Scott Benner 10/6/25 Scott Benner 10/6/25

#1645 All in the Family

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Three generations, one diagnosis. Mike, his daughter, and his son each face type 1 diabetes at different ages—sharing lessons on family, resilience, technology, and perspective gained through lived experience.

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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
Friends, we're all back together for the next episode of The Juicebox podcast. Welcome.

Mike 0:14
My name is Mike, and I am a type one diabetic. When I was diagnosed, I was 54 I am now 56 kind of unfortunately, I have a lot of experience with type one diabetes.

Scott Benner 0:31
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Mike 2:07
My name is Mike. I live in Utah, and I am a type one diabetic, newly diagnosed at the ripe age of when I was diagnosed, I was 54 I am now 56 kind of, unfortunately, I have a lot of experience with type one diabetes.

Scott Benner 2:26
Yeah, look at how you teased it out. Mike, that's, that's a bit of a storyteller in you there. That's excellent,

Mike 2:31
yeah, yeah, absolutely, unfortunately. It's, I don't know if you could say it's a horror story or a great story when it comes to diabetes. Unfortunately, baptism by fire, and I certainly thought I escaped it at my age, so I was a little shocked and devastated at the same time. Yeah, yeah. And here we are today.

Scott Benner 2:51
That's how I envision this, actually. So let's do this. Are there any other autoimmune issues in your family?

Mike 2:58
You know there is not. I have a daughter who was diagnosed pretty much same age as Arden, and at the time, I talked to my mom, and she said that they had an aunt that died prematurely, and they think it was type one, but other than that, it was just type two diabetes. So when my daughter, and then later my son, as we'll get into that, were diagnosed, they always wanted to know who to blame, and last spring, they decided to blame me.

Scott Benner 3:24
So when I said, Is there any other autoimmune in your family, you meant no other than my two children who have type one diabetes,

Mike 3:31
other than my two children who have type one diabetes, absolutely. Yeah. So I guess in a way, I was the beginning.

Unknown Speaker 3:37
Well, how many kids do you have in total?

Mike 3:41
Okay, so this will shock you a little bit, but I have seven. My wife has two. I had four, and then we adopted a girl out of the foster care when she was 13 years old. She's now 20.

Scott Benner 3:53
That's interesting that you didn't get to that math the way I expected you to, because I know you live in Utah

Mike 3:59
and I am not LDS and I have a bunch of kids.

Unknown Speaker 4:02
Yeah, when you said I have seven, I was

Scott Benner 4:04
like, why would you think? This is shocking to me, but Oh, so you came about them. You've been collecting them in a couple of different ways.

Mike 4:10
Yeah, exactly, yeah, adding on. But I don't think we're going to add any more. I think, I think, well, we're good at seven,

Unknown Speaker 4:16
yeah. So you have, I

Scott Benner 4:18
almost said, sired. What are we making puppies over here. Yeah. Why? Why did that pop into my head? You're the father of four children, natural children. I am the father of four natural children. Correct? Your wife showed up with two. My wife showed up with two. Yeah. And you stole one from the mall.

Mike 4:35
We stole one from the foster care program, yeah? And it was actually that's a whole podcast in itself, but a rewarding experience, and I could go on the road talking about how successful that is

Scott Benner 4:44
no kidding. Okay, so of your four kids that you had, I'm assuming in a previous marriage, what are their ages?

Mike 4:51
So my oldest son, who passed away in 2011 would have been 30. Five today. I have a daughter who is, will be 34 this winter, this December. She's my type one diabetic. My son, who is he lives in Portland. His name's Zach. He is 30, and he was diagnosed with type one diabetes four years ago, and then I have a younger daughter who's the only one that's not diabetic. She's 26

Unknown Speaker 5:25
like, I'm sorry to ask you, but how did your oldest son pass?

Mike 5:29
He went to a rough breakup and unfortunately, took his own life.

Unknown Speaker 5:32
Oh my gosh, at what age? Yeah,

Mike 5:35
he was 21 just barely turned 21 Oh, so it's been a while.

Scott Benner 5:40
Yeah, no, but still, did he have other I don't know how to ask you, this. Is that a thing you saw coming?

Mike 5:47
No, no. In fact, Scott, you know, whenever somebody happens, maybe even when Arden is diagnosed with type one diabetes, you think this doesn't happen to me, right? Like you're this happens to other people, not not me. So it was a shock. It was a huge shock. Of not something I was expecting by any means, but it, you know, it definitely was shocking.

Unknown Speaker 6:09
Well, I'm so sorry. So your daughter's diagnosed at two. Did you say

Mike 6:14
she was four years old when she was diagnosed? So back in 1995

Scott Benner 6:18
95 okay, so yeah, Arden was diagnosed when she was two, yeah, and in 90 Oh, my God, 2006 Yes, 2006 was a lot of math there. So, okay, so your daughter had had diabetes for 10 years by the time my kid was diagnosed, yeah, yeah. Definitely got a head start on you. Okay, so 1996 she's four years old. Do you remember that process? Do you remember how it presented?

Mike 6:47
You know, just like probably any parent yourself included, when you look back, you're like, how did we not catch it? But at the time, she never wet the bed. She was amazing. And then all of a sudden, she started wetting the bed. And we didn't think anything of it, because I had never even really heard of type one diabetes at the time. The internet is not what it is today. And so she started wetting the bed. And then we would start leaving the house, and we tell her, go to the bathroom. And I swear, we get like, two miles away, and she's, I have to go to the bathroom. And I remember saying, There's no way you have to go to the bathroom. You just went, but we would stop. Didn't really notice her drinking anything. She was only four, so didn't really notice if she was losing weight. And then she got sick, and she just didn't get any better. And my ex wife said, I'm going to take her to the doctor, and she did, and they did a urine test, and it came back, like, you need to take her the ER, right now, okay, and my wife called me, and she said, you know, you have to take her in. She has sugar in her urine. I'm like, Well, what does that mean? And she's, I don't know. And of course, you know, as soon as they get her the ER, they check her into ICU, and then we we find out about type one diabetes. Wow, you

Scott Benner 8:05
said she sick and she didn't get better. Like, would you describe her as, just, like, under the weather, or flu, like, symptoms or and how long did it last?

Mike 8:14
Yeah, just like the flu. That's really what we thought. She just had the flu. She just wasn't getting better. We hadn't put together any type of, you know, urination issues with bed wetting or even leaving the house. We hadn't put that together. But she, yeah, she had the flu and running a fever, and she just wasn't getting any better. And that's, that's when my ex wife

Scott Benner 8:34
decided to take like that. Do you know how long that process was? Was it days weeks where you thought she was sick?

Mike 8:40
I would say she was probably sick for about a week. And, you know, four year old being in daycare and around other kids, that was an abnormal. Kids are kind of petri dishes for disease, you know, sickness anyway, right? We really hadn't thought about it. It just lingered and lingered, and it wasn't getting better. She wasn't in full DKA by any means. So we were, we were very fortunate. Early on, it wasn't a Yeah, a quick trip to the ICU, even though it was, but in a roundabout way.

Scott Benner 9:07
So Mike, who takes care of the diabetes for the four year old, is it? Is it a shared experience between you and your ex, or is it one of the other and what did that look like back then? What kind of insulin? What were you doing for management?

Mike 9:20
So we were doing MDI at that time. There was no really pumps. They were around, but they weren't really readily it wasn't something certainly we were going to put on a four year old back then. I think they were about the size of a car battery. They were big. There was certainly no CGM. So, you know, we went through some education classes at the hospital, and of course, we went through a counseling class that it wasn't any of our fault, and we were sent home with, you know, vials and syringes, and that's what we gave her at that time. I don't even believe pens were available. And as I looked through that, you know, my wife worked in you. In the evenings and at night, and I worked during the day. So it was a shared 5050, and we're trying to, really just trying to figure it out, when I look at today's technology, you know, with CGM and pumps, and then I think back in 1995 I was sent home with a four year old and syringes and vials. How did I keep her alive? Like there was so much of a picture we didn't understand. And back then, you know, you hear this term, and I've even heard it on your podcast, they defined her as a brittle diabetic, meaning hard to control. It was just we didn't know the whole picture of what was going on. That's why she was hard to control.

Scott Benner 10:37
Yeah, no kidding. You said you don't know how you kept her alive, but how do you think you did it? What was it? Did you eventually find a rhythm, something that was agreeable, or, I don't, you know what I

Mike 10:47
mean, I think more, it's, you know, now that I'm on insulin, it's more I look back at how, at the time, I didn't realize how dangerous insulin was, okay, and you were always walking in a way, with a, you know, especially a type one diabetic at that age, you're kind of walking a tight line. But I think because of my young age, the internet wasn't what it is, so we really couldn't research it. We were just counting carbs, giving her the right amount of insulin, doing Lantus at night, and then, of course, trying to finger pricker, you know, as much as you can to get a good picture before meals, after meals, and kind of understand it, but you certainly didn't get that every five minute blood sugar to really obtain a full picture.

Unknown Speaker 11:30
Mike, are you old enough to

Scott Benner 11:32
appreciate that? 30 years ago, you couldn't really research something like that how different the world is. Like I imagine people younger than us are never really gonna understand that you just like somebody said something to and you went, Okay, well, the doctor said it, that's it. I will do this for the rest of our lives. Now, there's nowhere to check. Maybe you'd bump into somebody eventually who'd say something to you. You know, counterintuitive to what you'd heard the first time, but there was nowhere to go to find out. You know, it's crazy how much the access to information has changed in such a short I think of it as a short amount of time, but I'm assuming people think of 30 years as a long time, but it seems fast to me.

Mike 12:08
You know, it's funny you say that because, yeah, we were so isolated. I have a lot of medical professions, professionals in my family, and I look back at, like, just 100 years ago, you know, like when you look at the whole lifespan of humans existent, the leaps and bounds that we have made in the last 100 years, and then really, like you said, with technology information 30 years ago, that that just wasn't available, is such a short amount of time that now we have that. But I also question like, would it have been scary to have all that information back then, it certainly would have

Scott Benner 12:43
helped. It's possible that the knowledge, without the technology, might have been frightening, because you did say, like, you didn't know even that the insulin could be dangerous. So you were just doing you were just doing what they said. You weren't even thinking twice about, like, what might be happening afterwards,

Mike 12:58
right? Yeah, absolutely. And sadly, you know now, like, if you go low in the middle of the night, you get alarms, which are really annoying, because I get a ton of them. But back then, the only way we knew that she was going low is we would hear her cry. And at that point, you know, I don't, I think we were sleeping very lightly, just so we could always hear her. And it's just scary to think what was going on. And then, I think, even, like, what was going on 30 years before she was even diagnosed? How much scarier was that? Because at least we had test strips, and we had more than one a day.

Unknown Speaker 13:30
Do you recall what her a one, Cs were like back then? You know, she was

Mike 13:34
always, actually, for the most part, pretty good. She was in sixes. Never really got down in the fives, maybe, low sevens.

Unknown Speaker 13:42
They must have been thrilled with that back then. Yeah, they were. They were

Mike 13:45
really happy. You know, we were really good at always taking her the endocrinologist every time she had an appointment. We never really skipped any corners on it. We wanted to make sure she got the best care.

Scott Benner 13:57
Have you ever talked to her about what it was like to grow up with diabetes? Does she have remembrances or struggles or celebrations that she shared with you?

Unknown Speaker 14:08
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Scott Benner 14:11
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Mike 16:20
No, she doesn't, you know, she doesn't really know life without type one diabetes. So for her, it's very interesting. She just doesn't remember anything. You know, she was really great through the whole thing, especially as I look back now that I'm a type one but the only time she ever cried was the day we brought her home from the hospital and pricked her finger and gave her the first shot. Because, of course, she thought, I'm out of the hospital. I don't have to do this. And now she does. She never really cried. Now I look back and, you know, now that I'm type one, I look back and I think I wish I had understood a little bit more. But of course, I was trying to keep her, you know, her a 1c low, make sure her blood sugar wasn't spiking. So it was harder for me to understand, especially as she got into the teenage years of having a cheat day or a day I just don't want to be diabetic. I didn't understand those then,

Scott Benner 17:13
yeah, well, I mean, I think this is where, honestly, where your story is going to get the most interesting is, is when you're diagnosed, and you have the ability to look back over all this time with her, and then, of course, with your son as well. Yeah. How long does she have type one before your son's diagnosed? And was he diagnosed as an adult out of the house or with you still?

Mike 17:34
Yeah. So my son was in the Navy. He was stationed in San Diego, went in when he was, oh gosh, just 2021, years old. And he got out. He was out in August of 2021, he moved to Portland, bought a house. He was driving down to San Diego to see his wife's family, and all of a sudden he looked at his wife, said, I just don't feel good. He knew something was wrong. So this was December, Christmas of 2021, and he stopped at Walmart and bought a cheap checker and checked, and it said, hi to him. Want to know how he was doing that day, too. And he immediately looked his wife said, we have to go to the ICU. We have to get to the ER really quick. He went to the ER. And I remember when he called me and he said, Dad, I'm I'm in the hospital. I said, well, for what he said, type one diabetic. I just was complete shock,

Speaker 1 18:30
yeah, why, Mike? Because, because it just felt like it had happened once, it couldn't happen again.

Mike 18:36
Basically, yeah, it happened once, it shouldn't happen again. He was, you know, 2627 years old. It just didn't seem right. And then I remember I teared up in the moment we got off the phone with him, I said, you know, thinking like, you know, to God or whatever, you know, I'll take this. And unfortunately, I did, but somebody else didn't live up to their end,

Scott Benner 18:58
didn't do the exchange. They just brought it up. Yeah, exactly. I thought he was crying because he went from living from living in the weather of San Diego to the weather of Portland, Oregon. Oh, yeah, that'd make me upset. Wow. So he's diagnosed as a young married person. Had he been married long? At that point, he

Mike 19:14
had only been married about a year, so it was very new, you know, obviously, you know, he knew all about diabetes, and I would say, in the hospital, he was joking with me. We were FaceTiming, and he was uplifted. He was he was like, I'm going to be fine. It was more me that was almost devastated over it than course,

Scott Benner 19:33
you think that he felt like he was going to be fine, because he grew up with a sister who had it.

