're here now. Like, the rules have changed. Like I'm not, I'm not standing in front of you. Me personally, super fit and muscular with no fat on me and no risks of heart attacks. I'm 52. I'm carrying extra weight. A lot of it's in my stomach. You give me this medication. I'm not as hungry, I fill up sooner. I'm losing weight, and I have diarrhea feels like the cost of doing business to me. You know what I mean? Now, it wasn't so bad that I couldn't exist. And of course, if it was that would change it. I want to know too. And this is going to call for speculation but how many people have you stood in front of who experienced the side effects and you think yeah, stop taking this and how many of them do you think tougher out, it'll be okay. And like, it's sometimes it's just the resiliency of the person, not necessarily the medication. I know that I'm not blaming them. But I mean, people do have different tolerances for for trouble. Do you know what I mean? By do?

Dr. Blevins 30:16
You know? The answer is it's highly variable. I had a person in the office yesterday who was having pretty bad constipation, connected to a GLP. One method. And we did a few things. First of all, she didn't want to stop the meth because she's had good results. And just what you said, she's had good results, she understands the importance of the results, she's had her sugars are better, her weights down, everything's better, she feels better. But she has pretty notable constipation. So what do we do we cut back the dose a bit, I gave her some advice about treating constipation in general. And there ways to deal with it. Now some people come and say, is so bad, I can't take it. I go, you're the boss, not me. And let's let's go off of it. Or we might try different GLP one GRP. Med. This is surprisingly, sometimes changing the med can change the symptoms. And you wouldn't think it would be true. You would think that I'll be kind of similar in that way. But there are some there are some differences.

Scott Benner 31:14
My endo told me going from Wiko V to zap bound might help me with loose stool. Yeah, yeah. And she indicated that it's possible my acid reflux, which had gotten much better, could actually even get a little better again, yeah, it has been my finding. If I had known enough about the drug before I started, which I think people should, should know that I was very careful to take magnesium oxide every day, when I started the medication, like, I did not want to be constipated. And I also very thoughtfully, even though I am not a high fat person to begin with, I was extra careful not to eat high fat. Now, I mean, truth is, depending on the dose, I've had, you know, it's funny, I've had French fries in front of me at a table with a bunch of people. And I've reached out and had two or three of them, and you get to the third round, and you just like, I don't want this. And it just it's interesting how your brain works so much differently on this med than then it worked for me that my brain worked without it. Because I could have eaten them. But I was just like, I don't I don't want to do this.

Dr. Blevins 32:18
And that is so cool. Because you just saved yourself a few 100 calories. Yeah, that is that is the way those work, meds work. They do such a nice job with that. Fascinating.

Scott Benner 32:27
Yeah, let me ask you one, it's a little generalized, but just so that this information is in each episode that you do about GLP is this question, what specifically? Is it about a GLP? That helps lower insulin needs for type ones? And is there one that is preferred over another specifically for type ones? Well, the so forget, forget, for a minute. FDA approved, right? We know none of them are for type ones. But what's the mechanism of how a GLP helps lower your insulin needs? Yeah.

Dr. Blevins 32:58
And you're right, none of these were approved for type one. And we are doing a study you as we've talked about before, here in Austin, that's looking at one of these people with type one. And I hope that study pans out to show it's effective and safe. And maybe we'll get one approved, we sure hope so. But the way it could reduce insulin needs would be number one, it does slow down gastric emptying, so therefore, anything that goes in, it's absorbed more slowly. So there's less peaking of the carbohydrate, less less glucose flow from the intestine, at least it's delayed. And so that's a better way to put it. In addition, the medicine can reduce appetite a bit, so fewer calories and fewer carbs in lower glucose and lower insulin need. It can reduce then weight as a result of the decrease in appetite or early satiety. And that improves insulin sensitivity itself, as you know. Now, is there one that's preferred? I don't know. And I'm not gonna I don't think so. I will say that the one called terzetto appetite, which is Mount Yarrow. And set bound has the effect that the GLP one has on slowing emptying and reducing appetite, but also seems to increase insulin sensitivity. And so that that's an interesting phenomena to where everybody's still kind of working their way through that one. So it has that effect. So all of those mechanisms together, or intervene individually can help reduce the need for insulin

Scott Benner 34:41
to follow up questions, so ones for me personally, if it's slowing gastric emptying, meaning I'm probably going to bed with food, my stomach, how is my stomach acid going down? How come it's having that impact for the life of me the first time I lay down at night I thought Oh God, I don't think my dinners like through For me at and I expected more gastric reflux and I got less, what's the mechanism there? Yeah,

Dr. Blevins 35:07
you know, this is going to be something that varies from person to person, these meds can cause a worsening of reflux because they slow emptying. And that's what you'd expect. And some things happen that we can't explain, I will say this, when a person loses weight, they lose visceral, adiposity, visceral fat early on, they don't lose it all, they lose some of it. And that reduces then pressure on the stomach, that's just a mechanical thing that reduces reflux. And so and perhaps a person eats less as as they use the med to. And that might reduce volume. And that might actually reduce pressure in the in the stomach, then the pressure is what leads to the reflux into the esophagus, and the acid feeling. So there are a number of possible reasons that your symptoms are better. One may be the weight loss or reduction adiposity, visceral fat, and the other may be that you're eating lower volumes, and maybe not even notice and you are but the possibly you are I know that that's not have intrinsically any anti acid effect. I'll tell you that. Right. So

Scott Benner 36:15
it's more physical structural implications.

Dr. Blevins 36:19
I think so

Scott Benner 36:20
yeah, it makes sense to me, I'm going to ask a very specific question. This is actually for, like an acquaintance of mine. Yes, at birth, this person lost some of their intestine. So it had to be removed their whole life, they basically eat and then dump, right? Like it just That's how it goes. Right? Did GLP be bad for them? With that structural change? Interesting

Dr. Blevins 36:42
question. And this may also more generally be something people who have gastric bypass his might ask or gastric sleeve to in the answer is, well, first of all, the best answer is, I don't know. The other part of the answer is that person if they wanted to explore that would need to talk with their doctor and find out the you know, the pros and cons and whether it's even possible or feasible. And the answer is, it could in theory, because it slows down gastric emptying that slows down the lower intestine as well in many people. So how that how's that gonna work? I don't know. But it's an interesting thought.

Scott Benner 37:21
It's not a question that makes you like, throw up a stop sign up. Oh, hell no, don't do that. No,

Dr. Blevins 37:26
yeah. Okay. No, that's, it's, this is one of those things, you know, it's a negotiation with the doctor, of course, or that person may have a GI specialist, I don't know. But it's a negotiation, like so many things is, well, what about this? Would it be worth worth? worth trying? And that's, that's where I would take it. Let's

Scott Benner 37:43
listen. That's what I told them, especially when you're, this would be for weight loss for them, not diabetes. I said, My God, they're gonna give you a quarter of like, Wiko V to start, like, I don't think you're gonna get thrown into a giant problem. And if it's a problem, you're gonna live through it and stop, you know, so yeah,

Dr. Blevins 38:00
probably, you know, it's probably the only gi history and there's, there's some I might in general, that I would say as is kind of a contraindication to using them as would be if somebody has established gastroparesis, then adding a medicine that slows down the stomach even more, just, generally speaking, not a great idea. Yeah, most of these is recommended. You don't use them and people have gastroparesis hasn't been studied. And people have gastric sleeve or gastric bypass or a person like the person you're talking about. Know. And could it be tried? Possibly, you'll know pretty quickly. If it's a problem.

Scott Benner 38:37
Yeah, I have a note here to myself, because I knew this would probably come up at some point, talking about the difference between a person with type one who starts to experience digestion issues. Maybe because your pancreas has been impacted the way it has been, you're not getting digestive enzymes, maybe correctly from your pancreas anymore. People don't know that. But the frequency that I hear from newly diagnosed people or my son has stomach issues now that they have type one and they've had it for a year. For some reason, a lot of endos. Don't talk to type ones about using a pancreatic enzyme or a digestive enzyme, excuse me to help with digestion, or maybe add a magnesium oxide to help with elimination, and instead they end up eventually at a gastro who just says, Oh, if your stomach's emptying slowly, you have gastroparesis. The difference between that and someone who's had type one for 30 or 40 years and likely has nerve damage if they have gastroparesis, and I do think there's going to be a section of type ones who GLP aren't going to be a choice for because of actual gastroparesis, that that's affected that is a front what does that nerve called the feel like it starts with an F but I can't think of the name of it all of a sudden, Renick

Dr. Blevins 39:53
is one of the nerves but vagus nerve is there and I mean some people with with Type one do you have that neuropathy? The autonomic type neuropathy? Yeah, which leads to gastroparesis. And some of them don't know, they have gastroparesis. And they might find out if they, of course, it would be off label, if they used GLP, one type method. Yeah. And I've seen that, and they're gonna have more notable, and there could be people who have gastroparesis, who have had diabetes a short period of time, but But it's probably not caused by the diabetes. And so there are certain tests like a gastric emptying study, which is kind of funny study where people may have to intake some food that's got some radioactive stuff kind of mixed in with it. And then it's observed the emptying from the stomach is observed after they eat it. Yeah. But that kind of a test is an objective way to look at gastric emptying.

Scott Benner 40:46
I just want to bring it up. Because there's, there's a lot of thinking to be done around this issue around type one and GLP meds, I think, yeah, I think you're right. Scary. Scrambled eggs aside the gift that they give you for that? Right? Oh, stuff? That sounds kind of awful. Yeah. Would it be better? GLP? Is they mean than taking Metformin? I'm asking because my teenager has major insulin resistance and weight gain.

Dr. Blevins 41:14
Yeah. You know, Metformin, has a little bit of there's data in type one diabetes with metformin, and it can help a little bit, but it's not very consistent. Metformin, primarily seems to reduce a paddock that has liver glucose output. Is it an insulin sensitizer? Can it treat insulin resistance very effectively? The answer is well, in general, it's not a classic sensitizer can it lead to weight loss, and not very often and infrequently, occasionally, though, people get sort of almost like anorectic on Metformin. And we have to take them off. And that is very unusual. So I think Metformin has a potential role, it might be worth a try. It is, of course, it's not approved for type one either, but we try it at times. And so I don't think I mean, that for me might have some effect. What was Scott, what was the other part of that question?

Scott Benner 42:14
They have major insulin resistance and weight gain? Yeah. So I mean, let me ask you a different question about Metformin. And then we'll circle back around. It's one of those drugs that's used a lot by biohackers. Like with the idea of like Metformin fixes everything makes you live on like, is there any studies that tell me that just pop into Metformin is good for my longevity?

Dr. Blevins 42:38
You know, there's a lot of theory here. And Metformin may have some anti inflammatory effect. There are people that feel like it has some effect on reducing dementia. And as an effect on longevity, the data is not in on that one yet. And there's some studies going on. Actually, there's a large study going on to look at that kind of thing, but it's going to take that kind of study clearly can take a while to finish. And they'll hopefully be some stops along the way they will get information but the answer is unclear. Does it lower glucose and sugar? Yeah, it does. And is it good for type two diabetes? For sure. Is it is it a strong met? Not really. It's kind of a weak man, when it comes to lowering glucose. It plays well with virtually every medicine that we have in the type two space. And we do use it off label sometimes in type one.

Scott Benner 43:27
Okay. But GLP is are leaning towards packing some similar ideas with like me right away? What's the one that they want to they were trumpeting like heart disease with GRPs is down and and what else kidney disease. But is that? Is that just the function of keeping weight off and or blood sugars lower? You

Dr. Blevins 43:47
know, it's not really clear. I think that's a lot of it. But you know, that semaglutide which of course would be ozempic will go V rebel says the ozempic component that is looked at people went with type two diabetes and with existing heart disease, and found that there was a reduction in what was called major adverse cardiovascular events, and that would be cardiovascular death, and then also non fatal mi heart attack and non fatal stroke. So is it because of the weight loss? Hard to know? Is it because of the consequences of weight loss? Probably, yes. The lowering of blood pressure or maybe improving lipids, other anti inflammatory or other effects we don't even know about? And maybe so but in people with known heart disease, cardiovascular disease, and type two diabetes ozempic has really good data. And you know, that will go V recently, which is of course, the same thing for the weight loss is semaglutide with GAVI recently was approved to reduce the risk of those major adverse cardiovascular events, and people that have known heart disease and either obesity or overweight. So we know that these meds and other meds are the other meds like Manjaro is at bound, they're being studied in the same way. Trulicity showed improvement, you know, truelist, these Dula glue tie the other GLP. One. liraglutide showed that too, so that that whole area is very good. Usually, though I'll point this out. They're looking at people I've known known known cardiovascular disease, they're not looking at people who have type two diabetes and don't have any known disease. And they certainly have not looked at people with type one. Kidney, yes, there's some good data that shows that these meds and specifically semaglutide might actually have a beneficial effect on the kidneys. Interesting.

