#838 A Look at Tidepool Loop

Howard Look is the Founder, President, CEO of Tidepool. 

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

Scott Benner 0:00
Hello friends, and welcome to episode 838 of the Juicebox Podcast.

Today on the Juicebox Podcast, we're gonna take a look at tide pool. Did you feel bad pun? That's right, Howard look is on the show. He's the founder, president and CEO of tide pool to talk about tide pool in general, and the tide pool loop app that just received FDA clearance. While you're listening today, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your healthcare plan. We're becoming bold with insulin. If you're a person who has type one diabetes, or is the caregiver of someone with type one, please take 10 minutes out of today to go to T one D exchange.org. Forward slash juicebox. All I'm asking you to do join the registry, complete the survey, it should take you about 10 minutes, and you complete that survey. Your answers will help diabetes research to move forward. T one D exchange.org. Forward slash juicebox. I have a moment. So let me tell you that the Juicebox Podcast has an entire series worth of algorithm based episodes, including a ton about loop, check us out on Facebook, or at juicebox podcast.com. This episode of The Juicebox Podcast is sponsored by the Contour Next One blood glucose meter, you can find out all about that little meter at contour next.com forward slash juicebox get the meter that my daughter uses. Speaking of what my daughter uses, you could get your diabetes supplies the way we do from us med get your free benefits check right now at 888-721-1514 or by going to us med.com forward slash juicebox. quite a quite a team actually. And if you don't mind before we talk about everything that's going on recently. Can you talk about that? And you said you found it the whole thing? Was it just you in the beginning? Or is it you and a handful of people? How did that go?

Howard Look 2:17
Yeah, so it actually goes back to 2012 2013. So my daughter Katie was diagnosed in 2011. With type one, I was actually working at Amazon at the time, it was the consumer electronics subsidiary of Amazon called lab 126. And Katie gets diagnosed and my initial reaction was oh my god, I knew nothing about diabetes, I didn't know what insulin was, I didn't know there are different kinds of diabetes. And so it was really a crash course I think, like for a lot of parents. And you know, very quickly into our journey. She got put on a Medtronic insulin pump and originally the the enlight sensor. I'm not exactly answering your question, but I'll get to it in just a second. Because I think it's kind of part of the journey. So she was on the enlight sensor, which for her just didn't work. Like it wasn't comfortable. It wasn't accurate. You know, she would cry every time. It had to go in, we call it the harpoon. It just wasn't right for her. And fortunately, right around that time, is when the Dexcom g4 came out. And so then she's still on the Medtronic pump, but using a Dexcom G four. But we have this crazy situation where at the time, neither the Dexcom software nor Medtronic software would run on my Mac. And I was like, I can't see your data like this is crazy. And so, you know, I literally was saying who writes this stuff? Like, why is it so hard? It shouldn't be so hard to see the data. So I started asking around, I started meeting other people that felt like I did. I always like to give credit to Scott Hanselman. He had this great blog post in 2012 called the sad state of diabetes technology. And if you scroll, you know, 130 people down in the comments, you'll see me going Hi, my name is Howard. This is all kind of crazy. I'd like to do something about it. Anybody else want to do something about it? And so I started getting introduced to people, you know, like lean Desborough, like Brian Maslin people who were also tinkering and trying to make things better for living with type one. I eventually got introduced to a team of folks up at UCSF, Dr. Salia de and Dr. Aaron nine Steen and Dr. Denise Huang. And they had started a little company called Green Dot diabetes with another GeekDad for lack of a better way of saying it like me named Steve McCann. He also had a teenage daughter living with type one, and had been doing a little bit of hacking to visualize her data. And when I met that Team Steve and the doctors at UCSF. I was like, Oh my God, they're doing something about it, I want to do something about it. I initially proposed to Steve that he and I go to a startup together. And he said, You know what, I don't really want to do another startup, I want to go do this other thing. But if you do it, I'll give you your initial funding or his wife at the time, and he gave us our initial funding. And that was how tide pool was born. So it started as Green Dot diabetes for people at UCSF, and me, and Steve McCann, we decided to rename it tide pool in May of 2013. And that's when I became CEO. And we never looked back. From that point on, I started meeting people. The actual first person I hired at the time was Ben West, who I think is, you know, super well known in the DIY community. He's the guy who did the original reverse engineering of the Medtronic insulin pump, which ultimately led to open APs and loop and lots of other great things. I ended up meeting, Brandon Arbeiter, who I convinced to move to California and start typo with me. And the rest is history. As they say, We started small and humble. And we've kind of slowly grown over the last 10 years.

Scott Benner 6:18
It's it's an interesting way to build something just continuing to call out of this group of people who are all very focused for personal reasons. And yet, very technically adept. I'll tell you, there's I recognized almost every name you said. But I want to tell you that I did an interview with Dr. D. Once it's one of the best conversations I ever had about diabetes.

Howard Look 6:39
Oh, he's amazing. Yeah, I love it. We used to call him the basil whisperer. He is so good. And He's so calm, but so insightful. He can look at data and just go, Aha, we should look at your Basal rates between 3:30am and 6am. Or high, your ISF is off by 10%. At this time of day,

Scott Benner 6:58
I remember saying something that he agreed with, and I was so proud of myself. I was like, Wow, all right. But yeah, we had such a what I would consider to be a geeky conversation about using insulin. That was just really fascinating, and very, very informative. I still hear about it from people, they say it's one of the best episodes of the podcast. Oh, that's

Howard Look 7:17
great. Yeah. Solly dr. D, he is amazing. I consider him a close friend. I was actually just in touch with him earlier this week. And he was our original chief medical adviser at typo please tell

Scott Benner 7:32
him I said hello, if you see him again, Burwell. So. Okay, so I understand how you all are then aware of this loop algorithm that exists in the world, it's being made just by people. And, you know, we're gonna use words that if people don't understand the idea of sharing code online, I don't even understand what I do to be perfectly like, honestly, here like, Yeah, I'll give you an example. I have a GitHub account. I don't know what that means. I

Howard Look 8:00
happy to explain it.

Scott Benner 8:01
No, no, if you explain to me to go right through my head, and out the other side, which I think it's good about what you guys did, you know, lovely people will jump on zooms with me and help me rebuild my daughter's loop app sometimes. And as I'm doing it, I think, Oh, I do know how to do this. But I my brain just doesn't work that way. But my daughter has been using loop for a number of years now. And she began, I don't know how it I'm sorry, you my daughter is 18. She's in college. She's a freshman, she was diagnosed when she was two. So you have some context. And a listener of the podcast came to me one day and said, you should put your daughter on loop. And like gave me the big like Sal about it. And later, they came on the show to tell me that they just wanted my daughter to be on loop. So I could figure out how to use loops. So I could explain it to other people. And I was like, okay, but wow, what a big difference. Because I had taught myself I didn't realize that at the time. But I had taught myself to sort of be a living algorithm to to add basil and take it away and Bolus in strange places where nobody would ever think to Bolus and you know, that kind of thing. And I thought I'm so good at it. Like we don't need this. And you know, but who I was so wrong, you know, because I sleep now like a regular person. And you know, and my daughter is in college, taking care of herself. And you know, and maintaining a onesies that are just beyond respectable and eating what she wants and all this stuff. So I'm always very, very grateful that that person came to me and said that but it threw me into a world. That was at first it was off putting like, you know, the first time someone says to you that a bunch of strangers like faceless people wrote code that is going to know it's going to talk to your insulin pump and a CGM and it's going to make decisions about your insulin. It's mind numbing at first like Well, that can't be right. Like that. Like how does that happen? Ben, but then one day you guys came along and said, We're gonna take that code, and we're gonna get it FDA approved. And again, I was like, I don't understand how that works, either. So can you tell me that first? How was it? I know it is I just don't understand the process. How is it okay for you to go online and be like, here, we're taking this code? And we're going to put it through the FDA? Is it because it doesn't belong to anybody to begin with? Or can you explain that whole thing to me?

Howard Look 10:26
Yeah, it's a really great question and really gets to the heart of the ethos of the do it yourself and open source software development community. So you mentioned GitHub, GitHub is just a place online where people like to store their source code. And it happened to be very happens to be very popular with people in the open source community, as a way to share their work with other people. And so to tell the story, I have to back up a little bit, my daughter is in the same zone as your daughter, she's 22. Now was diagnosed when she's 11. She's a senior in college now and doing great. And back when she was a freshman in high school, one of the first open source do it yourself projects that came out was called Open APs. Scott Lee brand and Dana Lewis, along with building on top of the work that Ben West and John Kostik had done, made that happen. And my daughter, Katie, is Dana has the actual list. I don't remember the number. It's somewhere between 15 and 20, was my daughter was somewhere between number 15 and 25. And I don't remember the actual number, but it was very early on. I started meeting other people like Brandon Arbeiter, my colleague and Ben West, who were using open APs and getting amazing results. Like you, my wife and I, we were really struggling, I think is a fair word, you know, we would take turns getting up at night to check our daughter's blood sugar when she was having a rough night, we really knew there had to be a better way. And we went I started seeing what was possible. Based on a software algorithm making the decisions, it was just super clear to me, that software could do a much better job of making the minute to minute decisions like you and I can do a great job or daughter's can do a great job. But we're not going to stop every five minutes and do the math and figure out what the right thing to do is tirelessly, the software can do that. And so I did the work to build open APS for my daughter. In the beginning, it was this clunky rig with a big giant battery and a Raspberry Pi and the CareLink stick. And I every day, my job in the morning was to pack it all up and put it in a little camera case and stick it in her backpack and send her off to school. And then every night I took it out and made sure it all got charged and you know, logged in to make sure everything was working. Okay. And even with all that effort, it was totally worth it. Because like you said, there were really two big impacts to that one was my daughter, for the first time since being diagnosed could go back to living a much more normal life, she could just go about her day as a teenager, and not have to worry that she was going to go low or not have to worry that she was going to go high, because the system would just deal with it. And then the big win for my wife and I is not only could we worry less about her, we slept better. So it was just better for us as parents and better for our marriage and just better for our family. So it was super clear to me early on that that was the way things needed to go. Fast forward a couple of years. Loop becomes a project I was very fortunate to see loop early in its development cycle. I think the first person to show it to me was Ben caimans. At the time, he was VP of Engineering at Cana COMM At Academy. He lives with type one diabetes. And he was friends with Nate rec lift. Nate wrote the original version of a loop. And I went out to breakfast with Ben and saw what he was using saw the Reilly link the little doodad that you need in order to make it talk to a Medtronic insulin pump at the time. And I was like, what is that show me how that works. And he talked me through it. And so I was immediately hooked. I immediately got myself a Reilly link. I went and built it myself at the time early in the evolution of do it yourself loop. It was one big giant Google document that Jeremy Lucas and Katie De Simone had worked on. And I powered my way through that Google document. It took me half a day, but got it up and running. And it was incredible. So not only really didn't have that automation component, the ability to make decisions every five minutes, but because it was iPhone based, it meant I didn't have to bundle up that crazy battery, Raspberry Pi, stuff to send with my daughter, she could actually just control her diabetes from her phone. And it was it was absolutely mind blowing. So the cool thing about the work that all of these people did, you know, going way back to Ben's work, reverse engineering, the Medtronic insulin pump, John caustics, work, reverse engineering the Dexcom je for at the time protocol, the work that peach Suam did in order to design the Reilly link. And then the work that Nate rake lifted to build and publish loop. They all made it openly available, every single one of them said, I've done something good, this is going to be helpful for the rest of the diabetes community. And I'm not in this for the money. I just want to help people. And so they made it available. And to me, that is just one of the incredible stories out of the diabetes communities. How many people have done that how many people have said, This is not about the money. This is about helping our kids live more normal life, this is about helping ourselves to not have to have fear that our kids are going to make it through the night. And so we're just going to put this code out there and help as many people as we can. You asked, So how does it work? So everybody I mentioned, put their code online, most most people use GitHub these days. But it's not always GitHub, it's just a place to store the source code. And they generally make their code available using what's called a permissive open source license. So a lot of people have heard of the GPL, the GNU Public License, that's a less than permissive open source license that requires you to contribute your changes back. Lots of good reasons to do that. There are also permissive open source licenses. The two most notable ones are the MIT license and the BSD license. And those two licenses are really short. And you put them at the top of your source code. And it basically says, use it your own risk, do whatever you want, take it, change it, it's yours. The only requirement is that you put this copyright notice at the top of the file, you can do whatever you want. And that ability is what lets people take all these components and mix them up and do new wonderful things like create open APs and create a loop. And there are lots of other examples of that. So what we at tide pool decided to do was to take that open source code that Nate had published that each one had published. And we brought it in to tide pool. And when I say we brought it in, what does that mean, on on GitHub, you do what's called Creating a fork, it's really just making a copy of the code. But now all that code lives in tide pools account. And so we can make changes to it, we can publish those changes, and other people can take them if they want to. But because all of those people publish their code with a permissive open source license, it also means that we can bundle it up and package it and take it to the FDA and say, Hey, here's this work that we've done. Is it okay for us to call this a product that we're going to ship to the World Within FTAs regulations, and put it in the app store? So that's the work we did between 2018. And now 2023?