Mike 19:38
Yeah, exactly, yeah. He had the confidence. And he's just a great kid. Anyways, everything's positive. He's just fun to be around. You know? He he was kind of, in a way, of a lucky one. His a 1c when he went in was 17. He had been high, but because he had just got out of the military, he was able to go back. That was something they should have caught when he. Got out of the military. So the military will actually pay for his medical supplies, full pump and everything for the rest of his life.

Scott Benner 20:07
Oh, because he was in when this started and it wasn't caught, this falls under his veterans benefits,

Mike 20:14
absolutely, yep. So he'll have 100% and you know, when my daughter had it, one of the first things I was worried about was, like, this is this is not fair in life, because this is a lifetime expense that's not fair to her.

Unknown Speaker 20:27
Yeah, yeah. The cost

Scott Benner 20:30
is, I was just having a conversation with somebody about some generic insulin that's coming, and they're talking a lot about, like, what kind of pen is it going to go into? And, you know, like, they're, you know, at a company level, they're talking about all that. And somebody remarked, you know, I think, really, you should be a little more focused on just the fact that people need affordable insulin, put it in vials and give it to them. Yeah, let's stop worrying about, like, this part of it here, like, let's just, you know, there's a lot of people who can't afford their insulin. They're rationing, they're not eating sometimes because of it, like they don't care which one of the one of the pens you choose. Like, just, like, let's get it to them. And I thought it's interesting the way you you just talked about the financial side of it, right? Like, my gosh. Like, what a relief is it that someone else is going to pay for this stuff for your son versus your daughter, who's you know? Yeah, yeah, stuck paying for her whole life. Hey, yep. Is he still married?

Mike 21:26
Yes, he's still married. Lives in Portland, and he's on a pump and his a 1c was he was down to five, five, and they're trying to kick him up a little bit. They want Him more around that 5759,

Unknown Speaker 21:40
range, okay, is he experiencing a lot of lows

Mike 21:44
more than what they would like? He's on a he's on a T slim. Yeah, he tends to hover a little bit low, but then he allows a spike his his standard deviations a little bit on the higher side. Okay?

Scott Benner 21:56
And can I ask? I've been wondering this for 10 minutes now. Do you think that one of your kids getting type one diabetes at all added to the fact that you're divorced from their mom? Now, did it add a level of difficulty to your marriage? Or do you think they're not related?

Mike 22:12
No, I don't think it is. They've been diagnosed for about six years, and you know, it really didn't cause a lot of friction that part, there was some other things that just caused. Yeah, I

Scott Benner 22:23
don't need to know what they are. I just was wondering if that was a contributing factor or not.

Mike 22:28
No, I don't think it was.

Unknown Speaker 22:30
So now, how long ago was your son diagnosed?

Scott Benner 22:34
So he was diagnosed December of 2021, and it was like Chris day before Christmas, right? So four, maybe four years ago, in that range, this is some, like, couple of decades since your daughter's been type one. So your daughter's diagnosed at a really young age. You grow up as a father through all that, he's diagnosed more recently, and then it's just a couple years later that you are as well.

Mike 23:00
Yeah, my story was actually really interesting the way it came about. I was one of the very fortunate ones that I didn't go in a DKA or ICU or anything. But yes, it was just really about three years later that we had noticed something with me. And in 2023 I had worked for a company for about seven years, and I had another company that recruited me, and I decided to make the jump. And in between, I had a couple week period where I just decided to take couple weeks off. And I thought, well, I'm going to go in and get my physical done, because I have asthma, and so I need to get my asthma medication renewed. And I went to the doctor. They did a full blood palette. So this was September of 23 and it came back a few days later. And my primary care physician, she's a marathon runner, and maybe we should say that I I'm a cyclist. I used to race bikes, and at this time, I stopped racing in 2015 but I still work out anywhere from 10 to 15 hours a week. I'm on a bike, so I'm very I'm a very active person. And so, of course, with a lot of athletes, what happens is you tend to eat whatever you want, because you work out. And so my a 1c she called me, and it came back at five, nine. She said, Mike, your your a 1c is a little high. And she said, you know, obviously you're not a type two, but it, you know, she'd even mentioned diabetes. We really just talked about, you know, I should eat, stop eating sugar, and because I worked out, you know, your normal person would go, let's say, in the evening, eat one or two Oreo cookies. And I'm probably the guy that eats 10 to 12 cookies and then maybe washes it down with a brownie. I said, that's fine. So in September, when she said, You know, I bet if you just stop eating it, maybe just had a treat here or there on the weekends, you'll be fine. So I being who I am, I completely stopped eating sugar. Went to Mexico Cancun for a week. There I had some dessert. Fruits and a few drinks. I'm not a heavy drinker, but I really cut back drinking. And I went back for my and she was fantastic. She could have left it at that and said, Don't worry about coming back. Just stop eating sugar. But she said, come back in three months, and let's test it again. I went back three months later. It was December. It was right around probably December 20, so shortly before Christmas, and got my blood work done. And I remember I was actually in the department store checking out by my wife a Christmas present, and I got an email that my blood results came back, and I started opening it checked out. And as I was walking through the parking lot to my truck, I looked at it, and I saw my a 1c had gone from five, nine to six, and the tears started coming. I knew. I was like, Wait a minute. There's no way it can be six. Something has happened. Yeah, yeah, talk to the doctor. And you know, it was like, Okay, let's just keep watching it. We're going to test again in three more months. So in that time I was working out, there was Christmas Eve, and I thought, I'm gonna go to Walmart and just buy a glucose checker. Yeah, you shouldn't get the them fairly inexpensive there. And I checked, I just finished working out, got home, opened it up, checked it, my sugar levels were 180 I was like, This is not right. I shouldn't be 180 so I started checking it periodically, went through the holidays, didn't really have much sugar or anything. And then in March of 2022, or no, I'm sorry, March of 2024 we started looking for a second home, and we were looking in southern Utah at the same time, you know, there's a lot of stress going on of buying an additional home. My son was a type one diabetic, and I talked to him, you know, almost every other day, and he said, Dad, I'm going to send you CGM. He's like, I have so many. I'll send you one so we can get a clear picture. And he sent it. I was completely shocked. All of a sudden, I was seeing three hundreds. And I was like, This isn't good. I went down to do a home inspection on her house, and I came back and my sugar levels were so elevated, it was causing me a little stress. I actually thought I was having a heart attack. And went to the doctor the next day, did another one, A, 1c, check, and I had jumped from six to six, eight.

Scott Benner 27:25
Mike, the sadness you felt. Was it about your own health solely? Was it about what you thought you were losing, what you're about to experience? Or do you think you started to think more about your kids? Or do you think there's a combination of things in

Mike 27:38
there? I think when I looked at it. It was one of those. So I had worked out, you know, race bikes my entire life. And you know, racing, you know, 10 to 13,000 miles a year. And remember when I looked at my primary care physician, I don't think she even wanted to tell me what my a 1c was, because when she did tell me, I had to ask her, and she got real quiet, and she said, six, eight. And the tears came. And I was, you know, I was like, I did everything in my life not to be here. And of course, she said, It's not your fault. And she's, you know, she was real nice. She said, if anything, because of your lifestyle, you probably would have been here two years ago in a lot worse shape, so you didn't do anything. And so I think it was more it was just a shock, because I had always really taken great pride in really taking care of myself, being active, being healthy. I was the guy that would go to the doctor, and my blood pressure would be so low I would be really proud of that. So to go that was a huge swing for me to go from that to all of a sudden having a life changing disease, it

Scott Benner 28:47
was more about the, I guess, that psychological aspect of like, I think, how is it possible I put this much effort into something that still didn't work out?

Mike 28:55
Yeah, absolutely. And, you know, I've heard, you know, even on your podcast, other older people saying the same thing. I thought, I thought, you know, 5455 years old, I'd escaped that. I certainly knew what it was, but I thought it escaped.

Unknown Speaker 29:10
It was there a piece

Scott Benner 29:12
of the like you said earlier, like, you know, your daughter had type one for such a long time her your son's diagnosed. Later, you think, Oh, God, that can't happen. Like, it's already happened to us. Is is this like the Oh, it can't. How is it possibly going to happen a third time? Has happened twice? Or is it more about feeling like marked? Do you start feeling, oh, this thing feels like it's out. They get like, you know what? You know, I should mention this, right? It's the 50th anniversary of jaws. Remember, in Jaws where they act, they acted like the shark had something out for the family. Like, did you feel like that?

Mike 29:39
That didn't really cross my mind too much. What did cross my mind was my youngest daughter didn't have diabetes. Of Okay, is it going to happen? Pretty much every one of your direct siblings has it now. Your dad, like, are you next?

Scott Benner 29:56
Yeah, yeah. Now you're worried for her. It's going to come for her as well.

Unknown Speaker 29:59
Absolutely. Absolutely. How old is she? He is 27 and

Scott Benner 30:03
I guess it doesn't really matter, because now at this point you have, you have someone diagnosed at four, someone diagnosed at 21 someone diagnosed at 52 like there's no even rhyme or reason to the to the age there in the family. So this is just a thing I imagine you're going to worry about for the rest of your life

Mike 30:21
for her. Oh, yeah, absolutely, yeah. And so, of course, my, you know, my diabetes stories doesn't end there. So I was diagnosed, and then in June, I think it was June of last year, my wife's half brother wound up in the ICU DKA, and then it's like, wow. Now we have another one, no blood relation, but okay, now is my wife on that and we did go get her tested to for the antibodies.

Unknown Speaker 30:50
Like, I'm sorry, your current wife or your ex wife, my current wife?

Mike 30:53
Okay, yeah, oh, geez, yeah. And we've been together for 20 years, so it's been a long

Scott Benner 30:57
time. I was just gonna say, like, if, if we found it in your ex wife's family line, then it makes sense that you know that so many of your kids have it too. Is there anxiety in your family, like with your kids or yourself? Is anybody anxious? ADHD, anything like that?

Mike 31:14
No, not at all. If anything, we're the 100% opposite. We're the family that when something bad happens, we'll lick our wounds for a week or two, and then we'll start picking out the positive. Like, even me with type one diabetes, even though my daughter had it. Like, now I really understand how the whole digestive system works, the liver and everything. And it's like, it's like, okay, now I probably understand more about the digest the digestive system diabetes more than endocrinologists. So we're kind of always that family that picks the positive out of everything. Even when my son passed away, we picked out positive things, and that's just the way we are. Lick our wounds for for a little bit, and then we pick ourselves back up.

Speaker 1 31:56
Can you tell me some of the positive you identified after his passing?

Mike 32:00
Yeah, absolutely. You know, it was devastating because me, I had never even been to a funeral, and sort of to go to my, you know, the first one to be my son. But it really brought my children together closer, even closer than they were. And that was always the positive. And it actually taught me to let things go. There was a lot of things, even, like, I would argue with my ex wife and I was like, so much of that just didn't matter. After that, it was so insignificant. It just didn't matter.

Scott Benner 32:29
Yeah, you gained a perspective of 100 year old man in five seconds, really? Yeah, absolutely. I feel like diabetes has done that for me. Oh, and I feel like I see it with other people as well, you know, just at some point, I don't know the minutia and the silly things that we all like get upset about or argue about, I just when they happen now you just feel like, God, this is just so meaningless. You know, yeah, to

Mike 32:54
get worked up over senseless things. It just that's actually what came up. It was like, this just isn't worth energy, really negative energy anymore. And I really took that approach with my ex wife. I was like, I'm just not going to argue with you. I just don't care anymore.

Scott Benner 33:09
Yeah, just, I don't know, like, the words for it, but it's and it doesn't happen consciously in your head. But you know, like, what are we going to argue about where we're going to dinner? Like, Arden's pancreas doesn't make insulin, you know, or my son's not here anymore. Like, like, this is, this is a real thing that happened. So just because it happened to us this one time doesn't mean it's not happening to other people all over the world constantly, that people aren't battling depression, or, you know, quiet battles that nobody else knows about, and that there aren't shocked families left behind, or health issues that people are are just constantly fighting with, and we're gonna sit here and like, be mad that, you know, I don't know the gutter guys didn't come on the right day, or like, you know, like, just doesn't matter. I don't know. I just think it gives you, like, a lifetime's worth of perspective in a short amount of time. And I think a lot of people are lucky enough to level up from that and maybe find some clarity that they didn't have prior.

Mike 34:04
Yeah, I'll agree 100% Yeah. I really do think, you know, the t1 just changes everything for you. And you know now that I've been diagnosed with it, it really changes everything. More than raising children with t1 was one thing, or a child, and then having an adult or, you know, an adult child, but now having it myself, it's just everything is so different in life now, well, that's

Scott Benner 34:28
what I want to check with you, because it's, I mean, listen, it's easy for me to philosophize about it, right? Like, because it's, I don't have to take the insulin Arden does, right? Like, I don't get low she does, right? I don't have to worry about the future she does like those are all her actual lived problems, not mine, but I know how I feel, and I know how I've been impacted by it. But I guess my question to you is, is the did any of that change or deepen when it became your diagnosis, or are the feelings I'm feeling for a child really the same? That I would get if I had diabetes myself.

Mike 35:03
Yeah, it's, it's interesting. You know, obviously experiencing some lows and some highs. I have a different, completely different perspective of it. Now, when you watch, you know, your your girl, go through it, it's one thing. Now I'm experiencing it, and I don't know if it's worse because of my age. I don't know if that's something that could even be quantified, but I certainly have a whole new understanding. I remember when my daughter would come home and she, you know, her blood sugar would be high, and I'd ask her what she had for lunch, and, you know, how much insulin did you take? And I remember saying, like, did you forget your diabetes, and now I have an old news perspective of that, a clearer picture and certainly understanding of

Speaker 1 35:48
it. Have you contacted her and shared that with her? You know, we have

Mike 35:52
kind of a strained relationship, a little bit, which is sad, but no, I haven't. Certainly with my son. We talk all the time, and we can definitely correlate. He's actually maintained really well. I'm a little bit better than him, I think, yeah, but he's, he's really good at it. But, you know, I had a really scary low last December, and so it's nice to talk to somebody who's gone through that to get some understanding.