Scott Benner 45:47
Let's do one for people who are using now what happens if I go up and down on my dose? Because of the shortage of the medications? Is that gonna hurt me?

Dr. Blevins 45:56
And the answer is, it's gonna be really annoying, and it's gonna hurt your feelings for sure. And I don't know, I don't think it's going to hurt you, you're gonna have to chase the glucose is a little bit when you go down on the dose, or you have if if a person, for example, can get one dose, but they could get the lower dose, the pharmacy has the lower dose, they don't have the dose they're taking? Well, the lower dose is gonna be less effective. The person might have to adjust their glucose, sugar lowering meds a little bit. And, and they may feel differently. And then, you know, in a month or two months, they might get the dose, they were on that as now the higher dose, and they might have to reduce their their meds a bit. Is that going to hurt you? I don't think so. Is it going to annoy the heck out of you? Yes.

Scott Benner 46:42
Yeah. It's almost like somebody's going to reach in and change your Basal rates or something like that without telling you. Right? Right. And even if you're just on it, for I'm seeing people who are just on it for weight loss, they don't have diabetes, and the same things happen. And they call their pharmacy and their pharmacies like, Yeah, we don't have it. And you know, but we have this one, and you go, all right, I mean, some is better than none, if it's lower, but you can't just go from like, for example, you can't just go from five milligrams of zinc bound up to 12. Because that's what they have that'll crush you. Right?

Dr. Blevins 47:14
That can be a problem. And I think some people could probably tolerate that. But we don't know. And the whole idea about going up slowly, is just what you're implying is so that you maintain your tolerability of the medicine, and going up too far too fast, could bring out GI symptoms that you wouldn't have had otherwise. So that Euro it's a funny world right now, where the supply is difficult. I think there's been some improvement recently, you know, we're talking right now, late May 2024. And I think by by later in the year, the supplies gonna be better. I will tell you this, though, I said the same thing last year at the same time, and the supply didn't improve that much demand is so high for these meds, that it's been hard for the companies to keep up with supply.

Scott Benner 47:59
I think there's an indication there, by the way that because the demand is so high and consistently high and grows, that should be some indication that it's working for people, because sure everybody might want to try it. But if you try and it doesn't do anything you're not going to keep you're not going to keep doing it. You know, it's obviously at best, you know, just me guessing out into the world. But I don't imagine there'd be this trouble locating I mean, I've run around looking for this stuff, like a crackhead a couple of times. You know what I mean? Like, right, yeah, yeah. Yeah, hard to find sometimes hard to find and CVS Caremark just announced, they're just not going to carry it anymore through mail order. Because it's so inconsistent their ability to get it. But okay, but that explains the the moving around in in doses, I went, I'm into my second week of 10 milligrams is that bound? And I was I had plateaued on Rigo V, I couldn't I just wasn't losing any more weight on the go V. I got moved to that bound. My doctor, I think, started me at what is it two and a half, maybe with that, I quickly went to five. Yes, I lost six pounds. But after I and then they put me on, I plateaued she put me at seven and a half. And seven and a half just nothin. Like I started to gain those five or six pounds back that I lost with a switch. And now I'm on 10 for two weeks, and I've lost those six pounds again, right? And everything's back to where it was meaning I started to have sugar cravings at the end of when I was on lower dose of set bound. Now that it's higher, the cravings are gone. The weight loss is happening again. It's fascinating to watch, but you really do have to pay attention to do Yeah, I make a diary of it. I do it on the podcast, but I think if I wasn't making the diary, I wouldn't even be able to keep up with what's happening to me. Like I think it's that's my by the way, that's my little bit of help. I think you should make a diary about it if you're on it.

Dr. Blevins 49:55
I think that's a great idea. And I think I'm really glad you said what you did about titrating To increase the dose and then that you had results on the weight loss side, and because sometimes people will start at the lower doses, nothing's happening, this is not working. And, you know, hang in there titrate the dose, you get up to 7.5 of zet bound 10 12.5. Sometimes people attend, don't get results and got to 12.5 and their work. And there's a chance. I mean, they're always people that don't respond to any dose, that's for sure. But usually titrating up is going to allow a person to get some results, and that goes for what GAVI that goes for all of them.

Scott Benner 50:35
But Dr. Blevins, you're sitting here with this grand amount of knowledge and you're articulate about it, you know how to explain it in a way that people can understand. A lot of people don't get that from their physicians, a lot of some of their physicians are making decisions based on what they hear on Access Hollywood, you know what I mean? Like I hear it's making people throw up, you don't always get real thoughtful advice. And even the advice I'm getting is from a, from a very learned, like, level headed person, you know what I mean? And, and I have good communication with her as well. Like if I texted my endo right, now, she texts me back. Well, that's great. Like that kind of like, you know, like, if I said, Hey, I'm doing this and this happen, what do you think I should do? I'm thinking this, I'd get a note back. Yeah, yeah. And not most people don't have that, you know, it is

Dr. Blevins 51:23
important to realize that people who are prescribing, there's that thing in medicine called do no harm, and you don't want to make people sick with your medicine. And so realize that, the audience realize that, you know, you may not tolerate the medicine, and and you're communicating many times back and forth, just got, as you said, by text or by phone, or by, you know, Portal message or whatever. And you can't express exactly what's going on. And, and then the person on the other end is going to read, if the person said, Hey, I can't tolerate this medicine, they can say, Oh, you want to stop it. But there may be some middle middle ground there and actually communicating in person. Yeah. Or, you know, more completely can really make a big difference that

Scott Benner 52:06
knee jerk reactions from happening to Yeah, exactly. Here. Do GLP s reduce inflammation in the body? And has it shown any benefits for other autoimmune issues? Yeah,

Dr. Blevins 52:17
that's a great question. And that's, that's the hotbed of a lot of of research and a lot of discussion, and a number of studies. And the answer is, if you look at the studies that are so far available, you can see some reduction in markers of inflammation. Is that going to translate into some really good treatment for inflammatory conditions? I don't know. I don't think anybody knows. Like, if somebody has rheumatoid arthritis, as a GLP. One help? Who knows? I wouldn't predict Yes, because I don't see how that could happen. But it may be there. There'll be something down the road. That'll tell us more if a person has say osteo arthritis, the bone, bone on bone in their knees, hips. Does losing weight help that? Of course it does. And so, lots to learn here.

Scott Benner 53:08
Is AstraZeneca, developing a GLP that you know if I know

Dr. Blevins 53:12
that Boehringer Ingelheim is developing, and also there's some other companies developing company called structure. I'm not aware that AstraZeneca is and I'll just be the first to say, I don't know everything here. And we do a lot of clinical research here. And there may be things going on, I don't know about but I suspect that question was about boy and girl Ingelheim. The bigger answer here is, you know, there are a number of companies that are developing new GLP, one meds GLP, one gi P meds, and even those are dual agonists. And they're triple. And there's a whole wave of new generation meds coming through. And they're going to have different characteristics and they're going to have favorable characteristics we think. So, you know, hold on, and as you might expect, there's a lot of attention in this area in the pharmaceutical research industry. And there'll be more meds coming down the pike. Let

Scott Benner 54:05
me read you this. And I'll tell you what I think cat GPT four o says AstraZeneca is actively involved in developing a GLP medication. They have recently acquired the rights to a promising oral GLP one agonist called AECC 5004 from a Chinese biotech company called Echo gene. So good now, so great, let everyone he

Dr. Blevins 54:24
says AC is a big company. And many of the big companies have have focused a little bit more on on this area. So that is great news.

Scott Benner 54:35
I'm also excited for biosimilars to start popping up because obviously, these things are working for people, it's hard to turn them out. Some of the molecules work better. And you know, for some things, some for others, I think you can only benefit to have options and a fresh set of eyes. Doesn't always hurt either when people are trying to find something that does the job but isn't copying because that's the real problem right now. So people have patents. So you can't like nobody can knock it off as a generic yet there's, that's not going to happen for a while. And so if you want there to be more innovation, you've got to have all these companies looking at this at the same time. So

Dr. Blevins 55:13
that is so true. Yeah. Yeah, you know, this, this thing about these methods and their effect on what you talked about appetite. And one of the people asked a question asked about appetite. And these, these medicines help regulate appetite, which appetite gets people into trouble. And, like, you have three French fries, and you stop, that's great. Most of the time, you know, over the past, if you were me, a few French fries, oh, man, they all that looks good, I'm gonna have that whole basket. And if some cuts, something good tells me to stop that be really good and very healthy. It'd be interesting to see these meds approved just for appetite reduction, although that's probably going to happen, because I don't think the FDA is going to allow that approval for something they're going to want a disease condition. But appetite is frequently the root cause and these medicines reduce appetite, all of them.

Scott Benner 56:01
I'm waiting for Agra companies to start getting involved in trying to put a stop to them. Because you don't I mean, if I made Oreos, I'd be scared. Seriously? Yeah,

Dr. Blevins 56:11
that's a good point. And no carrying. I don't think Oreos have anything to worry about.

Scott Benner 56:16
I'll tell you what, are

Dr. Blevins 56:17
not the only an Oreo, and I'll eat it. What

Scott Benner 56:20
is is there any concern with long term use? Like I mean, for some people, listen, this is me looking online, right? I've seen some people say I lost the weight, I lost the med because of my insurance. And guess what, I'm fine. I didn't get any back. I learned how to eat better. Everything's going well, I'm active, etc. I've seen people say I've lost the med because of insurance. And I didn't change a thing about what I was doing, I put all the weight back on. So some people are going to have to take it forever. Is there a concern a safety concern with that, that you can think of

Dr. Blevins 56:50
Forever is a long time. And we have a lot of data with these meds. And we don't have like 20 year data yet. Trulicity ozempic have been, we talked about this earlier been a long time. And so far, no new signals have shown up like some weird findings. And so they look safe for long term. In general, I would say that for person to maintain the effect of the Med, most of the data says the person has to continue the Med, they might be able to reduce the frequency of administration and the dose to maintain. But they're going to need to continue the Med, they're going to be exceptions to that rule. They're going to be people who can stop and maintain. That is great. And they're going to people, the only people who take it on and on and on and they regain. But in general, if you continue to Matthew, if the effect continues. So we're looking at everybody's looking at the scientific community to look and see if there's anything long term that turned out to be a negative, but so far, so good. So it's not like the duration of time people are on it to the number of people. And they're really millions and millions and millions of people who've been on these meds now and no clear new signals have shown

Scott Benner 58:04
up. Yeah. Do you have a little more time? Are we done?

Dr. Blevins 58:07
Yeah, we can go? How about we could aim for another 10 or so

Scott Benner 58:11
minutes? Okay. I like to know if GLP is used in patients with thyroid concerns, Hashimoto specifically and or hyper cholesterol OMYA. Is that what that is? hypercholesterolemia?

Dr. Blevins 58:23
III, I think is what they're saying.

Scott Benner 58:26
What are their concerns with that?

Dr. Blevins 58:28
The answer is, there's no sign that GLP one meds or GLP. One GRP meds can make Hashimoto as improve, or worse, there's really no evidence there. And there, there is no evidence that these meds would make cholesterol worse. In fact, if you look at most of the data, you would see that the cholesterol levels improve. I could go through each fraction, I'll just say they improve when people are on these meds probably because of the effect on weight loss. There's no sign that there's a direct effect of these meds on cholesterol synthesis or absorption or any of that. But weight loss is magic. When it comes to improving cholesterol.

Scott Benner 59:11
I'm going to ask one for myself. And this is about you specifically, in your practice. You deal with a lot of adults. Yes. If I was your patient, and I came in, I said, Hey, you know, here's where I'm at so far. And you've watched me for the last 13 months. And I said I want to continue to make my my body stronger and give myself the best chance to live longer if I said I don't know anything about this Dr. Blevins but should I be on some sort of a testosterone replacement? Is that a conversation you would have with me or do you not see the value?