Scott Benner 18:48
Wow. Can I ask a question about that? Yeah. What stops somebody now that you have an FDA approved from resharing, the code online as the official tide pool code that you can just do DIY

Howard Look 19:00
does, nothing, nothing stops them. And in fact, we have published all of our code via open source that they can't call it tide pool. Dry pool is a trademark trademark name, and they have to get our permission to do that. They also can't say it's FDA clear. The thing that is FDA cleared is the package of the software compiled built. That includes all of the clinical evidence that they that we submitted all the verification and validation testing that we did all the human factors testing, we did a long laundry list of things that we needed to do in order to submit it to the FDA that we own that FDA clearance is that clearance.

Scott Benner 19:41
It's a that's why I wanted to bring it up that clearance encompasses much more than just the code that is the app. It's That's right. We're working on for all these this time now.

Howard Look 19:53
That's exactly right. In fact, if it were just the code, it would be easy because most of the code existed for us As long as DIY loopers have been using DIY loop, the work in getting to FDA clearance is a whole bunch of things. And I won't go into all the nerdy regulatory detail, but you need to submit clinical evidence. So the way we did that, with the FTAs encouragement was we collaborated with the DIY community and our friends at the Job Center for Health Research. And we did the jig, or sorry, the loop observational study. So the observational study loop was over 1000 people using the DIY version of the loop, many of whom hang out in the loop Facebook group, over 850 of those people ended up submitting at least six months, if not 12 months worth of data that we then gathered, actually, the Job Center for Health Research gathered it, they then did a bunch of statistical analysis on that data, we ended up with a two or 300 Page clinical study report and a bunch of other data analyses that we did. That package of clinical data is part of our submission, and was part of demonstrating to the FDA that the loop algorithm was safe and effective. So that's one big piece of it. Another big piece of it is what's called verification and validation. Most people just call it V and V for short. And that's really the effort to not just test the software, but to document with full traceability that you know that the requirement, the specific user story that is intended to be done, is working the way it's intended, and that you can demonstrate through test documentation that you have completely fulfilled that requirement and have reduced whatever risks may exist in that software. So we did a huge risk management effort, we did a huge verification validation effort that was part of our submission. And we're super proud of that. We also did Human Factors testing, one of the things you're required to do with an FDA submission is demonstrate that your software can be used by the general population. So we actually along with our partners at a firm called core HF and Philadelphia, ran rigorous formal Human Factors usability studies, where they gave people very specific tasks, and had watched them, do those tasks, and then recorded the data. Now, sidebar on this one. This is one of the things that was really challenging about our submission, we were ready to start our human factors test thing right around February, March of 2020. And typically, the way human factors testings work is you bring people into an office, and you sit them at a table and you give them the training, and then you have cameras all over them. And you have a one way mirror and you record the whole thing. That's all fabulous, unless a global pandemic breaks out. So right around the time we were starting, are getting ready to start a human factors testing, we had to completely redo the Human Factors protocol, because of COVID-19. We ended up running are human. So first, we had to redo the protocol to make it a completely remote human factor study. So people did the study from home, we recorded them over zoom, we recorded the screen of what they were seeing on their phone. And we did all that. And it was I don't know if anybody had done it that way before. But it was certainly new and novel for us and new and novel for the team we were working with. So we had to generate all that data and then submit that as part of our submission. And we did it it took extra time. But by August, September, we were doing full remote human factor studies.

Scott Benner 23:53
Can you tell me? Did you learn enough about the process with the FDA that if you had to do it again, do you think there would you be able to streamline what you did the first time? Was there a lot of learning? Oh,

Howard Look 24:03
heck yeah. Heck yeah, there was a ton of learning. The FDA calls us a first time sponsor, tons of things that we would be much, much better at doing it the second time. On top of the fact that now that we have a cleared system, that system becomes what's called a predicate device. So any future submissions we do will refer to this submission and say everything about this is the same except these parts and then they only have to look at the iterative parts.

Scott Benner 24:35
You know why I'm asking you that right? Because absolutely one of the best parts of loop is how, how flexible it is, and how it it morphs and changes so quickly. And you know, people from from my perspective, you feel like that happens more quickly, because you don't have to go to somebody at the end of a change and say, Hey, is this okay? But like, I mean, certainly example like I, what the version you have gotten through like, when did you start? What like what, what? What year did you grab the code and start this whole thing.

Howard Look 25:10
The process started in earnest mid 2018 2018.

Scott Benner 25:14
So now in 2022, my daughter's using loop three, I guess. And in the past, I've used the Peet's branch. I've used Ivan's branch I've used you know what I mean? Like, I've used so many different things I've used the auto Bolus I've used, you know, what this one is going to do? I think was going to make adjustments through basil adjustments. Is that correct? And if so, are you gonna keep going? Like, are you? Like, are you in a back room right now planning on the next thing or like, I know, it's weird to ask before you get the thing out. But you know,

Howard Look 25:46
not at all 100% We are absolutely not just thinking about but working on subsequent versions of tide pool lube. And you're bringing up a really important point. And this is where what we've done, which is to mesh the world of regulated medical device software with the world of do it yourself innovation. We're now seeing what that means. We submitted in December of 2020. It's now January of 2023. That was a long review process. Some of that was due to the pandemic. Some of that was because it took a lot of time to work through with the agency, what it means to build a truly interoperable system. And we can talk more about that. But what we have now becomes the foundation for all future iteration not just for us, but for anybody else that wants to submit a device that refers to type a loop as the predicate device. So yes, we definitely learned a ton and future submissions will go way faster because of that. But also, we can build upon the work we've already done. So by way of example, since your daughter is a looper, you may know about the overrides in DIY loop. So overrides showed up in DIY loop, very much near the end of the loop observational study. And what that means is most of the clinical data that we submitted, does not include data with people using overrides. So we can't we couldn't in our submission in December 2020 include overrides as part of the functionality. Now. It's clearly up and running and working in the DIY community. We have a version up and running in our development branch. And what we can do now is on top of the clearance that we already got go back with a another submission saying, Here's new clinical data, here's New vnv data, here's New Human Factors data, we now want to add this functionality on top of what we already submitted to and it'll be much easier to do that.

Scott Benner 27:57
That's very cool. Okay, that's amazing. I appreciate you giving me that. Like, for everybody listening, honestly, because there's a lot of words like the it's loop. If you don't know anything about it, you're listening right now you're like DIY, that means do it yourself. Okay. And then, you know, like, there's just too many phrases and words that I think people don't even like you say Raspberry Pi. Like, we all know what that means. You know, then I know what it means. But you know, So context is important, I have to say, so

Howard Look 28:26
maybe I can kind of build on that just for one second. Yeah. It's It is one thing I'm gonna make super clear the thing we did, makes typo loop not be a DIY do it yourself project. So DIY loop will continue to exist, the we are not waiting movement will continue doing its thing, innovating and trying new things out. And I love that I encourage innovation. And I'm very, very happy that the DIY community exists and will continue to exist. I pull loop is not a DIY project type of loop will be in the app store, just like any other app that people download to their phone. And I think that's one of the reasons why the work we did is so important. Because there are a whole lot of people that don't want to build the rest their own system. People who are like X code, I don't want to deal with compiling GitHub exco bla bla bla bla bla, I am dude, I am one

Scott Benner 29:20
of those people. I don't I don't want to do it. And you know, the things that machinations we went through to make sure that my daughter was okay when she went away to school and to make sure she was covered if the app should crash or like something like that. I don't want to live through any of that. So some at some point, then you're going to be able to go to your doctor and get a prescription that lets you go to the app store and download your app. Is that right? Is that how that's gonna work? It's

Howard Look 29:47
close. So the way it will work is typo loop will be in the App Store. Anybody will be able to download it just like you download any other app from the App Store. In order to activate it. You're going to need an activation code, which you'll get through your health care provider, we've created a healthcare provider portal where they can go to create a prescription. And this isn't like a prescription that you take to CVS or Walgreens, it's a digital prescription. But it will send you a code through text message or email that once once you type that code into tide pool loop, it unlocks all the functionality so that you can use it. And it will cause your entire set of initial settings, which you'll establish with your health care provider to get downloaded. Now, a lot of people will say, Well, wait a minute, can I change the settings by myself? And the answer is absolutely, positively Yes. It's just that initial set that your healthcare provider will establish. We all know that diabetes is self managed disease, we all know that there are some people that are comfortable changing their settings on their own. And there are lots of people who like to do it in coordination with their health care provider. We've made it so that the health care provider works with you to establish the initial set, but then you can go in and modify it over time.

Scott Benner 31:07
Okay, that's really great. Do you think there's a thirst with the pump companies that you have agreements with? Do you call them agreements? Who's it going to work with right when it comes out? I guess is the way I should ask.

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Howard Look 36:02
Yeah, so let me tell you the history of that, and then I'll bring you up to speed where we are today. So in 2018, we announced a development partnership with insolate, makers of Omni pod. In 2019, we announced development partnerships with both Medtronic and Dexcom. Now, let me take a step back for a second. In order to use typo loop you need three things. And these three things are all part of what the FDA calls their interoperability pathway. You need a continuous glucose monitor which the the FDA calls an IC CGM for interoperable continuous glucose monitor, you need an insulin pump. And the FDA calls that an ace pump or alternate controller enabled in insulin infusion pump, and then you need what's called an IEC. That's us an interoperable automated glycemic controller. So you need those three pieces. I CGM ace pump IRGC, where the IRGC with tight pull. So Dexcom is still very much a development partner with us. And we're very much looking forward to other continuous glucose monitor companies being becoming compatible with type polu. Medtronic in insolate, at this point in time, have said that they will not be our launch partners for as as pumps, we're very grateful to them for supporting the development of tide pool loop, I will tell you that we are working with another ace pump partner that isn't ready to talk about who they are yet, but we're really excited about them. It's a company that everyone knows and we think everyone loves, and it's going to make a really great combination with tight pollute. The great thing about type ULoop is that it was architected from the ground up to be interoperable, meaning we can add new CGM and add new Ace pumps. And we don't have to submit new evidence to the agency. Part of our submission was a set of plans and processes and nerdy regulatory speak. They're called SOPs, standard operating procedures, we came up with SOPs that we agreed with the FDA. As long as we follow those procedures, we can add new devices over time without a new submission to the FDA. And so for us, we feel like that's pretty groundbreaking. Typo loop is the first truly interoperable system that is designed from the ground up to allow new devices to be added over time. Without a new submission.

Scott Benner 38:37
This might be a question I shouldn't ask you, but do you think you'll get those companies back?

Howard Look 38:43
I'm never gonna give up. Like, I think interoperability is the best thing for the diabetes community. I think if you're a person living with diabetes, you should get to choose what CGM you use, what pump you use, and what the user experience and algorithm is that you use to manage your diabetes. I think interoperability is a great thing. I think the community appreciates this approach. And I think over time, we will see that company companies will start to embrace it as well.

