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Scott Benner 0:00
Hello friends and welcome to episode 1249 of the Juicebox Podcast.

Today on another episode of the Grand Rounds series, we talked to a Pediatric Endocrinologist, Dr. chasms gonna pull back the curtain and share his perspective on endocrinology. Nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. T one D exchange.org/juice. box you want to help, you can go to that link, join the registry, complete the survey and just like that, you will have helped with type one diabetes research that's T one D exchange.org/juice. Box, do it do it as a favor of me please take you like 10 minutes. Let me pay back that favor. If you like comfortable and quality, you're going to love cozy earth.com Go there, buy whatever you want. Save 30% off of everything you get with the offer code juicebox. And don't forget the private Facebook group Juicebox Podcast type one diabetes on Facebook. It's the greatest community there is bar none. It's a private group. So you have to answer a couple of questions to get in. But after we know you're not an algorithm. We're a evildoer. We'll let you write in there and you can meet 51,000 Other people living with diabetes Juicebox Podcast type one diabetes, no evildoers allowed. Did you know if just one person in your family has type one diabetes, you're up to 15 times more likely to get it to screen it like you mean it. One blood test can spot type one diabetes early tap now talk to a doctor or visit screened for type one.com For more info. Today's episode is sponsored by screen for type one. And also us med is sponsoring this episode of The Juicebox Podcast and we've been getting our diabetes supplies from us med for years, you can as well us med.com/juice box or call it 888-721-1514 Use the link or the number get your free benefits check it get started today with us med The podcast is also sponsored today by Omni pod five that's on the pod.com/juice box get over your FOMO fear of missing out on Omni pod and get started today with the Omni pod five using my link links in the show notes links at juicebox podcast.com. to screen for type one.com us med Omni pod and all of the sponsors when you use my links, you're supporting the production of the podcast and helping to keep it free and plentiful. My

Dr. Nader Kasim 2:44
name is Nadia Kasam. I'm a person who has type one diabetes diagnosed when I was 18. But I'm also a pediatric endocrinologist. I just like diabetes a lot. From the sense of an academic perspective. I think it sucks as a disease. Yeah,

Scott Benner 2:59
let's pick through it a little bit. So you're 18 When you're diagnosed?

Dr. Nader Kasim 3:03
Yeah, so as at first semester of college, it was when I was getting ready to learn medicine. It kind of hit me like a brick wall presented in decay. In the hospital for like a week. I had all the symptoms I lost like 20 pounds. Yeah. Didn't know what was going on.

Scott Benner 3:21
Not in your family. Nothing you were expecting.

Dr. Nader Kasim 3:24
Not really a distant relative with presumably type one. But everyone else has type two,

Scott Benner 3:31
presumably type one means they don't know. But that's probably what they have. Yeah, yeah. Just so old. They don't talk about it that way. Yes, yes. Gotcha. I have diabetes, I can't drink soda, something like that. Ah,

Dr. Nader Kasim 3:45
more so, you know, several generations ago, so I really can't explain what was happening at the time. How

Scott Benner 3:53
about other autoimmune issues, anything like that in your family or for yourself?

Dr. Nader Kasim 3:58
Alright, no, actually, no thyroid, no celiac. No inflammatory bowel disease or anything like Pernicious anemia or anything like that. Nice.

Scott Benner 4:06
I'll knock on wood for you. That's very good. Keep that going for you. So you're diagnosed the date teen you're away at school or somewhere local to your family.

Dr. Nader Kasim 4:17
So I was kind of both I was actually at school. I was living alone, but my family lived in the area. They were there. I had support, but I didn't see them often enough to really get their input on how to deal with things.

Scott Benner 4:32
Okay. How long ago was this? How old are you now?

Dr. Nader Kasim 4:34
I guess is my question. Yeah, some 3719 years. Yeah, you can do the math. Yeah,

Scott Benner 4:41
look at me. It's pretty impressive. Yeah, you saw me, not her. I was like 38 would have been 20. I'll just take one off of it. And that's exactly how my brain did it just now.

Dr. Nader Kasim 4:53
I do the same. Yeah, of course.

Scott Benner 4:54
So okay, so you it's an interesting time, right? Because you're diagnosed people We'll know you're a kid still, but you're away at college. So there's not a lot of, you know, there's not a lot they can do. If you want to keep going to college, they're not going to know, you also start learning about diabetes, presumably, or hopefully, while the rest of your family is not brought up to speed. So is that was that you're finding like, there was no one to help you?

Dr. Nader Kasim 5:21
I don't know if I would say it that way. There are people there. It's just, even though symptoms happen relatively rapidly. Because it's progressive, it takes a while for someone to say something. So you know, even it took 20 pounds of weight loss, falling asleep in the middle of class, for someone to say something. And it really took someone who hadn't seen me for a bit to say, You don't look well.

Scott Benner 5:51
It's hard because not everybody, you know, I just had a personal experience. I've lost 40 pounds using GLP medications in the last year. Nice. And I I'm looking for 20 More, by the way. But then I'm done. I was out in public, I saw a person I hadn't seen in years. And we're talking back and forth forever. And at the end, I said something about that. And the relief that came over them was really something because she said, Oh, I didn't want to say anything. I thought maybe you had cancer. Like it was that I looked that different to somebody but still, she wouldn't mention it. So like, it's it's interesting that it did a it takes a person who hasn't seen you in a while to notice enough of a change, but they also have to make the leap to say to you not are you okay? You know, it's really it's really something from your perspective. Did you notice the weight loss?

Dr. Nader Kasim 6:41
Yes. I mean, you do notice it, it's just you don't you find other explanations for it. And I mean, we've all heard this, right. Like, it's, you know, I, I thought I was getting sick with something else or had a stomach virus or, you know, so it's you play mental games with yourself. And because it's, although it's rapid, it's progressive. It's really hard to draw a line in the sand to be like, alright, nothing's right. I need to go seek care, especially as an adult,

Scott Benner 7:10
then how was your care? What did it look like for you 20 years ago is that I mean, that's faster acting insulin time, right? You were, you were doing I would imagine you started with MDI with something like love Amir Lantis.

Dr. Nader Kasim 7:23
So I was in DKA. So I was basically taken to the emergency room

Scott Benner 7:29
by a family friend. And, you know, I

Dr. Nader Kasim 7:34
started out in Saundra, and I was in the ICU for several days. And then when my dk or my diabetic ketoacidosis resolved, they switched me to injections. At that time, it was Lantus by vial, if I remember correctly, and rapid acting insulin was also by vial. Pens came out. It became more prominent shortly thereafter, so I switched relatively soon.

Scott Benner 8:04
And were you told taught to count carbs at that point. Getting older means a world of change, but some things still stay the same, like being at risk for type one diabetes. Because type one can happen at any age, so screen it like you mean it. If just one person in your family has type one, you're up to 15 times more likely to get it too. And 50% of type one diagnosis is happen after the age of 18. So screen it like you mean it. type one diabetes starts long before you need insulin and one blood test could help you spot it early and lower the risk of serious complications like diabetic ketoacidosis, known as DKA. So don't get caught by surprise. Screen it like you mean it. Because getting answers now can help you get prepared. The more you know, the more you can do. So don't wait. Talk to a doctor about how to get screened. Tap now or visit screen for type one.com. To learn more. Again, that's screen for type one.com and screen it like you mean it. This episode of The Juicebox Podcast is sponsored by Omni pod five, and I'm here to help you get rid of your FOMO fear of missing out on Omni pod. I see people all the time in my private Facebook group talking about their love for Omni pod five. Have you seen those posts and thought oh, I wish I could have that experience with an insulin pump too. If you answered yes to that question you might be experiencing FOMO fear of missing out on Omni pod. Now if you have FOMO it could be impacting you in all kinds of ways. Maybe you look at a body of water like a pool or a lake and think oh, I can't go in there. I don't want to have to like undo my pump and take off the tubing and all that stuff. I wish I could just jump in. Well, you could with an omni pod five. You might also just be scared. You look at a doorknob and you think oh it's coming for me. Can I take my two Being off, you won't have that thought with Omni pod five, I want to get rid of your fear of missing out on Omni pod by getting rid of these concerns. fantasizing about jumping into a swimming pool without disconnecting, or just wishing you could wear outfits without pockets. You're dreaming about Omni pod. The good news is you don't have to suffer from FOMO any longer. You can see all about Omni pod five, see what you're missing at Omni pod.com/juicebox. So no,

Dr. Nader Kasim 10:30
I was a carb exchange guy. The hospital I was diagnosed at was effectively a community hospital. So from my diabetes education perspective, you know, I got everything that I needed, but I wasn't really given the whole picture. You know, I was basically told, this is how you dose insulin. You know, you're supposed to, you know, one, one carb exchange equals this, you know, the multiple carb exchanges, you take this amount of insulin. It's given a sliding scale. I remember on the discharge summary, the sliding scale wasn't complete, it was all handwritten, and it wasn't completed. So remember, I had a high blood sugar. I was like, Oh, snap, I don't know what to do next.