Dr. Blevins 59:40
I would definitely have the conversation with you about that. And what I would wind up what do I do? It was I would first of all ask you about any symptoms related to low testosterone. And then I would check your levels. And then if you're low I would I would say you know your About your muscles, your mood, many things in your body will do better if you're normal. Would I put you on testosterone? If I find you to be normal? And the answer is I wouldn't. There's no evidence that putting people on testosterone who have normal levels is going to prolong life or improve things. And, and so it's another one of those benefit risk things. If the benefit, if you're low, the benefit, I think exceeds the risk, there is some risk potentially. So testosterone is not a cure all for everything. And if the levels normal, there's really no evidence that it could could help. And, you know, testosterone given to people who buy either gel injection, pellet, whatever, can have some negative kind of has some side effects and negatives. And like, they can increase the blood count, which could increase the thickness of your blood or viscosity, which could lead to stroke, things like that it gets overstimulate the prostate. That's another possibility. And I've had some people who are given testosterone who get very agitated, and that's not very often but it happens. And then we just we back off, or we stop it,

Scott Benner 1:01:10
you handled it exactly the way my doctor did. So I was just, I'm just, I was just interested in your response. Yeah. And my levels were didn't need addition. But I was in that mindset, I was like, how do I make sure that I'm stronger and fitter and have the best chance of staying alive as long as I can? Okay, so I'm gonna go to what I think is going to be a little bit of a long answer. So we'll finish with this one. Okay. This person says, I want to know the doctor's thoughts on micro dosing. GLP is specifically for people with autoimmune disease. And for people who do not need it to lose weight. My thoughts are that maybe a pharmaceutical version of these peptides, those far too high and too fast for type ones. Maybe micro dosing will negate many of the side effects, and maybe you'll get some of the inflammation, increased insulin sensitivity, and the other benefits that come along with it. I'm super interested in this because I just did an interview last week with CEOs from xirrus and beta bionics because they're working on a dual hormone pump. And I mean, honestly, what are we talking about there? We're talking about micro dosing glucagon in an insulin pump. So Exactly, yeah. So what do you think here about the idea of this possibility with GLP? Yes.

Dr. Blevins 1:02:19
You know, the micro dosing ideas are really interesting idea. And I will I'll be the algo right out and say, I'm not sure exactly what that dose is. But well, I know that means less than normal. And I would think it might be the same frequency or more frequent lower dose? Who knows, but micro dosing less than normal dosing, specifically for autoimmune diseases? And I'll say very quickly, no data? Would I do that before an autoimmune disease? Depends on which one you're talking about? Of course, some are more serious than others the answers for all of them, I guess, so is that independence? The answer is no, I wouldn't do that. I don't know, I don't have data for that. And what I use it for people who don't need to lose weight, well, that would be people who have diabetes, as to who don't need to lose weight, and some people's because it does have an effect on glucose metabolism. So I would use, the concept of micro dosing is interesting data is not available, it's all going to be personal use, and we'll really need I mean, you know, I'm a scientist, we need a study to tell us what to do anecdote is, is going to get people in trouble. And the thought the pharmaceutical dose could be dosed far too high, maybe for certain things, but not for what we're looking at that dose about right for blood sugar, and the weight loss and that, and then maybe people would have fewer side effects of micro dosing, that's true, they also may have no effect. So we really have to have a clear cut target, like, use it in someone who has a particular type of autoimmune, a group of people who have a certain kind of autoimmune condition, and have a placebo control, and use a lower dose and find out. I don't think those studies are being done, but you whoever wants to can suggest that to their people they know in the pharmaceutical industry? And would that increase some of the benefits like inflammation and sensitivity and things like that? I don't know, maybe, I think the current doses are pretty well worked out. These doses are taken from the bench to clinic, and all kinds of doses are looked at, you want a dose that actually has an effect, and it need to have a target like blood sugar or weight loss or something like that. And then you want to be sure that dose actually works. So I think the I think the current doses are effective. The concept of exploring other areas a great idea, and there are studies being done looking at like arthritis, like osteoarthritis, looking at sleep apnea. There's been some positive there already. That's about weight loss, I think. Yeah, and other other conditions, that maybe even some cognitive conditions like my Alzheimer's Could, could these meds help people, people looking at all kinds of things but until we have a good study, I don't think I would jump in and start using it that way. Yeah.

Scott Benner 1:05:03
Do you think you've seen anything? Even just, you know, N of one kind of like returns? Where people have experienced less gambling habits like other addictive natures that you've heard that talked about, but do you actually say it? I

Dr. Blevins 1:05:18
have not had a person come back and tell me that they took it and they were not going to Las Vegas as often, though, I've read about that. And I think it's fascinating cravings. Appetite is a type of craving, gambling as a type of craving alcohol, and alcoholism. I know for a fact some studies are going on looking at that. Do I know results? No. But I've had a few people come back and tell me they were less interested in drinking alcohol about drinks. And there may be something there? If so I sure hope there is. But I want to see a good study, come back and tell me that that actually was true. Yeah. And it may just be it's not, it's not a consistent thing. I've asked some people, do you drink any less? And they say no. So we need something to tell us more about that.

Scott Benner 1:06:05
I've noticed this thing. I'll end with this and ask you if you've seen it, too. I think it's possible that as a society, we've become so used to people's body mass being a larger, that now I'm seeing people use these medications, get down to what looks like a very nice healthy weight. And yet the people around them are shocked and say like, Oh, my God, you're too thin put weight back on, like, bah, bah, bah. And you if you really look at them, like from a reasonable perspective, they're not too thin, they're not to anything, they just look like a healthy human being. It almost feels like that's not what people are accustomed to looking at maybe with you personally or with people in general. But I was wondering if you've seen those kind of more psychological reactions? Absolutely.

Dr. Blevins 1:06:48
That that's true. Change is something that people notice and comment on. And in historically, when people have lost weight, it's because they're sick, and cancer or something like that. And I've certainly had people comment in that direction, or have people tell me, they've, they've been told they look sick, they need to eat? Yeah, their family, their friends, I'd say here, you need to pat yourself, get some get, you know, eat and gain some weight back. Even though what you said is correct. Their weight is now more normal than ever. I would tell people in the audience expect that and understand it, and take it as a compliment. And let people know what you're doing. And if you want to

Scott Benner 1:07:34
don't let it thwart you, I've seen people, it happened to somebody around me recently, they were so pressured by the oh my god, you're losing too much weight, pressure that they started thinking about not doing the medication, I said, Look, between you and me, I need to lose 15 pounds. And maybe more, I don't know, like, I have to tell you like my ability to understand how much weight I needed to lose is completely skewed. Because I started this thing thinking 20 pounds, I'll be great. When I got that 20 pounds. I was like, I don't even look any different. And now, if I said to somebody, somebody says, Hey, you look great. I'm like, thanks, I still have 1520 pounds loose. They go, that's not possible. And I'm like, Well, I can take my shirt off and share it with you if you want. But like I definitely still need to. Yeah, I just don't want people to get thrown off by knee jerk reactions to their visual appearance.

Dr. Blevins 1:08:21
You know what I mean? I agree. Yeah. Yeah, the nice thing about it is people are concerned. And they notice and, and there is a compliment. You know, it's it's people who are concerned, they think, Oh, is there something going on? I care? I want to know, or they may be they just playing nosy, I don't know. But then you could reassure them and say, you know, and now now everybody knows about these methods, almost everybody. And you could divulge or you don't have to you don't want to maybe tell people what you're doing. You could say now that I don't have cancer. I don't have some bad disease. I'm working on weight loss, and, and, or something like that. But yeah, it's a common phenomena. And everybody should just expect it. And it's actually a real big positive, but it comes off as Oh, you look, you've lost too much weight. And of course, the answer is no, you haven't.

Scott Benner 1:09:07
Yeah. And by the way, I don't actually care about the number of my weight. I care about the fat My body's holding. That's yeah, my concern is so exact whatever I end up looking like after I'm carrying a healthy amount of fat on me, is what I'm going to look like. Right. All right. Well, Dr. Bill Evans again, this is terrific. I feel like I could just have a podcast where I chat with you about anything and it would be good. So thank you. I appreciate your time again.

Dr. Blevins 1:09:32
Scott, thank you very much. It's fun. Yeah, I've enjoyed it.

Scott Benner 1:09:35
Great. And we're gonna head back again. Is that right? Yes. Oh, excellent. Great. Great. I'm super excited. Hold on one second.

Jalen is an incredible example of what's so many experience living with diabetes. You show up for yourself and others every day, never letting diabetes define you. And that is what the Medtronic champion Community is all about. Each of us is strong and together, we're even stronger. To hear more stories from the Medtronic champion community or to share your own story visit Medtronic diabetes.com/juicebox And look out online for the hashtag Medtronic champion. Having an easy to use an accurate blood glucose meter is just one click away. Contour next one.com/juicebox That's right Today's episode is sponsored by the contour next gen blood glucose meter. We're starting to get a nice grouping of GLP focused episodes. There's a full list of them in the featured tab in the private Facebook group. Thank you so much for listening. I'll be back soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com

#1237 Limited Access

Radwa is an ophthalmologist whose son and husband have type 1.

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:00
Hello friends and welcome to episode 1237 of the Juicebox Podcast.

rodeway is an ophthalmologist from Egypt who son has type one diabetes her husband, a surgeon also has type one. Today we're going to talk about access to technology costs around type one diabetes, and much more. Please don't forget that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan or becoming bold with insulin. When you place your first order for ag one with my link, you'll get five free travel packs and a free year's supply of vitamin D. Drink ag one.com/juice box. Are you a US resident who has type one diabetes or is the caregiver of someone with type one if you are please go to T one D exchange.org/juice. Box and complete their survey. Doing that helps in so many ways. It's hard to list them all here right now. takes you about 10 minutes. T one D exchange.org/juice box you will be helping people with type one. Probably be helping yourself, and you'll definitely be helping the podcast. Thank you so much for listening. I hope you guys do that. Let's get to run one. This episode of The Juicebox Podcast is sponsored by the only implantable sensor rated for long term wear up to six months. The ever since CGM ever since cgm.com/juicebox. Today's episode is also brought to you by touched by type one and they have a huge in person event coming up soon that is completely free for you to attend. Check out touched by type one.org For more information and get your absolutely free tickets to the event that's happening very soon in Orlando, Florida that I'll be at and so will Jenny

Radwa 2:10
I'm Rodwell. Okay from Egypt. This is how I would like everyone to know me. I've been following your podcasts for about a couple of years. I'm an ophthalmologist practicing one and I teach in Korea University. My husband is an orthopedic surgeon and a type one diabetic for around like for my son's elderly sons ages from 15 years. And I have a five year old type one diabetic has been diabetic for almost four years now. And definitely my look at although I'm a healthcare professional, I'm an ophthalmologist. So I'm really oriented with diabetes and its complications. But I've looked at diabetes differently since my son's diagnosis. Like it's been an eye opener for me about what we're missing here in our country, the things that we need to have, but we're not having the proper management of diabetes, you know,

Scott Benner 2:56
let me ask you a couple of questions and we'll and we'll dig into all of it. Okay. Okay, go ahead. So you and your husband have been together for how long?

Radwa 3:03
We've been like together for almost 20 years, like five years before we got married, or four years before we got married. And then we've been married for like 16 years. Okay.

Scott Benner 3:14
And did he have type one when you met him? Or did he develop it after you were married?

Radwa 3:18
No, after we were married while I was pregnant with my first son. I don't know why it was a shocker for him because they have a strong history of diabetes in their family like his mom had this. She's a type one diabetic when she was like 27. This is what we call the maturity onset diabetes of the young moody. And then he had his both siblings are diabetic, like his younger brother had had him since he was two and his sister since she was 10. But he was like, the only one in the family who didn't have diabetes. I think he thought he passed that, you know, you got away with it. Yeah, but he was like, seemed like his mom, you know, like he had the exact same gene.

Scott Benner 3:57
Yeah, in the mid in his mid 20s. He

Radwa 3:59
got it. Yeah, okay. Yeah, he was 26. Okay. All right.

Scott Benner 4:03
And I want to ask you, when he's diagnosed, and you're, you're pregnant at that time. Yeah. And then you look at the rest of his family, do you think, Oh, my kids are gonna get diabetes?

Radwa 4:17
Not really. No, actually, I, we always have that in the back of our minds, even before his diagnosis, you know, like, it's in their family. So they definitely might pass it on. And we always had in mind, like, you know, my elder kids, they don't have diabetes. I have a 15 year old and a 12 year old girl and a 15 year old boy. But whenever, like, for example, they had an accident during sleep, or we think they're drinking too much water, or the pee a lot. We immediately like, check them at home. So it was always in the back of our minds, you know?

Scott Benner 4:50
Yeah. Have you ever had them checked for antibodies? No. And I

Radwa 4:54
don't know why, but I don't want to do that. I'm like, if it happens, it happens. You know, like, well We have to have a healthy lifestyle in general, we don't overdose on sugar as much as we as much as possible. But I don't want to go and check them for antibodies and just make them live with it in the back of their mind. Like, you have the antibody. So we're gonna get diabetes at some point, you know,

Scott Benner 5:14
I hear so. Okay, so he he's diagnosed, what's his care like? And are you involved in it at all?