Scott Benner 39:14
It just, I mean, from my perspective, not knowing anything that's going on in any of those companies, but it just more options seems like a good idea. You know, I think so. Yeah. Like I, you know, it took right up until you said that, I sort of had like this little like the 10 year old me inside was all like, oh my god, the world is going to work the way it's supposed to, you know, we're going to, you're going to get this thing and it's going to just work here or here or wherever we want it to and pumps will just become like, like wheels, right? Like I'll have a car and then I'll pick which wheels I want to go on. And I thought that'll be terrific. And then you said that I was like, Oh, okay. So don't give up because and if they're listening, you should do that. It's it just makes sense. And it It's the only thing. I don't know. I mean, I can see why they wouldn't want to, I'm trying to think it through. But the other idea is that it's gonna bring more people to pumping in general. It just that makes sense to me. Anybody who's used lube would tell you I'm sure that's partly what was what happened when you were talking to the FDA. It's, it's astonishing how well it works. It's just it's really astonishing. And so, you know, I hope everybody gets a chance to use it. I have a lot of questions. Keep going. All right, I'll try to rapid fire them as best you can. Although it's the end on a Friday, we've all given up on enjoying this day, right? So we can just keep going. So you haven't joined me? At the moment? Do you have pumps that are on a compatibility list? Or are you not at that point yet?

Howard Look 40:48
We do have compatible pumps, we're not able to talk about who they are yet. Because the pump makers need to make their own decisions about when they're going to let the community know that they are going to be delivering a compatible

Scott Benner 41:02
device, whoever they are, in my opinion, they're going to have a great stranglehold on some great social media and the ability to make some exciting announcement that people are going to get behind. So I can't do you have a timeframe, you think

Howard Look 41:15
it's going to depend a lot on the device partners, and so we're ready to go whenever they are, we're gonna have some work to do with them to coordinate things like customer support handoffs, and pricing is a question that a lot of people want to understand we still going to work through that. How it's going to work, you know, will they subsidize lube? Will that be something that insurance pays for over time? Those are all details that we still need to work out with them.

Scott Benner 41:43
So I have a question. It's gonna sound shady. Sorry, I'm getting off the list here. Oh, they really stop somebody from using it. I mean, they can't stop them from DIY using it, why would they be able to stop them from using your version of it?

Howard Look 41:59
Well, our version, we are the only people that can put it in the app store. We are prohibited by law as a cleared product from distributing this until we've met the requirements that are laid out by the FDA. And one of those requirements is that there is a compatible ace pump that it can work with. So until there is a compatible ace pump, we may not put it in the app store. And as soon as there is a compatible AST pump, we can put it in the app store.

Scott Benner 42:28
My My point was that once that happens, can't I just pair it with a different pump? Like what would start?

Howard Look 42:36
Well, our code will only work with cleared compatible AST

Scott Benner 42:41
pumps. So it's on your side that it'll be it'll be I'm not calling it hobbled. But it'll make sure on your side that it only works with what's

Howard Look 42:49
right or clear. It only works with with products that meet the requirements of a cleared third party, interoperable ace pump. And

Scott Benner 42:56
one of those requirements is that the pump company wants the app to work with their pump. That's right. Yeah. Okay. Got it. Alright, thank you

Howard Look 43:04
that well, actually, let me let me let me correct that that's not completely right. There is a world in which a pump company could deliver a pump, which conforms to diabetes device interface standards, there are Bluetooth standards and I triple E standards. And it is possible that a company can deliver a pump that conforms with those standards, and not specifically say, here are the controllers that it works with. They could just say it will work with controllers that meet these standards. Yeah, that is, hypothetically possible. We haven't seen that happen yet. But I am optimistic about that in the future.

Scott Benner 43:46
I think in the original Jurassic Park movie, Jeff Goldblum says something like life will find a way and I think that's right here. So okay, we'll just keep a good example. Yeah. The algorithm that you have, will it consider digestion times? This is obviously a question from a looper, like, can you tell it like, Hey, this is going to hit more like pizza or more like candy or three hours or four hours? Can you set those with the app?

Howard Look 44:10
Yeah, absolutely. That is one of the unique and wonderful features of tide pool loop. This also exists in DIY loop. When you do a meal Bolus, you not only say here are the number of grams of carbs that I'm ingesting, but in loop you use an interface that uses emojis and the default emojis are lollipop taco and pizza. lollipop has the fastest carb absorption time 30 minutes and then taco and pizza are slower so you can say, here's a slice of Grandma's lasagna and it's clearly more like pizza than it is like a lollipop. So you tap the the the pizza icon

Scott Benner 44:54
can you still post date a Bolus? Can I you can Yeah, excellent. Yeah,

Howard Look 44:59
that's an Another great feature that we love about loop. And again, this exists in both DIY loop and tide pool loop. It's a feature that I think is really great for parents of small kids with type one, for example, you put a sandwich in front of your kid, you guess it's 30 grams of carbs, you Bolus for 30 grams of carbs, and then your kid decides to only eat half a sandwich. Well, it turns out with loop with type a loop and DIY loop, you can go back and edit that meal Bolus, it obviously doesn't pull insulin out of the body. But what it does is it modulates all future delivery of insulin to make up for the fact that it now knows that you ingested fewer carbs than originally planned,

Scott Benner 45:46
I would say that I think two of the best features that I would use all the time is that just be able to like, go back and say, Hey, we said 40, but you know, it was really 30. And you just tell it because maybe it can't get the insulin back. But it can start making decisions in the future with the idea that, hey, I think we have 10 carbs, too much insulin going, maybe I can take the basil away for longer or do something to try to impact it. And then the other thing is to be able to tell it, look, I'm gonna have 20 I'm gonna have a 20 carb impact from fat from French fries, like 90 minutes from now. And then when the loop starts seeing the impact comic goes, Oh, and you don't have to go back again and make a secondary Bolus. It's it's the loop version of, you know, like a square wave Bolus or something like that, which is

Howard Look 46:32
exactly and besides having knowledge of the carb absorption time of what you ingested. The other nice thing about the loop algorithm is that it pays attention to how your body actually reacted. Its dynamic carb absorption is the term it looks at what it predicted what happened and what actually happened. And then it uses that iteratively over the course of the absorption of the carbs in the insulin to make modifications to its prediction.

Scott Benner 47:05
Did you have to get clearance for different insulin surges that lie on the device manufacturer,

Howard Look 47:12
we did have to get cleared for different insulin, so very specifically tied pollut is cleared for use with chemo OG and Novolog. A lot of people ask about fiasco, during the clinical study, it was pretty early in the adoption of Fiesta, there wasn't a lot of data from VSP users. But over time, I think we can collect more clinical evidence and hopefully broaden the labeling to include other insulins. And just while I'm on labeling, it's labeled down to each six. Again, because there was plenty of data in the clinical study to support that. And overtime, I would expect that we can expand that as well.

Scott Benner 47:52
Wow, hey, everyone does but don't forget a Piedra. Don't worry, I know you're not going to but it's my daughter uses fantastic. Target blood sugar's user definable all the way. I mean, with regular loop, I don't know where does it stop you.

Howard Look 48:11
With DIY loop? I don't know the answer to that question with tide pool loop, the target range that is configurable by the user to anywhere between 87 milligrams per deciliter and 180 milligrams per deciliter.

Scott Benner 48:26
He's just trying to make me cry. Howard, is that what you're doing? That's beautiful. Thank you.

Howard Look 48:30
Thank you. I'm pretty happy.

Scott Benner 48:32
You should be. That's me. Hey, let me ask you a question. For the other pump manufacturers that are listening to this right now. And they're listening. So how tough was it to get clearance down to 87? Did it really? Was it really that tough of a slog like because they're all at like 112 or 110? Or something like that?

Howard Look 48:52
Well, you know, I don't know how to answer was it tough. It was a lot of work to gather, analyze and present the clinical data in a way that made it clear to the agency that this would be a safe and effective way to use tight pull loop. So was it tough? I would say it was a lot of work. And we're very grateful to the participants in the loop observational study, because the thing that made that possible was the people that were willing to do all of the work that it takes to participate in a clinical study and to make their data available so that we could include it with our submission.

Scott Benner 49:36
How valuable was that? That you were basically working with pioneers instead of people who were called through and found through like, the regular way they find people for stuff like that?

Howard Look 49:47
Oh, it was to me just an incredible testament to the willingness of the community to pay it forward. Yeah, like it is a ton of work. My daughter has been in several clinical studies. I don't know if your daughter has done that but you It is hard work. You have to answer questionnaires you have to install software to submit data, you have to be willing to let people have access to your data. You have to take home HBA when C kits, like it is a lot of effort to participate in a clinical study. And one of the amazing things about the loop observational study, as I said earlier, there were over 1000 people enrolled in the study, over 850 of which submitted at least six months and in some cases, 12 months of data. That is an enormous quantity of data, which you don't typically see in clinical trials for medical devices. In fact, if you think about it in terms of person days of use, in the study, the loop observational study, had three times the data of the Medtronic 670 G, pivotal study, tandem control, IQ study, and insolate horizon Omni pod five study combined, combined three times the data,

Scott Benner 51:04
do you know that I did a little survey? I, I get a lot of help from wonderful people sort of like us. So I, this MPH student came to me. She just just graduated from Hopkins, and she wanted to help the podcast somehow. And she said, How can I help? And I said, Well, I'd like to do a survey, like a legitimate survey about how the podcast helps people. And she helped me put it together. And we're still collecting at this point. But we've only been at it for about two and a half weeks, we have well over 700 respondents. And she just texted me one day. And she said serious medical organizations struggle to get anywhere near this number of respondents to a survey and I said, Yeah, well, these people are motivated, because the podcast helps them like if they're trying to give, they're looking for a way to give back. And it seems like you had the very same thing. So is it fair to say that the goal to having an 87 target on your system, get through the FDA is your desire? Your desires? What made it happen, right, your desire to do that, to well, it

Howard Look 52:06
was very clear. So first of all, before I answer that, I need to give a huge shout out both to the looped community that people who mostly participate in the loop Facebook group, but very specifically to Katie De Simone. Yeah, Katie was the conduit. She was the person who sat in that community and said, Hey, everybody, you've all been asking me how you can help pay it back or pay it forward. This is how you can do it. You can participate in this clinical study. So Katie's work to coordinate all of that, basically, as the liaison between the loop community. And the Job Center for Health Research that ran the study was just absolutely incomparable. We could not have generated all that data without Katie's efforts. And without the loop community, we

Scott Benner 52:54
don't know each other, personally, but I have such a warm feeling towards her because she's the first person to come on the show and just kindly explained to me while I was going, I don't understand I don't understand, like walking through a loop was to me so many years ago now. Yeah, yeah. He's

Howard Look 53:09
an amazing human. And I love her dearly. Yeah,

Scott Benner 53:11
me too. Okay, so. Alright, so 87. Cool. I don't even care what the top number was.

Howard Look 53:17
Oh, I didn't actually answer your question. Oh, sorry. Yeah. Yeah. So first, how did we come up the data with the data, and that was because of the loop community and the work that Katie did interfacing between the Job Center for Health Research and the loop community participants in that study. At the end of the day, we took all of the data. And we looked for very obvious places where the balance of risk of hypoglycemia and the safety of the lower target range made sense. And so that's just a ton of data analysis work that was done both by our data science team, and also the Job Center for Health Research. And then ultimately, it was a back and forth conversation with the agency where we presented the data we showed them where we thought the lines should be drawn and why we thought those lines made sense. And they agreed.

Scott Benner 54:09
I feel like the answer to this question is going to be no because of the time, the timing when you jumped in. But does the app have the ability to enter non pumped insulin like a Frezza or an injection? And to give it its iteration?

Howard Look 54:22
That's a great question. It currently does not have the ability to enter outdoor, non pump insulin. That's obviously a feature that we know a lot of people would love to have and some will consider for a future version of title.

Scott Benner 54:37
Okay, I'm sorry, I'm scrolling past the the questions that and by the way, it as we're thanking people, the listeners of the podcast sent four pages of terrific questions for me to talk to you. That's great because they probably know how or the what would happen is I would start pontificating, and then you and I like an hour and a half from now we'll be talking about something silly and they'd be like nobody asked any real questions in that would be my answer. They're trying to keep me on brand here. Boston, of for people who plan on just continuing to use the AI. Why does it help you at all? If they get the prescription? Like, here's the this is this question because this is somebody trying to steal they want to give back still.

