Why Your Carb Ratio Stopped Working (And Why It’s Not Your Fault)

You count the carbs perfectly. You weigh the food. You punch the numbers into your pump or calculate the dose for your pen exactly as your doctor taught you. The math is perfect.

And then, 45 minutes later, you watch your Dexcom arrow shoot straight up. You hit 250 mg/dL. You stay there for two hours, frustrated and exhausted, before crashing back down.

You assume the problem is the math. You think, "My insulin-to-carb ratio must be wrong. I need more insulin."

Here is the trap: If you change your ratio, you will likely go low next time. The problem isn't the amount of insulin. It’s the timing.

The "Right Amount" at the "Wrong Time" is Still a High

Standard medical advice teaches us to "Bolus and Eat." But this advice ignores the laws of physics.

• The Reality: Standard rapid-acting insulin takes 15–20 minutes to begin working and 60–90 minutes to peak.

• The Problem: Modern processed food (even "healthy" carbs) hits your bloodstream in minutes.

If you bolus and eat immediately, the food wins the race. It spikes your blood sugar before the insulin even wakes up. By the time the insulin starts working, it’s too late—you are already chasing a high.

The Solution: The "Tug-of-War"

Imagine your blood sugar is a flag in the middle of a tug-of-war rope. On one side is Insulin (pulling down). On the other side are Carbs (pulling up).

If you let the Carbs start pulling 20 minutes before the Insulin shows up, the flag flies into the sky (a spike).

To win, you must give the insulin a "head start." This is called a Pre-Bolus. By dosing 15, 20, or even 30 minutes before you eat, you allow the insulin to start pulling down just as the food starts pulling up. The forces cancel each other out, and the flag (your blood sugar) stays in the middle.

⚠️ The Safety Check (Read Before You Bolus)

Pre-bolusing is a power tool, but you must respect the current data. Context is King.

1. Never Pre-Bolus a Low: If your blood sugar is low (e.g., under 70 mg/dL) or your arrow is trending down, do not wait. Eat immediately. The "Tug-of-War" is already lost; you need the carbs to pull up instantly.

2. The "Pizza Effect": High-fat/high-protein meals digest much slower than standard carbs. If you pre-bolus a heavy meal (like pizza or steak) by 20 minutes, you may crash before the food digests. These meals often require an extended bolus or different timing.

3. Know Your Insulin: If you use ultra-rapid insulin (like Fiasp or Lyumjev), your wait times will be much shorter.

Stop Chasing the Ghost

You don’t need to change your ratio yet. You need to change your timing. You need to understand that "Timing and Amount" are equal partners. Even the perfect amount of insulin will fail if it arrives late to the party.

Ready to stop the spikes?

You don’t have to live on a rollercoaster. We break down exactly how to time your insulin safely, how to handle high-fat foods, and how to test your Pre-Bolus timing in the Diabetes Pro Tip Series.

Start Here:

🎧 Episode 1003: Pre-Bolus (The strategy that changes everything) - Apple Device, Spotify

🎧 Episode 1002: All About Insulin (Understanding how your tool actually works) - Apple Device, Spotify

🎧 Episode 1428: Small Sips Tug of War (The visual that makes it click) - Apple Device, Spotify

Stop blaming yourself for "bad numbers." It’s just data. And now you have the data to fix it.

How Hypothyroidism Alters Life with Type 1 Diabetes

Type 1 Diabetes × Hypothyroidism: what really changes (and how to manage it)

Why these two travel together

Both T1D and autoimmune thyroid disease are common autoimmune partners. Meta-analyses and reviews consistently show higher thyroid autoimmunity and thyroid dysfunction in people with T1D than in the general population—often antibody-positive first, with a subset progressing to overt hypo- or hyperthyroidism. Routine thyroid screening is recommended in standards of care for people with T1D. American Diabetes Association+3OUP Academic+3Frontiers+3

How hypothyroidism alters glucose control (two competing effects)

1) The “more resistant” pattern (often daytime) — supported, but variable

Low thyroid hormone can increase peripheral insulin resistance, particularly in muscle and adipose tissue. Clinically this can look like higher basal needs and post-meal spikes despite familiar carbs. Several human studies and reviews—especially in subclinical hypothyroidism—report worsened insulin resistance indices. Magnitude varies, and results aren’t uniform across all populations. OUP Academic+3BMJ Open+3BioMed Central+3

2) The “more sensitive (and lower dose)” pattern (often overnight/fasted) — supported in T1D case series/reviews

In T1D, untreated hypothyroidism can also reduce insulin clearance and slow gastric emptying, raising the risk of unpredictable hypoglycemia and lower insulin requirements (sometimes markedly) until euthyroid. This is described in ADA-family journals and case series; in practice it shows up as frequent lows and a need to step basal/bolus down while thyroid therapy is optimized. Diabetes Journals

What this means in the real world: some people with T1D + hypothyroidism see higher doses and more spikes; others see lower doses and more lows; many cycle between both as meals, activity, and gastric timing change. Expect pattern volatility until thyroid levels stabilize. (Mechanistic synthesis from sources above.)