Radwa 5:22
No, I wasn't really that involved. You know, he's a doctor. His mom is an endocrinologist actually, but an auditor in the criminologist. I don't know why I didn't give it much thought back then. Like he's an adult. He knows what he's doing. His hemoglobin agencies were around six and a half to seven and a half. So yeah, he's doing okay. And his mom is like, all over him. So I thought that was enough. But you know, after my son's diagnosis, no, it wasn't enough. And I'm all over him now.

Scott Benner 5:48
His mother was on him about it. How was her management and her kids even the

Radwa 5:55
went MDI, okay with, he used Lantus and overwrap it and it worked fine for him. And he didn't have a sensor, continuous glucose monitor that didn't have one. He's like, he blood checks his blood sugar like five, six times a day. He can feel the hypose. And he can feel when it's high, but he just checks it five, six times a day. And to be fair, we don't have CGM in Egypt. We just had the FreeStyle Libre two years ago, and only the first generation

Scott Benner 6:24
Oh, really? Just two years ago, just two years ago, you got three generations old leave rice. Yeah,

Radwa 6:29
I know. And we still up till now we only have the first generation. It's not even available all the time. Like anyone. I mean, when I started to get him the labor, when I heard about it, I got it from from another country. You know, like, I have a friend. I'm like, can you bring me this with you when you're coming? And he brought him like two, three. And they were like, eye openers for us? Yeah.

Scott Benner 6:48
So did he learn that those five checks a day are not telling the whole story? Yeah,

Radwa 6:53
he knows. He actually knows. But you know, he's a busy surgeon. He doesn't give it much thought. If I would say that. He just likes to eat healthy. He goes to the gym. He checks his blood sugar, five, six times a day. And he thought it was like it's okay. But definitely when he had the liver, he had much, much better control for her blood sugar for his blood sugar.

Scott Benner 7:16
Yeah, just just wearing a few of them helped him. Okay, but you know,

Radwa 7:20
at that point we never heard like he never thought about he thought having a pump would be a bit handicapping to have it stuck on him most of the day, because also in Egypt, we only have Medtronic and like the older virgins. Okay. Yeah.

Scott Benner 7:32
So there is an access issue for everything. Yeah.

Radwa 7:37
access issue. I tell you, we I flipped over backwards to get my son to Omnipod. You know, you're not going

Scott Benner 7:44
to be the first person I've spoken to, from, oh, wait a minute. I was gonna say from Egypt, but maybe that person was from Saudi Arabia, who told me this story about like, they actually get on a plane and fly here and buy it then fly back again. Oh,

Radwa 7:57
yeah. It's basically like, I didn't even have a prescription for my young. Yeah, my, my husband still MDI till now is like, because you know, we have to pay everything out of pocket, we bring the Dexcom from London, okay, because we have him registered there. And we have several friends who live there. So I just buy it online, send it to their home, and then they I buy like six months altogether. And then whenever they're back on vacation, they bring us the stock. So the Dexcom is easy. The problem is with Omnipod because usually you need a prescription for it anywhere. Okay. There are some few like websites in the states that outsource them. So we found the trusted website, and this is what we've been using for a while. I also order online and sent to my friends and I have several friends who live in the States. But recently, we were on the dash, okay, the low on the stock of that she doesn't have any dash. That was a big problem for us. Until eventually I found that Omnipod have a couple of months ago in Turkey in Istanbul, they have a company that is called Med salads, I think that outsources the Omnipod from the company itself, and they can work with an Egyptian prescription. So this is what we're doing right now. I fly to Istanbul to bring the stock can come back how

Scott Benner 9:12
far of a flight is that? No, it's just a couple of hours. Yes, a couple of hours. You know, you're gonna be extra mad when your kids older and doesn't appreciate anything you did for them.

Radwa 9:23
It's okay, like I take it as a chance to go and have a like a three day vacation.

Scott Benner 9:30
And come back. I have to go get your palm some buy.

Radwa 9:34
Get away from this for a couple of days. But yeah, you do have to bend over backwards. Bring his stuff. Yeah.

Scott Benner 9:39
Tell me why doing that was so important for your child. I hear what you're saying about your husband. Well, I guess maybe the question is, could you afford to do it for both of them if you if he if your husband was interested? This episode of The Juicebox Podcast is sponsored by the only six month where implantable CGM on the market. and it's very unique. So you go into an office, it's I've actually seen an insertion done online like a live one like, well, they recorded the entire videos less than eight minutes long and they're talking most of the time, the insertion took no time at all right? So you go into the office, they insert the sensor, now it's in there and working for six months, you go back six months later, they pop out that one, put it in another one, so two office visits a year to get really accurate and consistent CGM data that's neither here nor there for what I'm trying to say. So this thing's under your skin, right? And you then wear a transmitter over top of it, transmitters got this nice, gentle silicone adhesive that you change daily, so very little chance of having skin irritations. That's a plus. So you put the transmitter on it talks to your phone app tells you your blood sugar, your your alerts, your alarms, etc. But if you want to be discreet, for some reason, you take the transmitter off, just slip comes right off. No, like, you know, not like peeling at or having to rub off at he's just kind of pops right off the silicone stuff really cool. You'll say it. And now you're ready for your big day. Whatever that day is, it could be a prom, or a wedding or just a moment when you don't want something hanging on your arm. The ever sent CGM allows you to do that without wasting a sensor because you just take the transmitter off. And then when you're ready to use it again, you pop it back on, maybe you just want to take a shower without rocking a sensor with a bar of soap. Just remove the transmitter and put it back on when you're ready. Ever since cgm.com/juicebox, you really should check it out.

Radwa 11:37
No, no, he's interested. No. But, uh, yeah, I think it will be like, it will be very tight. And we don't want to go there. Because you know, we buy everything in dollars. And to give you some perspective, we're having a major economic crisis in Egypt nowadays for the past couple of years. And like $1 was around 15 Egyptian pounds. Now it's at 50. I understand. Well, yeah. And it's just and it might get worse, like, there's no stability there in the horizon. Up till now. So we don't want to like get stuck with being having both of them on Omnipod. And then we have to remove him from it. If we go into like a final financial, you can't afford it, you know, so he doesn't want to start there. And he doesn't want to go there. So

Scott Benner 12:24
make sure I understand correctly. If something cost $600. American, that's 600 times 50. For you for 30,000 Egyptian pounds, my currency. Yeah, and your currency. And I'm sorry, this is a weird thing to ask. You can say I don't want to tell you. But I mean, you're a doctor. He's a doctor. How much do you make a year in dollars? Do it? Do it? Do it in pounds? I guess you're not you an average?

Radwa 12:52
Yeah, I can't tell you by year I can give you by month and average. In Egypt. Also, you need to know that the medical field, like most of it is a private. Yeah. Like your work is a private sector. I mean, it's not like in the States, you don't work for a hospital and you have a paycheck every month. No, you work in several hospitals. And it's all depends on your flow. So it's really variable between a month and the other. You know, okay.

Scott Benner 13:16
So yeah, just give me an average month for a doctor. For

Radwa 13:21
a doctor. No, it varies a lot. Like, I could be like, I'm not I'm not working. I stopped doing any surgeries since the diagnosis because we can't You can't have both of us, like scrubbed in, and then the school tries to reach out and nobody answers, you know, so since my son's diagnosis, I've decided I'm not going to scrub in anymore. I'm working only as a clinician, like medical retina and ocular inflammatory diseases. Like I can make like around only this is so embarrassing. The number in dollars is like really embarrassing, but like $1,500 for example, a month, a month. Yeah.

Scott Benner 13:59
Oh my gosh, and that even but my

Radwa 14:02
husband is definitely like, it really varies like it depends on how many surgeries you have this month, but he can be like 10 times that or five times that you know, at that

Scott Benner 14:11
1500 number that 75,000 Egyptian pounds. And, and then the pumps alone and the decks coms could I mean, you could work all month to buy supplies for him.

Radwa 14:23
Yeah, my my husband asked the covers that it's funny. Yeah, we can afford it. Like it exactly costs us around. $3,000 a year. Okay. Are you at $3,000? A year for for the Omnipod? Right. Okay. And $3,000 for the Dexcom okay. Yeah, this is this is what it costs a year for us. Wow, an average. So

Scott Benner 14:45
at the current Jesus, is that right at the current exchange rate? It's 6000 times 50. Yeah, don't go there. No, I'm going to this is kind of fun. Oh my god. Okay,

Radwa 14:56
you can do it like, actually, we have also it's very cool. complicated. It's like in the bank, it's times 30. But in the black market, it's times 50. Because the bank doesn't give you dollars because they have a defect in it. It's very complicated. Like the difference between the banks and the black market is almost 20 pounds. Yeah. All

Scott Benner 15:14
I heard was that you're a doctor, and you made $1,500 in a month. And I think, I

Radwa 15:20
think you need to edit that.

Scott Benner 15:22
I think, Listen, I'm not kidding you. I can't talk my friends listen to them. Well, they know, they listen, they know you can be doing the other work and making more money. But you're doing this thing for your kid, which is lovely. But I'm just saying that people here should like here in America, and they should have some perspective is what I'm saying. You don't I mean?

Radwa 15:42
Yeah, but on the other hand, like definitely, the cost of living here is cheaper. You know? Like, I mean, if you come from America, and you have like, $2,000 on you, you could like, live well,

Scott Benner 15:54
wait, wait for how long? How long? Can I make it on two grand? It depends

Radwa 15:57
on where you go out and what you eat. And it's very complicated. First of all, yeah,

Scott Benner 16:02
my my way. I mean,

Radwa 16:06
you don't have to live you. But I mean, if you come here on vacation, it will be a really cheap vacation for you.

Scott Benner 16:10
Really? Yeah, I'll be I'll finally be able to live like, I'm Rich for a couple of minutes here saying, Yeah, man.

Radwa 16:17
But, but overall, you know, I mean, the cost of living in Egypt is definitely cheaper. We don't we all owe most of the people in Egypt, we own our homes. We don't have mortgage. Okay, or rent? Most of us, what's the home cost? Sorry,

Scott Benner 16:32
what's a home cost?

Radwa 16:34
You know, it's like, went like 10 Times up in the past three years. So also don't go there. Like, right now. You can't afford to own point. But yeah, it's very variable. It depends on how big the home is. And the area. We I understand

Scott Benner 16:49
there's a lot of all about economics. There's a lot of I'm super interested in this. So there's a lot of variables, but what do you think an average person lives in a home that cost them what? Like,

Radwa 16:59
you might have bought the home for only like, I don't know, you do the math for like, you bought it for 1 million, for example. But right now, it's worth six, you know, Oh, okay.

Scott Benner 17:09
And 1 million. 1 million British pounds. Egyptian. Excuse me. Yeah. And so that would be divided by 50. For 20 grand?

Radwa 17:21
Yeah. But you would have bought it for more than 20 grand because $1 was actually seven when you bought the home.

Scott Benner 17:30
But then that's 100 it's very complicated. Don't go there. But then that's $140,000. Basically, I'm telling you right now, you can't buy a box with a broken window here for under $300,000. Exactly. I know. I know that in New Jersey, where I live, like I'm sure it's different in other places. Don't get me wrong, but so I can bring $2,000 I'm just planning for myself. I could bring $2,000 to Egypt and have 50 times that I could have 100,000 Egyptian pounds, I would feel do I carry it in paper in my pockets like Scrooge McDuck or how do I do it? Does that a reference? You know?

Radwa 18:05
I think we could we should start this podcast. No, I'm having such

Scott Benner 18:09
a good time. So we'll get past that. But it's okay. No, love. Okay, go ahead. I just wanted to paint the picture, because somebody who's not a physician is not flying to Istanbul to get on the pots. Right. So most people there are living with MDI. And if they're lucky, a libre one, but probably not. Is that pretty accurate?

Radwa 18:31
Yes. Okay. Yes. If you're talking about the myth, the average human in Niger, in my country, you don't have we don't have insurance. Or actually we like we pay medical care and schools out of pocket. Most of the people that have money, people who don't have money, go to public schools, but they're not really getting like that good education. And they're the insurance would only cover the MDI, not even deep

Scott Benner 18:56
enough to keep you alive. And then what about the care? What are people because if doctors are cash pay, then most people are probably just going getting their insulin and their needles and then they're going off and there

Radwa 19:09
are people who are come like multinational companies are in good companies and they have insurance. We as doctors, we don't have insurance. We have the Syndicate, but the just the cover very little of whatever costs you go through. A lot of people they have insurance companies covering for them, but I think most of them will only cover MDI, okay, we didn't cover a pump or only if you have like a really, really good insurance, they would cover a pump.

Scott Benner 19:34
Is the insulin expensive there are no no it's very cheap, very cheap, okay?