Howard Look 55:16
Oh, that's super helpful. Does it help tide pool if someone gets a prescription but then continues to use DIY loop? I can't think of an immediate reason why that would be helpful. But let me let me go think about that. I couldn't either.

Scott Benner 55:29
But I just I thought it was another example of just people wanting to do something.

Howard Look 55:33
Here's a thought and this is, you know, one of the reasons again, why I think what we're doing is valuable. We have heard and you know, this is anecdotal, but I think there are some folks I know in Europe, for example, that have studied acceptance of DIY systems in endo clinics. We've heard anecdotally that there are some providers that are really uncomfortable with their patients using DIY systems. So one of the big benefits, I think of tide Palooza, being an FDA cleared product and being available in the App Store, is that for those people that have providers that are a little queasy about their patients beyond the DIY systems, this is a great alternative. So not only does it give the person living with diabetes, who may not want to build their own system, an alternative option that they can look at and go, Oh, great, that's FDA cleared, it also gives their provider a little more confidence because their provider can say, Okay, I'm no longer scared that you as my patient are using a system that I don't know anything about.

Scott Benner 56:40
Do you think that's mostly everybody just, I'm just gonna say what I was gonna say that's just as covering, right? Because like I've, I've seen doctors people mentioned and they go, no, don't you do that I've heard, I've heard people be told, if you do that, I'm dropping you as a patient. And I've seen people, doctors go, Cool, let's do it. And I've seen the one where the doctor pretends they don't know what you're saying they almost lost all their way through it when you tell them and then they just act like you never said it and keep going. I've seen all three of those things happen. So this is going to take any kind of that uncomfortableness for those types for those physicians, and allow them to say, hey, we've got a good, we've got a good thing for you to try here. It's FDA approved, they can get behind it. So then the next question comes, is who's going to help? But this is something I think about all the time? Are you guys gonna get involved with the training? Because we always say like, oh, the doctors will take care of it. But that's not really going to happen. You don't I mean, like, they're not gonna understand loop the way you do, or the way I do, I could, I could grab somebody's loop app right now who I don't even know and probably get it working in a day, you know, like and make adjustments to their stuff. But that's unfair to ask the doctors to do. And, you know, especially when things don't, what do I want to say, I was really good at using insulin. And then I got to watch Nightscout. And then I got way better at it. Like watching the algorithm do what it was, it was like a was like a Master's class in how insulin works. And I already had a good idea about it. But just to watch it, take basil away, and then give a little back and give some extra and then take it away again, I was like, Oh, my God, this is just a dance that never stops, really? Because I learned a lot that the doctors aren't going to get to see that, or are you going to figure out a way to train them? Or how does that gonna go?

Howard Look 58:29
Yeah, so let me unpack that question. There's a lot in there, how's training going to happen? How will doctors get access to the data? So we developed training both for the person living with diabetes, also caregivers, so part of our human factors, testing was testing what are called dyads. So parent and child pairings. So training that is targeted at parents and including training that is targeted at adolescents who are on the transition to self managed care. So we created a whole curriculum that is actually both built into the application, but also exists in traditional user manual form, and then take all of that we recreated healthcare provider training. So the healthcare providing Provider Training exists in traditional forms, we will also have lots of content on our website in terms of knowledge base, and support articles. And we will keep doing something we've been doing for years, which is online, both live and recorded webinars to teach people how to use it. At the end of the day, we feel really strongly that people need to be able to learn how to use it on their own their healthcare provider will be there. But we can't be dependent on the health care provider to provide training to the person living with diabetes that has to be self evident. And the way we do that is by building training right into the app, you have to go through an entire onboarding experience before you can start delivering insulin, and then there's help within the app at all times. If you have questions about something, how something works, you can actually get help from right within the app. So one of the things I'm really excited about is we heard both during the Human Factors testing, and you can also hear over and over from people in the DIY community is how elegant and simple using loop is. And I think that really helps make learning all that material much easier. Because you can look at it. Look at the homescreen of loop and just see, Aha, I see what my glucose is doing. I see what the insulin is doing. I see what the carbohydrates are doing. That all makes good sense to me. Yeah.

Scott Benner 1:00:44
Well, and then I did a thing I talked about earlier, I just did Nightscout as if everybody understands that. So that's an app I use to to, like, I can see my daughter's blood sugar and what her loop is doing. Are you guys going to have like a follow app for for a caregiver? Yeah.

Howard Look 1:01:00
Super, super, super question. And sorry, I forgot to touch on that. So popping back a level, I pull started life as a data management platform, and we are still a data management platform. So tide pool lube will automatically up to upload data to tide pool. So people will be able to see their data in tide pool for web in tide pool mobile. And yes, we will have a follower experience. That'll enable loved ones to be able to see your glucose and insulin data remotely.

Scott Benner 1:01:34
Yeah, I was gonna say you're gonna be like GitHub, but like, right. But nobody will understand that. So I'm not gonna say it. And let me always be clear, I'm always only about 90% sure of any of the things I'm saying around lupus, right, because I just am so not technically adept about about that side of it. But also, I think that gives me a lot of comfort, because, and for other people, because with a little bit of help, I was able to figure out a thing that my brain doesn't naturally do. Like when you were talking about like screens that explain things. I picturing myself sitting there going next, next, next and not reading because by because I'm broken. And and that's not a thing I learned by doing. But it's very comforting to think that it's going to be out there for people like this. And that, that that especially that that that idea that I'm I don't mean it this way. But the idea that I'm doing something wrong, or that it's not like that somebody hasn't said is okay, like just to take that weight off of people saying this is the FDA said this is okay. Like I think that's going to be really helpful for a lot of people and to help them move forward. Because I haven't said it to you yet. But I think algorithms are 1,000,000% the future and the present of how people manage can be managing their their insulin, it's just, it's just such a leap above trying to do it yourself.

Howard Look 1:02:58
I experienced Totally agree. I you know, obviously what we both want for our daughters is a cure for type one. Hopefully, research will pan out and that will happen in their lifetime between now and then I completely agree that the next best thing in terms of both achieving great outcomes. But even more importantly, for me, reducing the burden of living with type one is to have automated insulin delivery. So I'm very excited to that we're participating in that. And

Scott Benner 1:03:27
a tiny little thing that I always throw in, I think Aaron Kowalski sent it to me once it's just even if we could just make the cannula material better. So there's not, you know, so that sites work more the way you expect them to consistently would be such a big deal to I didn't ask a secondary question about the weather. You have a follow up. People also want to know if you can Bolus from that app like will a parent be able to Bolus from their own phone?

Howard Look 1:03:52
Yeah, so the version of tide pool loop that was just cleared does not have that functionality. We know that is something that people really love, and it's something that we will absolutely consider for future versions. I will tell you that. One of the things we spent a lot of time with the FDA on is cybersecurity. And once you open that up, it creates a mechanism by which someone could remotely deliver insulin, which definitely should give everyone pause. That's I think it can be done safely. But it's going to take a lot of work to demonstrate how it can happen safely.

Scott Benner 1:04:30
Do you have um, were you able to get Apple Watch? Can people use your bill? Absolutely.

Howard Look 1:04:36
Yeah, type of loop absolutely has, as part of its feature set the ability to use an Apple Watch and to discreetly manage your diabetes right from your watch. Okay.

Scott Benner 1:04:47
What are some of the well my first question is Where can people go to see a list of the functionality for assuming you have a website where I can see that?

Howard Look 1:04:57
Absolutely, we'd encourage everyone to go to tide pool.org/loop And you can read all about the tide pool loop and also sign up for our mailing list to get updates on things that are coming down the road.

Scott Benner 1:05:11
Do you in your mind, you don't have to share them with me. But is there a list of things like you said, like you, you're going to be able to add things to the to the app as you go. Like, I mean, the one that occurs to me is like auto Bolus, right? Adjustments adjustments through auto Bolus instead of through, like Temp Basal is that like one of the things you're looking at now?

Howard Look 1:05:30
That is absolutely something we're looking at right now, I would say that I talked about overrides. That's clearly the next big suite of functionality that we need to consider for the next version of tide pool loop. And we're working on that right now. And then the biggest thing, quite honestly, that we get asked about, and that we think is important is Android support. So this version of tide pull loop works on an iPhone, we chose that because that's what DIY loop did. So we were starting from an incredible foundation of an iPhone, an Apple Watch app written for iOS. But clearly, if we want to fulfill our mission, as a nonprofit, our goal is to have the broadest possible impact and to enable equitable access to the best possible diabetes technology. And in order to do that, we've got to get bloop onto Android. So that's really important to us as well. I can't say when that will be done. And when that will be ready. I just want everybody to know that it is really important to us. And that's part of our mission. As a nonprofit,

Scott Benner 1:06:35
you just reminded me by saying you're a nonprofit that I have a question here. I think what the person is really asking me is, how do you make money? Like, like, is it like, like, at first I thought, Oh, it was an angel investor that got you started? And then But then how does like you've got a big group of people working for you like, how does that all work?

Howard Look 1:06:55
Yeah, I really appreciate the questions. So over time, our goal is to be a self sustaining nonprofit. And we are generating revenue. Now. We get money from the device makers that we partner with, they pay us to integrate their devices into type of loop. And then over time, they will pay us because the more people that use type of loop with their devices, the more devices they will sell. So they will give us a share of that revenue as well. We also generate revenue through our data management platform, we always have had and always will have a free version of the data management platform. But last summer, we launched what we call tide pool plus, which is an enterprise version of tide pool for web that's very specifically geared towards the needs of enterprise healthcare provider clinics. So it provides functionality, for example, that allows it to integrate with their single sign on mechanism. It has functionality that allows them to manage their entire population of diabetes patients. So there's a dashboard where you can, for example, say, show me all my pregnant moms living with type one, or show me all my new diagnosis patients, or show me all my patients that are struggling with hypoglycemia, so that I can provide better proactive care, okay. And it also lets you do integration with electronic health record systems, for example. So we generate revenue through tide pool plus, which is our enterprise version of tide pool, we generate revenue through tide pool loop, doing both development work, and then ultimately ongoing. And then the final bit is we get incredible support. And I've got to give a shout out to JDRF to the Helmsley Charitable Trust in particular, that have really supported us tremendously over the years, and we would not be here without their support. And there are literally 1000s of individual donors that have reached out. And we get donations everywhere from $1, to $5, to $100, to 10,000, and sometimes hundreds of 1000s of dollars. And every one of those donors makes a difference to us. And it helps us do our work and continue on our mission. So for folks who are listening, who want to help support us, thank you in advance if you have support us, and if you'd like to support us, you can go to type o.org/donate

Scott Benner 1:09:25
That's really wonderful. It's it's actually it's, it's encouraging it really is to just to know that it's that the people don't just say, Oh, that would be nice, but I'm willing to do a thing and I mean, I listen, it's not it's not money, but I have that feeling a little bit like I'm trying to spread the word about algorithms because I just I just know how it will help people. And that's great. It just I think any I think anywhere where people can do something that fits in with their thing is really valuable.

Howard Look 1:09:55
I thought of one other way we make revenue and I'm remiss and talk combat. So I want to make sure your listeners know, one of the things we do is when you make a type pull account, we asked you, would you like to donate your data for research and product development? And 10s of 1000s I think we were well over 30,000 or 40,000. People have checked that box and said, Yes, I'd like to donate my data. That's a pretty amazing thing, because it lets us bundle up those datasets. We call this the tide pool Big Data donation project and create these massive longitudinal datasets, we anonymize them, we strip out all identifying information, but we bundled the datasets together. And we can give them away for free, which we do often to nonprofit academic researchers. But we can also license those datasets to for profit companies, whether they're doing pharmaceutical development, or diabetes, device development. And that's another way that we make revenue. One of the things we do as part of that program, because we're a nonprofit is we want to give back a little to the other diabetes nonprofits that are working so hard to make things better for everyone. So we let you choose which diabetes nonprofit, you want us to share that with that revenue with and we share 10% of the revenue that we get through the type of Big Data donation project back with other diabetes, nonprofits, nonprofits, like children with diabetes, JDRF diabetes sisters, beyond type one, there's a whole list there that people can choose from.