Scott Benner 36:20
Yeah, well, I mean, I don't know the source of your strain with your daughter, but, I mean, I would imagine it would mean something to her to know that, you know, like, you have a different perspective now that you have it, and you know you're sorry for for any time that you may have. Like, I don't know if that's fixes things with people or not, but I'm assuming we've all done that to a kid with type one, everybody who's a caregiver at some point or another, you say that thing, right? Like that, no matter how you mean it sounds like, what did you do? You know? Like, why did, how did you make this happen? Like, what did you not do that caused this that, as much as that's not your intention in the moment, I imagine it's overwhelmingly received that way from from the type ones themselves. So I don't know, maybe, you know, maybe she don't want to hear from you. I'm not asking you, but, but I feel like that'd be a thing somebody would want to know.

Mike 37:11
I definitely think we'll get we will have that conversation. You know, as you know, with Arden, when you're they're young, like that, even teenage, you're just trying to do everything to make sure that there's no effects 30 years down the road. So you want to keep them as in line as you can so there's not other health problems. And obviously that's something you very, you know, you care for very much. You want to make sure that they're really, you know, keeping in line and just being healthy. So I didn't really understand that. But, you know, there's days now I look at my numbers and and I'm really well controlled. I'm 98 to 99% in range every day. My standard deviations about 19% so I'm very well controlled. But even then, sometimes it's just like, you know, you just don't want to care about it one day. You just, you know, I read something that said the average diabetic makes an extra 150 to 200 decisions a day. And there's a lot of truth to that, that even though I raised a type one diabetic, I didn't understand it.

Scott Benner 38:15
Yeah, no, you can't possibly and, you know, now, right? That's not a just a thing. You've heard, like, I hear people make a lot of extra decisions, and they have type one now you're making those decisions. And yeah, again, your perspective is raised. You might be an Oracle by the time you're done, Mike, if stuff keeps happening to

Mike 38:30
you, my gosh. So I started having really high blood sugars. I was leaving town. My doctor was out of town, and somebody in her office had prescribed me Metformin because he didn't know me. So he's like, okay, he's got high blood sugar. It's type two. So I took that for a little while, I did nothing, and then I took a C peptide test, and it came back that I had the antibodies. And I called my doctor, and he said, Okay, and I was leaving town again, because, unfortunately, I travel sometimes, and she called me in Lantus, and she said, You know, I don't know if this is good or bad, but she's like, you're one of my only patients I could just call in insulin and not have to give him education. Like, yeah, sadly, I have too much education and type one diabetes.

Scott Benner 39:17
Yeah. Did you find that the experience with your daughter growing up and now your conversations with your son that you really there was nothing really left for you to understand, like you were just like, oh, I have it now. I know how to do it. Is there any gaps in your knowledge at all? Well?

Mike 39:33
So when I was raising my daughter, there was no CGM weren't around. So I definitely saw a very clear picture of what happens when you eat food to get that and see it. Yeah. The other thing is, I feel like no type one diabetes are alike. Everybody's different. We all have different eating habits. We we drink differently. Just everything's different our lifestyles. So even though I knew that you know if you if you draw it on paper or. Whiteboard of what diet, type one diabetes. It's perfect, right? Okay, you bring in this many carbs, you take this much insulin, no problem. But when you're actually living it in real life, it's not that clear. It's it's just an everyday is different. I'm pretty lucky. I eat I know the same thing every day. You know, I have a yogurt in the morning from going out training. I eat the same food. So it was more learning about myself and really understanding how the CGM work. There was that little gap, even though my son was on a CGM, my daughter's on a CGM, I didn't raise anybody on a CGM, right? So that part, there was a little bit of a learning curve, when to when to do a calibration, which it's very rare. I do one. I I'm pretty lucky. I'm one of the very few on the g7 that has failed. I think I've, over the last year and a half, I've had two that have failed.

Scott Benner 40:51
Yeah, my I don't think that makes you like one of the few. I think that maybe just people on the internet are, you know, more drawn to use the internet sometimes for talking about what's not working, trying to get help, and people who are putting on, you know, I say all the time, like, Arden has incredible success with the g7 but I don't go online and be like, Oh, there's another sensor that lasted 10 hours plus the 12 hour grace period, like, or 10 days plus 12 hours. Like, I mean, that's not a thing you get to tell people online, you know, yeah. Can I ask you about biking? How long have you been riding?

Mike 41:22
So I started riding in 1995 it was funny, I just barely moved to Utah, and I had a neighbor who was gonna go do this 100 mile big bike event and not even have a bike. And I was like, okay, yeah, I'll do it. So I went to Walmart, I bought a cheap mountain bike. Probably weighed 3000 pounds. I did it. I swore I'd never ride a bike again, and then that, later that year, I ended up buying my first road bike. Rode it very, very often, but I really didn't start racing bikes until 2005 2005 I really got into racing. Endurance bike racing was my big thing. That was the first year I did there's a race that they do here. It's fairly known throughout the nation. It's called Logan, the Jackson, and it's 206 miles. You go over three mountain ranges, and you do that all in one day. Jeez, yeah. So I did that. And 2005 was my first year. I'd even know I was going to do it until a week before I signed up for it. And then I decided that bike racing was for me. Done it 10 times. Now I actually stopped racing in 2015 but you know, in the highlight of my kind of my career, I raced 62 times in one year. So yeah, I raced, raced quite a bit.

Speaker 1 42:45
And was that just a thing you picked up at some point, or were you incredibly active before that?

Mike 42:50
No, I wasn't at all, really. I got out of the Navy, moved to Utah, done a little bit of running. I blew out my knee, came down into a rut the wrong way, blew it out. And so when I got into racing riding bikes, I always enjoyed it as kid, and it was just something I picked up. I was really good at it. If you look at me now, you would think, Wow, that's a really tall skinny guy by nature. I'm not a skinny person. I'm six one. I think at one point I was up to 225 pounds right now I weigh about 160 the riding is just because

Unknown Speaker 43:28
I'm sorry, the right, did the riding take the weight off of you?

Mike 43:30
Yeah, the riding weight took it off. I had done that event 95 then I gained some weight, and then I got back into it on a mountain bike with road tires on it so there were not knobby tires. And I went into the event, and I was keeping up with all the road guys, and I was like, All right, it's time to get back into this real bike. Time to get out riding. And so I do think the bike racing helped with the type one diabetes, because as I look back now, I think I struggled with this. My honeymoon phase was relatively short, and I think that's because I rode through my honeymoon phase and kept my sugar levels down the

Scott Benner 44:05
amount of time that you knew you had type one was short, but you think that maybe there was a longer honeymoon prior to you knowing that was kind of helped by your activity.

Mike 44:14
Yeah, absolutely. So I really suffered on the bike last year is I was getting diagnosed. I was getting on insulin. They had me on Metformin. I was carrying a lot of fatigue. I go on a 30 minute bike ride, come home, take a three hour nap. I was just wrecked, and I couldn't figure it out. And then once I was I've been on a pump now for about, oh, 50 days. Okay. And so when you eat, as you know, your carbs break down in the sugar, which translates to energy. Well, if you don't have any insulin, where's your body getting the energy from? It's breaking down your muscle. And now that I'm on insulin, and I'm regulated very well, I'm starting to build up muscle again. And I look back and think, wow, I was really suffering for three, four years, because now I can go out ride my bike, and, you know, I can hit four or five. 500 watts and maintain that for a little while, and actually get home and I'm not sore, I'm not fatigued, where I was for many years. And so now I'm starting to look back and think, was this, you know, I plot covid in 2000 did that trigger it? And I've really been suffering with this longer than what I know. It's hard to figure that one out,

Scott Benner 45:20
I actually found myself wondering if your son's service maybe didn't keep him very active, and maybe, like, when he was out, maybe that's why I actually wondered, like it was, you know, not enough there for me to say out loud at the moment, but you said it's able and super 1717. Yeah, right. So, so I don't know, like, you know, the activity definitely can help during those long, slow honeymoon periods, especially with like, Lada.

Mike 45:45
Yeah, absolutely. So one thing we found out with my son was he just found this out a couple months ago. My son has neuropathy, pretty bad. He's walking with a cane, really. And, yeah, he's only 30 years old. So of course, his doctor wanted to know why, like, why is he suffering so bad with all of this? Why is he walking with a cane? Why is he having foot problems? They pulled his medical records, and they found out that five years prior to his diagnosis, they did a blood workup on him and his a 1c was 6.8 and all they put in the note was, we'll watch it. Yeah, so he had been suffering with this for a very long time. The military didn't really thoroughly do what they should have done.

Speaker 1 46:31
Do you think your son had elevated blood sugars for five years before he was diagnosed? Oh gosh,

Mike 46:38
yep, five years because it did come back. He was a six eight. And as we all know, six eight, you know, that's, that's a big trigger. But I think especially, we see this a lot, and, you know, I read this on forums. I've heard it on your podcast of everybody, they automatically think it's type two at first, and older people, you know, and so that's tend to, you know, just eat better and it'll go away. And that's not the case, probably

Unknown Speaker 47:03
what they were thinking there too. So, yeah, absolutely,

Scott Benner 47:06
you know, you're doing a great job of telling your story, but is there something that drew you to want to be on the podcast that I I'm not covering or getting to,

Mike 47:14
you know? I so I started listening to your podcast because when my brother in law was diagnosed with type one. He also had a burning injury, and so I was going to the doctor with him to really help him out. I was already diagnosed at t1 I was just doing MDI at the time. So I was going to his pump education classes with him, helped him pick out a pump. And then when they educated on the educator told me about your podcast, and so I started listening to it. Then from basically Episode One, I think I got up to about four hundreds. Now I'm kind of going backwards, so it was more just helping him. He got the Omnipod. I thought I had a really interesting story. You know that my 30 years worth of diabetes, becoming a diabetic, yeah, and if anything, it was more wanted to, you know, it was almost like through experience of now looking back at what my daughter went through 30 years ago, of do everything you can, be supportive, help out. There's going to be those days, and I can only imagine being a teenager who's lived with diabetes for, let's say, 1012, years of how frustrating that has to be on a daily basis. And it's okay to get in the weeds with them and and let them be mad about the disease. And you know, it's okay. It's not something that can just easily be managed. It's probably one of the most self managed, frustrating diseases you know, known to man.

Speaker 1 48:45
Do you think that you in the

Scott Benner 48:48
pursuit of being supportive or keeping things in the right track? Do you think there were times that your daughter wanted to commiserate or be sad and you didn't let her

Mike 48:59
probably a little well, no, I definitely, we knew it was dying. It was very, very frustrating. But I think we, you know, we definitely wanted to understand, but maybe not as much understanding, of what it was because we weren't living with it. So you can understand as much as you you think you know, but until you're actually really living it, then you really get the full picture of it.

Scott Benner 49:22
Yeah, yeah. I, in the past, have worried that this is a great format for conversation, but at the same time, like, you have to be what the word is. You have to be, like, clear, and you can't get muddled when you're talking all the time. So, like, I've worried in the past that, like, just through trying to tell a story and not being able to tell every second of it. Sharing my perspective could even feel blase at times like and I don't feel that way at all. It's just that sometimes you say something, whether it's to another person, directly or here on a podcast or anywhere, and you can't give the entire context of what you're thinking so you get. Of like, you know, the tiniest point about what's being said right now, and then I can look back later and see how the person who heard that might have really benefited from more context or been put off because it sounds like you're simplifying something when you don't really feel that way. You're just trying to be concise. Does that all make sense or not? But yeah, I'm aware of that, but at the same time, like the podcast also has to be, you know, it has to flow, and it has to be entertaining, and every thought can't get broken down for 10 minutes. And anyway, it's just, it's interesting to me that you have so much time with a with a child, with type one, then you get to re experience it the way you did with your son, and then now you have this personal experience, like you said, it's just an interesting story. It's a it's a bit of a different pathway. Can I ask you, do you have worries about your own health moving forward, like, what are your expectations for the rest of your life?

Mike 50:53
You know, I so I had a really scary low last year 34 and it was more the Lantus went direct into a cell and hit right away. So there was 12 units that just injected me, and within 20 minutes, you hit like a

Scott Benner 51:09
blood vessel with your with your slow acting insulin.