Radwa 19:38
Like, come and buy like Could your stock of insulin and fly with it and you will believe how much it costs. Well,

Scott Benner 19:45
wait a minute, maybe now I'm coming. I come with my 2000 I get 100,000 Egyptian pounds. I spend 500 Egyptian pounds on insulin. I come back here and I'm kept enriched with the insulin I sell it on the black market over here. This is what you're telling me I should do?

Radwa 20:00
You might do that I can't I do that a pen of novel is around was 100. Now it's 160 Egyptian pounds. So you do the math. It's like $3. Right? Damn,

Scott Benner 20:10
that's something else. Okay, now you piss people off now that now they don't feel bad for you anymore. Nevermind.

Radwa 20:17
It's very different to your like the story of my son's diagnosis. I think this would be one that will tell me. That's not a common story. But it was a COVID times he was diagnosed on the seventh of April 2020. And, like I told you, we always had the diagnosis of diabetes in the back of our minds. We had just like, we had the lockdown on 17th, the weight of on 17th of March here in Egypt. And he had a party at his nursery the day before. I think he called the hand foot and mouth disease. Yeah. So we the first week of the lockup, he like had a fever and the vesicles in his mouth, and he lost weight. And it was okay. And it passed. And then the week after he was just so agitated, most of the time, he lost weight, but I'm like, yeah, he wasn't eating for a week. We're locked down. It's a different situation for him. And he's only a year and a half. He can't express himself. So maybe that's why he's not himself. But then what caught our attention was like, his diapers were filling really fast. I was sitting with my husband, I'm like, I can change his diapers like, enough, like, every three hours, and I think he's just full like a balloon. And he's like, Okay, why don't we doing him a test? You know, like we did with his siblings. Like when everybody had an accident, just come in, do a blood sugar, and usually comes out fine. And we're good. So we did that. And oh, my God, his blood sugar was 400. So I'm like, No, something's wrong. Let's like wash his hands and do that again. And it's like, 450 We tried his toes. It's still high. So when you like, yeah, he has diabetes.

Scott Benner 21:54
How did that strike your husband? Do you recall?

Radwa 21:56
It strike him really bad? Like, yeah, I thought it would strike me worse. But no, yeah. I mean, he was he didn't like fall apart. He was very helpful. He was there with me and every step, but no, it hit him really bad. Like he we had a bout a long bout of depression

Scott Benner 22:12
after it. Do you think he feels like it's his fault? No, no, it's not that he's

Radwa 22:17
just look, I'm a very religious and faithful person. And he is to like, he believes in God and everything. But he just like, why did this happen? You know, I have like, in my back of my mind, like, everything happens for a reason, and you just have to live with it. And God will be with us. You know, he's like, no, why did this happen to my son? You know, like, he's too young. He shouldn't this shouldn't be happening to him. You know, this. He was struggling with that, more or less,

Scott Benner 22:44
but he didn't feel that way for himself. What had happened? No, no, no. For him. It was good. God has a plan. I'm okay. That kind of stuff would have happened to his son. He was out. Yeah, yeah.

Radwa 22:55
Yeah, I understand. So what we did was like, okay, his blood sugar is high. So he has diabetes. Should we go to a hospital? What should we do? And then I called my dad and I'm like, No, I called my friends. Do you know a good endocrinologist? I have a friend whose son is a type one diabetic. I asked her who's his following with? Long story short, somebody sent me this pediatric endocrinologist number that they think she's really good. I called her over the phone. And she's like, No, you don't need to go to the hospital. I think you can manage him at home. Check his acetone, he did not have acetone at the time. So she's like, I think you're really early in the diagnosis. So you can do this at home. And I kept texting and talking to this endocrinologist over the phone and on WhatsApp for like, two weeks, she was like living with us. But she didn't see him like the first time she saw him was like six, seven months after his diagnosis, when, like everywhere, it's opened up and I took her took him just for a regular check. She told me all the labs that he needs to do and we had like the lab come over at home and we did everything. But you know, we did not have this dramatic experience of going to the hospital and being admitted with we just did everything at home. She's like, go on by the receiver and the Nova rapid give him blah, blah, blah, do him like a diabetes diary, what he eats, how many carbs and so on. And she started to tell me what a carb insulin ratio is and how I should like try to calculate it. And we did all this at home. Like definitely, us being locked down at that point was very helpful. Yeah. Yeah. I imagine you had nothing else to do. You know.

Scott Benner 24:32
We'll just focus on this since we're just bored out of our minds. Does the insulin need a prescription? Like she said, just go get insulin? Was it that easy? No,

Radwa 24:41
we don't we don't like most of the drugs in Egypt. You don't really need the prescription for them. Okay.

Scott Benner 24:45
I could just roll in there and be like, hey, I want to try this. I want to try this. ozempic make me thin Give it to me. Is that easy?

Radwa 24:52
Yeah. XInput because we're low on stock. You might get the prescription but it's not because you have to have a prescription for it. It's because they're low on stock, so they don't want people abusing it. I

Scott Benner 25:03
am coming to Egypt to be skinny and rich. This zyk you

Radwa 25:07
think that but that's not

Scott Benner 25:10
how it works? Works. I'm making it work that way. That's what I want. Well, yeah, yeah,

Radwa 25:15
you can get Yeah, like, there's this other drug. I can't remember its name right now. That's like those Olympic but came out before

Scott Benner 25:22
it Manjaro No, no trulicity

Radwa 25:27
trulicity Yes. And there's this other one that's cheaper I can remember. Gosh, this one is available, and you can just go and buy it.

Scott Benner 25:34
Okay. All right, I'm coming. I'm on my way. Like, seriously? I mean, what the heck, why you live in? So what's the downside of Egypt? That I don't know what like, what's gonna happen when I get there? I'll be like, Oh, this wasn't worth it or No,

Radwa 25:48
lovely place. Like, if you come on vacation or like, come to live here?

Scott Benner 25:52
I don't know, whatever. What do you think there are definitely a

Radwa 25:55
lot of downsides. Like, I'm telling you, I'm a doctor, and I make $1,500 I'm

Scott Benner 26:00
gonna have to bring all my money outside to bring all my money.

Radwa 26:04
But there's, there's other downsides. A lot of other jobs like, definitely. cooling system, for example, you have to go take your kids to a private school to get a good education. So you have to pay for it. And like, for example, in your in the States, when we went there, if you want to go to a good school, a good public school, you have to live in the area where the allow you to go to the school, and usually this area, the rents are higher, the houses are more expensive, you know. So like, instead, you have to pay for the school here in Egypt, you can go to any school you want, but you have to pay for it. I see. Because the public schooling system is not very, I don't want to go there. Let's focus on type one diabetes.

Scott Benner 26:51
I gotcha. All right, I have to ask, are you expecting your children to be doctors?

Radwa 26:56
No, I don't want them to be How come? I come from a family of doctors, like my both my parents are doctors and my husband, my husband's too. But recently, even in the states, like I mean, everywhere in the world has become very challenging to become a doctor. I mean, you were the working hours, the expectations. I don't know if you're feeling this around. But lately, doctors are not given the respect that they should be having, like the day before, like 20 years ago. No, I don't know if you feel that in your country. But there is a lot of problems with the health care system everywhere. Like in Britain, they're struggling with it in the States, the doctor, our friends, they're struggling like everybody is. So I think to be a doctor, you have to really want it to love it. It's like I don't tell them you, you can't be a doctor. I tell them it's your choice. But they have to really, really want it and ask for it to be able to do the work because it takes a lot of work to be a doctor.

Scott Benner 27:51
What other like professions, like when you think of your kids do you hope for like because here I think kids now I think there's this study that says that young people in America, if you ask them what they want to do for a living, they say they want to be a social media influencer.

Radwa 28:06
Most of them. Yes, like, my son at some point. He's like, Okay, I want to be a YouTuber. I'm like, No, this is not a job. This is something that you can do on the side.

Scott Benner 28:16
I said to my son, at one point, I'm like, if we're all influencing everybody who's making money, I hate somebody, somebody needs to do something.

Radwa 28:23
Yeah, it's something that's going wrong with the world that since the social media opened up that big, and it's definitely frustrating for the kids to watch. Like, okay, my, my dad is a doctor, but this football player, or this influenza, they make, like, they live a more luxurious life, and they make 10 times more money, you know, so it's, it's not very intriguing for them to become a doctor anymore. Like my dad works 18 hours a day. And he's always scrubbed in, and he's not available. And now I can be a YouTuber from the comfort of my home and make more money. You know, eventually that won't work out. Yeah, I think this is what gets into them. But no, I think there's a lot of professions like I'd love for my son to, for example, become an architect. Okay. I think they do. Like he's an artist. He's an art. Yeah, he likes to draw. And I think it's nice that, you know, like designing homes and designing buildings. And I think that's an interesting profession. But whatever I'm not, I'm not giving it much thought right now. Like, I just want him to get good grades. And then we can see what do we do?

Scott Benner 29:27
Well, I just realized I'm never coming because the flight is like 14 hours. So I'm not doing that.

Radwa 29:35
Several times, like, we just I'm jet lagged right now when I'm talking to you because we've just came back from our like, we had a Christmas vacation. Dozens in New York and the flight is not bad. Maybe the jetlag is

Scott Benner 29:49
the problem. I'll definitely throw a clot and drop that on that flight.

Radwa 29:53
And you don't have to take like, you can do transit flights, like if you go through Europe make so you'll have a Seven, eight hour flight and then another one that's like three, four hours and you're here.

Scott Benner 30:04
Okay. All right. I don't know. Practically close. This feels like when people asked me to come to Australia, who seems very far away, I'm not doing that. Like if I could fall asleep in a pod and wake up in Australia, that might be different, but I don't know. put me to sleep. I want to understand when your son's diagnosed. And how do you get from where you described with your MDI and learning at home to I need to find a CG like, where do you even learn about those things? First of all,

Radwa 30:34
first of all, ask for the CGM. We have a friend who was on the Dexcom. So I was like, Yeah, you need to have that for your son. And we had a friend who's in London, and he he mostly did it all for us. He like, registered him. And he brought us the Dexcom like, months later when he was coming. The doctor told me it's preferable to have a CGM. The only thing that we have in Egypt right now is the FreeStyle Libre. But I was like, No, it's not good enough. And then our friend suggested the Dexcom. He was on it. He will he used to bring it from London. Like we had him and duck on Dexcom, like just a couple of months after his diagnosis. And we only stayed on the Dexcom for two years. Dexcom with MCI, with the first week of diagnosis, what I did is like, I sat there and started to search for Facebook groups like Facebook support groups. Like I told you, I wasn't really involved with my husband. And I wanted to know more. I wanted to listen to people talking about it. I wanted to ask some questions. So I just started searching for Facebook support groups, I found several ones I didn't find actually the juice box, Facebook group at that point. But then people kept bringing up the Omni pod. And then one of them said, there's this Juicebox Podcast that's very useful. The podcasts kept coming up, like in the comments from different people. I didn't ask any question. I just kept reading questions and comments and questions and comments, trying to educate myself a bit. So I put that in the back of their mind. But I was at home. And at that time, I usually listen to like audiobooks or podcasts during commute during going to work. So I didn't think about listening to the podcast at that point. But I put it in the back of the mind. I went there and followed the podcast, but I didn't start listening at the point. And then when people started bringing up the Omnipod, I'm likely I need to know more about that. So that's when I started looking into the podcast, because people kept recommending it if you if you're going to put on an Omnipod you

Scott Benner 32:30
know, it's funny, I'm so happy that that worked out. But I don't think of it that way. I don't think I talked about anything on this podcast that you couldn't do with MDI, a T slim pump or Medtronic pumper, or anything else. Yeah, I

Radwa 32:45
know. But they said that it's useful like, because I

Scott Benner 32:49
have those pro tip episodes from Oh, so this was like, two summers ago, like August of 2022. Is that about when you found me?

Radwa 32:58
I found you before, but I started listening in 21. Okay, I guess by the end of 2001. Started like listening randomly. At that point, I didn't want to put on a pump on a two year old who's running around, because the pumps we have available here are the ones that you have to like, have an inner pocket for it and with him, and it's cannulated. And I was like, No, I can't do that. I feel very uncomfortable. If it got stuck in something or hung up on something it would be handicapping for him. So I went along with MTI. And then when I read about the Omnipod, and I felt that he can like go to swimming class with it that there is no cannula involved. And I was like, Okay, this is what I want for him. But I don't want to change the system that his nursery has been used to, like they give him injection in the nursery and everything. And I just keep following with the Dexcom and giving them instructions. This is how it's working like that. Like in the nursery. It's very, it's an open community, you can call at any time it's not like the school premises. So I can drop off anytime I want. And I if I need anything, I just call the teacher and tell her like, Oh, he's going Hi, give him blah, blah, blah, he's going glow, give him juice and so on. And

Scott Benner 34:09
we'll do all that and that nobody fights you about it or says that's not my job or anything like that. No, there.