Day-to-day signals that your thyroid may be off

• Your settings stop making sense: post-meal spikes despite careful counting or a run of unexplained lows—especially with fatigue, cold intolerance, dry skin/hair, or weight change.

• Basal “creep” or sudden drop: rising basals over weeks or the opposite—needing 10–30% less insulin with more lows, particularly overnight. Diabetes Journals

• Carpal tunnel/neuropathy, cramps, stiffness grow as glucose variability worsens. (Common with hypothyroid; can complicate device use and manual dexterity.) Diabetes Journals

Screening & monitoring (what guidelines say)

• Screen at diagnosis and repeat periodically: ADA Standards call out the increased autoimmune burden in T1D and endorse ongoing screening for thyroid disease (TSH ± free T4; antibodies when indicated). Pediatric and primary-care abridged resources and update decks explicitly note initial and repeat thyroid screening at regular intervals for T1D. Frequency is individualized (e.g., annually or if symptomatic/antibodies positive/pregnancy planning). Diabetes Journals+2Diabetes Journals+2

• Kids/teens with T1D: pediatric standards and ISPAD materials reinforce periodic thyroid checks given higher autoimmune clustering in youth. ISPAD+1

Suspected (needs more precision): exact “best” interval (e.g., every 1 vs 2 years) isn’t identical across guidelines and often depends on antibodies, symptoms, and prior results. (Guideline synthesis.) Diabetes Journals

Adjusting insulin and tech while hypothyroid is treated

1. Expect a moving target for 6–8 weeks after any levothyroxine change—the time it takes for TSH to re-equilibrate. Re-review basals, ISF, and I:C after each thyroid dose change or major lab shift. Diabetes Journals

2. If lows predominate (esp. fasting/overnight), first cut basal 10–20% and watch CGM overnight trends; consider more conservative correction factors until euthyroid. Diabetes Journals

3. If spikes dominate (esp. post-meal), review I:C and pre-bolus timing; consider modest basal increases only if nocturnal/fasting is also drifting up. (Balances the resistance vs clearance effects described above.) BMJ Open

4. Closed-loop/automation: expect algorithm “thrash” (over-correction, then suspends). Tighter alerts and shorter insulin-on-board assumptions can help during thyroid dose titration. (Practice inference based on mechanisms above.)

Suspected: we don’t have RCT-level data tying specific percentage changes in pump settings to degrees of hypothyroidism—the adjustments above are principle-driven and should be individualized. OUP Academic

Lipids, heart, kidneys: double-checking the “silent risks” in T1D

• Hypothyroidism worsens LDL/TG and can add bradycardia/low output—stacking CV risk on top of T1D. Treating the thyroid state typically improves lipids; re-check the lipid panel after euthyroid is achieved before escalating statin therapy. Diabetes Journals

• Overt hypothyroidism can lower eGFR and raise creatinine; kidney measures often improve after thyroid replacement—helpful context when interpreting microalbumin trends in T1D.

Suspected: CV event reduction with treating subclinical hypothyroidism is debated and likely age/TSH-dependent. Paloma Health

Pregnancy planning with T1D: thyroid gets a front-row seat

Untreated or undertreated maternal hypothyroidism increases risks (miscarriage, pre-eclampsia, low birth weight, neurodevelopmental effects). In T1D—where pregnancy is already high-touch—dose adjustments and tighter thyroid targets are standard; check early and often, including pre-conception. OUP Academic

Suspected: universal treatment thresholds for subclinical hypothyroidism in pregnancy still vary by guideline (TSH cutoffs, antibody status). Discuss individualized targets. Paloma Health

Quick checklist for people with T1D

• Ask for labs when your settings go sideways: TSH + free T4 (and TPO antibodies if not known). Diabetes Journals