Scott Benner 1:11:34
That's amazing. Thank you. I'm glad I asked that question I almost skipped over. Now I'm like, well, that worked out tide pool just in America or other places.

Howard Look 1:11:45
So the company is based in the US, but we do have international employees. We're a completely remote organization. I'm sitting here in Mountain View, California. Syrah is in Southern California, we've got people all over the US and in Europe. And over the course of time, we've had people in New Zealand and Australia and lots of other places Canada. In terms of use, we officially support our use in the United States. For our type of data management platform. We know we've got tons of users internationally, we are GDPR compliant, which is the data privacy regulation in the European Union. We don't specifically claim that we meet any locales, data privacy requirements, there are some pretty funky ones. Sometimes countries will say, Well, your servers have to be in our country. We don't do that yet. But we also don't shut people off. If we know that they're in another country. We know we've got a ton of people in Israel, for example, there's a ton of people in Northern Europe. And so our goal over time is to much more officially support other languages and other locales. Right now, we're largely US centric, but we definitely have a pretty healthy US population outside the US,

Scott Benner 1:13:05
for people who are familiar with lube and probably familiar with the app that you started with. Has there been anything like we talked about some things you've put into it? Was there anything taken out of it at the behest of the FDA? Or did it pretty much stay the way it was?

Howard Look 1:13:21
It is largely the way it was, I think the constraints on settings were the biggest thing, most notably target range being constrained to 87 to 180. And that wasn't necessarily something the FDA asked us to do. That was something that we knew we needed to do, in order to support support our submission with the clinical data we had. But by and large the features and functionality in tide pole loop map to the features and functionality in DIY loop. It's the DIY loop of mid 2020, however, so we have a little bit of work to do to catch up. But we'll be able to do that much more quickly. Now that we have clearance.

Scott Benner 1:14:00
Did they ask you to add nags? Like after a new site change? Like, don't forget to check your blood sugar like an hour after you made the site change? Did they ask you to put any stuff like that in?

Howard Look 1:14:11
They did not ask us to do anything like that. We did spend a lot of time with them talking through how alerts and alarms will work. And I want to give the agency a lot of credit on this. They really understand that there are just times when you don't want your phone to make noise. If you're getting married, you're in a wedding chapel, you're in a choir singing, you're in a recording studio. You know, it's terrible to think about but if you're in a lockdown situation in a school like there are just times when you don't want your app making noise and the FDA and tide pool iterated on a design for alerts and alarms that makes it possible to provide safe alerts and alarms arms that let you know when there's something you need to pay attention to. But they that also lets you mute them for significant periods of time so that you can accommodate those situations.

Scott Benner 1:15:12
Here's the question. Does this make my phone a medical device? Does that not have to buy me an iPhone knows what I'm asking?

Howard Look 1:15:23
Your iPhone is still an iPhone. Your iPhone is being used as a platform for software as a medical device. I don't think I can answer the question if if it actually turns I mean, the iPhone is not submitted to the FDA as a medical device if that's

Scott Benner 1:15:41
your question, right. But I can't run the app without it. That's right. Oh, I'm totally calling that No, I see. What's that? Yeah. Okay, I'm giving this a shot.

Howard Look 1:15:49
I'm gonna I'm just gonna go out on a limb and say your insurance company is not gonna buy

Scott Benner 1:15:53
Oh, no, they're gonna turn me down. Probably really disappointed. But I'm still gonna ask. Let us know how that goes. Oh, sure. It'll go like this. Hello, hello. I think they hung up. Well, I'm sorry, I lost my space here for a second. Oh, profile switching. People are wondering if you'd be able to like, you know, by using a menstruating woman as an example, like, you know, could I do pre menstrual during the event? I never know what to call it like that kind of stuff. Like, do you have that?

Howard Look 1:16:29
Sorry, I just lost a deal with it later. The work that we are working on now that will add override similar to what you see in DIY loop, I think it's the way that that will be accommodated. So you'll be able to have different forms of overrides for different parts of your menstrual cycle. Okay, but that does not exist in the type of loop that was cleared this week.

Scott Benner 1:16:59
Gotcha. I'm skipping that one. Hold on a second. I did that one. I'm doing good here. Howard. You are actually you're doing really well. I'm basically just reading.

Howard Look 1:17:10
These are great questions. Your your listeners really know what they're listening to and know what they're talking about.

Scott Benner 1:17:16
I agree with that. Can you be a salesman for a second? And answers to answer this question, why do I want this and I don't want control IQ or I don't want the Medtronic one or I don't want on the power? Like why do I want yours?

Howard Look 1:17:30
You know, I'm gonna politely declined to answer that. I think it's a great thing that there are different choices in the world. I think control IQ is going to be the right choice for a lot of people, I think Omni pod five is going to be the right choice for a lot of people. And I think for a lot of people type loop will be the right choice. What I want to see is more interoperability. And more choice, I want people to be able to say that's the right CGM. For me, that's the right pump for me. And this is the right user experience and algorithm for me, I agree with

Scott Benner 1:17:59
you, I was just asking the question, but But I, I 1,000,000% agree with you. I don't care. Honestly, no one should care. One company's not going to get all the business, there's somebody's always going to want to be to bliss or not want to be to bliss or want to use this, you know, want to use a Dexcom or rather use a libre or something. I mean, somebody eventually is going to want to use a Medtronic sensor. Sorry. And, you know, like, like, so when that happens, you don't want to just be like, Oh, now I have to use this thing. And at some point, all those companies have to see that there. I talked to too many people who are like, Well, I have a as an example, I have a Medtronic pump, but I want to use a Dexcom. And so they end up leaving Medtronic because of that. And I'm sure that happens in all different directions with all these companies, you would think that the idea of interoperability would be you think it would be paramount to them. Anyway, that's how I say it. But I'm not going to make the answer that but thank you. Is there any?

Howard Look 1:18:58
I'll answer it. I totally agree. I think that choice is a good thing. I think interoperability is a good thing. And I think the thing that interoperability and choice also lead to is greater access. At the end of the day, what I really want to see happen is everybody, everybody who is living with diabetes to get access to the right technology that works for them. And we just have a lot of work to do. And this is you know, way above my paygrade but as I'm sure your listeners know, the reimbursement system, the health care system, the way access to technology happens today is not fair and equitable. And we are a long way away from the new diagnosis kid with type one who's got a single parent on public assistance assurance, public assistance, insurance, getting access to the best path possible technology. And our small part in that is let's make it easier. Let's make It easier with an interoperable system so that someone can actually get access to the best possible care. Yeah, there's lots more to be done. But that's what I want to see happen.

Scott Benner 1:20:10
Amen. That's well said. Alright, Howard, let me ask you this. Is there anything? I didn't ask you something I should have? Wow.

Howard Look 1:20:17
We covered a lot of ground, Scott. I can't think of anything off the top of my head Syrah. Is there anything that you can think of in your head?

Scott Benner 1:20:28
I know that I was. The one thing I never do understand is that the difference between like, cleared by the FDA and approved by the FDA? Oh, yeah, that's a thing.

Howard Look 1:20:39
Absolutely. They are two different things. Here's the 62nd the digestive what that means. The FDA thinks about medical devices and products in risk levels, risk stratification. There are class one, class two and class three devices. class three is the riskiest and class one is the least risky. So tongue depressors, and band aids and over the counter medicines and things that don't carry a lot of risk are class one. Historically speaking, anything that is new is automatically designated class three because it carries unknown risk. What the FDA did was they created these pathways, and they're called de novo pathways, and de novo means we are going to consider this from new it means from the new and Latin as a class two device. So these interoperability pathways, the AGC, I, CGM and Ace pump designations that I talked about earlier, are all class two devices. When you submit a class three device, you have to go through what's called the PMA process premarket authorization, so are premarket approval. And so that's when you get FDA approved is when you have a class three device with a class two device, you're getting what's known as 510, take 510 K clearance. And what that's saying is, my device is just like this other device that is the same other class two device, and so you get FDA cleared. That's what we just did, we submitted a 510 K application, and we got clearance, or tied pollute our predicate device was control IQ. So part of our submission was going feature by feature capability by capability and saying, here's why our device is what's known as substantially equivalent to the control IQ. What's cool about us getting clearance now as a class two device is we can become the predicate device, or all future devices that want to do similar things to what we've done. Okay. We're pretty proud of that.

Scott Benner 1:22:47
Wow, you should be That's wonderful. This whole thing is amazing. You know, I have to tell you, just to give people the idea of about a span of time, I looked while you were talking, Your Honor, you brought up Dana and Scott, the husband and wife who back when open APs and they were talking about that. They were on my podcast on episode 63 and 64, concurrently. And my best guess is that you're going to be episode like 838 or something like that. Whoa. And when they were amazing, when they were talking back then it was like, I was gobsmacked. I was like, this lady says that, like you don't even know I'm like, she's saying that there's a thing on a thing. And she's saying Raspberry Pi. And I'm like, This sounds like stuff I don't understand. And then she's talking about how great her stuff is, and how our outcomes are. And then I didn't think of it for years. Like it just it felt to me like, like back then it just felt to me like it was three people who were doing this thing, and I happen to talk to a couple of them to see that. I don't know that. I mean, how many years later that is that was the beginning of 2016 that that happened? Well,

Howard Look 1:23:51
if I can pile on that for a second. I think Dana and Scott St. Louis and Scott Lee brand and it may be pronounced Lybrand, I apologies apologies, Scott, if I've got wrong. And before them, John caustic, who did the work to reverse engineer the Dexcom G for Ben West who did the work to reverse engineer the Medtronic insulin pump. And there's a whole bunch of other folks who worked on Nightscout. And I'll miss a bunch of names if I even try, but they all know who they are like those. Everyone who did all of that early work, laid this incredible foundation. And I often say that at tide pool, we're standing on the shoulders of giants. And it's very true. We could not have done this without the work of all the people I just mentioned without the work of Nate rock left, who wrote the original version of loop. And to me it is just incredible testament to how this community wants to make a difference. Like I said earlier, every single person is just saying hey, I think there's a better way to do it, I'm gonna go do it, I'm going to do it, I'm going to use it on myself, I'm going to share my work, I'm going to take contributions that other people make and make it even better. And everybody did that. And I hope in our little way tide pool is doing that too. We're sharing everything we're doing. openly, all of our code is out there, we're actually publishing all of our regulatory interactions openly because we want to help other innovators and entrepreneurs with their interactions with the FDA. And, you know, at the end of the day, it takes a village to help deal with this crappy disease. So we're trying to do the best we can. I

Scott Benner 1:25:38
can't thank you enough for having the idea and bringing it forward like this. And for all the people like us, I can't name them the way you can, but I'm so grateful for all of them. My daughter's life is, is monument monumentally different, like just different than it would have been otherwise? And I'm honestly, I'm not kidding you. I was I was gonna kill myself with the not sleeping thing. You know, the first the first few years I taught my talk myself into believing I was one of those people who didn't need sleep. Like you know, we all tell ourselves that at one point, like, I'll be okay. But man six, seven years into it, and I was I was hanging on by a, by a shoestring you know, and I hear it's a big deal for me. So and yeah, a lot of same people. Same.

Howard Look 1:26:20
My daughter has benefited my wife and I have benefited and 1000s of other people too.

Scott Benner 1:26:24
Okay, tide. pool.org. Right. That's it. All right.

Howard Look 1:26:28
I pulled out org slash loop, sign up, and we'll keep you updated. Howard, thank

Scott Benner 1:26:31
you so much.

Howard Look 1:26:32
I pray thanks for having me on Scott. I really appreciate it, I do too.