Mike 51:12
Yeah, I hit a blood vessel because I was working. I work from home. I have for, oh, I don't know, about 10 years now. So I work from home. I was staring at my computer, and, you know, the vision got really weird. I hadn't done anything different than what I do any other day. I had my yogurt, my coffee. Was staring at the computer, pretty, you know, intently. Vision started going weird. I looked out the window, looked back, and it still didn't clear up. And then, of course, then the alarms went off. I immediately finger pricked, and I was 34 and I yelled for my daughter to go get my wife, and she came in, and I thought I was in survival mode at that. What's that you thought you're going down? Oh, I was I was going down. I was sitting on the floor trying to open gummy bears. I didn't realize how bad, how hard gummy bears can be to open when your sugar levels at a 34 but it dropped me from 120 to 34 in 20 minutes. Wow. So it was I was coming down really fast. I didn't think a human person could sweat that much without working out. I remember when I finally came out of it. I was just completely soaked. So in that one, it that that was pretty hard understanding that had a great, positive experience with a dog on that experience, and so, yeah, I have incremental steps, you know, pretty well controlled we've talked about, you know how? You know, you typically 98 to 99% in range. Part of me at 56 I'm like, well, at least now I know what's probably, you know, I'm gonna die one day from some side effect of diabetes. I might be 95 or so, but, you know, it's there now that I'm on a pump I was doing MDI. So at the beginning of this year, when my a 1c was at five, five, they decided, like, Okay, we have to get you. We're just taking more Lantus than fast acting, and they wanted to switch it. They were like, you're having too many lows. It's interesting. When I'm on a bike and I'm going, you know, my heart rates, let's say 160 my blood sugars will spike. I won't drop. I'll actually go up really high. I remember one time I was mountain biking up in the mountains, and for 30 minutes I heard my Dexcom alarm go off because I was 252, 75 the whole time when I go hiking or I walk my dogs, that's when I go low and I can drop from, let's say, 120 to 80 within 20 minutes. So one of the things they wanted to do is back off the Lantus and start doing more fast acting insulin. And that actually raised my a 1c I was in Destin Florida for a wedding in May, and at the wedding at night, when I, I think I put my 12th shot in my leg, I said, That's it. It's it's time to go to a pump. Ordered my pump when I got back into Utah and started July 1, actually, of this year. Would you guess? So I don't. I got the Moby I like it. Yeah, I really like it. I love the software. I like seeing how it's works. Awesome when it gets automatic boluses, seeing how the basal rate turns off at night. Duping never bothered me. I actually didn't want to go with the Omnipod, because I, quite frankly, I just didn't want another big thing hanging off me. Because, you know, cycling, you're wearing, you know, tight spandex clothes, you know, outfit and everything. So I just didn't want another device hanging off me.

Unknown Speaker 54:35
You wear the Moby clipped onto your clothing. Yeah, yeah.

Mike 54:39
I just clip it on. I have the 23 inch tube. I tried the five inch tube that that about drove me nuts. I only did that once, so the Moby doesn't bother me at all. I sleep with it on. I think the Moby is actually really good. My daughter and my son are both on a T slim, and my brother in law, who was diagnosed last year, is on the Omnipod.

Scott Benner 55:00
Oh no, well, let me just say tandem diabetes.com/juicebox, omnipod.com/juicebox twist.com/juicebox and Medtronic diabetes.com/juicebox. You want to pump, please use one of my links. That's all I got there. Mike, thank you for letting me inject that.

Mike 55:15
Yeah, absolutely, yeah. I think the Mobi is fantastic, especially with the CGM. And if this pump died tomorrow, I'd go get another movie. Just wouldn't even be a question.

Scott Benner 55:25
It's great to hear people find stuff that jives with how they live and works the way they want it to. It's just the greatest thing. So I'm thrilled.

Mike 55:33
Yeah, I was apprehensive, though I can admit I really wanted to go with the tea slim, and I think that part of that was my age, of having a pump that didn't have a screen or anything, and I had to rely on a cell phone. That part kind of bothered me at first, and then when I just kind of saw maybe a little coaxing for my wife, of giving the Moby a try, I'm really glad I went

Scott Benner 55:57
with the Moby. Awesome, awesome. That's great. I'm very happy for you. Let's see what else we good. I mean, have we done it, as they say, or is there something we've left? I can't imagine we've left something out. Is there anybody left you're related to that could get diabetes?

Mike 56:10
Well, unfortunately, there is my daughter. I want her to go get tested. I want her to get the antibody test so we, if she has that, we can get her, you know, the proper medication to try and push that off.

Scott Benner 56:20
That's what was in my head. Did she respond well to that? When you suggested her, how does she feel about it?

Mike 56:27
He responded really well, I told her, because she told me that her primary physician said that, you know, she doesn't have a danger of being in didn't want to do it. And I said, let me know my endocrinologist will set you up with a chart, and they'll order the labs for you. She did it for my wife, and she'll do it for her too. I said, let me know. I'll even drive you over there. We'll go get it done if we can, you know, push this off as long as possible. Let's do it. She's very open to it. She lives about 70 miles away from me, and so she does want to do it. So we're going to take them to my endocrinologist and get that

Scott Benner 57:02
done. Strange for the doctor to say that that, I mean, you know, two of her three siblings have type one, and sadly, you don't know if the third one might have gotten it at some point. You, you know, you didn't have the opportunity to know that. Like, weird to think that it's not worth looking into. You know what? I mean, like, it seems obvious to me that it's a possibility, yeah,

Mike 57:22
especially when you have, you know your father, who was diagnosed in his 50s,

Unknown Speaker 57:29
yeah, yeah, legitimate.

Mike 57:31
So I really do want to get her tested. I don't know how much time we have, but I do have a great story of a dog story.

Scott Benner 57:37
I'll finish with a dog story. My God,

Mike 57:40
all right, so we have a house in southern Utah, and I would go hiking with my dogs a lot. They're both standard poodles. They'll be three years old this September, and they're brother and sister, and the sister is her name's Delilah, and I took her hiking on a Saturday, and my wife and I, we did four and a half miles, and the next day I got home from, you know, a two and a half three hour bike ride. My wife was not home, so I said, by eight, my blood sugars were about 190 and I said, All right, let's go. Let's go for a hike. And we hiked up to a top of a mesa, which is about 1000 vertical feet, about three quarters of the way up. She started looking back at me, and I was like, I'm okay. I thought maybe I broke her from the day before, and then about five minutes from the top, she just stopped and sat down, and I I pet her. I'm like, you're okay, you're all right. I'm sorry I broke you. And then we went, and then the vision started going. I went, Oh my gosh, I'm going low. Oh, she's trying to

Scott Benner 58:37
stop, yeah. So I

Mike 58:39
knew once I got to the top, I'd be okay, because my heart rate would come down and I'd be okay. So we pushed to the top, and sure enough, it went away. When I really went low last December. I didn't realize this at the time, but when I was sitting on the floor sweating, Delilah was right there, just staring at me, and I didn't put it together or anything. And then three weeks later, I was down Southern Utah again, hiking, and I started going lower, and all of a sudden, she kept looking back at me, looking back at me, and I was and then I put it together. And so whenever I drop low, if we're out hiking or walking, she will alert me. 10 to 15 minutes before that, I am dropping and I assure I'm okay, but she's naturally a diabetic alert dog. She won't wake me up or anything. But when we're out hiking the lower I go, she will actually, at some point, just sit and stop and

Scott Benner 59:32
like, gosh, isn't that awesome? That's really. Do you ever say to her, hey there? Delilah, oh yeah, all the time, I would. Does that start you singing the song, Yep, yeah,

Mike 59:46
but she's great. So we actually looked at having her professionally trained, and at the end of the day, we decided not to do it. Typically, they do that with puppies, not three year olds, but when they evaluated her, they actually really thought, okay, yep, she is an. Alert dog. We feel that we could get her, but I'm not uncontrolled enough to pay $11,000

Scott Benner 1:00:05
listen, you can't teach speed. That dog's a natural. Okay, yeah, exactly.

Mike 1:00:11
She is a natural. And I think part of that was, even when she was a younger puppy, one of her favorite games was to play hide and go seek in the house. And so she could find me in a closet, she would sniff me out. And so she's always really been in tune, but we didn't realize that until you know a few episodes in that she can recognize low blood sugars, which is really amazing.

Unknown Speaker 1:00:33
Is that breed known for that? Or no?

Mike 1:00:35
Yeah, we actually read that. They say one of the better Diabetic Alert dogs are poodles. About that.

Scott Benner 1:00:41
My parents had a poodle when I was born, not born, well, I guess born. When they brought me home, I'm adopted, and the dog, like, went after me one time, and my mom, like, got rid of the dog and, oh, wow, yeah, I've been told that story so many times because my mom loved that dog. Apparently, that was it. Like, my that's the story I was always told. Like, my mom's like, No, I wasn't gonna let her go after you. I believe the dog's name was Gigi, if I'm if I'm not mistaken,

Mike 1:01:09
yeah, I think poodles are great. I had one then she died about a year before we got the new ones. And she was 17. She was my girl. Went everywhere with me. You know, if I was out dinner, I would tell my wife, like, we got to hurry up and go home. I got to go home and play with Lily. That was my whole thing. Was going home and playing with her, and she died at 17, and it took me a long time to get another dog. But I'm all about the poodle breeds. I think they're amazing

Unknown Speaker 1:01:36
dogs. Yeah, 17 is a nice, long life for a dog. You know, if

Mike 1:01:40
I felt I got cheated. I felt I should have had another 17 years.

Speaker 1 1:01:43
Yeah, no, I can imagine. Well, Mike, you have a really good way about you. I enjoyed this too. What do you do for a living?

Mike 1:01:51
So I am director for a company that we do. We build data centers. Okay, so the power side of data centers, so like battery backup energy type system, so if the data center goes down, we still keep it up and running. So I'm a director, I have a sales team and a project management team, and we design and build data centers around the critical infrastructure.

Scott Benner 1:02:15
Well, it's really something, is AI going to put a real drain on power, the way they're talking about it? And do you guys, are you guys working on battery backup for that? I wouldn't imagine you could even, can you even approximate that kind of power?

Mike 1:02:29
You know, it's interesting, when you look at where, what we call is a network rack, of what the power capacity used to be for a network rack, say, five years ago, to where it is today. You know, back then, let's say thrive, three to five kilowatts per rack was a lot. Well, now you're talking anywhere from 511, 100 to 500 kilowatts per rack, really. And so the strain that it puts on those batteries, of course, everything's going lithium ion battery. When the AI servers spool up, they bring in so much power that actually, sometimes the utility can't even keep up, and they actually end up hitting battery backup systems to look for that power. So there's, there's a lot of strain on it, but data centers will never go away. If anything, they're getting more and more popular. They're popping up everywhere. It's an exciting time in our world. The actual hardest thing is now is it's not so much getting power to those systems. It's actually keeping them cool. That's going to be the challenge. Is keeping all those systems cool, because if they overheat, of course, they can't function. And how do you keep that much, you know, coolness around? So there's like direct to chip. You can do immersion it just goes on. That's a whole three hour podcast right there. It's it's exciting.

Scott Benner 1:03:45
Do you think the way that we create power is gonna have to change to keep up with it? I guess I'm asking specifically. Do you think that people are gonna have to look at more nuclear options to to generate electricity?

Mike 1:03:57
That's the way the industry is looking. When you get into like meta, Microsoft, Apple, all of those, they are looking at starting to do some type of nuclear, reactor, type things, many reactors to power those because of the amount of power drop. It's interesting. Data centers used to go to certain areas. Now data centers look for where they're wherever there's available power. So that seems to be what they're looking for. So if there's a utility that has an extra, say, 400 megawatts of power, that's where the data center is going. So that's where they look,

Scott Benner 1:04:30
you're gonna see the centers popping up where the energy already exists. Yep, yeah, that's gonna be how they pick their real estate. That's interesting. And you're not really limited. I mean, our data centers limited by distance. Not anymore, right? Because of the speed of the Internet doesn't really matter.

Mike 1:04:44
Not anymore. Yeah, yeah. And that's the way it used to be, used to want to put, like, data centers and populated areas, and now, with latency, it's just not really an issue. And so now they're popping up, and what you're seeing is is a lot of, like, modular power. Or containers that we can just populate all around the country, wherever we can get data centers. And so it's a changing landscape, and it's really exciting because we talked a little bit earlier, the way technology has changed over, let's say, the last 1020, 30 years. It's almost like a year now is really only like a month. It's just going so fast, it's changing so quickly,

Scott Benner 1:05:23
yeah, maybe one day it'll just be like, Back to the Future, and we'll all have our own, our own little

Unknown Speaker 1:05:28
reactor. We almost wait and then again, Mike,

Mike 1:05:34
it's almost going to be that way, right? Like it just has to power. Is going to be the biggest thing, drivers, but it also as a consumer, it's scary too, because as my utility rate going up because of all these data centers, because they have to add capacity, you might see that too. Your electric bill going up because they got to build more infrastructure to support the data center.

Scott Benner 1:05:55
My electric bill is definitely higher than it was a year and a half ago.

Mike 1:05:59
Absolutely. I asked my wife last night, and she said, Yeah, we were about $500

Scott Benner 1:06:03
a month. Yeah, like, ouch. I see it climbing, for sure. So all right, well, that's a that's definitely a different conversation, but I appreciate you sharing that with me. Thank you. I just, you're, you're, you know, good at talking. And you said, before we got got going, that you speak a lot at work, but I didn't ask you for what, so

Mike 1:06:22
I'm on the phone all the time. And my wife, she's just, yeah, she'll tell you, I can talk to anybody all day long.

Scott Benner 1:06:29
Well, it's, I think it's a great skill to have. It's, it's propelling me through my adulthood. So thank you absolutely. Yeah, I really appreciate this man. Hold on one second for me. Thank you. You

this episode of The Juicebox podcast is sponsored by the contour next gen blood glucose meter. Learn more and get started today at contour next.com/juicebox you thanks for tuning in today, and thanks to Medtronic diabetes for sponsoring this episode. We've been talking about Medtronic mini med 780 G system today, an automated insulin delivery system that helps make diabetes management easier day and night, whether it's their meal detection technology or the Medtronic extended infusion set. It all comes together to simplify life with diabetes. Go find out more at my link, Medtronic diabetes.com/juicebox.

I can't thank you enough for listening. Please make sure you're subscribed, you're following in your audio app. I'll be back tomorrow with another episode of The Juicebox podcast. Check out my algorithm pumping series to help you make sense of automated insulin delivery systems like Omnipod, five loop, Medtronic 780 G twist tandem control IQ and much more. Each episode will dive into the setup features and real world usage tips that can transform your daily type one diabetes management. We cut through the jargon, share personal experiences and show you how these algorithms can simplify and streamline your care. If you're curious about automated insulin pumping, go find the algorithm pumping series in the Juicebox podcast, easiest way. Juicebox podcast.com, and go up into the menu, click on series, and it'll be right there. 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 comfort or community. Check out Juicebox podcast, type one diabetes on Facebook. The episode you just heard was professionally edited by wrong way recording, wrong wayrecording.com.