Radwa 34:14
His nursery was very helpful. The teachers were amazing. And then we have to go to school. And that's when I was like, he can be on MDI in school. He can keep going back and forth between the doctor's office and his class for every injection or for every whatever. The summer before he went to school was like, No, I have to get the Omnipod Oh, I actually did is like I ordered the Omnipod and I had it like since April. I've had like a six month stock that we bought. And I kept looking at it. I'm like what I'm gonna do with that. Like, how I'm gonna do this. So okay, I'm just going to postpone this to the summer. I don't want to change his system right now. And I shut it off. And then when I talked to his endocrinologist, he's like, yeah, the Omnipod is ready. Good. I've tried to help one patient before with it, but I can't really remember all check it out and come back to you. I'm like, No, I can do that. You know? Yeah, yeah. I

Scott Benner 35:10
don't need your help. Yeah, if she's going

Radwa 35:12
to have to check online and ask around and then come back for me, like, if you're

Scott Benner 35:17
Googling I can Google. Also, I'm a doctor, too, by the way,

Radwa 35:22
is exactly what I did. Like a friend. Like she pushed me to do it. She had a, she's somebody I got to know because her her kid is diabetic, too. So we have like the small community, we communicate with each other. So she told me, like, we did the Omnipod at home, her her husband was totally in charge. And he was able to do it. So I'm like, if you can do it, I can do it. So I took a week off, I stayed with him. Totally at home, I read all about it. I watched all the videos. I'm like, Okay, I'm doing that. So I kept him at home. Even my husband wasn't available at the time, he was like, in a conference. And it was only me and my kids at home. I decided to put it on, I put it on. And I had already listened to several video, like several podcasts, and I watched several videos and the instructions of how to do it. And it just it just took me like three days to get his basil. Right, right. I think the most of the struggle was in the basil. It's the dash. It's not the Omnipod five. So there was no algorithm involved. Yeah, and and we got our we got there, and I watched his numbers getting really good. I was like, I kept telling my husband, you have to get some for yourself too. Well,

Scott Benner 36:35
that's what I was gonna ask as soon as you start seeing the benefit of it to turn to your husband and go, Hey, what are we doing here for you? Yes,

Radwa 36:41
exactly. But up till now, he's still resisting. And he's like, just let's keep all the money to like, a steady supply of Omnipod. Because it like, right now, if he doesn't have the Omnipod on him. I don't think I'll send him to school. You know? Yeah, it gets scary,

Scott Benner 37:00
doesn't it? Yeah, it's scary.

Radwa 37:03
And his teachers won't honestly in school, his teachers won't give him the injection. They're not allowed to. So I wouldn't feel comfortable him going back and forth to the clinic every time but his teachers, they would use the Omnipod. Easily your trouble. You have a WhatsApp group, me and the teachers. Yeah. I keep giving there. I told them, I'm totally in control. I'm gonna give you all the instructions whenever I need to. And this is what we do like, right? Yeah, I just send them on the WhatsApp right now he's going a bit low. Can you give him a biscuit or we have his supplies and in class, or Skittles, or juice box or whatever. And if he's going high, I send them like, give him 10 grams of carb or whatever. So it's easy for them to just press Bolus, put a number press OK. And that's it.

Scott Benner 37:49
Is it hard for you to know that you guys are making a financial decision that I don't want to say it's hurting your husband, but is it hard to know that you're making like, like a Sophie's Choice decision? You're like, we're gonna give it the I mean, I guess most people, definitely.

Radwa 38:03
Yeah, definitely. But you work with what you have. You know,

Scott Benner 38:07
they your husband sounds like a good guy. I'll tell you right now this this. You're not supposed you're not able to get mad at him now, because of this. This is very selfless.

Radwa 38:17
Yes, selfless. Honestly.

Scott Benner 38:18
It doesn't work that way. though. You're married, you can still be mme, it's fine. It's not this one. Generally,

Radwa 38:25
like, yeah, it's it's a choice. But like you said, it doesn't feel like we're harming him. It's just like, he has better options that we're not using right now. You know, no, I

Scott Benner 38:35
mean, he sounds like he's on top of his situation. So I don't think he's being harmed. But not I'm not saying you can't do well, with MDI. And testing. You certainly can. It? I mean, it makes the point really, that you're having to make a decision, there's a thing you'd like to do, and you can't and that it's not just, you know, it's not just in one country, there's problems exist everywhere, for the most part. Exactly. Yeah. And they're happening to you to doctors, which is not a thing people would expect, you know, yes.

Radwa 39:02
Yeah, it's not common. But but the healthcare system, like as well, we hear so different. Like, it has a lot of privileges. Like if you want to do an MRI, you just go into an MRI, you know, you like if you know, you need one, you can just go and do it.

Scott Benner 39:16
Are they financially, like, difficult to get? No, no. Health care? So it's not monetized the same way?

Radwa 39:24
Yeah, health care here is very different. It's a lot cheaper. You don't have to, like ask permission, and wait, like, for example, if you don't have an elective surgery bypass, for example, to lose weight. The next day, like I know, the waiting list, and for example, in the UK is around a year and a half to do that. Or if you want to do a hip replacement. You might have to wait for your turn here. You can do it just the next day, even through insurance, you know, because

Scott Benner 39:53
there's availability of doctors or because Why do you think that is why do you think there's that Instant Access,

Radwa 40:01
doctors are much more available. It's not like that where there's a lot of doctors, but the doctors are available. Like I told you, I handled my son at home, and I had my doctor on WhatsApp. And my patients can reach me on WhatsApp anytime. Like if they have an emergency, if they need to ask about something, they can just text me and I answer back. No, it works really differently here. Like, you could just go and book an appointment and go, Yeah, you don't have to go for example, through our primary care doctor, we don't have that here. And then he decides if you need to see an endocrinologist or not, I think there's an episode I was listening to a few days ago. And she was talking about the struggle to, like diagnose her kid. And they kept in the ER, sending her back home with COVID Sending her kid back home with COVID. But like here, you would have not just an ER doctor, you would have like whole specialists available. If you go to the ER at any time, you know, you

Scott Benner 40:59
know, I found myself laughing earlier when the doctor offered to Google on the pod for you and look it up. But I actually thought later, I should.

Radwa 41:07
She knows Omni pod. And she worked with it like once but a couple of years before. So she's like, I can't remember what we did back then I need to recheck. Yeah,

Scott Benner 41:16
but um, I laughed and I shouldn't have because what I should have saw was a person who was willing to tell you, I would like to help you. I don't know what I'm doing. Let me go find out about it. And I'll get back to you. Whereas I think that I hear a lot of doctors here just either pretending they know what they're talking about, or just ignoring you if you ask something that they don't or say. Or they would say something like, Oh, don't use that pump. I heard it's no good. Wouldn't what they really mean is I know how to use this one. So let's stick with that.

Radwa 41:44
We definitely have like, like this person was saying before podcast, doctors are humans, like you can find the mean one and a kind one and helpful one and an egoistic one, you know. So what I was like referring to here, and each of the doctors are more available for the patients like they're not somebody that you have to go through a whole lot of system and people work to reach. You could just

Scott Benner 42:10
call them up. Yeah, call them up and say my ankle hurts. Could you look inside of it and find out what's wrong with it? Yeah,

Radwa 42:14
not all the doctors, of course, are that reachable. Some, some are really more busy. Some, like, their ego makes you go through like his secretary or personal assistant or, like they have a waiting list or whatever. But I mean, you're not. But I mean, generally you can reach a specialist that you want to go to, like, in no time.

Scott Benner 42:37
If I needed LASIK surgery, and you didn't you were still doing it. I call you up and I'm like, hey, I need LASIK. You. Can I come in? You give me the ones over? I definitely need it. We get together tomorrow and do it. I pay cash for that. Yeah, what does that cost?

Radwa 42:53
LASIK is not covered by insurance. I can't tell you that. Okay, very cheap. Oh my god. If you make like, it will cost around 200 to two $50.

Scott Benner 43:04
I spent $99 on dinner the other night. You mean? Oh,

Radwa 43:09
I just came back from New York. I'm telling

Scott Benner 43:11
you, oh, please spend a fortune on food. But a $9 bagel in New York is what you did. That's fascinating. Wow. And can I ask a question? Just please. Oh, head did not. Let's not use the eyes as an example. But am I getting the same level of care as I would somewhere else? And in Egypt? Yeah. versus New York. If I get my hip replaced?

Radwa 43:33
It depends. Yeah, if you get a hip replacement, definitely you're getting the same care. But the doctors here are really good. What we like maybe the fact of intimate is like the nursing, like, you're not always lucky with the nursing staff you have some are really well trained and some are like they're not that well trained. You know, the nursing. They don't have like a system

Scott Benner 43:54
to train nurses. It's almost just a job you get. Exactly yeah. Wow, that's interesting too.

Radwa 44:01
Oh, but the doctors that you like my cousin had a real problem with her back and she she needed to see a neurologist and they gave her an appointment like after eight month I'm like, okay, just come to Egypt I'll book you an appointment with the best neurologist we have go and see him and then go back you don't need to wait eight months to see a neurologist

Scott Benner 44:21
you know I have a friend who needed a just an iron infusion in Canada. And it took like a year Exactly. Yeah. Dragon asked the whole time like exhausted brain fog, you know, blah blah blah. And they just it's just takes forever and the way it was explained to me is that I guess Canada does it on that are you going to die system? So like the the closer you are to dying, the faster you get to a doctor. But then people start with these small problems and by the time they actually get to the doctor, they're in a much worse situation. They're dying like right like it just I was like, that doesn't make sense. Yeah, it's so something else. So access is, it's really great. Yeah. All right, definitely.

Radwa 45:03
Like I think this is a really good thing. Like, if you can see a specialist and if he needs an MRI, he tells you go and have an MRI you can have the next day, and then send him the report the day after, you know, it's that fast.

Scott Benner 45:16
Well, listen, if you have good insurance here, you get treated well to, this isn't going to be a weird example. But I woke up one morning, a couple of years ago, and my toe hurt terribly. Like to the point where I thought did I wake up in the middle of the night and like kick a wall or something and not know it, you know? And I thought it would go away, and it didn't. And it got worse and worse. And I ignored it for a very long time just thinking like, Oh, it's a ligament or something, it'll get better. Who knows. But once I decided I can't take this pain anymore. And this is, you know, stopping me from walking correctly, I have to go do something like that. I called the guy. The guy said, you know, I got an appointment. The next week I came over, he took a look at it, because I can get on the schedule. I had a surgery three weeks after I called him. Okay, that's fine. And that was fine. But it's because I have good health insurance. So when they see my health insurance, they see oh, we're getting paid for this. And now you're on the schedule. You know what I mean? Oh, I wonder what that toe surgery cost? Do? You know, I don't even know. Like, I have no idea what that what the doctor made.

Radwa 46:20
I know any in the States, you don't even look at the bill like the insurance is paying that I don't even

Scott Benner 46:24
know if I got a bill. You know, I already put out enough money with Arden at the beginning of the year that I didn't even know anything for the doctor's visit. Like I just walked. You are out of the deductible. Yeah, it was out of my deductible already. So I'm never bothered. I bet you if I went and looked at that, I bet you that doctor made 40 or 50 grand doing that thing? You don't II mean? Yeah, you gotta come over here. Just do a couple of lasix and go home.

Radwa 46:47
Like I told you live in the States are like a year and a half. Right? Husband has his fellowship there. And in Houston, a Methodist Hospital. And we have good insurance. But thank God within, like, in that year, we're going to use it. Yeah. So we have like limited experience with it. But it was a good year. Like we had a good year.

Scott Benner 47:07
I was gonna say you should come over here do five lasix and go home a king.

Radwa 47:12
Yeah, I guess we should do that. Not

Scott Benner 47:14
that easy. It's not you can't practice medicine outside of Egypt.

Radwa 47:18
No, like in the states to practice medicine. You have to do like what's called the USMLE II, this is what my husband did. And then you have to have like, it depends on the state. Each state has its license, you have to have the state license to practice

Scott Benner 47:32
seems like a scam to me. Basically, you have to come here pay a half a million dollars to get educated so that you can go charge somebody 40 grand to fix their toe. That's what it sounds like. Whatever.

Radwa 47:42
But anyway, this is how it looks here. And I think it's it's been good for us like having his doctor available when we were locked down. And we didn't have to take him to the hospital to give him the care he needed. So I think this was a good thing.

Scott Benner 47:57
Yeah. No, no, it really is. This whole conversation is incredibly. How involved did your mother in law try to get involved when your son was diagnosed?