Scott Benner 1:26:41
First, I'd like to thank Howard for coming on the show and talking to me today about tide pool loop. And of course, I also want to thank the Contour Next One blood glucose meter, contour next.com forward slash juice box head over there today. See the meter that my daughter uses. It's incredibly accurate. It's one of the reasons I love it the most. Also want to thank us Med and remind you to go to us med.com forward slash juice box to get your free benefits check. Or you can call 888-721-1514. Last reminder, juicebox podcast.com. type one diabetes is our private Facebook group in the feature tab, a list of algorithm based episodes where you can find them at the top of juicebox podcast.com. They're in your episode guides. That's where you'll find the episode guides, or they're in your podcast players. Just use a search like Juicebox Podcast and then you got to find out the names of the episodes. There's like Fox and the loop house and the loop de loop. And you'll see there's a bunch of in there, go find the list. I'll I'll do that. You know what I'm in a good mood. I'll put a list of the episode numbers in the show notes of your podcast player. So in the show notes of the audio app you're listening in right now. Besides links to all the sponsors. I'll put the episode numbers of all of the algorithm based episodes. That sounds good. Alright. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

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#837 Marvelous Marla

Mar has LADA, Hashimoto's and a few other issues.

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

Scott Benner 0:00
Hello friends, and welcome to episode 837 of the Juicebox Podcast.

On today's episode we'll be speaking with Marla, she has diabetes Hashimotos something going on with her kidneys. And another thing that I can't pronounce, so why don't we wait till we get into the episode for you to find out about that. While you're listening today, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan, or becoming bold with insulin. And for those of you who are getting ready to skip through the ads, I've got a new advertiser today, and they have a 35% off coupon code for you. So maybe don't touch that button so quick. If you have type one diabetes, or are the caregiver of someone with type one diabetes, and are a US resident, please go to T one D exchange.org. Forward slash juicebox. Join the registry, you complete the survey. And when you finish that survey, you'll be helping diabetes research to move forward. It's super simple, completely safe, and you will really be helping that link again is T one D exchange.org. Forward slash juicebox. It really does just take like 10 minutes. This episode of The Juicebox Podcast is sponsored by cozy earth. Because the Earth has you covered for your bedding bath and sleep wear needs. There has been a cozy Earth product on Oprah's Favorite Things list for five years in a row. I'm going to tell you all about the sheets that I'm sleeping on right now, a little later. But for now, here's what you need cozy earth.com. And when you check out use the code juicebox to save 35% off your order. What'd I just say? 35% 35% of you spent $1 You save 35 cents. I understand $2.70 You understand the math of this. It's a fairly significant amount of money. They have a ton of stuff. It is all incredibly comfortable. I will tell you more about it later, like I said, but for now cozier.com 35% off at checkout with the code juicebox it's all one word ju ice box. The podcast is also sponsored today by touched by type one. This is a wonderful organization that I'm talking about. Just go to their website and check out what they're doing for people touched by type one.org NO BULL you understand I'm saying set a small group of dedicated people helping others with type one diabetes. Check out their initiatives like the D box program and dancing for diabetes. Find them on Facebook and Instagram touched by type one that will warm your heart. Take five minutes today to feel better at touched by type one dotwork.

Mar 3:07
My name is Mark and I am diagnosed with LADA five years ago. How old are you? I will be 56 later this year in October.

Scott Benner 3:20
That's a good that's a good age.

Mar 3:22
Yeah, I guess so. Better than not.

Scott Benner 3:25
You know, you and I have a lot in common Martin. Yeah. Now did you just say your name differently because of an accent or am I saying Marla and I shouldn't be it? No,

Mar 3:33
no, a lot of people call me Mark. My name is Marla. But a lot of people call me bar so either one is fine.

Scott Benner 3:39
Oh Mark your mark. Okay. 56 Lada for five years,

Mar 3:46
five years now. Yeah.

Scott Benner 3:48
Interesting. Tell me how they explained allotted to you?

Mar 3:53
Well, it was kind of a long process because I was told five years prior to the diagnosis date that I had type two. So it started with my primary care doctor saying, you know, your blood sugar's a little elevated, I think you're pre diabetic, start watching your diet, you know, try to get more exercise. And I have two friends that are type two close friends. And so I just started doing what they were doing. And that went on for a while, about a year and then she said, Okay, now you're diabetic. And she added Metformin in over the next probably four years. You know, I really I struggled. I mean, I did everything my friends were doing their numbers were really good. Mine just slowly kept rising. And my doctor kept saying to me, you know, I would tell her, I promise you, I'm doing what I'm supposed to do, and I don't know why it's not working. And she would say, Well, don't worry, I know you're trying. I think yours is autoimmune anyway. But, you know, when she said that to me, I didn't understand what she meant because I I had always thought that only kids were diagnosed with type one. And I didn't make that connection. Oh, autoimmune type one. I thought that she meant because I have so many other autoimmune disorders. It was making the diabetes difficult to manage. Oh, I see. I never, I never asked her like, Well, what do you mean by that? So things got really bad. And my numbers got really high. And that's when I got the lot of diagnosis.

Scott Benner 5:28
How long did really bad last?

Mar 5:31
Um, you know, I, I had a hysterectomy the summer before my diagnosis. And so for several months following that, I really felt horrible. But I attributed that to recovering from the hysterectomy because it's a big surgery. And, you know, I was extremely tired. And I felt nauseous all the time. And my numbers were high, but I knew that they, you know, I had been through a surgery and I was recovering. And so all of these things that were going on, I just thought, well, this is because of the surgery, you know, and so it's probably several months.

Scott Benner 6:08
Wow. Why did you have the hysterectomy?

Mar 6:12
I had endometriosis, which I've read is frequently associated with autoimmune disorders, but I couldn't I can't find anything that says Yes, it definitely is. And so it basically you know, was like a, just a never ending period. And the only way to cure that is to remove the uterus,

Scott Benner 6:31
a medical condition characterized by the growth of cells that build up inside the uterus. That sounds like you. Yep. Okay.

Mar 6:38
Yeah, I was happy to have them take it out. They couldn't do it fast enough.

Scott Benner 6:42
Do you have children? I do not. Was that ever an issue for you?

Mar 6:48
You No, no, I was okay with never having I never really figured if I did, I did if I didn't, I didn't.

Scott Benner 6:54
I sat through a two and a half hour presentation last night of the high school that made me rethink having children. I'm trying to see if I can find a relationship to it. And autoimmune is an add in Wow. How do you say it add an add no

Mar 7:09
meiosis.

Scott Benner 7:11
Is it something in

Mar 7:12
my my gynecologist explained to me as being like she said, it's an endometriosis that's confined to the uterus is basically what you're dealing with. And she said, the uterus just continues to once it starts, you know, getting into this. Oh, my computer's making noise. I'm sorry. There's once it gets start into this, you know, stage where it's just continuing to bleed. It just won't stop. And I had a 60 day period, which made me almost want to lose my mind.

Scott Benner 7:42
Man, period means stop. Yeah.

Mar 7:47
I know. Someone tell my uterus. Yeah. So that's what led to the diagnosis because she, you know, they did a DNC and they said, Oh, it'll, it'll, it'll be okay. Now you're just probably starting menopause. And I was like, Well, okay, I'm a little. Seems like I might be a little young for that. Yeah. And she's like, No, not really. And she said, it takes a long time. I said, Okay. And I remember and I really liked her, but she said to me, I don't know why this happened, but it's not going to happen again. And I thought, okay, that doesn't make sense. But, um, and so the DNC kind of fix things temporarily. And then it came back and she said, Well, we need to do an MRI. And that was how they diagnosed it. And then she said, You need a hysterectomy. That's the one way to fix this. Okay.

Scott Benner 8:31
All right. Yeah. You said you have other autoimmune diseases. What else do you have?

Mar 8:37
I have rheumatoid arthritis. I have IGA nephropathy. I have Hashimotos thyroiditis. And then the latter.

Scott Benner 8:48
What was the one between RA and Hashimotos?

Mar 8:51
It's IGA nephropathy. So it's a condition where basically you build up too much protein, your kidneys, which then makes them stop working.

Scott Benner 9:01
Have you had, are you on dialysis?

Mar 9:05
No. So my kidneys are still functioning. I was diagnosed with that, in 2007. If you were to look at my kidney function, it's slowly decline. Over the last, what, 15 years, but I am right now and probably speak, I wrote they fluctuate between stage. I don't know why they split three into two, they'd have stage three and stage three B, I'm not sure why they do that. But I fluctuate between those two stages, which is somewhere between I think 50 and 60% of my kidney function remains.

Scott Benner 9:41
What came first. Did you get the Hashimotos first, so it

Mar 9:47
was the rheumatoid arthritis first, then the IGA than the Hashimotos? One Well, that's that was the order of the diagnosis. I you know, honestly, I could have had, they told me I couldn't have the IGA for years, but Before it was diagnosed, it was diagnosed by accident.

Scott Benner 10:05
All right, how old were you?

Mar 10:08
So that was in 2001. So I would have to do some math, I think.

Scott Benner 10:14
Hold on 2156. This is my time. 3035.

Mar 10:18
Yeah, somewhere. And then I've heard your comments about math several times.

Scott Benner 10:22
I was like I saw I saw simple low numbers. I was like, I can get this one. So how did ra percent for you?

Mar 10:31
So Ra was just a pain in my hip that was persistent. And I, I had was buying a house and I can remember, it was Thanksgiving. I was buying a house the following spring, I moved in. And I can remember thinking if this pain in my hip doesn't go away, I'm going to have trouble moving. And it took about nine months for them to finally give me a an RA diagnosis, because they said typically, it's symmetric, and mine was asymmetric. And it still is. And they said, well, that's just not, you know, we think it's rheumatoid arthritis. But that's not how it presents. So they looked for everything else. And they it took them a long time, they bounced me back and forth between rheumatology and orthopedics. And they finally I think, just couldn't find anything else. And it presented as RA in every other way. And they they said, Okay, well, alright, your rheumatoid factors are through the roof. We think it's Ra. We don't know why it's asymmetrical. But this is what you have.

Scott Benner 11:30
Just in the one hip.

Mar 11:33
Well, it later got into the other side, but it's never thankfully, I've never had issues on both sides of of any joint at the same time. It's always just one thing.

Scott Benner 11:42
Do you take any medication for it?

Mar 11:44
I did for about five years, but I don't anymore. And I haven't since you know, the early 2006 Or seven, I stopped taking meds?

Scott Benner 11:53
Did the meds work? Or no,

Mar 11:55
you know, they did initially they took they had to go in and do I forget what they call the procedure, but they stick a big needle in there and pull the fluid out of the hip joint. And they did that I was in the hospital overnight, because my leg was actually pulled because there was so much fluid in there. And they pulled the fluid out and put me on meds right away. And I was good. And I stayed on those meds for probably four or five years. And then I just, you know, I didn't want to stay on them if I didn't need to. Because I mean, it sounds probably bad, but you can't drink. And I'm not I don't have issues with alcohol. But I do like to have drank here and there. And I asked my doctor, can I can I come off this medicine? Can we see how it goes? And he's like, Yeah, let's try it. And so it was fine. And so I've stayed off of it.

Scott Benner 12:44
Okay, so you. You got off the medication, so you could drink once in a while?

Mar 12:49
Yeah, I like to have Yeah, I like to have whiskey once in a while. At that time. I didn't drink whiskey. But, you know, I didn't want to break the rules. I don't want to put my liver at risk by drinking alcohol when I'm on this meds on these meds. And, you know, I couldn't couldn't do that. And, you know, I also thought, well, you know, it might be good to just see how things are going without the medication. And it turns out, I mean, I've been off the medication since 2005 2006. And I I've been okay, so I feel like, why take it if I don't need it,

Scott Benner 13:20
okay, means a level of pain and discomfort you're okay with?

Mar 13:24
Yeah, I mean, there are plenty of days that I don't have any pain at all. But then there are days when, you know, just last week, one of my, the joint on my left foot of my big toe was hurting so bad. I couldn't walk for a couple of days. I mean, I didn't walk, but it was very painful. And then I woke up and it was done. It's fine. And that's how it's always been, you know, I'll have a joint that just doesn't want to work, right. And it hurts for you know, X number of days. And then it just goes away, which is, you know,

Scott Benner 13:52
frustrating that and is it? I mean, are you keep talking about a little bit when it was first happening? What's it like to get a diagnosis like that, that doesn't seem very impactful.