• Stay consistent with levothyroxine (empty stomach, same time daily; separate from iron/calcium/PPIs). Re-test 6–8 weeks after any change. Diabetes Journals

• Expect insulin changes during thyroid titration—log basal/bolus moves and CGM patterns; adjust gradually. Diabetes Journals

• Re-check lipids and kidney labs once euthyroid before making big therapy jumps. Diabetes Journals

• If pregnant/trying: loop in endocrine + OB early; monitor thyroid more frequently than usual. OUP Academic

Bottom line for T1D

Hypothyroidism changes the rules of insulin math through two opposite forces—a tendency toward peripheral resistance and a tendency toward lower insulin clearance and delayed gastric emptying. Which one dominates differs by person and even time-of-day. Screen regularly, treat to euthyroid, and expect to adjust insulin settings more than once on the way there. Once the thyroid is steady, your CGM and pump behave more predictably again. BMJ Open+1

Read more about the type 1 diabetes impacts.

🎧 Hear an Endocrinologist Break It Down

If you want to hear this topic straight from a specialist who lives it every day, listen to Episode 413 of the Juicebox Podcast featuring Dr. Adi Benito, an endocrinologist who explains how thyroid disorders and Type 1 diabetes constantly influence each other.

In this conversation, Dr. Benito and Scott unpack:

• Why thyroid problems are so common in people with Type 1 diabetes

• How low thyroid levels quietly distort insulin sensitivity, digestion, and weight

• What “normal” thyroid labs can miss — and when to push for deeper testing

• How treating hypothyroidism can smooth out blood-sugar swings and energy levels

It’s a practical, myth-busting talk that connects the science to real-world management — exactly the kind of clarity you wish every endo visit had.

👉 Listen to Juicebox Podcast Episode 413 — Dr. Adi Benito on Thyroid and Type 1 Diabetes

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🔬 Understanding Your Thyroid Test Results — The Real-World Breakdown

1. “Normal” vs. “Optimal”

• Reference range for TSH: ~0.45 – 4.5 mIU/L

• Optimal range for most people: ~0.5 – 2.5 mIU/L
  A “normal” result doesn’t always mean your thyroid is working optimally for you. Many people still experience fatigue, weight gain, brain fog, or glucose swings even when their numbers look fine.

2. Why “In-Range” Doesn’t Always Mean Healthy

TSH is a pituitary signal, not a direct measure of thyroid hormone activity in your cells. You can have “normal” TSH and still feel hypothyroid because of issues downstream—like how your body converts, absorbs, or uses those hormones.

You can have normal labs and still struggle with:

• Poor conversion of T4 → T3 (the active hormone)

• Iron, selenium, or B12 deficiency affecting hormone use

• Autoimmune gastritis or celiac disease blocking absorption

• Early Hashimoto’s, where antibodies are active but the gland isn’t fully failing yet

3. When to Treat

Treatment decisions aren’t just about numbers—they’re about patterns, context, and how you actually feel.

Guideline-based starting points:

• TSH > 6–7 mIU/L (especially under age 65): raises cardiovascular and stroke risk → treat.

• TSH > 2.5 mIU/L in women trying to conceive or pregnant → treat.

• Goiter + positive antibodies → treat, even if TSH is still “normal.”

Symptom-driven care:

• If symptoms of hypothyroidism persist—fatigue, brain fog, cold intolerance, slow recovery from lows, brittle hair, joint pain—you still deserve investigation.

• In select cases, clinicians may trial low-dose therapy or adjust medication based on symptoms, even with “borderline” or “normal” labs, after ruling out other causes.

• The goal: treat the person, not the paper. Labs confirm the story; they shouldn’t silence it.

4. Beyond TSH: Tests That Tell the Full Story

Ask for a more complete panel when something feels off:

• Free T4 and Free T3 — show active hormone levels

• Thyroid peroxidase (TPO) and thyroglobulin antibodies (TgAb) — detect Hashimoto’s

• Ferritin and vitamin B12 — deficiencies mimic hypothyroid fatigue

• Vitamin D — supports immune and thyroid function

• Reverse T3 (if symptoms persist) — shows blocked hormone conversion

5. Symptoms That Should Prompt a Re-Check

• Fatigue, sluggishness, or mental fog

• Feeling cold easily

• Weight changes without reason

• Joint or muscle pain

• Hair loss, dry skin, or brittle nails

• Constipation

• Irregular or heavy periods

• Repeated low blood sugars or insulin resistance swings

• In kids: slowed growth or delayed puberty

6. Frequency of Monitoring

• Every 6–12 months if stable

• Every 6–8 weeks after a dose change or when symptoms return

• More often if pregnant, switching meds, or changing insulin regimens (for people with T1D)

7. Medication Realities

• Consistency is everything: stay with the same brand/manufacturer—shape and color matter.