Scott Benner 11:10
But, uh, yeah, how long? How long did you manage that way.

Dr. Nader Kasim 11:14
So the way it worked, then was they would actually refer you to your primary care provider, and then your primary care provider would refer you to an endocrinologist. So I'd say it took me about half a year to connect between the two. So I don't know if I really got any formal education or you know, kind of like a, like a medical home for a bit. Okay. It's really unfortunate. Yeah,

Scott Benner 11:41
so the healthcare provider just turns into the person who gives you like, here's needles, and you need a prescription for this and that kind of stuff. Yeah, yeah. And I,

Dr. Nader Kasim 11:51
I think from a medical perspective, like I was, I was given enough to, to kind of deal with the circumstance at the time. But you don't you don't get any of the nuanced stuff that you know, you kind of wish that someone told you later, like, this is how insurance works. You know, like, half your supplies might not come through the pharmacy. This thing costs a bazillion dollars.

Scott Benner 12:12
Yeah, Pre-Bolus. But now, I'm always high. If it doesn't come back down. It does, then it's fine. Yeah, that's the extent. So do you know what your outcomes were? Like? Like, say through your undergrad, for example? Yeah, so

Dr. Nader Kasim 12:31
I was pretty well controlled. So I honeymooned. So that helped a lot. And I kind of honeymoon for a bit, probably say, close to two years. I think it didn't take me long to figure out the impact of nutrition and activity and whatnot on blood sugar control. It did take me a while to understand what the big picture

Scott Benner 12:55
would be, as far as you know, what

Dr. Nader Kasim 12:57
the point of treating diabetes is. I'd say I lived a big portion of my life. genuinely having the goal of not being back in the hospital in the UK, when in all reality, that really isn't your primary driver. Right. You know, it's not not to have a heart attack or stroke or so, but I think for the most part, I did well, I did a lot of self learning. You know, I I wish that there were podcasts at the time that, you know, that would effectively you know, supplement. Whenever care, I did not get or supplement the care that I actually got their books. You know, I was I was in college, I was able to read medical literature. I I fared

Scott Benner 13:40
Yeah. Okay. It's interesting that you would say no, I mean, not interesting. Like, oh, I can't believe it. I hear people say it all the time, but that you didn't even have a goal in mind. Is is kind of fascinating, right? I mean, they 20 years later, doesn't that throw you off as a pediatric endo that, that people would that an 18 year old kid would be out in the world at college and not know why he was doing what he was doing?

Dr. Nader Kasim 14:05
Yeah, yeah. i And honestly, I still see this all the time. You know, in between transfers of care that we read, and people who've had diabetes for years, I asked, I asked that question. I'm like, what's going to come see us every three months? What's the point?

Scott Benner 14:21
And if I could tell you

Dr. Nader Kasim 14:24
how many I don't know how I was or, you know, I don't want to be in DKA. Or that again, no one really talks about the long term outlook.

Scott Benner 14:35
It's really common. Is it so common that it's not upsetting?

Dr. Nader Kasim 14:42
It really bothers me because you know, as an it's tough because I'm a pretender. So it's, it's hard. It's hard to expect a child to you know, to say this, especially if they're younger. But especially with like the older kiddos, just get them not knowing

Scott Benner 15:00
feels like, feels like feels like a big, big

Dr. Nader Kasim 15:06
gap in knowledge. And it's, you know, that's it's a place where emphasis should be placed, I think, do

Scott Benner 15:12
their parents know, generally speaking, where are you dealing with an entire family of people who just they're taking the steps, but they don't know why?

Dr. Nader Kasim 15:20
I would say, Yeah, I would say families as well. I think parents know, they just don't confidently know. So they're, they're aware that they're at risk for long term complications, you know, but it's, it's typically along the lines of I'm afraid of getting nephropathy or retinopathy. So like kidney disease and eye disease, because it happened to another family member, or it's because of, you know, to happen to someone that they knew,

Scott Benner 15:48
or I thought on a television show or something like that. Yeah.

Dr. Nader Kasim 15:52
Well, and just because it's, you know, you're talking mostly diabetes is type two. So, a lot of a lot of people who have type two, they can even get those complications early on, it doesn't take a long time, per se. Yeah,

Scott Benner 16:06
it's, um, I don't know, like, it just seems to me that, even while we're talking about it now, it wouldn't take me that long to explain type one diabetes to a person and why what they need to do is important, and then what those things are, you see it happen? I mean, you're in a position to do something about it, obviously, like, what's the, what's the thing that stops it from happening?

Dr. Nader Kasim 16:28
I think it's, it's partly because of our taught, like, as medical providers. But I also think it's part of human nature in the sense of how we think about things. So when we compartmentalize the two types of diabetes, so making generalizations here, but you know, we think of type two as the,

Scott Benner 16:50
you know, diabetes that's,

Dr. Nader Kasim 16:54
you know, heavily impacted by lifestyle choice and whatnot, when in all reality, that's really not what type two is, you know, for type one diabetes, we effectively remove the life style choice component of it. And we kind of put it in this box of, you know, we take insulin, and insulin normalizes our blood sugar. And that's how we treat it. That's correct, to an extent, because, you know, the most impactful thing you can do to reduce your risk of heart disease and whatnot, is to normalize your blood sugars, but there are many other aspects in life that impact your risk of developing these problems. I think if we can't convey this, then we're doing a huge disservice to, you know, people who are generally trying to lead healthy lives with diabetes, and they're not going to realize the impact of lifestyle choices until later in life. So it's going to be one of those too late circumstances. Um, but I think, on the medical side of things, we do the same thing. So when we're taught, you know, we, we oftentimes put a lot of emphasis on making lifestyle changes, or type two diabetes when you know, and then for type one, diabetes, there's a tremendous amount of focus on dosing changes, and, you know, the technology aspect of things. And when we kind of put the other things, I guess, to the side,

Scott Benner 18:25
it feels like, what you're telling me is that physicians are going to say, lifestyle, lifestyle lifestyle, and that's the last thing that patients are going to focus on.

Dr. Nader Kasim 18:36
That's also true, I think, I think it's, it's a harder thing to, it's a harder to harder sell. So if you have a short duration of time to meet with a patient, it's going to be very difficult to put a lot of focus on diet and exercise. And mental health is very similar to that, you know, and they're, they're very hand in hand, right?