Radwa 48:07
She tried at first a bit, but right now she's not involved at all. Like in the beginning. She's like, okay, what are you giving him what he's doing? But you know, by that time she's already in pension. I don't know what you retired like, yeah, yeah, she's retired. And she wasn't oriented. Like when I started mentioning Omnipod and Dexcom she's not oriented with these devices at all. Like I told you before, we don't have them in Egypt. And that's very, very interesting topic. Like in the area I live we have like a 13 Starbucks and a 12 McDonald's but we don't have Omnipod in Egypt, you know? Yeah, like how is this more important? How is it more important to franchise Starbucks or and have like 12 just in the block we live and then we can get access to like important medical devices you know, I

Scott Benner 48:57
think that these companies just don't know how to do business in other countries. You don't I mean to go set up somewhere else is a big undertaking I mean, on the pod sent, um, they have an office I think in England now. Yeah, and so you know, but I actually have a number of times Matt, I think I've had dinner once with the person who they who Omni pod sent to England to like set the whole like to get the thing rolling. It's a big undertaking you've got to you know, you've got to move people uproot people send people over there to learn how to do business in another country and then get the entire things it's it's a hell of an undertaking. I

Radwa 49:33
guess the other way would be like, what happened in Turkey where some businessman or whatever, decide to like franchise, the company and be in control of it in his country,

Scott Benner 49:43
you know, on the I've never heard of that before. I'm glad it exists, but I don't know about

Radwa 49:48
it. It does. But but the point is, I think in Egypt, it would be not worth it to invest in something like that because like I told you, most of us will pay out of pocket for it. And by the time we comes here to be even more expensive than the state. So that will be like a financial burden for most of the Egyptians. Yeah. To pay them pay a middleman. Yeah, you need to get the insurance companies on board. So that's when it can, like be financially good for the company.

Scott Benner 50:16
And accessible to people there. Yeah,

Radwa 50:19
exactly. So I think it's a, it's a big thing to do right now. But it's just, you know, it's a struggle for us using the Omnipod. I like I have four or five friends who use the Omnipod for the kids, and we're all struggling together. And whenever we find the source, I keep calling them and I'm like, Hey, I found it in Turkey. So we can go there and get our stock, or we found this website, or that guy who outsources them from the states and whatever. Yes. So it's a real struggle that I feel like, we need to get out of, you know,

Scott Benner 50:50
it's interesting that another country doesn't knock off medical supplies, you know what I mean? Like, copy them, like companies that are outside of like caring about, you know, I'm saying it happens all the time.

Radwa 50:59
I understand. Yeah. But this is like very advanced technology for somebody to just knock it off, because it doesn't work properly. You're killing people.

Scott Benner 51:07
Yeah. Well, I assumed that somebody wouldn't care about that. And they would try it. I just found myself thinking it's interesting that that doesn't happen. Maybe countries stay on top of stuff like that, so that nobody gets hurt. But yeah, there's got to your point, there's got to be a way right. They, they make the damn things they know how to make them. If there was more countries, they could send them to, they could build more infrastructure and make more I'm sure they'd be happy to make more if they could sell more. I guess it's just the Yeah, that's the process of, of actually distributing it. Once you get to the country and understanding all the rules and regulations there and working within them. I guess that's where the hard work comes in. Yes, exactly. Okay. Well, that's something How comfortable are you? A few years later, that you know what you're doing? Like, how's your son's a onesies? Has he does he do better than your husband? For example?

Radwa 51:57
Yeah, definitely. His average is around like 6.2 to six and a half. That's wonderful. But his time and range is not always perfect, because he's really young, and I can stay on top of it. Especially in this last year. He's like, he'd go and eat something and not tell me before, not everything was accessible for him. And maybe when he grows up, he would understand that he has to tell me before he eats, but right now he can just go and grab a biscuit. And not tell me, you know, yeah. So I have to be on top of things. Definitely Omnipod. Five would have helped with that. But it's not available in Turkey. And it would be a more of a financial burden for us right now. So we're waiting on it a bit.

Scott Benner 52:36
Do you ever consider doing one of the do it yourself algorithms?

Radwa 52:40
Yeah, I was thinking about doing it that summer, because I have a couple of friends who has been trying with it. And they did not succeed yet. So I'm waiting for them to succeed. And then they tell me exactly what to do. I didn't have time. Like, maybe in the summer when he's at home with me all the time. We can do that. But it will be very difficult when he's coming and going back. And, you know, like his pens, like half his day in school.

Scott Benner 53:03
Yeah. Yeah, no, I understand. I'm actually aren't using Iaps now. But the truth is, is that if somebody wouldn't have helped me set it up, I wouldn't have known how to do it. It's got so many settings. It's like mind boggling.

Radwa 53:16
Yeah, I heard it's so difficult. So I need to, like take the time off and have them with me all the time. And we can try that.

Scott Benner 53:22
Yeah, I don't even understand like people start are asking me now like to talk about I'm like, I don't even know what to say to be perfectly honest. Because what happened? Yeah, cuz Arden's off at college, and it's working so well that it doesn't need a lot of intervention from us. Wow. And at the same time, you know, I don't know how I got to the settings because somebody Mike who's been on the podcast, he was just like, make this one that make this one that turn this to that make it this number, this this? No, well, let's assess it and it'll work. I think I put it on her and made some changes to her insulin sensitivity. And carb ratio, I think I made her carb ratio weaker and our instance sensitivity, I had to make it stronger. And then it just started working. And I was like, alright, well, okay. But now she's actually using, I don't think I don't know how much I've spoken about this yet. is pretty new. She's using a GLP. So right now it's ozempic. Oh, okay. Yeah, she wants that we want her doctor wants her to switch to Manjaro at some point, but we were having trouble getting it. So she's using ozempic Right now, but not even like a therapeutic dose. She's using like point two, five. I was at milligrams maybe

Radwa 54:35
help her like Did it help? Because I was actually thinking about that for my husband. I was like, You

Scott Benner 54:41
have no idea. Like, I can't wait to do an episode about it to really talk about it. But my oh my god, my rough math tells me that Arden will use over 11,000 fewer units of insulin in 2024

Radwa 54:57
Wow, okay. You know, I have this idea, I used ozempic to lose weight for a couple of months. Okay, and I saw the results, and I went all over my husband, I was like, I think you would really benefit from ozempic. Like, you don't have that his diabetes is not that bad. You know, the one he got a 26. He doesn't go like crazy high. He actually when he started going to the gym, we went very lower with his doses recently. So I was like, if you go on to the Olympics, I think you can just keep up with the Basal and need the noval rapid to a minimum. So I've been pushing him about it. And he's been resisting for a while. But after he said that, Oh, my God. I'm going to be all over him.

Scott Benner 55:39
Her daytime Basal went from 1.1. an hour to point seven. Wow. And her spikes are, you know, when she gets a meal spike, they're much lower. I used to say, I would tell people, right, like, I think of one ad is high. Think of 200 as a spike, we really screwed up. And now I think of 140 as high in one ad is a spike that we screwed up. Wow. Well, she's coming back down more gently, quicker. Like this morning was her first day of college for I don't whatever semester, this isn't some a quarter. This is for her sophomore year. So I watched her. She it's fascinating. She's 700 miles from me. And I knew what time she was getting up and going to class this morning. So while she was heading to class, I sent her a text that said no good luck this quarter. And so I know she's, she's on her way to the building. And I'm watching her blood sugar go from like 110 to 120 to 130. And then the algorithms like oh, what's happening? It stopped her at 149. And it brought her back down in like two hours. So is a pretty big adrenaline rush that she got art and takes school very seriously. So she's like, I think it's stressful for her. So she gets this big push that the algorithm is not expecting it pushed it back down. She went from like 119 to 149 and back down again. And I'm wondering what's going to happen now during the day because schools you know, it's she's back at school, it's different. Now, I don't know what her schedule is like yet, like I gotta let her settle into her schedule a little bit before we can make changes her last 24 hours, I would consider not good. And there's been one spike to one ad, there's been a couple of stretches where her blood sugar's were holding, let me look. So I can really tell you a couple of stretches where they were in the 140s after two different meals. And other than that, it's been pretty much between 120 and 94, actually 120 and 70. For the rest of the time, that's 24 hours. So I would say 20 of her hours are between 70 and 110. And maybe for hours that were up around 140. And then one spike. That was worse

Radwa 58:05
with Omnipod dash with my son, we we don't get these numbers, like he spikes to 220 and 230 sometimes, especially that we can't always do Pre-Bolus thing, you know, I can't be sure if he's going to eat his meal or not. Like he's not that helpful yet, right. So, but definitely having something like the Omnipod five with me with an algorithm will definitely be of much help. I'm looking into it this summer. But those Olympic I'm definitely pushing it in my husband as soon as he goes.

Scott Benner 58:35
I mean, not just that, from March to now to January, I've lost 38 pounds with weego, which is those Empik right. And last week, my endocrinologist who's you know, helping me with this is also the same person that helps them with their diabetes and my the rest of my family with their, with their thyroid stuff. She's like, let's get you on Manjaro if we can, and I was like, okay, which is now called zek bound for weight loss. So she wrote me the script, and we took it off. And they were like, Hey, we can get that. I was like, great. So I shot the first zap bound like a couple of days ago. And I'm assuming there's going to be like a period of time where you know, something. I don't know what the hell's gonna happen. The weego V for me was good, obviously. But I had definitely plateaued. I was not going to lose any more weight. I still had some stomach acid stuff. My Oh god, I can't bother. I'm so sorry to say this. I haven't had a nice firm bowel movement in a while.

Radwa 59:35
Yes. I was asking. I was gonna ask you about that. Yeah. Yeah. It's not

Scott Benner 59:39
enough to like make you go well, I don't want to do this because you're losing 40 pounds, but at the same time, I'm just like, I would like that to go back to normal. Yeah,

Radwa 59:46
to go back to normal. The manzara doesn't have the same side effect.

Scott Benner 59:50
She said that uh, I very well might not see the bowel movement side effect. And then it also has something in it that helps with stomach acid. So she's like, I love this for you. Let's do Try

Radwa 1:00:00
this. Yeah, it does. And it's actually like, from what I heard, it helps you, like those Olympic helps you to lose around 12% of your body weight. But the Manjaro helps you to lose 18%. Yeah,

Scott Benner 1:00:10
that's what I'm stronger. I'm hopeful, like, one way or the other. I need something just for management. And this is not about like, I know people who don't understand it would think, Oh, yeah, you have to shoot something to keep yourself from eating a bunch of food. It's not like that. I met the part with the GLP where I can eat fine. Like I don't, I'm not limited about how much i i can physically eat if I want to. Exactly. I am making different decisions. But I think those decisions are more because I like I like better how I feel and how I look. So that's me,

Radwa 1:00:41
like I told you, I'd had an experience with it. And I was like, this is not bad. I don't feel like I'm not depressed. I'm not like, I don't want to eat something that I can't eat it when I want to eat something I do. I do eat it. Yeah. But it just it helps me with controlling a lot of like, the unnecessary cravings that you get. And it helps you to keep yourself in shape. My wife

Scott Benner 1:01:04
says that it stopped the food noise in our head. Exactly. Yeah. She said she'd wake up in the morning. And the first thing she would think is what am I going to have for breakfast? And then she said, while she was making breakfast, she was thinking about lunch. And she's like, she's like, that is completely stopped for me. Now I don't have that. I actually I think I have some sort of a deficiency that that it made up for it. Because my body is, is operating way better right now. And it's got very little to do with what I'm eating being different. So, yeah, pretty, it's pretty great. But back back there for type ones. To be clear for people who are listening, our insurance is not covering ozempic for art and, and our doctor is helping us get it from somewhere else to so we're paying cash for it. But it's very doable, because it's cheaper where it's coming from. And on top of that, she's not really using much of it. So the pens lasting forever for

Radwa 1:02:00
us. So she uses like a very small dose,

Scott Benner 1:02:03
the smallest dose and it's apps and the doctors like we're not going to move this up if we don't have to like look what it's doing for oh, by the way, also is it cleared up her acne by like 80%. Wow. Because we think Arden probably has PCOS. Okay. And so now we're waiting to see this is her. Again, I feel so bad. And I'm sorry if I'm dead and you're listening to this 20 years later. I'm sorry that I'm about to say Arden is about to get her second period since she's been using it now for like over a month. Sorry hours. And I'm hoping that it's a less impactful period because Arden can have heavy painful periods. So if you bet for our than right now Dad, she don't care. And so so if that if that makes that even better? Well, then hell like now it's and we are seeing that online, which I'm going to keep saying over and over again. There are women online who have not been able to be pregnant for their lives who have PCOS who are using we go view ozempic Those Those GLP medications and they're getting pregnant.

