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

#1240 Weekly News 6/29/24

Diabetes News for 6/29/24

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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 1240 of the Juicebox Podcast

I'm back with another News episode and other type one diabetes informative little what's going on in the world 15 minute podcast episode just for you while you're listening to it, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise Always consult a physician before making any changes to your health care plan. In just a moment, Scotty is going to read you the news. 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 Hey guys, T one D exchange.org/juice box head over there. Now take the survey we're looking for type ones and the caregivers of type ones who are US residents to spend 10 minutes completing the survey to help type one diabetes research T one D exchange.org/juicebox. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes. I'm introducing a new advertiser today, hold on one second to learn more.

Your kids mean everything to you, and you do anything for them, especially if they're at risk. So when it comes to type one diabetes, screen it like you mean it because if even just one person in your family has type one, your child is up to 15 times more likely to get it. But just one blood test can help you spot it early. So don't wait. Talk to your doctor about screening. Tap now or visit screened for type one.com To get more info. This episode of The Juicebox Podcast is sponsored by screen it like you mean it.com Everybody seemed to enjoy when I read the news last week and a short episode. So I'm going to do it again this week with a twist. This week I'm going to tell you a little bit about stuff. I've heard a little bit about stuff I've read and we're going to let chat GPT tell us a little bit. Let's start with the old chatter GPT or I asked it for a brief synopsis of some of the latest type one diabetes news and it broke it down into five different areas. First area was vertex pharmaceuticals. Stem cell therapy, says that positive results had been reported from a trial where participants with type one diabetes were able to produce their own insulin following treatment derived from stem cells. And then I said to chat GPT break that down for me with some easy bullet points and it did positive trial results. Vertex pharmaceuticals reported successful outcomes from a stem cell trial for type one, participants in the trial were able to produce significant participants in the trial were able to produce sufficient insulin on their own after receiving the stem cell therapy says that the therapy mechanism is that the treatment involves using stem cells to regenerate insulin producing cells in the pancreas. This therapy offers significant hope for more effective and long term treatments for type one impact on patients. It says the ability to produce insulin independently blah, blah, blah research significance. Yeah, but was this a human trial? Or mice? Let's see if it knows it's looking on the interweb boopity boopity boopity Boop it's looking at clinical trials sense.com. Let's see here the key points recent advancements, I guess of action, safety and tolerability, clinical trial details global expansion. The stem cell therapy VX 880 is currently undergoing a phase one slash to clinical in trial on human so that's cool. Participants in the trial have shown significant improvement with some achieving insulin independence. For example, one patient achieved insulin independence at day 270 With an HPA once they have 5.2 v x eight ad involves the infusion of stem cell derived fully differentiated isolated cells into the hepatic paddock excuse me, portal vein. These cells are designed to restore pancreatic isolate cell function enable glucose responsive insulin production is very cool. You got to ask yourself though, couldn't your autoimmune issue just go get those cells too but sure we're getting to that. They say the therapy has been well tolerated with most adverse events being mild to moderate no serious adverse events related to the treatment have been reported. Clinical Trial details. The trial is multi centered, single arm and open label designed to evaluate the safety and efficacy of VX 880. It includes multiple parts with approximately 17 patients expected to be in one rolled. All right. That's pretty cool. Thank you chat GPT Overlord, that was lovely. Let's go to the next thing it told us about. The FDA has approved land teacher the first donor cell therapy specifically for type one diabetes patients with severe and reoccurring low blood sugar. Clinical trials showed that many participants lived without external insulin for up to five years post therapy that's led tindora has an FDA approval. Let's find out more about that, shall we? I'll say to the Overlord, tell me more about the