Scott Benner 18:56
So the way I think about it, and the I guess the footing that I started off on with the podcast was I thought, well, I know about how to use insulin, and I know the good outcomes that come from it. And I'm pretty good at communicating those things. But here are the things that I can't control like I can I can put that information into people's minds into their ears and let them hear it. I can't control what they eat. I can't control if they exercise, I can't control if they're mentally healthy. Like there's so many things that I can't impact. What could I give these people? And I thought, I'll give them the knowledge of how insulin works, and they can apply it to their lifestyle, and at least have the healthiest outcome possible. No matter what their lifestyle is, like. I think that the things I talked about on the podcast would work as well for you if you had 20 carbs a day is if you had 200 carbs a day, then But moreover, the idea that you can tell somebody just eat differently, that'll help and that you should expect them to go Go home and do that is kind of insane to me. Like I know they should. I know we all should. But I don't think that's what happens. So I started with Well, let me give them something that's rock, solid and concrete. And then they can do what they're adults or they're the parents of children like they can do what they want to do with that information. And hopefully, they'll see the benefit of it, and make these adjustments along the way. I very steadfastly do not tell people how to eat, it is not in my purview. I do not care how you eat it, it's not up to me. But privately in my mind, if you don't think that I don't hope that you Bolus for a cheeseburger and fries with ice cream later, and then see what that's like. And then maybe the next day have you know, something a little more low carb, something a little more, a little less processed less oil, stuff like that and see the difference. I do hope you see that. But I don't think it's up to me to help you do it. That's sort of how I think about it. But you're in a different position. Like, you get the end of the stick if people don't have good outcomes, right, because they're gonna blame you at some point. diabetes comes with a lot of things to remember. So it's nice when someone takes something off of your plate. US med has done that for us. When it's time for art and supplies to be refreshed. We get an email rolls up in your inbox says hi Arden. This is your friendly reorder email from us med. You open up the email to big button it says click here to reorder. And you're done. Finally, somebody taking away a responsibility. Instead of adding one. US med has done that for us. An email arrives, we click on a link and the next thing you know, your products are at the front door. That simple. Us med.com/juice box or call 888-721-1514 I never have to wonder if Arden has enough supplies. I click on one link, I open up a box, I put the stuff in the drawer. And we're done. US med carries everything from insulin pumps, and diabetes testing supplies to the latest CGM like the libre three and the Dexcom g7. They accept Medicare nationwide, over 800 private insurers. And all you have to do to get started is called 888-721-1514. Or go to my link us med.com/juicebox. Using that number, or my link helps to support the production of the Juicebox Podcast, even though they're the one having the fries and the ice cream.

Dr. Nader Kasim 22:33
Well, so I think you're spot on. And I it's really the intention is not to necessarily dictate or tell people how they should be eating. But in all reality, it's it's to educate. It's you know, and even even when you look at the diabetes guidelines, like the recommendations, just a regular general pediatric diet, yeah. So but if I can tell you how many people are not aware of just aspects of eating. So like the differences between food types, you consider the processed food versus a whole food, the impact of protein, the quality of the protein, same with fats, you know, the quality of your fat and how that's actually really relevant. None of that is very well known among I'd say most, most people who have diabetes, as a medical provider, I think that's really how we should approach it is to teach people, I think, similar to many other things that involve behavior, you kind of need to gauge where people are at and whether that that advice is welcomed or not welcomed. But I think as a medical provider, it's important to at least broach the subject and at least get a feel as to where people are at just because of how relevant it is to

Scott Benner 23:47
know everything delve into that idea of welcome or not welcome for a second because I think if I can stand away cold and calculated off to the side, third person, it's your job to tell me whether I'm gonna listen to you or not. But you're dancing, a different dance, because if you lose the group, what is that going to have? It's going to put it that's like, it's like you're a head coach. If you lose the team, if you lose the locker room, you'll lose the team. So like, so if you come at somebody the wrong way, and build a wall between the two of you, you might never get that wall down again. But if you don't broach the subject, they're going to end up having trouble. And so you're left to decide how to deal with that. And I want to ask you your opinion, but it's been my, you know, my experience so far. A lot of times the brain that makes a good doctor is not the same brain that makes a great communicator. Is that fair? I think that's I think that's true. Okay.

Dr. Nader Kasim 24:42
But I mean, it's, it's someone walks in to the office, right? You

Scott Benner 24:47
have half an hour with them.

Dr. Nader Kasim 24:51
Entire half an hour is not going to be about eating or activity or you're not going to know exactly where they're at in life. You don't know what their stressors are. or you can certainly get a vibe for it. It's kind of part of your mission, you kind of need to figure out, Is this the right time? What's the level of interest? Someone willing to actually share their knowledge about that particular subject? And then really give them what they're, what they're ready for what they're asking, if they're receptive to feedback. You know, we see this oftentimes in kids that are active, that are involved in sports, you know, they're coming to you with questions, that becomes the theme of the visit, because the next time they come around, something else might be happening might not be a priority. So I think that's a really good way to

Scott Benner 25:37
kind of attack it from, you know, from that perspective, is it possible that the medium that I have to speak to people is just better suited to disseminate this information than an office visit? Or a doctor patient relationship?

Dr. Nader Kasim 25:53
Yeah, hands down on the table. I mean, it's just like what I told you about myself earlier, like, I needed to fill knowledge gaps, you know, when I got diagnosed, so I went ahead and sought out information, I was ready for that information I wanted to learn. So I think that's one of the pros of, you know, a podcast or a book or, you know, an online article, whatever is that you can seek it out when you're ready. Yeah, you know, but I think, you know, but even as a provider, we can still get a vibe, as to where someone's at in this conversation and potentially provide these resources. So I think there's a difference between going and seeking it out yourself versus, you know, being able to provide information when someone is actually ready for that, or if they're interested in it, is

Scott Benner 26:39
it possible that that may be should be communicated to a person, the the kind of idea that, look, there's this information here, you need it, if you have it and understand it, your life is going to be happier and healthier, and probably easier. But there is no way for me to rush you to the place that you need to be to absorb all this to want to absorb all this, I need you to know that it's here. I need you to know what it is. And I'm willing, as your physician to sit back and wait for you to be ready to take it up. Because that's the truth. Right? Like, that's how me You've described it. I've seen it here for 1100 episodes, and all the conversations I've had, this is exactly right. People do not take care of themselves until they're damn good and ready to. And often they won't do it unless it's for someone else. Like I'm getting married, I want to be healthier because or I'm pregnant, or I want to have a baby, or I want to be around for my family or I saw this thing happen. And I don't want that to happen to me. Like that's generally speaking how most people make the leap. Maybe it's important for them to know that this is a very human reaction they're having right now, I know, you don't want to hear about Pre-Bolus I know you don't want to learn that, you know, the French fries have fat in it, it slows down your digestion, and therefore, you know, you're gonna spike like 90 minutes after you eat them like, and you're gonna think I don't know what happened, I already covered the carbs. And you know, they need to know all that stuff. But is it not? Maybe incumbent upon us to tell them because as far as humanity goes, I don't know that we know a lot about ourselves. Like, you can stand back as a physician and say, I know how this is going. As a matter of fact, I bet if I said to you, right now, think of a patient that you don't believe is going to do well. These people start popping into your heads, you know what I mean? And then there's probably people who think, Oh, if they just make this one leap, I know they're going to do better. I bet this person figures it out when they're in college or when they become I'm sure these people all present you like different parts of this path. And but we don't know that about ourselves. Like, you know what I mean? Like, you always need somebody to tell you who you are, it's hard to figure it out for yourself.

Dr. Nader Kasim 28:51
Yeah, I I agree. And I think I think it's more so it's almost like a reminder, just like how you get spam, emails, advertisements that pop up, like they stuff like that just triggers you mentally. So I think I think if you engage in conversations repeatedly, your interest kind of shifts, and it's part of that is based on life circumstance, what your personal goals are, but also, if it's on top of mind more frequently, I think it's more likely to change. It's very similar to smoking. So if you think about people who smoke, you know, the more you ask them about quitting, you know, engaging where they're at better than they typically do. So I think it's kind of similar. I don't think it's remotely close, but kind of the same. Well, it's

Scott Benner 29:40
actually fascinating that you brought that up, because as you were talking, I thought, if the conversation keeps going the way I think it's going to, I'm gonna make a joke that we should get those PR people from the 50s who sold cigarettes to everybody and retask them with teaching people to Pre-Bolus or pay attention to like their foods or I I actually thought that Oh, like, let's get great marketing people to tell us good things that we need instead of the bad things. Maybe that would work. You don't mean like, there's something to that. I mean, there really is, like you said, you have to hear it over and over and over again, I've learned from making the podcast and even just getting someone to click on a link is an excruciating task. Like you have to first tell them that the link exists and explain to them what it is. And then sometimes you have to do that sometimes up to 10 times before they remember the link, and then think, okay, maybe I'll check it out. And that's just how we work. And so it makes sense. You know, it's interesting, because I'm doing these two series at the same time. And you and I spoke about this before we started to record because we weren't 100% Sure, and maybe still aren't. Which app which series this episode belongs into, but I'm doing this grand rounds thing, which is, it's aimed at doctors to tell them look, this is what people who have type one diabetes want to know, it's what they told us they wish somebody would have said or how they would have said it, etc. Here's the reasons why. You know, and Jenny and I are going through and discussing all of them. And at the same time, I'm doing another series called cold wind, where people are coming on health care providers, other professionals, completely anonymously. And they're basically blowing the whistle on what they see at their jobs. And, as I'm recording these episodes, I am stuck in this paradox where I both find myself vehemently defending the doctors, because they seem like they're in an impossible situation. And at the same time defending the patients, because these doctors are the only thing that they have. And it's just it's just a it's a situation that I don't like, the more more conversations I have about it, the less answers I say the fewer answers I say my wife would be so upset if she heard me say less answers, the fewer answers I see. But you know what I mean? Like you're in a, it's you. You're the one they're counting on. But you're in a human situation that that's almost unfair to ask, have you because it's probably not going to go well, unless they're in the right place to receive the information and then put it into practice? Yeah. So what do we do?