Radwa 1:03:04
So yeah, it's not the first time I hear about that there. I

Scott Benner 1:03:08
know there's a group of women talking about it online. I saw a group of people in on Reddit talking about their, their connective tissue disorders. I can never say it correctly. And that slows me down when I'm about to say ears. Hold on a second. It's the danlos Do you know what that is? It's an autoimmune downloas Ehlers Danlos yes, that I actually saw a Reddit thread of a bunch of people with that, who said that they think their symptoms are getting better on GLP now, I don't know if they're losing weight, it's putting less stress on their joints and maybe it feels better because of that. Not sure or if it's actually helping them with it somehow I have no idea but I mean, when you start seeing 25 people say oh my god that's happening for you to like, that's crazy.

Radwa 1:03:58
You know what I mean? So that's crazy. And the first time I hear about it too Yeah, you

Scott Benner 1:04:02
got to pick her out on the internet to hear people talking a little bit about about things but for I 1,000,000% believe that if terrible people with you know money focus is don't get in the way you're gonna see GLP medications that are given to people with type one in great numbers over the next couple of years.

Radwa 1:04:25
I really hope that because what I've been seeing is like the opposite like every like week I find an article about somebody's like oh simply killed my wife and then you read the article and was impeded did not kill his wife well, he just died she was almost eight but she didn't die from was Olympic. You know? No, I don't know what's wrong, but like, articles keep popping up for me like on Instagram, or from us daily or whatever. And it's always about how side effects of Olympic you know,

Scott Benner 1:04:58
I don't want to be consumed AOC theorists are at Roswell, but I'm assuming that that article is planted by like a sugar manufacturer who's like, oh, that's probably Oh god, these people keep shooting this DLP we're going out of business. Honestly, I mean, I, I don't obviously I have no idea. But if people if their cravings are curbed, and they're losing weight and having the, you know, the experience I'm having, which is, you know, I prefer to feel like this than to eat that, or, you know, even just the quantity. I told you, I spent 100 My wife and I went out to dinner the other night I got this really is a beautiful bowl of pasta with shrimp and crab in it. It's a spicy had a red sauce is really good. I really loved it. I did not finish. Exactly,

Radwa 1:05:42
yeah, but that's good. Like, you get to eat what you like. But you don't have to like overstuff yourself.

Scott Benner 1:05:48
Exactly. And this that overstuffing because there's no way I wouldn't have finished that without ozempic.

Radwa 1:05:53
Exactly. Like when I was on it. I'm, I'm a person who's like, my favorite food is ice cream. And like, my kids always make fun of me. If I get a pint of ice cream, I could finish it while I'm sitting on it. You know, like, I don't stop eating ice cream until it's done. But now I get to eat. Like if I crave ice cream, I eat it. But I definitely can't finish the point. It's like, a few spoons. And I'm done. And I'm happy.

Scott Benner 1:06:16
Exactly. Am I and my joints feel better, too. Because I've lost weight, my ankles feel better, my feet feel better. Like, you know, all that stuff that I before would be like, Oh, I'm old. That's why my heel hurts. That it turns out that my heel hurts because I was carrying around an infant with me on my ass in an Amen. I feel much better. Now. My wife looks amazing and feels much better. This whole thing of people like making fun of it and everything. They really don't understand what they're talking about. So that's probably yes, yeah. But I get I also get them feeling past like, you know, imagine you're skinny and you've been like stopping yourself from eating stuff you want for years. And you're like, wait a minute. That's not fair. I had to have willpower. But, but it wasn't willpower, though. Like, I don't know one other way to say it like it's an unconscious thing that happens. Exactly. Yeah. Feels like you're being drawn by your own chemistry. I don't know. Another way to put it. Yeah. Anyway, is there anything we haven't talked about that we should have?

Radwa 1:07:12
I guess not. I just want like yesterday, I was just listening to your wrap up. How sad you were that day. And all I wanted to tell you like you were talking to I'm just helping the top 10% of the top 10%. Believe me, like you're doing a lot like not just in your country, like everywhere for the type one diabetes community. And I just wanted to get that through to you. I know you hear that a lot. But just hearing the wrap up yesterday made me feel like I have to tell you that very nice. Like I thank you really, when I started listening to your blog, I just listened to the first episode, the one where you were talking about the background music that was made by your like, kids friends. And it went from there to here. And you need to remind yourself of that, like, every time.

Scott Benner 1:07:57
Well, I got a lovely note this morning from a gentleman. And that said something similar. He said he heard an episode recently that just really changed how he thought about his own health and that he was doing better. And it's because of the podcast. And he heard me. So for people who don't know, like at the end of the year, I always do like some episode where like think like last year I talked to Jenny like I realized that never talked to Jenny like she was a person we always come on and talk about like management stuff. And this year, I wanted to just kind of do a wrap up because it's been a kind of a difficult year. Like behind the scenes, Apple made some changes to their, their podcast app, it impacted downloads of back catalogue stuff, which is going to impact my, my overall number and I don't know, it took away my I don't know another way to put this, I need something to get me up in the morning. We all need something to get us up in the morning, right? And so I use helping people and reaching people as my measurements, right? If I'm helping people good. That's our goal. That's our only goal. Actually, that's if anybody needs to know the The Secret to Building something successful. I only focus on helping people. If they give if I help them, it'll grow on its own. I don't have to worry about that. And then but the other side is the growth. And if when I plant toe, or if the growth slows down, I don't see it as Oh, I'm not succeeding. I see it as like, oh, it's not working. Like I have this information that I know helps people How am I not figuring out how to better get it in other people's hands? And I don't know another way to explain it other than winning feels winning makes you feel like playing, if that makes sense. So yeah,

Radwa 1:09:43
but believe me, you're reaching a lot of people even if you can't see it, and when you talked about like for somebody to listen to your, to your podcasts, they have to be educated well, people have to look for it. You know, it's not like people have to really care to start aren't looking and listening to a podcast about their health or about how to do things better. Or, you know, like, we have a lot of diabetics here in Egypt after my son's diagnosis. As an ophthalmologist, I use I used to get a lot of people to check the fundus, for example, regularly because they're diabetics, and I'm like, Yeah, hi. And how long have you been diabetic? I checked the funders. They're good. And I just let them go. Now whenever I see a diabetic in my clinic, I just keep educating them. Like, do you have a CGM on? Do you have a pump on? What was your last moment? Anyone? See, I think you should listen to the, to this podcast. Like if the they have good English. I keep recommending your podcast to them. Like sometimes stuff happens that you can't see.

Scott Benner 1:10:44
No, I know. And the crazy thing is, right, well, I know what that's happening. Like, I'm really aware of it. To be clear, so everybody knows what I'm talking about. They average this is gonna sound ridiculous. The average download for the, how do I say this, I get a certain amount of devices every day that come on to the podcast. They are now downloading, I think it's point seven fewer episodes per device per day. But I have a lot of people listening. And point sevens add up pretty quickly. And so it's the same amount of people listening, that hasn't changed. They all you know, if they're subscribed, they get the they get the latest download episodes, everything works, they don't see the back catalogue as much and and that's going to hit my overall number. Like it won't hit my new some, like, new downloads for new episode number, like advertisers are still going to be happy, is what I'm saying. But I'm not like leaping forward the way I was before and that you're not where you want to be. It was exciting for me. Like, I don't know, another way to put it like it keeps me like it gets me up in the morning. Like I'm gonna go. I'm gonna go win. Like that's how it feels when I get up in the morning. Like, you know, as crazy as it sounds. And I do hope this doesn't sound too. It's not callous. I don't feel callous about it. But when four people a day tell you they saved your life, you save their life. You don't get the same jolt out of it anymore. I really don't know another way to say that. Like I do you understand me irregular. Like yeah, like how many people look at have you in your life and said, Oh my god, I can see again. Thank you. All right. And the first time someone says that to you like you took their cataract out, for example, you're probably like, I'm a goddamn miracle worker. You're welcome. And, and then the 1,000th time somebody says, Yeah, I know I moved the cataract you're fine. You can see now and like, and but it's not dismissive. I don't feel dismissive about it. I'm thrilled. Every time somebody tells me. It's just it's almost like gambling. Like I don't get as much of a telly.

Radwa 1:12:51
It's almost like drugs. Like you have to get a higher dose. Drug.

Scott Benner 1:12:56
Yeah, right. Right. Basically, my I don't get jacked up the way I used to when somebody says my agency was this and that I cry more now. Than then I the excitement. I used to get excited, like I'm doing it. And now it makes me sad. But like, it's almost like I'm feeling their emotions more. Now, when it happens. Like I got a note this morning that you know what I can probably, I'm not going to identify the person, obviously. Okay. And it was from a man which actually, it was interesting. It struck me differently, because guys are not usually very emotional. Yeah. So if you hear this, sir, please just know, nobody knows it's you. But it says, Hey, Scott, I don't normally do this. But I thought I needed to privately message you. When I'm all caught up on new episodes, I scroll through past ones that I haven't listened to before. I happen to randomly click on 1030 to loss of liberty. And I just wanted to drop you a quick line to say that I appreciate everything you do. For me as a type one diabetic, Liberty story of her husband was eerily close to mine. I recently got my health back on track that insulin pump and started listening to your podcast a little over three months ago. Although I don't have nearly as many health issues as he did before he passed away. The mental health issues almost losing my family and some of the medical issues are identical to my story. This episode hit me like a blow to my head of what could have happened to me. And then as I'm reading this right there in bed this morning that made me cry. Like I was I like emotional. I know you must get tired of doing this sometimes. But I just thought I'd let you know that what you do helps me every single day and hearing that episode today gave me more motivation to continue on my path. Thank you again for everything you do. It's much appreciated that made me cry this morning. Before I would have gotten like as like, it would have felt like I don't know what I'm assuming cocaine feels like. Like, you know, like I would have been like, Yes, I did it. I said a thing. It helped the sky. I would have been excited by it. Now I'm just touched by it. I was using the numbers to get my Joel. And anyway, Tim Cook.

Radwa 1:15:02
I hope this year is much, much, much better for you.

Scott Benner 1:15:05
I also want to point out that I did 5.6 million downloads list. So it's not like it was. I feel I feel stupid. I'm not complaining. But, uh, you know, I feel that that's just how I feel like so I got on and that episode and I started talking about it. I wanted to do this episode at the end, it was like, we did 5.6 million downloads this year, and everything was great. And I just I felt solid, and it's how it came out. So I feel bad, because everybody's reaching out to me to tell me, it's okay now, but you're very nice. Thank you.

Radwa 1:15:37
This year is gonna be a lot better. Oh, my God,

Scott Benner 1:15:40
if Tim Cook gets out of my way, is damn Apple app. You know, I mean, what are you doing? Cut me a break China trying to reach people. And by the way, this serious like taking the numbers out of it for a second. The real problem is that I need people to hear those back catalogue episodes so that they're helped. So they have a success, like this person who wrote to me did, and that they see a benefit for their health. And then they tell somebody else about the podcast. If you never get helped, then you won't have the success. If you don't have the success you won't pass it on. And word of mouth. Word of mouth is how this works.

Radwa 1:16:17
A year and a half ago, this is how I came across the diabetes pro tip episode. Like I had tons of episodes in front of me and I didn't know where to start. And then when this popped up, I listened to it. I'm like, oh, there's a diabetes pro tip. So I kept looking for them and listening to them. Like, you really helped.

Scott Benner 1:16:33
Oh, I'm glad that series is. I mean, I know it's out of my head and Jenny's head. But I it's one of the things I'm more proud of like I know you listen to that series, you can get an A one seeing the low success. No problem.

Radwa 1:16:46
It's really good. And it's to the point. So ya

Scott Benner 1:16:51
know, it's just conversational enough, but it's technical enough. It strikes strikes a good balance. It really does. Exactly. I appreciate I'm glad it helped you. And thank you for telling me. Thank you. Yeah, if you would have wrote it to me, I would have cried in my bed. Just so you know. Well, I can at idiot. Anyway, hold on for me for one second. This was terrific. Thank you. Thank you.

Hey, don't forget to check out touched by type one.org. Go to their programs tab and find out about that huge upcoming event. It's an in person event in Orlando, Florida. It's absolutely free for you and anyone else you know who would like to attend touched by type one.org. And if you can't come to Orlando, still check them out on Facebook and Instagram. I want to thank the ever since CGM for sponsoring this episode of The Juicebox Podcast and invite you to go to ever sent cgm.com/juicebox. To learn more about this terrific device. You can head over now and just absorb everything that the website has to offer. And that way you'll know if ever since feels right for you ever since cgm.com/juicebox. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. If you're living with type one diabetes, the afterdark collection from the Juicebox Podcast is the only place to hear the stories that no one else talks about. From drugs to depression, self harm, trauma, addiction, and so much more. Go to juicebox podcast.com up in the menu and click on after dark. There you'll see a full list of all of the after dark episodes. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com