Mar 14:04
So I mean, it was, you know, it was a little frustrating. I was in my mid 30s. And my I remember my rheumatologist telling me, oh, you're gonna get other autoimmune disorders? And I said, why? What do you mean? And he said, Because you do if you get one, you get more. And so that was a little frightening because I was, you know, still young at that point and thinking, Well, what else is gonna happen? You know, and then you if you you know, if you look up pictures of people with rheumatoid arthritis, their hands sometimes, well, those are worst case scenarios, you know, but their hands are like, you know, they can't use them. And I was afraid, you know, what am I going to do if that happens to me, and how am I going to, how am I going to be independent and, you know, so it was kind of kind of frustrating, kind of scary, but then I just thought, well, you don't know that that's going to happen, and it may never happen, and it hasn't, I mean, I have some I don't forget what they're called, but like my knuckles have some nodules on them, that you can see they're not Huge I can kill them. They bug me, but they don't really do anything about them. But I don't have. There's no part of my life that's impacted to the point where I can't do something because of the RA. Okay? Which if things stay that way, I'm fine. Okay.

Scott Benner 15:15
Okay, so you're 35? Around 35 When this happens, how long after that? Do you hear about the kidneys?

Mar 15:23
Um, well, it was 2007. And I had the flu. And I mentioned to my doctor, just, you know, off the cuff. I said, Oh, you know, I think I was really dehydrated, because my urine was like coffee color. And she said, What do you mean, it was coffee color? And I said, Yeah, I said, you know, I couldn't keep anything down. And I think I got really dehydrated. And she said, Well, let's check that. And so whatever she saw on the results of the urine tests, she sent me to a nephrologist, who said, well, we need to do a kidney biopsy. And that's how they diagnose that. And so what happens with that disease is it's often not diagnosed until it's in advanced stages, because the symptoms are, you know, I don't know, not there like you don't, you know, I was lucky, I guess that I had that issue with the coffee colored urine, because otherwise they they wouldn't have caught it, you know, anywhere near that early.

Scott Benner 16:24
Okay, so Hashimotos comes when

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Mar 20:33
That came probably around 2010 ish. And that was because I had my bloodwork showed a ton of calcium. Like my calcium levels were too high.

Scott Benner 20:46
Yeah, high calcium. That's one of the indicators. How about Yeah, that's how they caught it. Yeah.

Mar 20:51
And they said, Well, let's take you I was on some medication, I can't remember what it was that they said could elevate your calcium levels. So they, they took me off of that, and put me on something else. And so it didn't didn't, you know, resolve and kept getting worse. And I don't remember all the different tests that they did. But it ended up that I had a large benign tumor on one of my parathyroid glands and I had large tumors on my thyroid, and they said the parathyroid has to come up, you can't leave it. And while we're in there, we're going to take most of your thyroid because it's covered with benign tumors. So they did that. I still have little bits of my thyroid left. But you know, I take Synthroid everyday and I will for the rest of my life.

Scott Benner 21:36
And is that fairly well maintained? Do you see a lot of symptoms from thyroid or no?

Mar 21:42
No, I think it's pretty well maintained. My numbers are usually pretty good.

Scott Benner 21:45
How about how you forgetting the numbers, how you feel like you can get rested, your hair doesn't fall out, etc? Well, I

Mar 21:52
do have what I think is probably more hair loss than I than I should I mean in the drain, but I my hair doesn't look thin. And I am frequently tired. But I don't know if if Teague is from Hashimotos or not. I just don't know

Scott Benner 22:10
when you said your numbers are good. What's your TSH?

Mar 22:14
Ah, you know, I really don't know what I can tell you. Yeah, take a look. Yeah, when you look, let me log in. I just have bloodwork because I just reached out to my doctor. In fact, I see her later today. Perfect. Um, but I did reach out to her because I said, you know, I'm really kind of tired all the time.

Scott Benner 22:31
Scott's gonna help.

Mar 22:36
And I said, you know, I thought maybe my iron was low or something. Let's see test results. 1.440 So

Scott Benner 22:49
it is good. Yeah. All right. So you're gonna check your I do an iron panel. Check your ferritin that kind of stuff.

Mar 22:54
Yeah, she did all that my ferritin was only 18 which is on the low side.

Scott Benner 22:59
Oh, much too low. Yeah, yeah, yes. Yeah. So

Mar 23:03
so I could that could be why I've been tired lately. She told me you know, get a multivitamin and start taking iron.

Scott Benner 23:09
That takes forever, but okay. Yeah. Ask her if she'd like to get you an infusion.

Mar 23:15
I couldn't ask her about that. Actually. i Yeah, I'm gonna see her later today. So I will

Scott Benner 23:18
I had one. Lovely Marlo. Really? Yeah. So it goes in. And then once your body starts making new blood cells, it makes them now with the correct amount of iron in your system, and you just feel better. Oh, really? Okay. Well,

Mar 23:34
definitely ask her. Thank

Scott Benner 23:35
you. But we also want to know why your iron is so low. Well, that's been

Mar 23:39
an issue I've had for as long as I can remember, every time I have bloodwork, they tell me, you know, your iron is low every time it's pretty iliac

Scott Benner 23:47
or a see like even a celiac intolerance.

Mar 23:53
Well, they tested me for celiac and that was negative.

Scott Benner 23:55
Okay. Do you do you think you don't do well with gluten? No, I think I do fine. You're fine. Okay. Yeah. So then it's an absorption thing, I would guess. And I'll tell you what helped for me. Let's everybody remind each other I barely got through high school and I'm not a doctor, but you know, podcasts and all that like sorbic acid, vitamin C, along along with my iron supplements, so I could take iron supplements and it didn't matter. Not they didn't touch anything, that I got the infusions and got to the point where I thought, oh, gosh, I'm a person who's gonna have to get infusions for the rest of my life. This will be fun, because they only lasted for like six months or so. Yeah, but then it turned out I just wasn't absorbing the iron. So now I take a quality iron supplement along with the sorbic acid, same time, two tablets down and my body picks that up. Fine.

Mar 24:50
Okay, I'll definitely try that.

Scott Benner 24:51
Give it a whirl. Well, thank you. I don't want you to be tired. Yeah,

Mar 24:55
I don't want to be tired.

Scott Benner 24:57
Honestly, Marla, you got enough going on. You don't need another thing. I agree. So now after hearing about all of this, yeah, I'm baffled that when you get a diabetes diagnosis that someone doesn't go, well, she has RA and Hashimotos. And this kidney thing, this is clearly type one diabetes.

Mar 25:16
Yeah. Well, I am to now that I know more, but at the time, you know, I knew nothing about this. I mean, I, like many people had always heard that only kids are diagnosed with type one. So all the times that she said to me, and it was many times, you know, don't worry, I know you're trying, I think this is autoimmune. It just never occurred to me to say, What do you mean by that? I think like I said, I had all these autoimmune things happening. And I thought, well, that means that it's these other diseases are making my diabetes difficult to manage. It's just the way it is.

Scott Benner 25:46
Yeah, I understand. Yeah. But you know what I'm saying, though, like Lada or type one, whatever it is that you, you know, have an I don't, I'm gonna dig into it with you. Sometimes. I don't even know if it matters, to be honest, what they call it. But I just don't see how a doctor doesn't see other autoimmune issues and not put you on Metformin. Well, I wasn't meant for I'm saying, I don't know how that happened to you. Yeah, it's just it's, it seems a little obvious to me. Like, you know, when you're watching a movie, you're like, that's the guy that's gonna die first. And everyone knows, like, they could have wrote this a little better. So we all didn't see immediately that the character of Eddie is going to be murdered. And it just seems to me like it. It was kind of set up for them to understand.

Mar 26:32
Yeah, no, I would agree based on what I know now. And I mean, looking back, the Metformin did nothing but make me sick. I couldn't take it half the time.

Scott Benner 26:40
Yeah, I wouldn't imagine did you lose weight on it?

Mar 26:43
I did not. Which was a question my doctor used to ask me all the time. And she also she put me on Giannoulias put me on Victoza. And, you know, I didn't lose any way through any of it. Although, you know, I will say it's, it takes a lot for me to not power through and eat something if I am hungry.

Scott Benner 27:03
There you go. Your head down girl, huh? Yeah. Done.

Mar 27:09
I have to have some extreme nausea. Otherwise, you know, it's time to eat and I'm hungry.

Scott Benner 27:15
Okay, so going back to when you realize Lada? How does How is Lada explained to you? And is this fine endocrinologist or a general practitioner?

Mar 27:27
No, just my internal medicine doctor, she's she, I had been on vacation. This was you know, the December after my, my summer hysterectomy months leading into this was not feeling good thinking it was the surgery. I went on vacation like I always do over the holidays that come back from vacation and I you know, not rested, like you would be after a vacation. You know, my job, my job is stressful. I commute an hour plus one way, you know, I can think of all kinds of reasons why I would be tired at the end of the day. But this was more than that. And so come back and vacation. I'm not any better. You know, and I tested my fasting glucose that morning, and it was 450. And I thought, well, I'll get to work. I'll eat some breakfast. It'll come down. I don't really know why I thought that the breakfast I chose was oatmeal. And tested two hours after and it was 583. And so if a faculty member came by my office, I knew he had diabetes, because he had told me before about his diagnosis story. So he stopped by for something. And I said, you know, Hey, um, my blood sugar is 583 Do you think I should call my doctor? You know, I don't know why I even asked him because I knew the answer. And his eyes, you know, popped out of his head. He's like, yes, you should call her isa while he was I have a meeting that I have to go to. I'm coming back in a half an hour. If you haven't heard from her. You and I are walking over to the endo clinic right now. Because I work in a hospital. And I said no, no, no show. So she'll call me back. So I might chartered her. And she's very good about answering it. She did within like 15 minutes. And she said, come to the clinic. You need insulin. And so the conversation I had with her she said it again. At that point, I think yours is autoimmune. And I finally said What do you mean by that? And she said, Well, I think that yours is type one. And I said I didn't understand the kids that you've had could be diagnosed with that if you weren't a kid only kids get that and she said no adults can get it too. And so I went over got the insulin, you know, did my first insulin shot within two days felt night and day better. And they said you need to make an appointment with an endocrinologist and so all the information that I got from my primary care doctor, was you know, she said my basil I don't really or when she sent it out, I did a shot at night. It was I think it was Lantis or basil blur or something. And she said, if you eat a big meal, take four units, if you eat a small meal, take two units, and you know, get into siendo Well, it was a four month wait to get into see an endocrinologist. So I started researching lotto and reading about, you know, decks, comps and insulin pumps, and, you know, all these terms that were brand new to me. And so I called her back within about a month or six weeks and said, I don't want to stick my fingers because once I knew I had something that I could do something about now I have insulin, like, you know, before, when I thought I had type two, and nothing I was doing was working. You know, you after a while, you just kind of think, well, you know, um, nothing I'm doing is working anyway. So why am I trying? So once I figured out like, okay, now I need to take insulin, and I can manage this number. I'm sticking my fingers like crazy. And I figured out right away that this is not going to work. I don't like this. So I think within a month or six weeks, I said, you know, I read about this Dexcom Can I have this? And she said yeah, absolutely. And it took a while for the you know, paperwork and whatnot. But I was on the Dexcom G five by early April, because this all happened early January. Okay. So three months, and I had a Dex which I love. Um, and then by the time I saw my endocrinologist, probably in May. I had researched pumps. And I said, I don't want to give myself shots anymore. Can I have an insulin pump? And she said, Yeah, which one do you want. And I had researched the T slim and the Omni pod and I was leaning toward the Omni pod because I didn't want the tubes. But I knew that I knew that this decision was going to last me like, you know, for years, and I thought I'd better meet with the reps and talk to people in real life of real people. And so just reading online about these products before I make a decision, but I really kind of knew that I wanted to Omni pod and that's what I chose. And that's what I've been on ever since.