Dr. Nader Kasim 32:14
It's one of those things where I think

Scott Benner 32:17
you just you keep, keep pressing, you don't want to press too hard. You want to give them

Dr. Nader Kasim 32:26
you know, information that's relevant to them at that moment in time. I think that's all you can do. I mean, really, the the other thing that I've personally seen, that helps a lot is, and I think this goes to human nature, is that we learn from each other. So there's a big difference between telling someone to do something, or even effectively planting an idea, versus having someone learn from an experience or like a role model. Yeah. So as an example, like I do, diabetes can. And I can tell you, how often things change when, you know, children interact with other children who have diabetes. And it's not just from a dosing perspective, it's all the other behaviors that go into diabetes, it's all the other coping mechanisms that you have to basically feel normal in your skin. That's, that's not from anyone telling you anything, it's from seeing other people do the exact same thing, see them succeed, see them fail, see them get mad. So I think that's really valuable, too. Unfortunately, in the office, we can offer that. So I think that's where, you know, being engaged in diabetes outside of an office becomes really, really important. And I think it's eerily similar to things like your podcast, because it really does give a sense of community. And I think that's, that's a way that we learn as humans is to kind of emulate and, you know, mimic other human beings.

Scott Benner 33:55
You know, I've said this a number of times in the podcast, but I feel like it fits here as well. There's times when I think there should be mass appointments that are management specific, like not every time you come in, but what if twice a year or three times a year there, you know, there was a you guys did seminars instead of you know, and I know it turns into a billing issue and an insurance issue and like all this stuff, like it's the doctors don't have time to do it. But I've given talks, like to hundreds of people at a time, and then received back emails from a large portion of them, saying, Hey, I did better the week after I heard you speak. I don't even know why. I couldn't even begin to tell you what I did. But we talked about diabetes for two hours and my blood sugar's were better than next day. I think that's important. And I don't think people like it's nice to say that you went out and found the information, but you're who you are, and there are plenty of people who aren't going to go they're going to hear, count my carbs, shoot the insulin. drink a juice if I get low Don't be high for too long, because I don't want to be in DKA. That's it. And they'll do that every day, they will not change, they won't wonder about if there's more, they'll think that's the whole game. If their health gets bad, they'll say things like, well, that's just diabetes, or you know, it's my lot in life, it happened to me, never thinking like, this is a thing I could impact. And not not like, with information that's so hard to get or tools that, you know, I can never find like just understanding how insulin works, you can make a significant dent, like I say it on the podcast, because I want people to hear it and believe it, but just Pre-Bolus in your meals could bring your agency down a full point. But just that without even understanding the rest of it. And yet, people won't wonder about that. And it isn't until they get into a terrible situation, and go out to find a thing, that they even hear some of these ideas, but you have no idea how many notes I get from grown adults who have had diabetes for 20 or 30 years. Who will, they're praising me in this email, on and on and on. And when I get to the end, what are they praising me for? I taught him to Pre-Bolus their meal, they have 30 bad years, because they didn't know that, like, that's insane. Yeah, yeah, I'll say it again, I'm not sharing any special knowledge that I have, that the rest of the world doesn't have. I just found a way to communicate it in a, in a form that people can take up easily. And I've scaled it, which, uh, you know, if you're looking for things I'm proud of just scaling the podcast is a big deal. Like I was back, I'm like, Oh, I'm helping 10 people, that's really amazing. Like, you know, this, but a lot of people don't know the feeling of helping 10 people. It's amazing. 100 people, it's amazing. It doesn't really change the good feeling, whether you help one person, 10 people or 100 people, it's exactly the same. But once you realize that you have this knowledge that changed someone's life for the better. I almost get into a panic. I'm like, Well, how do I reach all the people who need to know this? And so I put a bunch of effort into scaling. And all it did was prove out over and over again, that this basic kind of baseline information, communicated well helps people on on a mass scale. How do we get that to them? In a doctor's office? Because most of them, believe it or not, are never going to find the podcast. Listen, here's what I'm Yes. My question is, you're diagnosed when you're 18, you're already on your way to becoming a doctor, did you become an endocrinologist? Because of your diagnosis? Yes,

Dr. Nader Kasim 37:28
basically. So I was going into as going into medicine at the time, so I did kind of like, you know, I'm going into med school, knowing, knowing freshman year of college, I didn't know what type of physician I was going to be. And then, you know, it's kind of threw me in the door.

Scott Benner 37:42
Can I ask you a cultural question that everyone's not gonna understand, but you will, and some people will? Sure. Did you want to be a doctor?

Dr. Nader Kasim 37:52
Oh, yeah, you did. And hence, hands down on the table. This

Scott Benner 37:54
was a family thing where you're gonna go be a doctor? No, okay.

Dr. Nader Kasim 37:59
No, both of my parents are like, math people and statisticians. And you

Scott Benner 38:03
know why I'm asking, though, right? Just because most physicians have family members that are? Well, I was actually thinking culturally, I see a lot of you're going to go be in medicine. Like, that's a good paying job. It's, it's a respectable job, go be in that job. And I just I know, a lot of kids who are currently trying to be nurses and doctors who don't want to be but their parents pushed them in that direction. I was just wondering if you were pushed by parents, or if it was the thing you actually really wanted to do? No,

Dr. Nader Kasim 38:35
I wasn't pushed by anyone. And actually, it's kind of funny, I was given advice not to go into medicine, because of the effectively the commitment and the debt burden and the high risk of not making it through the entire pathway and getting stuck with that. But I think, at least for me, just mentally, I'm a very

Scott Benner 38:57
sciency you know, type of person,

Dr. Nader Kasim 39:01
I geek out on technology. So just by by nature, I, I needed to be in a science field. And I was originally planning on doing computer science. And I actually did web design for a short bit and quickly realized I did not like it. When it wasn't for fun. So then, you know, that's how I basically landed.

Scott Benner 39:24
Okay. Oh, that's amazing. Are you more of a people person doctor or a medicine? Or do you try to straddle the middle? To be honest, I don't know what that is. So I think some doctors can be can lack people skills, and but still very passionately feel about what they're doing because they love the medicine of it. And I think there are some people who just want to help people, and they've learned the medicine so they could help the people. Does that make sense? Yeah.