• Take on an empty stomach, 30–60 minutes before breakfast; avoid coffee, calcium, iron, and magnesium nearby.

• Missed dose? Take two the next day — levothyroxine is long-acting.

• Birth-control pills can bind thyroid hormone → recheck labs after 4–6 weeks.

• Tirosint (liquid capsule) helps if you have celiac, gastritis, or take acid reducers.

8. Evidence-Based Supplement Support

• Selenium (80 µg daily) — lowers antibodies, supports gland health

• Myo-inositol + selenium — improves TSH balance and well-being

• Vitamin D — modulates immune activity

• Nigella sativa (black cumin seed) — can help normalize TSH and weight

• Ashwagandha — sometimes supports mild hypothyroid symptoms

• Iron (+ vitamin C) — low ferritin (< 50 µg/L) worsens fatigue

⚠️ Avoid “thyroid support” blends or excess iodine — they can backfire on autoimmune thyroid disease.

9. T3 Add-On Therapy

For some people who stay symptomatic even with normal labs on T4:

• Adding T3 (liothyronine) can help if the body struggles to convert T4 → T3.

• Not for use in pregnancy or in those with heart rhythm disorders.

• Should be a carefully supervised trial, never a DIY experiment.

10. Consequences of Ignoring It

Untreated or undertreated hypothyroidism can lead to:

• Elevated cholesterol and cardiovascular disease

• Fatty liver and metabolic slowdown

• Insulin resistance or poor glucose control

• Infertility, miscarriage risk, and irregular cycles

• Depression, brain fog, low libido

• Hair thinning, brittle nails, and skin changes

• Cognitive decline and memory problems over time

💡 Bottom Line

“Normal” numbers can still hide a sluggish thyroid. The best clinicians look at the whole person—symptoms, labs, and response to treatment—to find balance. Don’t settle for being told “you’re fine” when your body says otherwise. The goal isn’t just to normalize TSH—it’s to feel well, think clearly, and live fully.

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Always consult your healthcare provider before making medical decisions. Read the full disclaimer.

Untreated (or Undertreated) Hypothyroidism: The Full Picture

Why this matters

Thyroid hormone sets the body’s idle speed. When it’s too low, multiple systems slow: metabolism, heart and vessels, nerves, muscles and tendons, mood and cognition, fertility and pregnancy physiology. Most complications are preventable or reversible with correct diagnosis and consistent treatment. Cleveland Clinic

Metabolism, Weight, Skin & Gut

Supported

• Slowed metabolic rate → fatigue and weight gain; cold intolerance; dry skin/hair; constipation from reduced gut motility. Cleveland Clinic

Suspected / needs more evidence

• Specific thresholds of thyroid deficiency that predict which patients will gain weight vs. stay stable are not firmly established. (Individual variability is high.) (Inference from broad clinical sources.)

Cardiovascular & Lipids

Supported

• Atherogenic dyslipidemia (↑ LDL and triglycerides) and higher cardiovascular risk with overt hypothyroidism; risk improves with appropriate therapy. JAMA Network+2Frontiers+2

• Potential for bradycardia, reduced cardiac output; with long-standing severe disease, heart failure can occur. JAMA Network

Suspected / needs more evidence

• In subclinical hypothyroidism, the benefit of routine treatment to prevent hard CV outcomes remains debated; data are mixed and age-dependent. Frontiers+1

Neurologic, Cognitive & Mood

Supported

• Cognitive slowing/“brain fog” and depressed mood commonly accompany untreated disease and tend to improve when euthyroid. (General endocrine reviews.) Clinical Knowledge Summaries

• Peripheral neuropathy can occur in chronic disease; carpal tunnel appears more often in people with hypothyroidism. Cleveland Clinic+1

Suspected / needs more evidence

• Direct causation of dementia by hypothyroidism in older adults remains uncertain; association ≠ causation. (Mixed epidemiology.) (Inference from guideline tone.) Clinical Knowledge Summaries

Muscles, Tendons & Joints

Supported

• Hypothyroid myopathy: proximal muscle weakness, cramps, delayed relaxation; CK may be elevated and normalizes with treatment. Rarely rhabdomyolysis. Cleveland Clinic

• Entrapment neuropathies—especially carpal tunnel syndrome—are more frequent. Cleveland Clinic

• Joint stiffness and non-inflammatory effusions can occur. (Guideline/background reviews.) Clinical Knowledge Summaries

Suspected / needs more evidence

• A higher rate of frozen shoulder and generalized tendinopathy in hypothyroidism is frequently reported clinically, but high-quality causality data are limited; associations are plausible via matrix/glycosaminoglycan changes. (Mechanistic inference + mixed clinical studies.)