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Scott Benner 10/4/25 Scott Benner 10/4/25

#1644 Bolus 4 - Bananas

Jenny and Scott talk about bolusing for Bananas.

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Scott Benner 0:00
Welcome back, friends. You are listening to the Juicebox podcast

in every episode of Bolus for Jenny Smith and I are going to take a few minutes to talk through how to Bolus for a single item of food, Jenny and I are going to follow a little bit of a roadmap called meal bolt. Measure the meal, evaluate yourself. Add the base units, layer a correction. Build the Bolus shape, offset the timing. Look at the CGM tweak for next time. Having said that, these episodes are going to be very conversational and not incredibly technical. We want you to hear how we think about it, but we also would like you to know that this is kind of the pathway we're considering while we're talking about it. So while you might not hear us say every letter of meal bolt in every episode, we will be thinking about it while we're talking if you want to learn more, go to Juicebox podcast.com. Forward slash, meal, dash, bolt. But for now, we'll find out how to Bolus for today's subject,

nothing you hear on the Juicebox podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your healthcare plan? Jenny, let's do a simple, simple food, right? Yay, bananas. Banana. Bananas, before diabetes, were a thing that hung in my house on like, a little hook, right? And they were like, grab and go food, you know, like, if you got up in the morning, you running out the door, you didn't have time, you took a banana, you know, your middle of the day, you're hungry, grab a banana, and then all of a sudden it felt like bananas were more like we gave Arden an IV of glucose, and so they became lesser around the house for a little while. They're back now, but you know, let's talk about how to Bolus for one because I bet you that people you know, would like to utilize bananas, but people with type one are probably thinking like, that's a tough one for me. Yeah. So what do you think about a banana?

Jennifer Smith, CDE 2:08
Well, I am excited that you brought up bananas, mainly because I think it brings into consideration something that you wouldn't really know about unless you studied sort of food chemistry and how things how things work in food. So bananas are not unique, but they're a great example of a ripeness factor, and when we're talking about bolusing for them, like my husband can eat a banana whether it's green or yellow with brown spots, it doesn't matter. Okay. He likes a banana. It's totally fine. Green bananas, they make me kind of cringe, yeah, but the fact of the matter is, their glycemic impact is going to be much lower when they are not as ripe, and the reason is because the sugars are not as developed, the easiest way to describe it, so the carbohydrate content isn't changing. But how quick your body can digest the carbohydrates the sugars changes as the fruit becomes more and more ripe. It's also the reason, similar to other really ripe foods, meaning, when we're going to eat them, your tropical fruits, your melons, we eat them at peak, peak ripeness, because that's when we have the most sugar flavor. Yeah. So if you're going to eat a banana, like, I like, if I eat a banana, I like a banana to taste like a banana.

Scott Benner 3:39
So I think that when they're not ripe enough, how do they feel? To me, like they're powdery. Does that make sense? It feels like there's a All right, this is gonna be a weird thing for me. I love this

Jennifer Smith, CDE 3:48
conversation. Okay, you're like, a mouth feel kind of person, too.

Scott Benner 3:53
They feel like they're coated in powder or something like that's the I get, like, an icky feeling when I bite into one that's not ripe enough at the perfect ripeness. And to me, that's, it's still solid, but a little soft and not squishy, and there's no brown like, that's the perfect spot for a Benner. For me, I could probably eat like three of them, if, because they're they're so tasty. There is that your sweet spot for a banana too. No pun intended.

Jennifer Smith, CDE 4:16
It is. They're not squishy yet, right? You would not make banana bread out of them, those usually have lots of brown dots. Yes, they are yellow. And you can, I don't know if you've ever done this, people are gonna be like, Jenny, it's just weird. But I can smell the difference. Oh, sure. I can smell the skin, even if it's turned to the color that I think it should be to have the taste that I want. I can smell it and be like, nope. Another day, like, I know this will be good tomorrow.

Scott Benner 4:47
Does that mean that in practice and theory, there are three different kinds of impacts you might get from a banana, like the ripe impact, the just right impact and the squishy impact. Yes, geez. So you know what it makes me think of. You know when people. Will say, You know what I hate about diabetes, do the same thing over and over every day, and it comes out differently and blah, blah, blah. But if you're just having a Benner every day as they get riper and riper, you are not doing the same thing over and over every day, correct? Interesting.

Jennifer Smith, CDE 5:12
Okay, yeah. Whereas other fruits, you know, things like apples, which tend to be lower glycemic in terms of the whole scheme of fruits, our berries tend to be fairly low glycemic. Kiwi, interestingly, tends to be lower glycemic. Pears that are a little bit more crisp, crunchy, like an apple, tend to be lower glycemic. Most of the fruits that you're going to eat at that place where they taste the best to you, they're going to be a higher impact. You're making me think

Scott Benner 5:40
I'm going to make banana bread next time I see the bananas get a little bananas get a little soft too. I haven't done that in a while. So okay, so if you're gonna, if you're a person who likes a greener, less ripe banana, it's gonna take less Pre-Bolus time, right, significantly, or just less, less by

Jennifer Smith, CDE 5:57
let's say you're a typical 20 minute Pre-Bolus person for a ripe banana, for a non ripe banana, kind of greenish, yet you're probably looking at five to 10

Scott Benner 6:09
minutes honestly. And then to swap on the other side of that middle line. If you're a squishy banana lover, it's gonna hit you right away, right? She's on the face she just made like, Oh, please don't eat them when they're like that, listen, I'm with you. Like, there's a moment they get a little too soft. And I was like, I can't do this anymore. They go in my freezer. Then, oh, that's a good

Jennifer Smith, CDE 6:28
idea, yeah, I put them in the freeze. I've got, like, a banana bag that I put them in in the freezer, and then they either become we chop them up for smoothies, or we make banana ice cream, yeah, which is super fun. Or you can make banana bread out of them. I thought

Scott Benner 6:43
you're gonna say banana hammock. And I was like, wait, don't do that. Here's one for you. When they get too soft, I use them too my god, I use a little piece of a soft banana in the cages with my reptiles. Because if fruit flies get in there, they congregate there, then the animals can go over and, like, pick them off real easily. So see, it's a good you're still functional. Yeah, cool. It's not that cool. It's bizarre. So regular ripeness in the middle 20 minutes, I would

Jennifer Smith, CDE 7:15
say 20 minutes, honestly, and maybe first thing in the morning, if you're a I have to have my banana. First thing every single morning you might be looking at longer is the

Scott Benner 7:25
banana. One of those things the morning that, like, if you're doing the like, I'm gonna Bolus while I'm getting ready, I can time it so that I hit the kitchen, scarf down that banana as I'm going out the door, and it'll just grab the fall the insulin and hold me there. Yeah, yeah. Okay. I know it takes a lot to think about it, but this is a great example of, like, timing an amount. Here it is, you know, and understanding the impact of your food. Now, the real super squishy ones, that's like, liquid sugar, almost when it gets in your mouth, like it hits you real, real quick.

Jennifer Smith, CDE 7:53
It's gonna hit you really fast. I mean, it's one of the things I really like for lower blood sugars, because it does work really fast, at least for me, are the unsweetened banana chips like the dehydrated banana because they work fast. And usually those are, you know, at a point where they're really easy to slice, and then they dehydrate them and whatever, yeah, they do to them.

Scott Benner 8:17
But quick, if Arden gets low overnight, she has two different kinds of lows. Like, there's a low where you're like, Hey, I just need something quick to fix this. And there's a low where she says, I feel like this is because I'm hungry. I don't know. Like, if that makes sense, I don't think there's anything in my stomach. Like, I need to eat something now, even at like, three in the morning, when that happens, she always asks for a banana. Oh, that's interesting, yeah, because it fixes the low and it makes her feel fuller, and then she's good. She doesn't always want food when she's low, like, she doesn't always want a full feeling when she's low. Sometimes she just wants the number to

Unknown Speaker 8:51
get fixed, right? Which would be

Jennifer Smith, CDE 8:53
juice, because juice doesn't really make you have a fullness, yeah?

Scott Benner 8:58
Just bang, bang. That's nice and easy. But when she's also feels hungry at that time. It's always a banana. She asks for, like, always, oh, okay, so, I mean, obviously we're going to need to look down the road and see what happened afterwards, because I think a lot of people are going to get a spike when they're first trying to figure this out, right? If you Bolus for it just right on the Pre-Bolus and the, yeah, the timing and the amount was all settled. Is a banana really a thing you have to look at later. There's not going to be any, like, late rise.

Jennifer Smith, CDE 9:24
There's not going to be lingering. It's going to be a true what insulin was formulated to cover, which is carbohydrate, yeah, in and out, right? And in and out, yeah.

Scott Benner 9:33
So banana and all and simple sugars in general are about like, quelling the spike before they happen. So it doesn't happen, and then just using enough insulin so that it doesn't create a low later. But you shouldn't see a high from it if you stop the high from ever happening. Does that make sense? Because of the right Pre-Bolus? Okay, all right. So, I mean, so still look, you know, afterwards, and see, you know, how am I making out? But that's going to be to fix your Pre-Bolus. For it next time, not really about anything else, correct? Awesome. All right. Well, I'm glad I picked something you were so happy about. I said, Jenny, like, we have a little bit of time left. You want to do bananas? She lit right up. Can I tell people? You said, Sure, I was just talking about bananas with somebody else today. And if you don't want advice from a person who is already talking about bananas, even when they're not being recorded about it, then I think you're crazy that Jenny is definitely the one. Yeah. Thank you very much. Thank you.

In each episode of The Bolus four series, Jenny Smith and I are going to pick one food and talk through the Bolus thing for that food. We hope you find it valuable. Generally speaking, we're going to follow a bit of a formula, the meal bolt formula, M, E, A, l, B, O, L, T. You can learn more about it at Juicebox podcast.com, forward slash, meal, dash, bolt. But here's what it is, step 1m. Measure the meal. E, evaluate yourself. A, add the base units, l, layer a, correction B, build the Bolus shape, O, offset the timing. L, look at the CGM and T, tweak for next time. In a nutshell, we measure our meal, total carbohydrates, protein, fat, consider the glycemic index and the glycemic load, and then we evaluate yourself. What's your current blood sugar? How much insulin is on board, and what kind of activity are you going to be involved in or not involved in you have any stress hormones, illness? What's going on with you? Then a we add the base units your carbs divided by insulin to carb ratio, just a simple Bolus l layer of correction, right? Do you have to add or subtract insulin based on your current blood sugar? Build the Bolus shape. Are we going to give it all up front, 100% for a fast digesting meal, or is there going to be like a combo or a square wave Bolus? Does it have to be extended? I'll set the timing. This is about pre bolusing. Does it take a couple of minutes this meal, or maybe 20 minutes? Are we going to have to, again, consider combo square wave boluses and meals, figure out the timing of that meal and then L, look at the CGM an hour later, was there a fast spike? Three hours later? Was there a delayed rise? Five hours later? Is there any lingering effect from fat and protein? Tweak, tweak for next time. T, what did you eat? How much insulin and when? What did your blood sugar curve look like? What would you do next time? This is what we're going to talk about in every episode of Bolus for measure the meal, evaluate yourself. Add the base units, layer a correction, build the Bolus shape, offset the timing. Look at the CGM tweak for next time, but it's not going to be that confusing, and we're not going to ask you to remember all of that stuff, but that's the pathway that Jenny and I are going to use to speak about each Bolus. Hey, thanks for listening all the way to the end. I really appreciate your loyalty and listenership. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox podcast. The episode you just heard was professionally edited by wrong way recording, wrongway recording.com,

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Scott Benner 10/3/25 Scott Benner 10/3/25

#1643 Grand Rounds: Stephen E. Gitelman, MD

A conversation with Dr. Steve Gittleman on predicting, preventing, and treating type 1 diabetes—covering genetics, environmental triggers, screening, and emerging therapies like teplizumab to delay or alter disease progression.

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Scott Benner 0:00
Welcome back, friends. You are listening to the Juicebox Podcast.

Dr Steve Gittleman 0:13
I'm Dr Steve Gittleman. I direct the children's Diabetes Program at the University of California at San Francisco. In this role, I help manage patients in the clinic, and then I spend a lot of my time in the research world trying to better understand why type one happens, and how we can alter that natural course of progression to clinical diabetes.

Scott Benner 0:36
My grand rounds series was designed by listeners to tell doctors what they need, and it also helps you to understand what to ask for. There's a mental wellness series that addresses the emotional side of diabetes and practical ways to stay balanced. And when we talk about GLP medications, well we'll break down what they are, how they may help you, and if they fit into your diabetes management plan. What do these three things have in common? They're all available at Juicebox podcast.com up in the menu. I know it can be hard to find these things in a podcast app, so we've collected them all for you at Juicebox podcast.com Please don't forget that nothing you hear on the Juicebox podcast should be considered advice medical or otherwise. Always consult a physician before making any changes to your healthcare plan or becoming bold with insulin. The episode you're about to listen to was sponsored by touched by type one. Go check them out right now on Facebook, Instagram, and of course, at touched by type one.org, check out that Programs tab when you get to the website to see all the great things that they're doing for people living with type one diabetes touched by type one.org I'd like to thank the ever since 365 for sponsoring this episode of The Juicebox podcast, and remind you that if you want the only sensor that gets inserted once a year and not every 14 days you want the ever since CGM, ever since cgm.com/juicebox one year, one CGM. Today's episode is sponsored by the tandem mobi system with control iq plus technology, if you are looking for the only system with auto Bolus, multiple wear options and full control from your personal iPhone you're looking for tandems, newest pump and algorithm. Use my link to support the podcast tandem diabetes.com/juicebox, check it out.

Dr Steve Gittleman 2:33
I'm Dr Steve get I direct the children's Diabetes Program at the University of California at San Francisco. In this role, I help manage patients in the clinic, and then I spend a lot of my time in the research world trying to better understand why type one happens and how we can alter that natural course of progression to clinical diabetes.