Dr. Nader Kasim 39:51
I don't know. I don't necessarily think I do well, with people like in other words, I probably not well said but it's it's More so that, in general, I'm typically laid back. And I think, you know, through a care perspective, that also shows like, I am pretty conversational, really, my intention is to walk in, you know, get to know you as a person, that type of thing and troubleshoot things that are meaningful to you. So that's, that's how I roll. I've just taken my experiences from past medical providers, and I basically figured out that that's how I vibed well, with others, so I tried

Scott Benner 40:30
to try to do that. Yeah, I think if I was, if I was an endocrinologist, I've never thought about this before, but just now it started running through my head. I think if I was an endocrinologist, I would be like, of the camp of like, listen, we're all gonna, like, talk and be nice and have be friendly and everything. But by the time a year goes by, you're gonna know how to handle how to handle your insulin and your meals. And then we'll branch out from there, you know, if you want to go talk to a therapist about how you feel you should do that, you know, if you want to talk to a nutritionist, you should definitely do that. Here are all your other options of things that you could be doing. But in this office, we're going to talk about how to functionally use insulin so that you have outcomes that are repeatable and desirable. Because I think it's like teaching somebody to throw a baseball. You know, like, when you when you show up? You're pretty young. Still? I don't know. Do you have any kids? Yeah, yeah, two girls, oh, two girls, okay. So they're awesome. Excellent. So you go out there the first time you try to get those girls to throw something to you, and their elbow flies the wrong way, and the ball goes eight feet to the right and everything. And it's demoralizing. You can see it on children's faces, like, Oh, my God, I can't even get this done. You know what I mean? And then you teach them technically how to do it, whether they love softball or baseball, when it's over or not, who cares? What you can see is the confidence that comes from picking that ball up not thinking and putting it where you want it to be. And I kind of think about the diabetes like that, like, I want you to be able to no matter what your situation is to be able to pick up that ball, throw it, it goes where you want. And then you have a tool, that you have an actual skill and a tool, and you can go put it to work wherever you want. And it comes with confidence. And I think that once you have that, then the next meal, it's a little more difficult, or the high blood sugar that you know doesn't come down and and at first, you're like, there's no reason for this, you can actually step back, apply your knowledge and your tools to it and come up with a reason why fix it and move on. And I don't know, I just think that that would be the way I would roll. I've seen it happen. I've seen people send graphs and they're out of their minds like you can you can sometimes read in an email a person who's about to like, just flip out, you know what I mean? Like I've they've done that they've beat their head against the same wall over and over again, nothing's changing. Their diabetes is not where they want it to be. They feel like apps use emojis. Oh my god, they just they're just like, I need help. Like, and by the way, you know that a person needs help when they're writing to a stranger that they heard on a podcast. Like that's when you know, somebody's in trouble. Me because there's a lot of like, leaps in there to make you know, and then I don't know them. I don't know their trials or tribulations. I don't know their IQ. I don't know their financial situation. I just go you got a pump or no pump. What insulin are you using? You have a CGM. You do Can you show me a graph? Great. I see a 24 hour graph. Great. This looks like you don't have enough basil. This looks like you have too much bass. It looks like you're not Pre-Bolus In your meals. Are you Pre-Bolus In your meals? You're not you should try that. Have your basil tested now? Well, I see. You seem real stable, but your stable 180. Let's get your basil right. And it doesn't take. I just did it with a lady. I don't know her. She just sent me a graph like she panicked, sent me a graph, like through a direct message. I think I message back and forth with her for four days. And like five days later, her doctor was like, my god, how did you fix all this? And she's like, I messaged the guy on the internet. Like, that's awesome. Yeah. But I didn't tell her what to do. Keep in mind, I asked her questions. And I let the answers that she had informed what she thought she should do next. Then if she wasn't sure I'm like, What are you thinking? And she's like, I think it might be basil. And I'd say I tend to agree with you here. And she said, How much should I move it? And I said, I can't tell you that. But I can tell you that based on your kids weight. I think he needs about 22 units of Basal insulin a day. But she was at like 16 I was like don't just like crank it up to 22 Just know that I'm thinking that the high end of the possibility is 22. But let's go slow. It took her like three days to fix it. Once she had the basil right? Boom, everything was like magic. And then she went back looked at her carb ratios. She started having these thoughts about like, Oh, I was covering for my basil with the Bolus is for the meals. And because I so I said to her now that your basil is right. Be really careful at meals and corrections because the way you do it is probably now Oh, maybe a little heavy handed. So let's be careful that. And if that ends up being so then let's reevaluate those things too. But I'm telling you, they're back and forth and a DM with a person I don't know. And they it's not maybe more than 15 times back and forth, and everything's fine now. So like, when that's possible, can you see why people are upset? And why they say my endo doesn't help me? Yeah,

Dr. Nader Kasim 45:25
I think that's a struggle, in general, and it's hard. I oftentimes feel that's because a lot of people are also overwhelmed with everything that goes into diabetes, just in general. And when that happens, there's oftentimes no conductor. So good example is, you know, patient, you know, is newly diagnosed at the point where they want to start pursuing tack, you know, the reading about CGM and insulin pump therapy and automated insulin delivery. And you know, 90% of their time is going into figuring out how to obtain these doing all the necessary trainings and education. And finally, they have everything in hand. And they're like, oh, wow, I have like, two apps I need to look through. I don't even know which one I need to look and people can be overwhelmed. Yeah, like one doesn't go to my so a lot of a lot of the same kind of behaviors that would go into injection, kind of the simplistic, you know, Basal testing and whatnot, people are hesitant to, to kind of rediscover that. I don't know if that's the word. But so there's a lot of hand holding, at least what we do in our clinic. And I think it works relatively well say that it doesn't work for some, but we typically have, we put strong emphasis on gauging where they're at, like glycemic control. Yeah. And then we teach pattern recognition. So we basically tell people, all right, you know, remember, you know, you're, you're effectively have a Bolus and a Basal dose, and you're running high post meal that's oftentimes reflective of your Bolus, etc. And then we effectively try to connect dots so that if they understand that they're not in range, they can go and see where they're running high, to effectively understand what dose change needs to be made. And I say it this way, because some people are not, they will never feel comfortable changing their own dose. Although we are huge proponents of doing that, like literally, the last diabetes ed class that we talked about, is to effectively empower people to change their doses, to whatever comfort they have. I think that works really, really well, because it effectively tells people Alright, this is the goal, this is where we want you to be this is what's going to minimize, you know, your risk of complications long term, this is how you go and look for highs. And then this is how you're gonna identify for those change needs to happen. And then they reach out to us. And then eventually, once they start reaching out to us, regardless of the degree of help they need,

Scott Benner 47:58
that's when we can

Dr. Nader Kasim 48:01
basically, layer on top of that we can talk about, you know, bolusing strategies, split Bolus, you know, timing of insulin impact of certain food choices, how to, you know, cover proteins and fats. And yeah,

Scott Benner 48:15
when they know how to keep adjusting their settings for these things actually have a shot at working, right? Because a lot of times they know the tools, but their settings are so off, they still have bad outcomes. And then they're like, it doesn't work. Yeah, like, yeah, I tried to do a Temp Basal, but it didn't work. Well. Yeah, what your Basal is point five, and ours should be point nine and our, you know, tamping it up 10% isn't gonna change anything. It's, you know, it's 40% Too weak to begin with. So for me, again, I think it's, you teach them how to get their settings, right? You teach them how to make adjustments. And I know this is gonna sound silly, but I think most people listen to this podcast know how to adjust their insulin because I say, if your blood sugar is too high, you don't have enough insulin. And if it's too low, you might have too much insulin. It's just, it's just that that kind of stuff that's so simple, that a doctor wouldn't say because there's, you know, 8000 caveats that go along with that, and you don't have time to explain them all are you know, but the truth is, that's about right. If you're high all the time, you don't have enough insulin. Like it's not like turning it into something that sounds like, oh, you know, the problem is your insulin to carb ratio might be off like, great. You just lost people. You know, you know, your insulin sensitivity. By the way, when you start telling people insulin sensitivity, and then turning the number down, makes it stronger, and turning the number up makes it weaker. I think you lose people there too.

Dr. Nader Kasim 49:39
Yeah. And then the next sentence, you said correction factor, and they're like, why?

Scott Benner 49:43
Yeah, what are we? I don't know what we're talking about. And, and that's why I don't talk about it that way. Yeah, no, you're you're 100%

Dr. Nader Kasim 49:50
Correct. I mean, like, exercise is probably the best example of what you're saying. Like if I can tell you how many people walk in and they're like, oh, All right. You know, I keep going low during activity, my doses are off my, you know, and then I tell them, the reason you go low is because of insulin. You know that right? Yeah. And they're like, Oh, yeah. And then they finally it clicks. They're like, Oh, snap. But you know, I took I took in like, you know, six units of insulin an hour ago for lunch. Yeah, that didn't even cross my mind that I had insulin on board. Yeah, but perfect example of, you know, people just need to be told that this is what

Scott Benner 50:29
you want to exercise. Don't have active insulin going. And you're probably going to be okay. Yeah, if your settings are right, by the way, if you're, by the way over basil, because is that a thing? Will you admit to do endos over basil people because they're afraid they're not going to cover the food? Well?

Dr. Nader Kasim 50:45
Oh, yeah, absolutely. And I think I mean, we see that less, because most people are on AI D now. Yep. And you know, with a significant portion of AI D, you kind of lose control of that, even. But yeah, we still see it.