If You Live With Type 1 Diabetes (T1D)

Supported

• Autoimmune thyroid disease is the most common autoimmune comorbidity in T1D, occurring in roughly 17–30% (often antibody-positive first; a smaller fraction develop clinical hypothyroidism). Annual TSH screening is recommended. Diabetes Journals+2Diabetes Journals+2

• Untreated hypothyroidism can worsen insulin resistance and glycemic variability in diabetes. JAMA Network+1

Suspected / needs more evidence

• The exact magnitude by which hypothyroidism changes bolus ratios/basal needs in T1D varies and is not pinned to uniform dose multipliers in the literature—clinically observed, but individualized. (Mechanistic plausibility + clinical experience.)

When Type 1 Meets Thyroid: The Hidden Tug-of-War

For people living with Type 1 diabetes, thyroid health isn’t just a side note—it’s a key part of blood-sugar control. This in-depth (but plain-spoken) guide unpacks how low thyroid hormone levels can throw off insulin sensitivity, meal timing, and pump settings, why patterns get erratic, and what to do about it.

You’ll learn:

• Why thyroid disease is so common alongside Type 1

• How hypothyroidism can make you both more resistant and more sensitive to insulin

• What lab work and dose changes to ask for

• Practical steps to keep your tech, dosing, and thyroid meds working together

Read the full deep dive → How Hypothyroidism Alters Life with Type 1 Diabetes

Hematologic, Renal & Fluids

Supported

• Anemia occurs more often in hypothyroid states. (Guideline background.) Clinical Knowledge Summaries

• Severe disease can reduce glomerular filtration and contribute to fluid retention; function improves with treatment. (Reviews.) Europe PMC

Suspected / needs more evidence

• The exact prevalence and reversibility of mild kidney impairment in subclinical disease are not well defined. Europe PMC

Fertility, Pregnancy & Child Development

Supported

• Untreated/undertreated maternal hypothyroidism is linked to miscarriage, pre-eclampsia, anemia, placental issues, postpartum hemorrhage, congestive heart failure (rare), and low birth weight; timely treatment mitigates risk. The American Thyroid Association+2The American Thyroid Association+2

• Thyroid hormone requirements increase early in pregnancy; many patients need dose adjustments and close TSH/free T4 monitoring. The American Thyroid Association

Suspected / needs more evidence

• Universal treatment of subclinical hypothyroidism in pregnancy improves all meaningful outcomes—guidelines recommend treatment in many scenarios, but some outcome data are still evolving. The American Thyroid Association+1

Thyroid Gland & Endocrine Context

Supported

• Goiter may develop from chronic TSH stimulation in untreated disease. (Guideline background.) Clinical Knowledge Summaries

• Autoimmune hypothyroidism (Hashimoto’s) is the most common cause in iodine-replete settings. Cleveland Clinic

Suspected / needs more evidence

• The pace at which antibody-positive individuals progress to overt hypothyroidism varies widely and is hard to predict at the individual level. (Long-term natural-history uncertainty.)

What to do (accurate, guideline-consistent)

• Test and (re)test appropriately: TSH and free T4 for diagnosis; in T1D, screen yearly or with new symptoms. Adjust dose and re-check labs ~6–8 weeks after any change. Clinical Knowledge Summaries+1

• Treat consistently: Levothyroxine on an empty stomach, same time daily; separate from iron, calcium, and PPIs by several hours. Aim for euthyroid targets individualized to age, pregnancy status, and comorbidities. Clinical Knowledge Summaries

• Escalate promptly in pregnancy: Increase monitoring and dosing early; coordinate endocrine–OB care. Clinical Knowledge Su

Downstream Issues: What Happens When Hypothyroidism Lingers Too Long

When thyroid hormones stay low for months or years, the effects move from symptoms to multisystem complications. Many are reversible with proper treatment; some become entrenched if delays are long.