Scott Benner 2:54
Awesome. I would like to understand a little bit about your background first, so I'm going to take you back a little farther than people usually do when you're in high school. What do you think you think you want to be when

Dr Steve Gittleman 3:02
you grow up? Well, yeah, I think the seeds for me were planted even earlier. I say that just because of issues within my family, you know, I think a lot of people that end up in a diabetes career have both personal and professional motivators. So for me, what I heard about as a child growing up was my maternal grandfather, and he developed type one shortly after the discovery of insulin. He was kind of held out in our family as just, you know, one of those miracle experiences he lived many decades. His Life wasn't easy. I heard how he had to take a train from upstate New York to Boston to pick up his regular allotments of insulin, and how my grandmother modified her recipes to make them more appropriate for someone with diabetes. So I heard about his life then I watched as others on both sides of my family developed issues, either with type one or other autoimmune issues. So you know, I saw firsthand how that impacted their lives. My next intersection with the whole challenge was my father happened to work as an adult kidney specialist at the University of North Carolina, where I went to medical school, and I was very surprised as a medical student, to see young adults who are his patients who had kidney failure. You know, I used to nudge him. Why aren't your patients doing better? This was, you know, a different era before we really understood how important it was to keep blood sugars in a near target range to prevent these things. But he basically gave me a nudge and just said, you know, why don't you try and help the field? You know? Why? Why is this happening? Can't we better manage diabetes? I think you could prevent all this if you really knew what was going on. So I think. That was, that was the gauntlet, uh, threw it down to me at an early, early

Scott Benner 5:04
age. And so does that lead you to endocrinology? Then that idea?

Dr Steve Gittleman 5:10
Yeah, so in high school, you know, I was interested in science and biology and intrigued by what he was doing as a physician scientist, I think the two things I kept in the back of my mind as I was heading off to college was, gosh, I think I like biology. Probably want to go into medicine, but, man, I really enjoy summer camp. I want to make sure I can stay involved as a camp counselor and be outside and play. So with those two primary goals, you know, frame shifting down many years of training. You know, diabetes, you know there was that personal connection and just scientific curiosity, yeah, but then I spend a lot of my time at diabetes camp every summer, and so somehow, I guess those high school goals came to pass.

Scott Benner 5:59
Excellent. Hey, what other autoimmune issues run through your family?

Dr Steve Gittleman 6:04
Yeah, it turns out I have a grandparent with rheumatoid arthritis. There's thyroid issues, others with type one. I think those are the main, main issues of note.

Scott Benner 6:15
And how about for yourself, or any of your FA Do you have children?

Dr Steve Gittleman 6:19
Maybe. Yeah, yeah. So I do not have type one, and I always preface this by saying yet, because, you know, I have those genetic underpinnings, and this can happen at any age, less likely as you get older, I have three children, and they've all been screened for their risk repeatedly over time and have tested negative to date, but you know, we continue to watch them closely over time.

Scott Benner 6:46
Sure. Well, I'll knock on something for you. Thank you. Yeah, yeah, no, of course. So Okay, right now today, you're a practicing physician, but you also consider yourself, just like your father, you're also involved in research, so I feel like maybe we want to talk more about the research aspect of what you're doing first, how does that begin? And how long ago did you start? I don't know if you have a lab or what you do, but I'd like to understand how you're set up and what your goals are.

Dr Steve Gittleman 7:12
Yeah, along the way in my training, I did do a lot of laboratory work, and it was not in diabetes, specifically, a great experience. I think I got fairly deep into that and missed, you know, more personal connections with patients. So I shifted gears and moved from that lab based existence to more clinical research. You know, I think the question that many of us working in type one have continued to ask over time is, why can't we screen and predict who's at risk and stop this from happening? Yeah, I think it's an exciting time. It's, you know, it's very natural question to ask. You would think we would have answered this many decades ago. You know, I think we're making nice inroads in at least the prediction side, and then if you can find people at risk, Boy, wouldn't it be nice if we could delay or prevent diabetes from happening? So I think finally, we have at least one therapy that's that's doing that.

Speaker 1 8:16
Which do you think is, is the answer in terms of therapies, or

Scott Benner 8:21
you said you think you have a therapy. I mean, there's a, I mean, there's a couple of them out there, right? But is there one that you that you like the best

Dr Steve Gittleman 8:29
when we talk about altering the course of type one? I think there been, you know, you can intervene, really, in three different arenas. And you probably talk about these widely on your your podcast. You could come in before clinical disease try and screen and predict and try and prevent it from happening. You could come in shortly after diagnosis and try and extend what we call the honeymoon phase. At the time of diagnosis, you may have up to 40% of your insulin producing beta cells. Beta cells still present. So extending that honeymoon can make a big difference clinically. And then for people with longer standing type one, you know, I think the question is, why can't we replace the missing beta cells? So it's kind of, you know, those, those three main places to intervene, prevention, preservation, replacement. So if I was going to make a t shirt for my research team, I think that would be the that would be the tagline, yeah, yeah, that's the mantra. You know, I don't work much on the replacement side of things. I follow very closely. I think that's very exciting. But I do think a lot of what we learn on the prevention and preservation side may apply to the replacement side. So I think there's nice conversation between investigators that work across those three phases to inform and support and guide each other.

Scott Benner 9:55
How do you describe what you're most focused on? Which of those three phases? Interests you the most, and where are you having the most success?

Dr Steve Gittleman 10:04
Yeah, yeah. So, you know, as a pediatrician, I think a lot of our focus is on prevention. Prevention trials are different, difficult to conduct, and so what's happened over time is a lot of times our proven ground is come in with something shortly after diagnosis to try and extend the honeymoon. And if it's safe and effective there, it's something that we can consider taking into the at risk population and maybe think about using in replacement strategies.

Scott Benner 10:37
Okay, let me make sure I understand. So if you had a mechanism to extend the honeymoon and it was safe, then maybe you could use it prophylactically in high risk people. And I guess you'd just have to, if they didn't get type one, you'd say, I guess it worked. The entire thing, as you're talking about it, is so predicated on finding these people, getting them to be interested in helping over long term, not being able to really promise them anything that part of it seems incredibly frustrating to me, even as you're just starting to as you're starting to explain it, can you talk about how difficult it is to find the people to even work with?

Dr Steve Gittleman 11:15
Yeah, I think that's a great question. So it kind of takes us back to, you know, screening strategies, which we've been actively working on around the world for several decades now. And you know our initial focus has been on families where someone already has type one, because we know just from studying family history that they're 10 to 15 fold higher risk. The unaffected family members are 10 to 15 fold higher risk for eventually developing type one compared to the general population. You know, we've looked to try and better understand genetics. The genetics of type one is very complicated. A lot of it is driven by genes that determine self versus non self, but there are over 50 other regions in the genome that are involved. So genetics alone is tricky to use as a predictor. In and of itself, we think that your risk for developing type one is driven by a combination of both genetics and environmental triggers. It's even harder to prove genetic or environmental triggers. You know, we all face such a myriad of different things, I think we have some good leads there, and we could talk more about that. But practically speaking, I think one of the big breakthroughs was screening for an immune measure called Auto antibodies. And we don't think the auto antibodies are causing the destruction of the beta cells, but we think that they're a signal that the immune system has been turned on and is actively targeting the beta cells, and so we can measure now up to five of these different markers in the bloodstream. And I think what we've learned is if you have two or more of these markers, eventually you're very likely to develop type one diabetes. So the first part of our predictive algorithm is really looking at that immune marker. The other piece that we use is, if you're moving down a pathway towards type one, sooner or later, you'd expect your metabolism to start to shift. And so usually this is not something someone's going to notice clinically, you know, with the classic signs and symptoms of nuance of diabetes, but there's subtle increases in blood sugar. And so we can do a stress test on the pancreas, the beta cell, and do an oral glucose tolerance test, much as much like what is done during pregnancy to screen for diabetes, and so we can start to see mildly elevated blood sugars. That tell us, not only is the immune system turned on, but the pancreas is starting to be challenged and not functioning fully normally. And so, you know, we now break these, these steps into what we call stages. So stage one, two or more auto antibodies, we now call that the onset of type one. Biochemically, blood sugars are normal. You're asymptomatic, but eventually we think you'll move to clinical diabetes and need insulin. Stage two is the combination of the immunologic activation, the antibodies, plus the subtle change in blood sugars, we call that stage two, and then stage three is what we used to call nuance at type one. That's when your blood sugars are elevated. You need to initiate supplemental insulin therapy, but you still have those that under current of beta cell function.

Scott Benner 14:40
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Dr Steve Gittleman 17:01
I think this is, you know, one very challenging aspect of all the work we do. And I should say that all this work is funded, you know, in in larger research teams, the National Institutes of Health has been a tremendous funder of this breakthrough, T 1d has been very helpful their international organizations in Europe and Australia all trying to better understand this. And you know, we compare notes and work closely together. There have been lots of interesting studies into this question, and a lot of it's based on epidemiologic observations. So for instance, a lot of interest in early feeding practice. Can breastfeeding prevent the development of type one? Can avoidance of cow's milk formulas prevent the development of diabetes? You know, we see these interesting observations and studies and populations that support these notions, but we don't really know for sure, unless we do kind of a classical clinical trial, you know, what we'd call a randomized perspective, placebo controlled study to answer it. And for the milk question, it was a really nice study called trigger that was conducted in patients in many places in the world. It didn't work. And so I think the prevailing thought is, well, there are two prevailing thoughts. You know, I think one is maybe the beta cell just isn't a very robust cell and doesn't handle stress very well. So maybe it's a series of different challenges over time, whether it's different feeding issues, whether it's different viral exposures over time, just some of that non specific inflammation and challenge to the beta cell. It catches up to it over time, and it just can't withstand those, those challenges, the inflammation and and other aspects, and it fades, and you don't have enough there to sustain your blood sugar control, right? I think the other issue that's been at the forefront of thought for quite a while is maybe, you know, there's a lot of lot of interesting observations that suggest virus is a culprit and different infections. You know, most of the infections have been dropping over time because of vaccination, but viruses have been a challenge. Highest risk for for type one is as you move away from the equator towards the poles. If you move from a region of low risk, say, you know Cairo to Helsinki in Finland, which is the highest risk in the world, you assume that risk in the region you've moved to, there's a seasonality to type one presentations. There's kind of clusters outbreaks, and certain locales where we see type one. So it starts to suggest, you know, infection and maybe virus is part of this. And there are studies suggesting that particular viruses may. A way to home to and invade the beta cell itself and cause destruction. One amazing development will be if we can define particular virus or types of viruses that do this and then vaccinate against them early in life, and just at a very early stage, eliminate risk for progression to type. One sure, a lot of work going on in this area. So I'm, I'm not doing it full justice, because it's, it's complicated, and it's, it's actively evolving, but, but I think you have the gist of it.

Scott Benner 20:32
No, I do. My most of my daughter had Hand, Foot Mouth before she was diagnosed, and at some point, Francisco Leon from prevention bio, who, I guess they eventually sold their their drug off to Sanofi, right? It's to miss a Plov now. Is that what it is? When he was on the podcast, he talked about his idea of like, I'd love to be able to vaccinate for Coxsackie, because I think if we stop kids from getting Coxsackie, we might stop kids from getting type one diabetes. And he seemed very passionate about that, that specific idea, I feel like that's what you're saying here too. Is that there's it's so interesting, like, as you move away from the poles, you said, away from the equator, excuse me, towards the poles. How many people come on here, and while they're telling their story, I don't think it's of any surprise. Many people are very captured with the desire to understand why they or their child got type one. And you know, as they're speaking, you can almost after you do it long enough, you can almost just jump to it and go, Hey, are you know? Are you English or you know, is your background? Are you Scottish? Are you from this part of the country where, you know, like you you're talking to somebody from America, and you realize, like, they're from Minnesota, and their their lineage goes right back over to, you know, Scandinavian countries. And there's a lot of through lines there that I've seen just from talking to people over and over again. It made me feel like kind of going back to my first question about, like, how do you possibly get all these people to do this work. I was thinking like, Would it be easier to just give everyone a survey and ask them all the things you need to know? And at the end, the last question is, do you have type one diabetes? Because that I keep thinking like, I mean, how old are you, sir, 6767 you've been at this a while. I imagine I have indeed, yes, yeah. How do we take what's in your head, like, your lifetime worth of experience and layered on top of somebody else's so that we can continue to, you know, to move forward and not just, like, not have the things that you know, those little aha moments that you've had? How do we not let them disappear so that we can actually get to an answer? I mean, that's a big question, but,

Dr Steve Gittleman 22:42
yeah, you asked a few questions, important questions in there, you know, I think part of this is, you know, the scientific process, you know, we study, we publish, we critique, we're intellectually honest with each other. We try and build on, you know, any positive study to move things forward, we try and learn from anything that didn't work. If it didn't work, why didn't it work? You know, we just stand on the shoulders of the people that came before us. So it's, you know, I think there, there's some issues in life, some diseases that are just simpler and, you know, we have the answer and we're on to other things. You know, gosh, penicillin will treat strep throat. You know, a week or two of treatment, you don't look back. Type One is a complicated issue. You know, simplest terms, it's selective destruction of a single cell type. But the why of it? You know, it's not a single answer. There's not a single gene, not a single environmental trigger, likely, not a single aspect of the immune system. But it's this complex stew of things that we have to disentangle to move things forward.