Scott Benner 50:58
Do you think automatic devices, and you know, like, something paired with the CGM that's making the insulin decision for you? Do you think the greater the prevalence is with them? Do you think the less people are going to know fundamentally about their diabetes? Do you think they're just going to lean on it and say, I'll just let this thing do it?

Dr. Nader Kasim 51:17
I don't think so. And medically, there's evidence to suggest that that's really not the case. So they've put insulin pumps on newly diagnosed patients, even before learning how to do injections. And they were effectively taught injections kind of like after the fact, um, kind of as an on an as needed basis. And those people do well. And they they do, you know, arguably better, and not necessarily the right choice for everyone. But the point that I'm making is that you might be losing a skill, you might not be taught a particular skill that could potentially be valuable, but getting it taught later. Might be a reasonable idea. Yeah.

Scott Benner 51:55
So I don't I don't think so I'm

Dr. Nader Kasim 51:56
glad that I kind of superiority of the devices are really evident. So taking it away from someone with the intention of, you know, quote, unquote, teaching them how to drive a manual car, I think it's kind of silly,

Scott Benner 52:08
I find it to be an old idea as well. Yeah, I'm just worried that if something becomes so automated, that if you took it off them, they wouldn't know how to help themselves. I do think that's true. I mean, you know, I look at my daughter's Basal insulin, you know, overnight last night, even, you know, just absolutely, like, you know, the, the algorithm took her basil away for an hour and a half, and then it gave it back, and then it almost immediately was like, well, I shouldn't have done that and took it away again. Right. So like, that's not a thing that if you just go back to shooting love Amir for example, or Lantos, or CB, even, that's never going to happen. And they're not going to know, because they're going to think Well, when I was on a pump, everything worked. And now I'm injecting it doesn't work anymore, because they don't see the impacts of the insulin. And that's again, why I'm gonna go back over and over again, I'm gonna sound old. At some point, if people don't know that basil is first, and without a good Basal insulin, you're lost. And they don't know about the ratios, they don't know how to attack different foods, because they those foods have different needs. They're never going to understand what they're doing. And it's going to be a problem, even on an automatic system. Because if you don't know how to Bolus for something, if you look at Chinese food and say, Oh, this is 50 carbs, and think it's going to be the same as bolusing. For you know, another thing that's not deep fried, doesn't have sugar on it, and isn't like breaded. But it's also 50 carbs, you're going to be confused forever, because you're gonna say 50 carbs, 50 carbs, why didn't it work the same? Because of all these different impacts on your digestion, and, and all these other things that no one talks about? But it's not that hard to talk about, in a way. You know, what these conversations are, they depress me, and they get me excited at the same time, because the part of what I feel like we're saying is, if you get lucky enough to find a doctor who understands and can communicate it, you're probably going to be okay. Yeah, but what if I don't get that? Yeah,

Dr. Nader Kasim 54:03
I am going to add to that, because I feel like part of the benefits to these types of conversations is that it's empowering, right? So like, you know, if you go and you slam Chinese food, and you run a high blood sugar, you're going to feel defeated, and you're going to feel like your your treatment isn't working and you're failing and, and all that. So if you can give people pieces of knowledge, to effectively really take the reins and take control over their diabetes, then I think that makes it very empowering. So if you're able to make decisions about how you eat and how you dose and have a good outcome after that, you're gonna want to do it again. Yes. Because you know, you're not going to wake up in the middle of the night treating a low, you're not good exam. That's actually a great example, right? Like, for example, if you're gonna go go into eating Chinese food at like 10pm with like a bazillion units of insulin because you inflated the dose knowing that your blood sugars are gonna get demolished, but then you deal with a low you know, if you chose Maybe a Thai Chinese food a little bit earlier in the day. So you didn't have like a morning, I mean, an evening low, you're gonna feel awesome about that. Because you made the choice you thought it through, you know? So I think that's the value of talking to people about insulin as well, is that it really changes attitudes around. Really what's what's happening? versus you know, here's a machine, I hope you fare well on it. And if you know, if you keep typing numbers in it, you should do okay. I mean, that's, that's, that's really what would happen if you didn't have these conversations, right? Yeah.

Scott Benner 55:36
Now, yeah, I would tell you that one of the bigger surprises for me when I start, I mean, this podcast is I'm in my 10th year right now. So I've been doing it a long time. But when I first started doing it, I thought, Well, I'm really good at insulin, I'll explain it on the podcast. And that's what the podcast will be. And it has been very beneficial. I think anybody who's heard the Pro Tip series, or the, you know, the ball beginning series for really newly diagnosed, people would probably agree with that about the value of it. But it's the conversations that really just, I don't know, supercharge it. And I did not expect that. I really didn't, until I started having them, and listening and thinking, there's a ton of value here. Like they're, you know, I'm talking to a 24 year old person, thinking of a conversation I had recently this 24 year old girl, and she struggles, you know, it just it doesn't go her way. And she's real active during the day because of her job. And she's got a little vacillation, or you can hear in her voice, that she's beaten up. You don't I mean, like, she's just she's fought one too many wars, and they haven't gone her way. But at the end of the conversation, she's invigorated again. And that's great for her. But that's not really the way I think about it. While I'm talking to her, like, I'm happy to have a conversation with her, and I am speaking directly to her and about her. But in the back of my mind, I'm thinking 10s of 1000s of people are going to hear this, and they're going to think, oh, that's what's happening to me. And then they don't feel as alone. And then it feels more possible. That's the kind of stuff that we we can't value that enough. And it's almost impossible to explain to a person, the value of it. You know what I mean? Like, I've tried to tell somebody, you don't know, go listen to this, like, just go listen to somebody talk about what went right for them, or what went wrong for them. It'll help you earn ritual. And some people look you a lot of people look at you cross, like, you know, hearing someone's story is not going to fix my low blood sugar. But it is, it actually will. It's it's not a thing I expected, I didn't realize it when I started doing this. I also don't know how you're supposed to do that as a physician, either.

Dr. Nader Kasim 57:48
I think I think this goes full circle, right? We were just talking about, you know, experiences in terms of, you know, counseling, you know, people have diabetes, you know, it's, it's just like camp, right? Like, that's how we learn as humans, it's, there's a difference between being told something, and experiencing it with someone or learning it from someone in the sense of hearing a story. Like I think I think that's the value of those types of things. So I think it's just, we're, we're back to where we started.

Scott Benner 58:17
And you can do that purposefully. And I'm gonna pull the curtain back a little bit. It's almost an hour, you and I have been talking. We didn't come full circle by mistake. You understand? Yeah, yeah, I do this for a living. But doctors, you do it for a living to you do your thing to like, be purposeful about it. I had a real honest conversation for the last hour. But at the same time, I had half a mind on not just having the conversation, but leaving it behind for other people to follow as a roadmap. And I, you know, I think that's it, I think you can do that. I'm gonna just come out and say, and I hope the doctors don't take this the wrong way. I'd be a terrific endocrinologist about diabetes, I'm sure I don't know anything about anything else. Although I'm not bad with thyroid stuff. I have a lot of thoughts about anemia that I think are valuable. Also, I think I'm undecided. GRPs, by the way, and what they're going to do in the next 10 years for people, that aside, I think I could do your job. I actually think I do it every day. I do it in small chunks in personal conversations. And I do it in bigger chunks by teaching myself from other people, and learning how to talk to the next person because of that, and you have to make some generalizations when you do that. That's not a bad thing all the time. Like you don't want to generalize, put somebody in a box and be wrong about them, obviously, because that's a disservice. That's pretty infuriating. But I mean, bigger generalizations like, people forget to Pre-Bolus or people forget that they have diabetes where they don't want to be bothered by this. Some people don't want to think about it. Some people like so talk to that person that way. Like here's how you can tell I tell my daughter, I'm like, you don't want to think about this, do these things. And then you won't have to think about this otherwise because my daughter is not one of those like, like you guys, like her Jenny talking Jenny is a healthy person. She eats healthy on purpose. I once asked her when you go on a road trip with your family and like, where do you stop to eat? And she goes, we don't stop to eat on a road trip. I was like, What the hell? How do you eat? You know what she said? She brings food with her. I was like, God, damn, I never thought of that. Like,

Dr. Nader Kasim 20:00:24
I was like, why would you do that?