🫀 Cardiovascular Consequences

Supported

• Overt hypothyroidism drives atherogenic dyslipidemia (↑LDL, ↑triglycerides) and contributes to atherosclerosis/heart disease; lipid abnormalities generally improve with levothyroxine. BioMed Central

• Can cause bradycardia and reduced cardiac output; severe, prolonged cases may develop heart failure. JAMA Network

• Pericardial effusion is a recognized complication, occasionally progressing to tamponade; typically improves after thyroid replacement. Heart+1

Suspected (needs qualification)

• In subclinical hypothyroidism, excess CV event risk and benefit of treatment remain debated and appear to vary by age, baseline risk, and TSH level. OUP Academic+1

🧠 Neurologic & Cognitive

Supported

• Cognitive slowing, memory complaints, and depressed mood are common in untreated hypothyroidism and often improve with euthyroidism. JAMA Network

• Peripheral neuropathy and carpal tunnel syndrome (CTS) occur more often in hypothyroid patients; proposed mechanisms include mucopolysaccharide deposition and nerve entrapment. MDPI

Suspected

• Association with dementia in older adults is reported but causality and effect size remain uncertain across studies. ScienceDirect+1

🦴 Musculoskeletal

Supported

• Hypothyroid myopathy: proximal weakness, cramps, delayed relaxation; CK elevation is common and typically falls with treatment. Rhabdomyolysis is rare but documented in severe/compounded cases (e.g., with statins). JAMA Network+1

• Non-inflammatory joint effusions (highly viscous) can occur, especially in knees/wrists/hands. ScienceDirect

• CTS risk is increased in hypothyroidism. MDPI

Suspected

• Higher rates of frozen shoulder and broader tendinopathy are reported; newer Mendelian-randomization and clinical outcome data suggest association, but causality and magnitude remain under study. BioMed Central+1

• Direct bone fragility/osteoporosis from hypothyroidism isn’t strongly supported; alterations in bone turnover are described, whereas osteoporosis is classically linked to hyperthyroidism. (Synthesis of reviews.) JAMA Network

🩸 Hematologic, Renal & Electrolytes

Supported

• Anemia (often normocytic or macrocytic) is more prevalent with low thyroid function. OUP Academic

• Renal effects: overt hypothyroidism can reduce GFR and raise creatinine; kidney function often improves after levothyroxine. SpringerLink

Suspected

• Hyponatremia is described, but robust data suggest it’s uncommon and mainly a feature of severehypothyroidism/myxedema; in milder disease, look hard for other causes. OUP Academic+2BioMed Central+2

• The prevalence and reversibility of subtle kidney changes in subclinical hypothyroidism are not well defined. BioMed Central

👶 Fertility, Pregnancy & Child Development

Supported

• Untreated maternal hypothyroidism increases risks such as miscarriage, pre-eclampsia, low birth weight and adverse neurodevelopmental outcomes; dose adjustment and close monitoring early in pregnancy are standard of care (ATA 2017). Liebert Online+2JAMA Network+2

Suspected

• Universal treatment of subclinical hypothyroidism in pregnancy is still debated; recommendations depend on TSH level, antibodies, and local guidelines. JAMA Network

🧬 Autoimmune & Endocrine Overlap (incl. Type 1 Diabetes)

Supported

• Autoimmune thyroid disease is the most frequent autoimmune comorbidity in type 1 diabetes; hypothyroidism can worsen insulin resistance and glycemic variability. JAMA Network

Suspected

• The quantitative impact of correcting hypothyroidism on long-term glycemic outcomes (e.g., A1C trajectories) in T1D is plausible but not precisely defined across populations. JAMA Network

☠️ Rare but Severe: Myxedema (Decompensated Hypothyroidism)

Supported

• A life-threatening state of severe, untreated/undertreated hypothyroidism with high mortality; presents with hypothermia, bradycardia, altered mental status, and multisystem failure—emergency treatment required. Reported mortality ranges widely. Endotext+2UpToDate+2

🎧 Hear an Endocrinologist Break It Down

If you want to hear this topic straight from a specialist who lives it every day, listen to Episode 413 of the Juicebox Podcast featuring Dr. Adi Benito, an endocrinologist who explains how thyroid disorders and Type 1 diabetes constantly influence each other.