Scott Benner 23:55
Because if you consider, I mean, everything you've brought up, and even everything that I've seen over the years, like, if it's, you know, there's some environmental and some, you know, I mean, I can't tell you how many people have come on here and said, like, I had a car accident, then I got type one diabetes, or, like, you know, like I had a very traumatic event, somebody died, and then it happened. There's some people who think that trauma started. I'm pretty certain my daughter's Coxsackie is the impetus. But of course, if you look back through my my wife's family, there's a ton of autoimmune stuff with those people. They're, you know, English and Irish lineage. There's things that now, in hindsight, I can say like, Oh, that makes sense. My wife has thyroid issues. So does my son. I'm adopted, so we don't have any idea of, like, what I bring to the mix, right? But I can tell you that I've been anemic through my life, like there's sometimes you start interviewing people, talk to a mom, and then she tells you about her family's background and the husband's family background. And I just initially think, like, oh my god, I bet you three of her kids are gonna have an autoimmune issue. And an hour later into the conversation, they all do. And I just want, I don't know if I've talked myself out of my question. I. Don't know. Like, I feel like everything that's being gathered it all makes a ton of sense, but I see what you're saying that. Like, why would like, I guess the question would be, like, why, if I have a family of six people and they all are living in the same house and all experience the same death of a person, or we're in the same car accident, why does one of them get type one and not the other? Like, that's the real question, right? Like, it's why you and not me.

Dr Steve Gittleman 25:23
Yeah, yeah. I mean, I, I'm the father of twins. They're not identical twins. But if you study identical twins, that's in some ways, kind of ground zero for genetics. You know, if twin a has type one diabetes, what happens to identical twin B and the classic observations would say, Well, maybe 30 to 50% of those unaffected twins will eventually develop type one. It turns out, if we follow the unaffected twin long enough, like you know, 567, decades, eventually, twin B does develop type one. It is intriguing that the timing is very different. The nature is very different from one individual to another. And, you know, although twins grow up in a similar environment, they diverge their genetics. You know, it's kind of a misnomer that all aspects of the genome are the same between identical twins. You know, the immune system has very complex rearrangements over time. But it just tells you, you know, genetics alone isn't the answer, and we just need to know more about those environmental triggers. You know, there's kind of parallel worlds that we look constantly across that, you know other other complex diseases in in our human experience that are this tricky interplay between genetics environmental triggers, right? So I think some of the best studies that are being done, such as the the environmental determinants of diabetes and youth, the Teddy network, some of the efforts in Scandinavia, they're trying prospectively in life, to collect all biologic samples from a given individual at different periods over time and careful histories and surveys and things, and then go back and try and link infections and life experiences to changes in the immune response and changes in metabolism and risk for progression to type one. So I think the right stays are being done. It just takes a lot of people and careful analysis and reassessment over time to put the pieces together. I'll make one other comment is, you know, I think a lot of the focus is you're kind of alluding to is people of Northern European ancestry, type one happens, you know, in almost any race ethnicity, it's increasing where it's being studied. The incidence is increasing in different places around the world. In the US, it's increasing, probably at a higher rate in those of Latino ancestry, we're just starting to understand some of the issues with type one, for instance, in Africa, where we know clinically that people look like they have type one with loss of beta cells, but the process may be very different. We talk about type one is, if it's one entity, but we're starting to realize that, you know, maybe there's subtypes. Maybe there's, you know, different pathways, different triggers, different processes, that result in this n clinical picture where, gosh, you don't have enough beta cell function and you have to take supplemental insulin. Yeah, probably the more I talk, the grayer it all sounds.

Scott Benner 28:43
This is where the conversation is really though, because if I stop and look back at all the different things that I've spoken to people about, people who come on and talk about, I don't know, they had hives, and then they took an injectable and the hives went away. Like, isn't there something to learn from that? Like, isn't there something to learn from how GLP medications are impacting people right now, you know, and their inflammation, for example, is there not something to be learned from isn't all of this going to, in the end, be somehow connected? I think this podcast lets me have these kind of big conversations we've I obviously have no specific training. I don't understand any of this. I'm just the person in the middle who, luckily or unluckily, gets to have a lot of conversations with a lot of people with autoimmune issues. And like, you know, one that I bring up a lot that started to shock me, but stopped shocking me now is the amount of people who will say that they have a bipolar person in their family line, like the amount of people I talk to have type one diabetes, who are like, Oh, my uncle's bipolar, my aunt's bipolar, my grandmother was bipolar. Like, it's overwhelming. How many people bring that up? It's overwhelming. How many people with type one diabetes talk about anxiety in their families? This many people can't have anxiety. Like, and is that all inflammation related? Like, are all these things somehow tangentially to. Touching each other, and is the key to understanding the big picture, understanding little bits of all of the pictures. I keep sitting here thinking like, you know, I had this conversation with this researcher once who he thought that covid was great for research because he said he thought it forced labs to start sharing with each other more. And then I had another person come in here recently who said that they think that AI is going to be one of the ways that they can get through all this information, maybe more judiciously otherwise. Aren't you just waiting for some happy accident? Do you know what I mean for you know what I'm saying?

Dr Steve Gittleman 30:37
Yeah, yeah, you again, raised a couple of very interesting issues for me to comment on. Please take the guest prerogative and selectively and address one or two of them, because they're all all great conversation points that we could spend a lot of please. Please. You know, how do you pull all these different observations together, or any kind of unifying hypotheses that we could use and capitalize on and think about intervening to alter the course. So, you know, these are hard hypotheses to prove and act on, but I'll just, I'll throw two of them out there. One is obesity and the accelerator hypothesis, and the other is what's called the hygiene hypothesis. And you know, these probably have been talked about in other podcasts, and I'll just try and succinctly mention them, and then I want to talk some about things that have been successful, and they give us hope that we can alter the course of this, even if we don't fully have all the pieces of the puzzle. So the accelerated hypothesis suggests that, gosh, if you're overweight or obese, that kind of starts to look like risk for type two. Your pancreas has to work harder, secrete more insulin. You become resistant to insulin, and in fact, you know those at risk and progressing to type one, there's a high chance in this day and age that you will be overweight or obese. So maybe that is an additional stress and strain in someone who's at risk for progressing. They might progress faster to stage three or nuance at diabetes. So you would think, you know, maybe if we treated obesity earlier in the in the course of life, maybe we could lower the risk. We haven't done that study but, but it is a way forward the hygiene hypothesis. It'll take me a minute to set this one up, please. I'll just tell you that full family disclosure, my wife is a children's infectious disease specialist, and of course, the goal in her world is, let's minimize risk for infection, and so in a world now where we're very careful with antibiotic use and Purell and avoiding infections and exposures and using vaccines widely, it's great for minimizing risk for infection, And I am not in any way bashing vaccines in the discussion today. I don't think they have any role in initiating autoimmunity, so I'll just get that out there. But maybe by lowering risk for infection, we're increasing risk for autoimmunity, and that maybe some of those early exposures and infections that were common in prior decades would were actually lowering risk for autoimmunity. So the tension in our family is, you know, if food falls on the floor, I'm happy for the kids to pick it up and eat it, and she's horrified. And I'm being a little silly here, but you get the idea that maybe in a more sterile world, we've increased our risk for autoimmunity. The risk is increasing, not just for type one, but for all autoimmune conditions.

Scott Benner 33:48
Yeah, what's that? George Carlin bit, where he says, When he grew up, they used to swim in the in the East River, and everybody was healthy as a horse, and that river was disgusting. I take your point. So as we get more I guess, adept at keeping everything clean. We're not giving our bodies opportunities to have small, little, conquerable infections and germs that it can learn how to deal with. And therefore, you've sheltered your immune system, and then all of a sudden, you slam it with something, and it doesn't know how to fight back at all, and boom. You think the beta cells. It's po I think I heard you say earlier, maybe the beta cells are just a little more easier to damage, maybe, or less able to like, I don't know. I know. I forget how you put it exactly, but it's, it's odd, because Steve, I feel like it stuck with me, but then all your words left me. But what was it you said that it's possible the beta cells are be less resilient. Less resilient, okay,

Dr Steve Gittleman 34:41
you cut your skin. Gosh, it'll repair beautifully many times over and On you go. But maybe beta cells, they don't regenerate very well. They don't handle stress very well. They're just not a very robust, resilient cell type, yeah, yeah, but I don't want to leave people. Are feeling hopeless, because we actually have had some very exciting results with interventions. If you want, I can train, you know, give the view from 10,000 feet on where those stand and where I see that going.

Scott Benner 35:14
Yeah, no, well, first of all, I don't see your conversation is feeling sad at all. I It's incredibly interesting. I'm again, Steve, you don't know me. I barely graduated from high school. I have no I did not go to college, and yet, like just making this podcast, I think, has allowed me to just hear people's stories in a different way, maybe because I don't have any preconceived notions, or I don't really even have the ability to talk down to anybody. I don't have enough education to even do that. The odd little things that I've seen along the way, I'll give you one from my personal experience, I'm maybe two years into using a GLP medication that I only used for weight. That's why I was using it. I've lost 70 pounds. Wow. I weigh about 166 pounds today. I think I started at 236 Wow. Congratulations. Thank you very much. I had been anemic a lot of my life. No bleeding, no like, I just anemic, and it caught up to me in my adult years, to the point where I would have to get iron infusions just to, like, exist, because my ferritin would go down into single digits sometimes, and I couldn't function. I have not needed an iron infusion since I started using a GLP medication, and my ferritin stays up now. Now simple like, guess maybe my digestion works better, and my food is actually having time to be processed differently, and I'm actually getting the iron out of my food and I wasn't before. I don't know if that's the reason. That's my guess, but what an interesting thing to learn. You know what I mean, like an unexpected thing to learn. Like, how crazy is it about how many women who couldn't get pregnant their whole lives, who believe they have PCOS, for example, went on a GLP and then got pregnant? Those are the little places where I think, like, don't ignore what that means around inflammation, or what it could possibly mean around inflammation. There's this documentary, I think it's just on Netflix. I have no idea how valuable it is or not, but there's this person in it that tells this story. It's about gut biome, the documentary, Ah, yep. And she talks about how she took, you know, the details of it, I think probably would skeeve people out, right? But she took, you know, she she seeded her gut with somebody else's fecal matter. I don't know the technical aspects of how this works, but she did it you're doing well, no, thank you. She did it from either a boyfriend or a brother, and she developed the person's acne. So she had never had acne her entire life. She seated herself with this person's and then the person has acne, and she got acne, so she thought, well, I'll change to the other person. She's a change to the brother, or change to the boyfriend. I forget what the order was. And then that person is depressed. And she'd never had depression in her life, but developed depression when she did it. And I thought, like, that's like, worth remembering. Like, I don't know what to make of that. Do you understand? Like, I'd be a terrible scientist, Steve. I'm already bored with the idea. I'm like, That's a great idea. Someone should do something with that. But like, I wouldn't be good at digging through the details of it, but I think somewhere between ladies with PCOS having kids, and guys not being anemic anymore, and this gut seeding, and people with type one, and I feel like glps being used with people with type one are going to teach us a lot over the next decade. And I'm so excited to find out what those things are going to be. You know, injectables for allergies and like, what are they quelling in the immune system? Like, what is there to take out of that? Like, it feels to me like there are little bits of all these things that will someday, I don't know. I feel like someday you're gonna load all these into your personal computer, Steve, and ask it to make sense of all of it. It's gonna spit the answer back out. And I just, I wonder how long that's gonna take, but I'm excited for people like you to figure it out. I want you. Are you paying attention to AI, like, or is that like, yeah,

Dr Steve Gittleman 39:07
yeah. No, absolutely, absolutely. And you know, there is so much information that we're collecting, but it is hard to know how to best sift through it, and the data sets get larger and larger for all this. So I agree with everything you're saying. It kind of feels like, boy, they're important breadcrumbs in and around us. How what we follow, and you know we gonna Is there a meaningful end along that path?

Scott Benner 39:35
Yes. So yeah, go ahead. Your 10,000 foot view of it, please. Yeah.

Dr Steve Gittleman 39:40
You know, we talked about being able to screen and predict, I will tell you, up until 2018 there had been a number of very well conducted prevention trials and those at risk for type one, you know, they were supported by these epidemiologic observations. We've been talking about, the interventions were tested in animal models of type one of which, they're not too many and too many good ones, unfortunately and oftentimes. There's a pilot study that suggested, hey, I think this is going to work. The long and short of all those studies up until that point was we could identify people at risk. None of the treatments worked. We were frustrated, the field basically shifted to the idea that, why don't we focus on people with new onset type one, where we again, we could see if we could find something safe and effective there, and if it worked, then we could bring that into prevention. Okay, I will tell you, as we're talking today, there are actually 11 different therapies that have extended the honeymoon now, and I'm talking about larger, what we call phase two or higher level studies, placebo controlled, well powered, you know, with a reasonable number of people, one of those has been well evaluated at stage two. So moving from people with nuance of diabetes, where it extended the honeymoon safe and effective, to looking at people at high risk at stage two, and that's the drug you mentioned earlier, called teplizumab, that's the first prevention trial that worked. We can talk through the details. We probably don't have time for all

Scott Benner 41:21
that, but Steve, first of all, I make a podcast. I have nothing but time. We're only on your schedule. Don't worry about that. But the second thing here is, I'm going to ask you a question if you're not comfortable answering. Because I'm going to ask you to just kind of guess. But I have been wondering for years why Sanofi would pay $3 billion for a drug that is so hard to administer, and I can only come up with that. They must feel like something else is going to come from it at some point. Is that a fair guess on my point? Or do you have a thought about it? That's a lot of money to buy a drug? Yeah.

Dr Steve Gittleman 41:55
I mean, I'm not a business person. I'm a Yeah. But you know, in the history of man, the only other approved therapy for type one is insulin, you know, that's replacing the missing component, the missing hormone. It's not getting it. The underlying root cause of the problem teplicit Mab is, you know, a type of immune therapy called a monoclonal antibody. It targets T cells, which we think is a very important part of that immune infiltration and destruction of beta cells. So it's getting more at the root cause of things. So, you know, I think, you know, we've been tremendously excited that this, after years of development, it's getting a toehold, and it's basically, first of all, I think it's showing we know what we're doing here. Here is a therapy that can delay, if not, you know, prevent, until the end of time, the development type one, it doesn't work for everybody. You've mentioned the challenges in giving the medication, and there are a number of questions we can ask based on the success, but, you know, I think we have to mark the moment and realize, wow, so we can do this. Where shall I go with the discussion from here? Let me talk a little bit about some of the aspects of duplicit map and where I see it going and and then kind of bigger picture, about therapies. Thank you. So just to kind of summarize what success looks like at this point in time. So the studies to date, you know, it was one prevention trial. It was about 76 people. The average delay in the onset of type one was two to three years in the group that got the drug versus those that were in a placebo group, some of those people who got the drug have now gone over 10 years without developing type one. The treatment in the trial was daily IV infusion of the medication in an outpatient setting for 14 days and then stopping nothing, no further therapy. The people that are having that long, lasting response. It's a little over a third of those who got the drug. You know, we can look at this glass, half full, half empty. Not everyone responds. It would be nice to know up front. Can we predict who's going to have that super extended response? Or could we know shortly after they've gotten the drug, how the immune system's changed? We're not there yet. We're working on, I think we have some good leads.