Latendresse approval. From the very beginning, your kids mean everything to you. That means you do anything for them, especially if they're at risk. So when it comes to type one diabetes, screen it like you mean it because even if just one person in the family has it, your child is up to 15 times more likely to get it to screen it like you mean it. Because type one diabetes can develop at any age. And once you get results, you can get prepared for your child's future. So screen it like you mean it type one starts long before there are symptoms, but one blood test could help you to spot it early, before they need insulin, and could lower the risk of serious complications like diabetic ketoacidosis or DKA. Talk to your doctor about how to screen for type one diabetes, because the more you know, the more you can do. So don't wait. Tap now or visit screened for type one.com. To learn more. Again, that screen for type one.com screen it like you mean it give me some bullet points. Boop boop, boop, boop doesn't make that noise. It's actually very high tech. It's already typing here. Here's some key points about the FDA approval. The tindora is the first ever approved cell therapy for type one diabetes patients with severe and reoccurring but while we already read that, it involves the infusion of ice blood cells from deceased donors into the patient's liver, enabling the production of insulin with the body. In trials 21 of 30 participants did not need insulin for at least one year after receiving the therapy. 11 participants remained insulin dependent independent excuse me for one to five years and 10 participants. For more than five years, five participants required external insulin after the therapy and did not achieve insulin independence. There were serious adverse events including two deaths during the trial, one from multi organ failure and sepsis and another from progressive confusion and global atrophy. These events were associated with unnecessary Amin Oh, immunosuppressant therapy that goes with it. So they're given you the cells but you gotta get the your immune system suppressed. Ah, okay. This is this, this treatment is aimed at patients with a type one diabetes experiencing recurrent severe hyperglycemia and those with hypoglycemia unawareness, making it a crucial option for those who cannot maintain stable glucose levels through current methods into the liver. Okay, so All right, well, this is I mean, it's interesting stuff you don't I mean, it's just I don't think it's ready to be on your Walgreens counter just yet. How about this CRISPR therapeutics and vitae site have received Health Canada approval to begin trials for VCT x 210 and CRISPR edited stem cell therapy aiming to replace insulin production beta cells without the need for immune Oh, suppression. Hold up a second. Let's let let's let him tell me more in bullet points, because Scotty doesn't wanna have to break down a paragraph. Therapy overview VC T X 210 is a CRISPR edited system stem cell therapy designed to replace insulin producing beta cells and patients with type one. The therapy uses CRISPR cast nine gene editing technology to modify stem cells making them capable of evading the immune system and eliminating the need for immuno suppression. Now we're talking Health Canada let's see the clinical trial application has been approved by Health Canada making it the first gene edited therapy for diabetes to approach clinical trials. Hey, Health Canada. Lovely. The mechanism of therapy V CT X to 10 involves editing donor derived stem cells to create insulin producing beta cells that are implement implanted, excuse me into the patient. These cells are engineered to avoid immune detection and destruction. I would like to maybe do that with some other cells too. About the ones can I could we fix people's thyroid? Could we who wait a minute, there's a lot here isn't there? The phase one trial will evaluate the safety tolerability and immune evasion of VCT x 210 and type one patients oh god bless you. I hope this goes well. therapy is a joint effort between CRISPR therapeutics and vitae site via site. Hey, if anybody wants to come on and talk about this, I'd love to hear more about this from one of these entities and I will reach out and see what I can figure out. Hey, this chat GPT tells us what's going on segment is pretty freakin great. And inhaled insulin study the new data presented at the ADL at fourth Scientific Sessions indicates that inhaled insulin are present safe and effective for improving glycemic control and HPA once the levels and type one patients. I'm actually going to have an episode about this with Dr. Blevins coming up in a couple of weeks. You know Dr. Blevins from the GLP episodes, and he's going to be talking to us about Frezza and something else. I don't want to give it everything away right now but stuff is coming. All right. Well, there's