In this conversation, Dr. Benito and Scott unpack:

• Why thyroid problems are so common in people with Type 1 diabetes

• How low thyroid levels quietly distort insulin sensitivity, digestion, and weight

• What “normal” thyroid labs can miss — and when to push for deeper testing

• How treating hypothyroidism can smooth out blood-sugar swings and energy levels

It’s a practical, myth-busting talk that connects the science to real-world management — exactly the kind of clarity you wish every endo visit had.

👉 Listen to Juicebox Podcast Episode 413 — Dr. Adi Benito on Thyroid and Type 1 Diabetes

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Always consult your healthcare provider before making medical decisions. Read the full disclaimer.

“Type 2” That Wasn’t: Catching LADA Before It Catches You

Curtis drove a brown delivery truck through the Texas heat. He worked long days, ate clean, and still watched his glucose climb. Metformin didn’t fix it. Ozempic didn’t move the scale. Mornings ran high; days off ran higher. Something wasn’t adding up.

When Type 2 Doesn’t Behave Like Type 2

LADA—latent autoimmune diabetes in adults—is an adult-onset autoimmune diabetes that can masquerade as type 2 early on. It’s defined by islet autoantibodies with a slower progression to insulin dependence than classic type 1 and may account for ~2–12% of adult-onset diabetes. researchportal.helsinki.fi

The Red Flags

If your story sounds like Curtis’s, watch for these patterns that often prompt testing for autoimmune diabetes in adults:

• You’re active and eating intentionally, but glucose still trends up.

• Morning highs (“dawn phenomenon”) that don’t budge with lifestyle tweaks.

• Therapies that usually help in type 2 underperform or stall.

• A GLP-1 may help parts of the picture, but you ultimately feel better on insulin.

(Clinically, the ADA’s Standards of Care recommend considering autoimmune testing in adults when the presentation suggests type 1 diabetes rather than straightforward type 2.) Diabetes Journals

The Tests That Tell the Truth

Ask for two things—both are standard in the literature and consensus guidance:

1. Autoantibodies: GAD65, IA-2, and ZnT8 (± IAA). Positive results indicate autoimmune diabetes (including LADA) rather than type 2. researchportal.helsinki.fi

2. C-peptide WITH a simultaneous glucose value. C-peptide reflects your own insulin secretion, but the number only makes sense in the context of current glycemia; many guidelines recommend measuring it alongside glucose (often after a carb-containing meal or stimulus). DiabetesontheNet

Treatment Nuance: Why Getting the Label Right Matters

Once antibodies confirmed Curtis had LADA, insulin made sense—and he felt human again. Early, appropriate insulincan improve control and symptoms in LADA; however, preserving β-cell function with early insulin is not proven. In the randomized BALAD study, bedtime insulin did not preserve C-peptide better than sitagliptin over ~21 months. (Practical implication: choose therapy for metabolic control and safety; don’t count on insulin alone to “save” C-peptide.) Frontiers

Expert summaries for primary care echo this nuance: insulin is effective and safe; avoid sulfonylureas (they may accelerate β-cell loss), and tailor therapy to phenotype and C-peptide. AAFP+1

Hear Curtis tell how he pushed for the right labs—and what changed next in episode 1667 →

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🧾 LADA Self-Advocacy Checklist (Print/Bring to Your Visit)

• ✅ Ask: “Could this be LADA (adult-onset autoimmune diabetes)?”

• ✅ Order antibodies: GAD65, IA-2, ZnT8 (± IAA) to assess autoimmunity. researchportal.helsinki.fi

• ✅ Order C-peptide with glucose (fasting or stimulated) so results are interpretable. DiabetesontheNet

• ✅ Bring data: CGM or meter downloads, highlighting morning highs and days-off patterns.

• ✅ Document history: weight/activity trends; what helped vs. didn’t.

• ✅ Ask for an endocrinology referral if results are equivocal or treatment is stalling.

• ✅ Discuss therapy goals: practical glucose control now; understand that β-cell “preservation” evidence in LADA is mixed, and avoid sulfonylureas. AAFP

• ✅ Follow the science, not the label: If you feel better on insulin (or your data say so), that’s valid even if you were first told “type 2.” (ADA supports antibody testing when adult presentation suggests autoimmune disease.) Diabetes Journals

Bottom line: If your “type 2” doesn’t act like type 2, test for autoimmunity and interpret C-peptide correctly. Getting the diagnosis right is what unlocked Curtis’s progress—and it can unlock yours, too.

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What Is Type 1 Diabetes? Understanding the Condition, One Small Step at a Time

What Is Type 1 Diabetes?