Scott Benner 20:00:25
Oh my god, where you could get like a Milky Way bar at the store, like, like, you know, and I'm like, Oh, she's an actual healthy eater. Like, she would never stop at a gas station. Like they, she just wouldn't do that. So when you're talking to Jenny, you talk to Jenny about who she is. When I talked to my daughter, I talked to my daughter about who she is, right? My daughter is not a person who wants to be involved with diabetes, but she also wants to be healthy. If you ask her personally, and I say, Why do you do this, she'll go because I don't want to die. Like that's she's motivated by her own health, about the longevity of her of her existence and, and her ability to do the things that she wants to do while she's alive. She doesn't give a shit about diabetes. When I tried to explain something to her. She's like, I don't care. And I'm like, I know you don't. But this parts important and she knows if I go this parts important, she stops. She's like, he's gonna tell me something I actually really need to know if I started telling her something that's extraneous, or like, you know, like the geeky stuff that you enjoy. And actually, I guess, oddly enough, I enjoy by the way, how weird is it that we anyway, like, like, she gets lost. She's like, don't care, don't care, don't care. And I'm like, okay, so I don't bother her with that stuff. I gave her the tools she needs. I gave her the knowledge she needs. Could she have more? She could does she need them? Not right now. That's how I put her. I mean, my daughter has a one C, she just she just left. She just went back to college. She was home for like, seven weeks. In the seven weeks she was home or when she was 5.6. Right? And that's her managing herself completely by herself. And when she was this awesome. Oh my God, when she was in college, the first year as a freshman. I said just do the things you know how to do. And she struggled a bit because the food was crappy. Now when I say that, processed and fried, okay, just when you hear crappy here, processed and fried, not real ingredients, fried food. And she was using insane amounts of insulin. And like and I don't mean insane, like the number I mean, versus what she would have used at home eating the way we eat here, which is not like super clean or anything like that. It's just much better. But she stuck with it. She did not give up. And she came home with I think of a six five a one C after her freshman year. All I did when I saw how bad the food was and how it was impacting her as I told her look above all else Pre-Bolus. And don't stare at a high blood sugar. Do something about it. Those are the two things I told her and she came home her freshman year with a six, five. Now she left with a six one I think, but okay, bad food, different variable. We fix that she came home. I said what fixes this problem. She said if I had my own place with the kitchen, I could eat better. We petitioned the school, we got her a place to stay that had a kitchen. She came home the next time or he once he was six one. She got it back down to where it was before she left. Then we got her home. And I watched it come down a little bit. But she was fighting and I said Ah she's just like a longer story. But we think Arden probably has PCOS. Right. So she sees a little bit of insulin resistance, tough periods, acne, stuff like that. I don't sit back and go, Oh, well, that's her a lot in life. I get in the game. And I figure that out. So right now, and I think this is the first time I'm saying this on the podcast. Arden is shooting point two, five of ozempic a week, just that she's never going to titrate up, it's going to stay just like that. Her Basal went from 1.1 an hour to point seven an hour. She's using seven units less insulin a day in basil. And based on her total daily insulin, I think it's completely possible that in 2024, Arden will use 11,000 fewer units of insulin for point two, five of us Olympic once a week. And I don't know if that's right for everybody. I don't know if you can get your doctor to be on board with that kind of stuff, etc, and so on. I just tell the story to tell you that when I see a problem, I fix it. And I tried to explain to RT and what the ozempic did, and she went okay, I got it. And then I tried to get a little deeper into it. And she went, I don't care. And I was like Gotcha. So I didn't burden her with more. But if she sees it helping her, like she's seeing it, she'll keep doing it. So I don't know, and I don't know where you fall on that but I think GRPs are going to become as soon as insurance companies pull their head out of their formulary s you're gonna see GRPs for type ones pretty quickly. Yeah,

Dr. Nader Kasim 20:04:53
I've so I use it situationally and it's it's amazing like, you know, there are people that are just insulin resistant, and it's really evident. And, wow, just a whiff of with almost any GLP. One will, will help. It's

Scott Benner 20:05:09
insane. Yeah, like, I mean, honestly, I'm about to interview the mother of a little girl, I think she's like 12 or 13, who's had type one for three years, and is now not even using Basal insulin anymore. Because of this, she got put on we go V for weight. And they, her insulin is just kept dropping and dropping and dropping. Yeah, I'm not saying it, you understand kids got type one diabetes, I'm sure at some point. But it turns out this child might have been in like an extended kind of like lotto situation, that this was enough to help along the way. I mean, it's just, it's fascinating stuff. I mean, the reason we started Arden for was, you know, the really painful long and excessive periods, and the and the pain in the stomach. And we got on that my wife was on a Facebook group for for GRPs. And she said, Scott, I keep coming every time I come back as a new woman who hasn't been able to have a baby for 20 years is pregnant on a GLP medication. And I'm like, Get out of here, really. And she's been telling me about that for six months, I started Googling it. And there's already some testing going on that women are just like, who could not get pregnant before are seeing like pregnancies on GRPs. And that spurs more conversation that tells you like, Oh, I'm taking it for PCOS. And it's really helped with my PCOS symptoms. And I'm telling you Arden's acne cleared up 80% on it. It's an I don't think we're not sure where her her dose is going to be yet. So I'm not sure that we're there yet on where it's going to be. But her acne cleared up 80% her insulin needs went down the way I just explained. She lost 10 pounds. And she just generally looks better. I saw I don't know if he's this. Listen, this is a little weird, but I saw a thread on Reddit. And hey, read it. I appreciate how cool you guys are about the podcast. Thank you. I saw a thread on Reddit where people with I'm gonna mispronounce his ears. danlos? Can you tell it say that for me? Oh, yeah, there's downloads. Okay. There's a whole group of people that have that connective tissue disorder, who are saying that a lot of their symptoms went away on a GLP medication? Ah, yeah.

Dr. Nader Kasim 20:07:19
I don't know if I saw that. Just insane.

Scott Benner 20:07:21
I you know, I'm on the internet. And so like, I don't know, like, like, look, who knows, if that's a real thing. Maybe they have it. And they were heavier, and they lost weight. And it's easier on their joints. Like, I have no idea what it is. But like, that's the kind of like, thing where the community stuff really does help. Because like, someone hears that and goes, maybe I should look into that, like, maybe I should find out about this Pre-Bolus ng thing. You know what I mean? Like, and I don't know, to me, I appreciate this conversation greatly. But in the end, what I hear is, the model that set up right now works great for some things and doesn't work right for type one diabetes in a doctor's visit with with a physician, like there's not enough time, there's too many variables. There's doctors who aren't great communicators, there's doctors who don't have a lot of good information. There's patients who aren't good communication communicators, patients who are not interested in doing well for themselves and everywhere in between. And with all these different variables, how can this static system work? It'll work for some people, and it won't for others. And that's just what it's going to be your smart young person who has type one, I didn't hear you go, Oh, my God, I have a great idea. Let me tell you how we can fix this? Well,

Dr. Nader Kasim 20:08:36
I mean, the way I look at this is that we're effectively like cheerleaders. So I was, I was gonna disagree with you at one,

Scott Benner 20:08:43
at one point, please do. And that is, you know, we will never ever

Dr. Nader Kasim 20:08:49
know the person who has diabetes as well as they know themselves, we will never understand the child and the parent will eventually know more about their child's diabetes more than us. So we are effectively like cheerleaders, what makes us useful to most people who have diabetes, and I say us as in like, endos, and other diabetes care providers is that we see the gamut. So you know, we were a clinic have to close to 2000 Yeah, we see the stupid we see every walk of life, we can kind of get an idea of what would be average, what would be an outlier, what would be and we can kind of augment your, the person's expertise in their own diabetes. So I think as a medical care provider, that's how we become valuable. So I think you're right you can you can you know, diabetes, this as well as, you know, any endocrinologist just you probably don't see, you know, as as many different people as us well for you because they have a podcast maybe but I don't