there's the chat GVT effort. diatribe came back with a little little recap of stuff. They heard about pumps. They talked about tide pool being at Ada with their new twist AI D system, which of course is tide pool loop and this new twist pump. That Dexcom stello will be available in August. This is already something we've talked about on the podcast before Dexcom stello. Of course, the CGM is designed to be worn on the back of the arm. Though people with diabetes tend to get creative with placement says the author for up to 15 days and the readings are displayed directly using a smartphone app spokesperson said pricing will be announced closer to the launch date. This is like no. This is for type twos that don't use insulin. You won't need a prescription for this. This will be a walk in and buy thing. By the way. This article was written by Paul Helsel for diatribe. Paul, thank you very much for letting us read your article. What else does Paul say? There's some study results from tandem Medtronic and insolate. At the ADA conference tandem highlighted at small mobi pumps. Citing a recent study conducted by the Barbara Davis Center for diabetes the University of Colorado, which showed time and range improved without an increase in time below range using control IQ. The device integrates with iPhone Babaji 67, Medtronic offered data showing that its mini med seven ADG AI D system reduces sleep interruptions and improve time and range during sleep cool. The system's ability to deliver small bonuses every five minutes company said also helped reduce the dawn phenomenon rate from 12.2% to 4.5. And slightly increased the time and range from 12 to 6am. It's insolate. Excuse me, insula which is Omni pod presented a study at Ada showing its Omnipod five system could benefit people with type two diabetes who use insulin participating participants excuse me who were previously using injections or pump therapy saw improvement, they wouldn't see reduced blood sugar spikes and hyperglycemia. The company said as well, time and range improved by 20%. And overall insulin was used by overall insulin was reduced by 23 units a day. That's really great. Thank you diatribe. Thank you, Paul. Lovely, lovely. Lovely. Like I said, I'm gonna have Dr. Blevins on to talk about a Frezza. And actually, he's gonna come on and talk about some other stuff too. Maybe we'll I don't want to give it away. Again, I look at me, I'm teasing myself. I shouldn't do that. This ain't bad. This is not bad for a little bit of news this week. Hmm. Looks like there are people out there working with stem cells, people working on automated insulin delivery systems to get them working better and to cover more people. Dexcom is going to be helping out with type two diabetes with their new product. So all in all, a good week at Ada. I got a lot of reports back from Ada, my, my people were everywhere telling me the good and the bad and sometimes the ugly. And I'll tell you what made me think maybe I'll go to ADA set up a little booth and do a little Juicebox Podcast thing at the 85th annual EDA. So Scott he's looking into that there's little news for me to you. I don't need other people running around talking about me. I can talk about myself. What else we got here, kids, anything anything else you want to know? Oh, July 2, the juicebox cruise goes on sale. Head into the private Facebook group or the public Facebook page. We are doing a cruise for Juicebox Podcast listeners. You can get all the details there that goes on sale July 2 in the Facebook group. First we want to make sure that everybody who is a Facebook group member has an opportunity to get a cabin before we go wider with the offering. So go check that out. We want to get a bunch of Juicebox Podcast listeners together family, adults, anybody who's interested in coming, be a great five day trip. We're going to make a couple of ports of call in Mexico all the details of the details will be in the post. And there'll be a private Facebook group for people who put down a deposit so you guys can meet each other and really get to know each other before the cruise embarks on June 14 and 2025 I'll add a little bit of my own news. A group of coders have split a branch of IEPs off to something called trio. It's in beta right now. Arden's running it loving the loving the branch very much. If you're a DIY looper and you've ever thought about looking into IEPs I might look at trio instead. For me to you, I think that's worth looking into. Alright, so I guess that's the end of Scott reads the internet today. I wish you were here to say no Scott s this of the chat GPT overlord. But I don't I don't have anything else. Although you know what, hold on. What's that new Canadian insulin that once weekly, we're going to be just seeing if Chechi here is what I'm talking about. We talked about a genuine Yeah, it's called a weekly. I will say again, Novo Nordisk Whoever named it genius. Aw, IQ li a weekly. Health Canada approved a weekly on March 12 2020. Ford is set to become available across Canada starting June 30th. Geez, that's like right now. 2024. Weekly is a Basal insulin designed to be administered once a week. It works through a time release mechanism gradually releasing insulin over the course of a week. Clinical trials included both type one and type two patients, but the therapy is expected to be most beneficial for those with type two diabetes. type one diabetes patients will still require additional fast acting insulin injections at mealtimes. Well, yeah, but that that might just be Chachi Beatty, not quite understanding. I mean, if it's a once weekly Basal, then that's valuable for everybody. The most common side effects included hypoglycemia, and injection site reactions with bruising, pain and swelling that's from Yahoo Finance. A weekly aims to improve glycemic control with fewer injections, potentially increasing adherence to insulin therapy and reducing the risk of diabetes related complications, etc. and so on. Hey, if somebody in Canada ends up using a weekly I'd love for you to come on and tell me about it. That'd be absolutely wonderful. But I guess that's gonna be it for now. I will. I will see you again soon. Let me know if we should keep doing this little news thing. I'm up for this. I like this a lot. But if you guys hate it, like I'm not gonna You don't I mean, send me an email.

Did you know if just one person in your family has type one diabetes, you're up to 15 times more likely to get it to screen it like you mean it. One blood test can spot type one diabetes early. Tap now, talk to a doctor or visit screened for type one.com For more info. If you're looking for community around type one diabetes, check out the Juicebox Podcast private Facebook group Juicebox Podcast type one diabetes, but everybody is welcome. Type one type two gestational loved ones. It doesn't matter to me. If you're impacted by diabetes, and you're looking for support, comfort or community check out Juicebox Podcast type one diabetes on Facebook. The diabetes variable series from the Juicebox Podcast goes over all the little things that affect your diabetes that you might not think about travel and exercise to hydration and even trampolines. juicebox podcast.com. Go up in the menu and click on diabetes variables. 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.

#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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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