Scott Benner 44:29
Did they have any other auto immune benefits other than not getting type one? They get sick less often, anything like tangible

Dr Steve Gittleman 44:40
you know there, there's certainly occasionally people that have other concurrent autoimmune issues, and I don't think there have been enough for us to really know if it alters the course or risk for other autoimmune conditions, the main other things that run with type one thyroid disease and maybe up to 20% Celiac disease, maybe in five to 8% not clear that any of those other conditions are impacted by this. Okay, you would also wonder, well, this is great. How can we build on this response and get an even better response? One of the considerations is maybe we give a second course of this sometime down the road, another 14 day. Course, it could be at a set time interval, like six or 12 months later, it could be following the immune and metabolic response and coming in if it starts to slip. This has only been used in eight and older. And as I mentioned, I think at the top, the incidence of type one is increasing, particularly in younger children, or it's increasing at a rate of three to 5% per year for those under age six. So it would be great if we get these therapies into younger children, and we actually have fully enrolled a study now for children under eight to look at the safety and efficacy in that age group. The idea of simplifying the regimen, as you mentioned, it's not the world's most convenient thing to have to get 14 daily doses and disrupt your life and spend your week and weekends with us. So ultimately, someone has to explore a different therapeutic protocol. And I'll just leave it at that. You could wonder if this could work even earlier in the disease process. I mentioned we used it at stage two, that highest risk point, but maybe if we came in earlier at stage one, it could work even better. I also mentioned that we have 1111, treatments that look very promising in new onset, really duplicit maps, the main one it's gotten. You know this notoriety because we've conducted a stage two study with it, but you could think about any of those other therapies that have worked at stage pre new onset, and move them upstream into Stage Two or stage one, and evaluate them. And those would be the things you know, if they worked by different mechanisms, if you're thinking about combinations, maybe use to place a map plus one of those as a way to really get an additive or synergistic response. So, you know, for me, I think we're, we're at the end of the beginning. You know, it's super exciting that the policeman has worked. You know that that idea that we learn from what we've done in the past and try and build on it? I mean, now's our time. I'll just tell you one other thing you mentioned. I don't know if you you stated as positive things from covid. One thing that we learned from covid was we were conducting a teplicit Bab study during covid, and so a lot of studies were stopped. You know, because of the risk of immune therapy during covid, we don't think of this drug as immunosuppressive. We think of it is immunomodulatory. We give it for a brief period of time, it resets the immune response. It doesn't require chronic therapy. And so we're very keen to continue the studies during covid in part to evaluate its safety. And sure enough, in the trial, the people who got to please med were not at higher risk for covid or severe covid, or, you know, required hospitalization or treatment for covid, it occurred in an even likelihood between the drug treated and the placebo group. So we learned a lot about just kind of the nature of this therapy, kind of the thoughts of using it moving forward. Moving forward, right?

Scott Benner 48:43
That's interesting. If you feel like you've said everything you I mean, obviously I think you could probably talk for another year about this, but if you feel like we've buttoned that up nicely, Can I shift you a little bit into into your practice and ask you a couple of questions? Okay, yeah, that's awesome. Thank you. I appreciate it. I know it's a big change I'd like to throw out to you an episode or two that I've done in the last couple of years that sticks with me over and over again, right? So I talked to the mother of a young girl who has type one diabetes. She's in her teens, and the mom has PCOS and had a weight struggle that she eliminated with GLP medication. She notices the daughter, who's had type one for many years, of three, four years, type one diabetes, using, you know, 50 units a day, like, you know, has the genetic markers. She's type one, et cetera, the daughter is starting to gain weight. The mother sees it as maybe PCOS as well. Talks a doctor into GLP for the kid. Sometime not long later, the daughter takes her insulin pump off and is only injecting one unit of basal insulin a day, which goes on for a long time now. A couple of years later, her insulin need is rising again, just. Put her pump back on recently, etc. If all that on its face is true, what? What the hell happened? Why would a kid who's been using insulin full force for four years suddenly not need hardly a fraction of it for two years on a on, just on osempic?

Dr Steve Gittleman 50:20
Yeah. So this is a provocative area. It's extraordinary.

Scott Benner 50:23
And I know it's Yeah, yeah. Most people I talk to, if it helps them, they get maybe a 15, 20% reduction in their insulin needs, right? And I'll make the argument that maybe they have insulin resistance on top of type one, and that's why it's helping them. But this one specific story freaks me out.

Dr Steve Gittleman 50:39
Go ahead. I'm sorry, yeah, no, I think without knowing more details or studying this person more in a clinical research setting, it may be hard for us to really know. Let me see if I can set up the response. I went on and on about therapies to target the immune system. Part of our idealized therapy for type one is take the edge off the immune response and, you know, decrease that autoimmune attack. But what can we do to support the beta cell? What can we do to help it function better regenerate? We actually have lots of potential, promising drugs. On the immune side, it's still a big question mark on what to do to support the poor beta cell. Into that conversation comes the question about GLP, one receptor agonist, and a few other types of drugs these days in animal models, the study suggests that the GLP one receptor paragus might be doing some interesting things to beta cell survival, certainly function, maybe regeneration. There's been some hope that that could be part of the missing puzzle, and that if we combine immune therapy with this class of drugs. That's the secret sauce. The studies to date that I've seen haven't looked I mean, I think what they show is, if you have beta cell function, the GOP one receptor agonists are very helpful in in supporting the beta cell, in secreting the insulin it's capable of making it's not clear that it's altering the natural course of disease, that it's preserving beta cells longer or causing any regeneration. You know, in your particular example, I'm not sure I can fully answer the question. You know, it may be, as you mentioned, that it lowered insulin resistance, that there was pre existing beta cell function underneath everything, and it just helped the existing beta cells function better for a period of time, but ultimately, over time, the beta cells fade and disappear. When we talk about the honeymoon, it can be highly variable. And basically the number of those cells, the function of those cells, the durability of those cells, it's most closely related to your age of diagnosis. So two year old is who gets type one? I think that's what you mentioned your My daughter was just too Yeah, yeah. Yeah. She probably didn't start with very many, and they probably disappeared fairly quickly. You know, if you got type one tomorrow, you probably would have a lot more beta cells there, and they would last longer, and you'd have a much different experience for this child, adolescent that you're describing. Is so. What I should say is, at any age, despite what I just said, there's a great deal of heterogeneity. Some two year olds will have more of a honeymoon. Some adults may have a very short honeymoon, and some may have a very long honeymoon. So age is a proxy for something we don't fully understand in this process of beta cell destruction. But I think in your in your example there, I think the GLP one receptor agonist might have come in and helped support her underlying beta cell function. While it existed, she had a nice ride in her honeymoon. It just ended up fading, and then she's now having to give insulin back.

Scott Benner 54:21
Yeah, my expectation is that somewhere between the PCOS and the weight gain that was muting whatever kind of honeymoon she was going to have, and then you kind of lift that weight, and then the honeymoon kind of returned. It's almost how it like, I mean, that's a very rudimentary way of thinking about it, but like, that's the only thing that makes sense to me after talking to them a couple of times in the podcast and hearing their story, but I mean, she was literally down to injecting one unit of basal a day. Yeah, yeah,

Dr Steve Gittleman 54:51
that's quite a remarkable story. Yeah. And those, those are the kinds of stories. Those are like the breadcrumbs that we're talking about earlier. Is if we know unusual cases and try and tease apart how and why things are happening there, that might give us important insights to what we do moving forward with a, you know, a larger trial,

Scott Benner 55:13
no, I think so too is going to be quite a pivot. But you said that at some point you thought you were too bench focused and not paying enough attention to your to your patients, that's obviously happened a long time ago to you. Can you kind of lay out for me and for other endos who are listening, what your I guess, core theories are about how to support your patients. How do you, what did you do with that information you know, that experience, and how did you turn it into a practice that's been going for so long? How do you, what do you think the keys are to supporting people with type one in a clinical setting?

Dr Steve Gittleman 55:45
Yeah, that's a big question. A lot of this gets to the heart of just training and practice of clinical medicine in this day and age, I think traditionally, training is an in hospital experience. Most of what you know, trainees in medicine are learning is someone who's had an acute challenge and is admitted for ketoacidosis, and, you know, goes into the intensive care unit, out to the ward and then is sent home their next next intersection with someone with diabetes. You know, it's probably a very busy outpatient clinical setting where you know they may only have 15 minutes. How in the world can you really appreciate what life with a chronic condition like diabetes is about in those kinds of experiences? So I think part of the fundamental change for me, I just happened to maintain my curiosity about diabetes, despite the fact that I was working on a very reductionist aspect of Endocrinology in a laboratory. And, you know, I asked my department chair to go to diabetes camp one summer. You know that one week experience to me was just revelatory. You would think I would have known growing up my family and other types of experiences, but just kind of, you know, meeting kids, living with them, looking at how challenging it was to ask them or their families to make such complicated decisions, day in and day out. You know, there's no other condition quite like this, just trying to convey that challenge and making sure as healthcare providers that people have the empathy and realize the inadequacy of the tools that we're giving people. You know, I think that's a large part of what I tried to bring to our clinic and our team and just try and help people along the way. Yeah, that's lovely. That's part of what shook me up and just helped me shift direction. I will say one other fundamental change that I think has been great for pediatricians. You know, it used to be and you probably saw this with your daughter. Kids get up to graduate from high school, and you know this school says, Congratulations, here's your diploma on you go to college or your first job. We did the same thing in diabetes clinic. Yeah, you've graduated. We've done all we can for you. Good luck. And there's a lot that gets lost in those ensuing years as a young adult. And so one thing that has been very helpful to us with, you know, some of the change in healthcare legislation, and being able to follow people up to 25 now in a pediatric practice, through Obamacare and other mechanisms. You know, we get to support people through those further years. And so I think the baton is passed from healthcare provider to that young adult in a very different way. Now we kind of just ensure that all that success in the pediatric years is maintained as they move on to an adult diabetes practice

Scott Benner 58:59
carried over into a time when they can actually, you know, what do they talk about? You know, your brain is not fully formed till you're in your mid 20s, right? Like until it That's right. It makes a ton of sense to me. The, you know, I go back to over and over again interviews I've done with adults who are, you know, in their late 20s or early 30s, who retrospectively look back on their college years or after high school years as times when their parents said, oh, you know, you know what you're doing, and then they went off and they just completely ignored it for four years, or, you know, like or to put very little effort into their management. And then, as adults with a fully formed brain and an understanding of what had happened to them over the last decade. Come on here and tell me, I wish my parents would have stayed involved longer, even if I was pushing them away as an adult. Now, I wish they would have pushed back on that because of what I think I lost in my health by by allowing an ill formed person who's not ready yet. Take care of something so complicated to be the sole provider of the of their own care for those formative years right in there, yeah. I've just heard it so many times that I believe in it so strongly. Yeah, yeah.

Dr Steve Gittleman 1:00:15
One, one slide that I often use in educating, you know, trainees, and also with parents, is this image of a child riding a bike and then the parent, kind of running along beside them or near them to catch them if they happen to fall. So we really stress this idea that you're you're focusing on this, this, this notion of interdependence that you know maybe you're not hovering quite as closely I just would not fully let go. It's too important an issue. It's so much to ask in an adolescent and young adult who's got so many other things they're working on, staying involved and supporting as best you can through those years is super important to their long term success.

Scott Benner 1:00:59
It's an incredible balance to strike, and I'm in the middle of this with my daughter right now, between her spreading her wings and feeling confident and me not smothering her and also not allowing her a 1c to go from where we were able to keep it as a child to where it ends up for most people when they're 21 in college. So you know we are. The balance we're trying to strike right now is that she manages herself the way she likes, as long as her a, 1c, stays in the sixes somewhere, and if it starts to drift up too high, then we have another conversation about, hey, you need to Pre-Bolus. You know, when you see a rising blood sugar, we can't ignore that. You're gonna have to readdress it my daughter, you know, for transparency, we, I don't know if you call it micro dosing, because she doesn't do it every day, but she uses a less than therapeutic amount of of Manja No, which really helps, which really helps her, but be even down to, like, take your thyroid meds like you think that's easy. It's a little tiny pill. It's not that easy. When you're 21 to do it every day, you know, and to remember, I always say Steve, like, when this part's over, if she doesn't hate us and she's healthy, we won that. I give up and I'm done then, then I'm out that I'm that I'm sending a card that says, Congratulations on the birth of your diabetes. Good luck taking care of it. I gotta go. I can't thank you enough for for the time and the thought that you put into this. I'm going to tell you right now, while we're still recording, anytime you want to come back on for any topic that you think would be important for people to hear about, I'd be thrilled to have you.

Dr Steve Gittleman 1:02:32
Oh, I appreciate that, Scott, yeah, thanks for the thoughtful conversation. You know, I appreciate your questions and comments very much, a work in progress, but I hope we're leaving the conversation. You know, just hopeful we are getting there. I think the things that we're asking people to do with their diabetes today is going to get outmoded and get simpler and more definitive. Thank your family and all those others out there who are working through this. For your patients, it's taking time, but we are indeed getting there.

Scott Benner 1:03:06
I appreciate that very much. Okay, hold on one second for me.

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