Finding out that you — or your child — has type 1 diabetes (T1D) can feel like the ground drops out from under you. Suddenly, there’s talk of insulin, carb ratios, blood sugar numbers, and alarms you didn’t even know existed yesterday. It’s overwhelming, and that’s okay.

Let’s take a deep breath and start where it all begins: understanding what type 1 diabetes actually is — and how you can live well with it.

What Type 1 Diabetes Really Means

Type 1 diabetes is an autoimmune condition — meaning your immune system mistakenly attacks the beta cells in your pancreas that make insulin.

Insulin is the hormone that helps move glucose (sugar) from your blood into your cells, where it’s used for energy. Without insulin, sugar builds up in your bloodstream. That’s why people with T1D must take insulin through injections or an insulin pump to live — it replaces what the body no longer makes.

It’s important to know: nothing you did caused this.

Type 1 diabetes isn’t about eating too much sugar or not exercising enough. It’s about your immune system misfiring. It can happen to anyone — at any age — and it’s no one’s fault.

The First Days: Start with Bold Beginnings

Those first weeks after diagnosis are emotional, confusing, and full of information you’re expected to master overnight. That’s exactly why the Bold Beginnings series exists — to help you take your first confident steps.

In Bold Beginnings, you’ll hear real conversations about:

• What insulin really does and how to use it safely

• The truth about “highs” and “lows”

• How to dose for carbs without fear

• Why small wins matter more than perfection

You’ll learn how other families and adults have navigated those same early, sleepless nights and slowly built a sense of normalcy again. It’s a series designed to replace panic with perspective.

Living the Day-to-Day: Small Sips Make Big Change

Once you’re past the initial shock, you’ll start to realize something: type 1 diabetes doesn’t have a finish line. It’s a rhythm. It’s trial, error, and adjustment.

That’s the heart of the Small Sips series — because lasting progress doesn’t happen all at once. It happens in small, steady improvements that add up over time.

In these episodes, you’ll learn things like:

• How to time your pre-bolus for smoother numbers

• What to look for in CGM patterns (and when to ignore the noise)

• How food, activity, hormones, and stress all shift your needs

• The small habits that make big differences

When you focus on just one “sip” at a time — one idea, one pattern, one tweak — diabetes becomes a puzzle you can actually solve.

Taking Control: Pro Tips for the Next Level

After you’ve found your footing, you’ll start craving more understanding — not just what to do, but why. That’s when the Pro Tip series becomes your secret weapon.

These episodes dive into the advanced strategies that make blood sugars more predictable and less stressful, including:

• How to calculate your insulin-to-carb ratio more accurately

• What fat and protein really do to your blood sugar

• When to adjust basal rates or correction factors

• How to think ahead for exercise, hormones, and illness

Pro Tips are the kind of lessons most people learn the hard way — years in — but you can start mastering them now.

The Juicebox Podcast is the world’s most-listened-to type 1 diabetes podcast — trusted by hundreds of thousands of people living with T1D and the caregivers who love them. Every episode is free and built around real conversations that make diabetes management feel understandable and doable. Listen on your Apple devices, Spotify or your favorite audio app.

The show’s companion Facebook community is also completely free — a supportive space where listeners share experiences, ask questions, and learn from one another. Whether you’re newly diagnosed or decades in, you’ll find real help, real stories, and zero judgment.

The Good News: You Can Live Fully with Type 1 Diabetes

Here’s the truth: diabetes management is constant work, but it’s completely possible to live a healthy, flexible, normal life.

Technology like continuous glucose monitors (CGMs), smart insulin pumps, and new insulin formulations have made blood sugar management easier and safer than ever before. Add the right education and mindset, and you’ll find stability sooner than you think.

If you or your child is newly diagnosed, remember this:

• You’re not behind — everyone starts here.

• You don’t have to be perfect — you just have to learn.

• You’re not alone — there’s a community waiting to help.

Start with Bold Beginnings, keep learning through Small Sips, and empower yourself with Pro Tips. The more you understand, the calmer and more confident you’ll feel.

Because living well with type 1 diabetes isn’t about chasing perfect numbers. It’s about building the skills — and trust in yourself — to manage whatever comes next.

✅ Fact Sources

• Centers for Disease Control and Prevention (CDC): What Is Type 1 Diabetes?

• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK): Type 1 Diabetes Overview

• American Diabetes Association: Type 1 Diabetes Basics

• JDRF: Understanding Type 1 Diabetes