Scott Benner 20:09:52
disagree with you, because I do find myself wondering because I do work in a room. I don't actually see any of the people I'm talking to. Am I just attracting? And I'm sure you can think this, am I just attracting a certain segment of the population who works well with what I'm doing. And that's completely possible. And if that's the case, and I'm happy to help those people, but, but I would share this is that if you've ever heard the Pro Tip series, at some point, the Pro Tip series, you'll hear me describe Pre-Bolus thing as a tug of war. I don't know if you've ever heard me say that before. And the explanation has been told back to me by clinicians and people the same, that it's the clearest explanation of bolusing insulin they've ever gotten in their life. And I came up with it on the fly, gees, a long time ago, maybe over 10 years ago, because I used to be this person who wrote a blog. And once in a while someone would get on Facebook and have a problem or somewhere online to have a problem. And someone would say, you should find this guy, he can help you. But back then what that meant was, is like, they'd call me on the phone. And I'd be like, Hey, what's going on, and we talk for 3040 minutes, and I hit, you know, what I think of is the most important pieces that would kind of get them going in the right direction, hopefully let them find their own path. But I was talking once this very young girl, she's in her early 20s. But she had had, she had a baby that was already four, four years old, I think. And it was clear to me she had dropped out of high school to have her baby, she was waiting tables. And you know, I don't think she was, you know, I hate to say this out loud. But she was not the brightest person I've ever spoken to in my entire life, I guess I'm just gonna come out and say, and I explained Basal insulin. I think she got that I explained bolusing. And she was, she was concerned enough for her child to stop me and say, I don't understand what you're saying. And in that moment, I recognized I was either going to tell her, I couldn't help her. And she was going to go struggle for her whole life. And that baby was going to live with anyone see in the eights and nines, where I was going to find another way to say it. And I said to her, have you ever been in a tug of war? And she said, Yes. I said, you can picture the rope with the flag in the middle. And she said, I can I sit? Okay, well, instead of like, one team on one side and one team on the other side. And the goal is for one team to pull that flag on their side. And when, let's imagine that on one side of the rope, it's carbs. And on the other side is insulin. And the new goal is for the flag never to move. And then I just explained it from there. And I got done. And she said, I got it. And I was like, oh, that's terrific. Thank you. And like months later, I get a message from her. She now has my phone number, right? So I get a text from her Can I call you? And I'm like, okay, so she calls me and when we say hello, she's crying. And I swear to you, my first thought was this a really long time ago, my first thought is God, did I say something to her that caused the problem? You know? I'm like, are you okay? What's wrong? And she just says, Thank you. I want to thank you through tears and choking and snot and crying. I want to thank you. Well, Mike, what are you thanking me for? And she says, My daughter, she's sitting on the floor playing for the last hour. And this is how I remember her from before the diabetes. And I was like that I'm crying. You know? Now I'm going to cry now, actually, if I'm being honest with you, and such a real memory for me. And I said, why I actually had to break it off because it was too much like actual emotion. I was like, Why are you calling me for call somebody else? She's like, No, she's like, You did this. And I stopped her. I said, I didn't do this. You did this. I just told you how insulin works. And she we talked, we chatted for a little while and we got off the phone. That was that. She said my daughter was sitting on the floor playing for an hour or more her blood sugar never got too high. Never got too low. She kept saying like, you should see how steady it is. And I was like, Yeah, I know. Like, it's, it's how it works when you have your stuff, right? And she's like, but everybody told me she was brittle. And I said, Yeah, that just means you aren't using insulin correctly. And I think older type ones would disagree with this. But I don't think brittle is even a real thing.

Dr. Nader Kasim 20:14:05
I hate I hate that word. Yeah, yeah, I

Scott Benner 20:14:07
think people don't know how to use insulin, and it makes you look like you're all over the place. And somebody says, and then some at some point, a doctor says Oh, uh, you know, you must be brutal. Nothing we can do. You know, and I get that back then no monitors, no, sometimes no meters and their CGM. So for sure. I can see how they might think that. But that's how I think of this job. So I think of that girl who's now in her 30s and her kids probably 15 years old. And I think that kid's life might be better, because I took 15 minutes to explain to her mom how like insulin works. You know, that's amazing. Yeah. So I it's what I hope for everybody. I hope everybody gets something out of these conversations and goes forward and does this. I mean, there's part of me that thinks that doctors are just going to be pissed at me for talking like this. And there's part of me that hopes that they'll listen, I don't know what's going to happen, but I'm just going to keep telling the story.

Dr. Nader Kasim 20:14:58
I think you should. Thank you is there's definitely a void. And I think, just like I started out, I mean, I, this is this is how we learn. So and you're, you're, you're contributing to that. So don't stop. No,

Scott Benner 20:15:10
no, no, please don't Don't worry, I'm, I love this job. I tell people all the time. I am 52 years old, when I was 16, my grandmother forced my uncle to give me a job in his sheetmetal shop. With the day I graduated from high school. When everybody else went out to a party after graduation, I went home and went to bed because I had to get up at six in the morning and go to my uncle's sheetmetal shop and work there full time. I'd already been working there for three years part time, and I honestly thought that was my whole life. And if you go find that kid and tell him one day, you're going to make a living, you're going to enjoy what you're doing, and you're going to help people, that kid would not have believed you. So um, I have no plans on not doing this. This is the maybe the greatest thing I've done outside of my family in my life. So you know, but I use that that girl, like she sits in my heart when I do this podcast, and her story about her kid, and everybody else's that I've ever bumped into. I just get sad when I hear. When I hear doctors say there's nothing I could do. They didn't understand. And I'm like I think everybody can understand. You just have to distill it enough that it works for everyone. I think that one of the biggest mistakes we make, I'll leave you with this. I think we teach to the least common denominator. And I think that's a bit of a mistake, right? I think you should just assume that everyone can absorb the information and wants it, you just have to find a way to say it. So that the least and the greatest of us, as far as our ability to understand that we can all hear it. And I think that I think that's what I've done here really is I've just found a common sense way to talk about diabetes in a plain spoken manner. And it doesn't matter if you've got a master's degree, or you had to drop out of high school to have your baby, I think you can understand it. And that's all I think the doctor should be striving for honestly. So anyway, that's said, I agree. Thank you. I appreciate it. I appreciate you doing this very much. So back to our original question at the beginning. No reason to make you anonymous and this right.

Dr. Nader Kasim 20:17:17
No, no, I don't mind at all. Good.

Scott Benner 20:17:20
Thank you. I really do appreciate it. Yeah, it was lovely of you to do this, especially on a late on a Friday afternoon. And I have to tell if you want to come back sometime. I'd love to have you back.

Dr. Nader Kasim 20:17:28
Hey, thank you. I appreciate it. Yeah, and I honestly, if you ever want to do anything speaking wise, I'm involved in camp here in Michigan, both kids and adults. So it'd be awesome to have you as a talk. I

Scott Benner 20:17:41
appreciate I would love to do that. I can't I can never wrap my head around. But you know what? Let's stop the recording. And we'll talk about it privately. Do you mind?

Yeah, by all means, thanks so much.

type one diabetes can happen at any age. Are you at risk, screen it like you mean it? Because if just one person in your family has type one, you're up to 15 times more likely to get it to screen it like you mean it. One blood test can help you spot it early. And the more you know, the more you can do so don't wait. Talk to your doctor about screening. Tap now or visit screen for type one.com To get more info and screen it like you mean it. Arden has been getting her diabetes supplies from us med for three years. You can as well us med.com/juice box or call 888-721-1514 My thanks to us med for sponsoring this episode. And for being longtime sponsors of the Juicebox Podcast. There are links in the show notes and links at juicebox podcast.com. To us Med and all the sponsors. A huge thanks to Omni pod, not just my longest sponsor, but my first one Omni pod.com/juice box if you love the podcast, and you love tubeless insulin pumps, this link is for you. Omni pod.com/juice box. If you enjoyed today's episode, go check out the rest of the Grand Rounds series. There's links let's see where you can find them. Well, here's the easiest place go into the private Facebook group go up to the feature tab. There's links of all the series in there you'll see every episode of the Grand Rounds series, you'll be able to go back into your podcast app and listen until your heart's content. If you're not already subscribed or following in your favorite audio app, please take the time now to do that. It really helps the show and get those automatic downloads set up so you never miss an episode. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast. The episode you just heard was professionally edited by wrong way recording. Wrong way recording.com