Scott Benner 32:11
And that's been really beneficial for you being on a poll. Yeah,

Mar 32:15
yeah. I mean, my numbers are. They're not where I want them to be, honestly, but they're not horrible. And my endocrinologist is always telling me you're you know, you're too hard on yourself. diabetes is hard. You're doing really well.

Scott Benner 32:29
Well, that's good. Where are you at that you aren't happy with?

Mar 32:32
Well, I my agency is 6.5 Not bad. But I would like it to be lower my time and range is 86%. Also not bad. But I would like it to be above 90.

Scott Benner 32:43
What do you call? What do you call in range? What's your range you're shooting for?

Mar 32:47
Um, well, I have my alarm set, according to what I learned on your podcast now. Um, so my low alarm is 70 my high alarm is 130. But the in range on the decks is just the normal 7180 Yeah.

Scott Benner 33:04
How often do you think you're between 7130? Um, maybe half the time? Yeah, that's probably where you'll make up that other half a point of a one C is losing those. Those 50 points between, you know, I don't know. 3130 and 180. Right in there. Yeah, yeah. And so what do you think? What do you have happened? You have spikes at meals?

Mar 33:32
I have. I have the same exact breakfast every day. And I can't figure it out. And I don't know why. Yep, I eat the same thing every day. I mean, I was doing that before I listened to your podcast of you know, eat the same meal figured out. And so what I started doing is writing down like, Okay, this is what my insulin or my blood sugar was when I Pre-Bolus Here's what it is when I ate. Here's why it was right after I ate. Here's what I did. Sometimes I do a Temp Basal. Sometimes I do an extended Bolus, sometimes I just do a you know, corrective dose before I think I need the corrective dose. Sometimes I just Bolus a lot more upfront. Now this morning, things have been going pretty

Scott Benner 34:14
well. Right. Um, what did you What do you eat every morning?

Mar 34:18
So I have a piece of bread that I make also thank you to your podcast. Yeah, I mean, I like to bake anyway. And I thought, Well, why am I buying bread when I could just make bread? So I have a piece of bread that I make. I had eggs, coffee, and I usually put either some Greek cheese on the bread or some goat cheese just a little bit. So I eat that same breakfast every single day. Do you need I do fine. And sometimes I don't.

Scott Benner 34:43
Do you need insulin for coffee when you're having it by itself? Yes. Okay. What is sometimes you do fine and sometimes you don't let's put numbers on that when you don't. Where's the spike go?

Mar 34:54
So, I think Monday I went up to like 240 Okay,

Scott Benner 35:00
And then but there are times where the exact same Bolus it doesn't happen.

Mar 35:06
Well, that's the thing. I'm not sure I'm boasting the exact same thing every time. How come? Because well, because like, okay, it didn't work Monday. So I thought, Well, that wasn't the right Bolus, because I do agree with what you say like if you're if your number is going up, you either didn't time it or you didn't use enough. I do agree that's true. So I thought, well, I didn't use enough, so then I'll use more, or I'll spread it out. Or like I said, I'll just do a preemptive corrective dose.

Scott Benner 35:34
Do you ever pay attention to where your site is? Or if it's an old or new site on your pump? In relation to what the success or not that you're having in the morning? No, I would think about that. Like, am I like, is today a good day? Is that the second day of the pump? Or the first day of the pump?

Mar 35:56
Should you know today? Let's see I just changed my pump. Last evening when I get home.

Scott Benner 36:03
This is so this is a pump that's 12 hours old. And it's it's doing well for your for your breakfast. I'd be super interested to see what happens. This is Thursday, Saturday morning, when this pump is on its last legs. Is it? Is it different? I would also look where do you where your pod, arms belly thighs.

Mar 36:22
It's on my arm right now. But I typically where I'm on my legs.

Scott Benner 36:25
Okay, our legs? Do legs need more insulin than arms? Or vice versa? Well, that's a good question. I don't know, this is what I would be looking at. Because I mean, if you have if you're doing the same exact meal, and I mean, a couple of eggs, a little bit of goat cheese bread you made yourself which we know. I mean, if you're using my recipe doesn't have very much sugar in it at all, honestly. Right? Yeah. And so I Yeah, and there's no high fructose corn syrup in it, etc. Right? So it shouldn't be hitting you all that hard. And if the Bolus is working sometimes and not others, I'd look outside of the of the carbs and the insulin for something else. The first thing I think of is pump placement or age of the infusion set. Okay, those are my thoughts. Okay. If that works, send me an email. I will. I want to know, okay. Okay. So, so you treat you know, so that they they're still calling you Lada like, is that your diagnosis?

Mar 37:25
Yeah, it says Lata and then parenthetically says type one. Okay. So, you know, I don't know I asked my endocrinologist about that. And she said, you know, Lada, she said, there's people that call it type 1.5. They call it Lada. She said, it's basically type one she said your pancreas just takes longer to shut off she said kids that have this their pancreas is done it you know, just shuts off there. You know, instantly, you know, need insulin. She said you have probably been experiencing this for years. You know, she said it just takes a long, longer time.

Scott Benner 37:58
Also, in fairness, not that you just not that you misspoke, but there are adults who get type one and their pancreas just gives up the way you express. Yeah, yeah. Excuse me. Okay, so are you noticing that like, as time goes on, do things need more insulin very slowly?

Mar 38:18
Oh, yeah. I don't honestly know how to answer that.

Scott Benner 38:24
Okay. That's okay. But it's just yeah.

Mar 38:29
I just don't know I I just don't know the answer is I need more than I did five years ago.

Scott Benner 38:35
Yeah. In your heart, the way you treat every day and what you see other people doing You You You act as if you have type one diabetes, and that there's no real thought about it. Otherwise, I imagine.

Mar 38:45
No, no, I mean, I just Yeah, I yeah, I would agree

Scott Benner 38:52
with that. Okay. All right. Yeah, I mean, if you don't agree with it, then that's just me saying here's what I think Mark Thanks, Scott. I don't think that too bad move on

I'm sorry me myself. What? I just I imagining a scenario where I just tell people what they think and somehow podcast today builds on I'm going to tell him how he feels about Bri. But I'll tell you that would not be a lot of fun to listen to. What made you want to come on the podcast?

Mar 39:28
Well, I just found your podcast and was suddenly like wow, these are you know, real people who are crazy because in the in the like real people who are crazy that have the same thing that I have or similar to what I have, I guess if not is not exactly type one.

Scott Benner 39:47
Before we get into that Marla do you find a lot of real people are crazy.

Mar 39:51
I mean, if you look in the online community, you can find some people that are not helpful. Maybe crazy is the wrong word but not helpful at all. All, or extreme or judgmental or, you know, admonishing. And so when I started listening to the podcast, I don't remember how I found it. But I thought, yeah, okay, you know, I'll see what they have to say. And I just was thinking, wow, this, these things, these, this advice could actually work. And these people are doing this and having success. And because I feel like I am largely reactive, like, I check my I hear you say you don't even check your daughter's number, you just listen for the alarms, and I'm constantly looking at my phone, constantly looking at it to see what the number is. And when it's not what I think it should be, it's because I've done something wrong. Now, I know that that's not true, but that is what I feel and think. So you know, that I'm reacting constantly to this high number. And I feel like I could do better to to put myself in a more proactive, you know, response, instead of just always reacting to things I

Scott Benner 41:05
understand. It's a large part of, I mean, if you, you know, you hear me on the podcast, obviously, I follow the conversations, when I'm talking to people, I don't just break in with thoughts that are, you know, out of left field, but a big part of how I think about diabetes is about acting first. It's about it's about attacking it, and then seeing what happens next. And knowing I made what happened happen. Like, I think once you wait for diabetes to happen, and you're responding, you're always behind, you're always chasing, and therefore, you get up and down numbers, and you never feel confident about anything you're doing. Because then there's always an aspect of what's happening that is unknown to you.

Mar 41:48
That's exactly right. Yeah, that's exactly how I feel like I, I react and try to, you know, I've learned a lot from the pockets, like don't get over 200, because it's much more difficult to come back down to is much more insulin. You know, when I see 160, I start, you know, trying to correct, I try to be very good about Pre-Bolus, seeing, you know, not being afraid to use more insulin and stuff. But I still feel like, I'm not doing something I should be doing to keep my keep my line a little more level and not be so reactive. And I often don't know what's happening.

Scott Benner 42:26
It's interesting that you that you bring this up today, because I just yesterday interviewed a woman who's the mother of a nine year old, actually, your episodes will come out really close together. So anyway, it probably just came out. And she had been on the podcast previously. She came on in 2017 when the podcast was like two years old, and was on an episode called the normal floor. And then she came back just to sort of do an update and talk some more. And she was still talking about some of the struggles she has one of them was that she has trouble Pre-Bolus at school because she's worried the kid's gonna get low. But here's what happens every day. She doesn't Pre-Bolus Enough. The kids blood sugar jumps up, the insulin becomes unbalanced with the foods that the food is the digestive system, and he crashes low. And I said so. You don't Pre-Bolus Because you don't want him to be low. And she said, Yeah. And I said, Well, what happens when you don't Pre-Bolus later and she goes, he gets a low? And I thought do I need to keep talking right now? You know, like, I'll let the silence work for me here. And she goes, Oh, yeah, or something. And I was like it just it doesn't matter. Big picture, you're using insulin, you're probably going to have lows sometimes. I prefer to have a low you caused than a low that happened to me. And I really ironically, as we're talking about it, Arden, you would know this, but in the first 20 minutes of this episode, I helped Arden fix a low that she's having at school. Oh, well. And so she it looks to me like what happened? It's just a crazy little thing. But it looks to me like what happened was she Bolus accurately for for a food that she had. Problem is this is the second day of her placebo of her birth control pill. And she doesn't think about it like that as much but you start getting, you know, there's a shift. So anyway, the Bolus was a little heavy. And she's gets this diagonal down arrow that's just not stopping she sees at around 65 and tries to hit it with some candy. Why candy and not juice. While I find out later. It's because she doesn't have a juice honor. So the candy doesn't work as quickly as she's expecting because she usually treats with juice and she would she expected a quicker response the way she gets from the juice. So she gets low enough to 50 where I text her and go, Hey, you're paying attention to this right? And she goes yay, I know. And I'm like okay, so I said what you do? She told me about the candy. And I said, you know your tests she tested the CGM was accurate. I said, I really think I would drink half a juice here. Five minutes later I get a text it says too late, too late means Arden doesn't like to have a half juice box on her desk. So she banged the hold us down. So I just texted her and said Bolus suggested, which is and by the way your Dexcom warmup period is over. Is that

Mar 45:30
That's my my alarm at 1310.

Scott Benner 45:33
I was that's the noise you used for that alarm? Yeah. Yeah. So you know, anyway, Arden's on loop, I told her to put in carbs for the candy, not for all of the juice, and we let it catch her low. If she was home, I would have just told her to Bolus like I actually would have Bolus did a 50 blood sugar after she drank the juice. But since she wasn't a way, I just told her to hold off. Now the insulin is going in. She shooting up, it'll stop around 150 and come back down again. Okay, if that all makes sense. But anyway, if if we would have Bolus for the candy and maybe a half of the juice, as her blood sugar was 58 She wouldn't be shooting off the way she is right now. You know, so and that's my point of telling the story, which is you have to be ahead of it. Right? You just Oh, and and I'm not disappointed that she had a low because she was appropriately aggressive for what she ate. And I would rather her have a low that she made happen than a low that just happens to her. Right? Is my reason for bringing it up. Yeah, that's all. I mean, is that a mindset thing for you? Why do you not do it? Because it sounds like you know,

Mar 46:53
I think I don't mind. Like during the day, all day long, I'm fine with you know, using much more insulin if I need to. I guess I just with breakfast. I'm struggling with how much and I also I well, I should mention this too. I don't want to have to eat extra calories if I don't need them. Because I'm always watching how much I'm eating. Yeah, I

Scott Benner 47:18
don't want you to do that either. But could we? We now I'm in this with you. Could we start upping your basil early morning before you get up?

Mar 47:30
Yeah, I just made adjustments to my basil because I thought about that yesterday. Because, you know, I knew I was coming on as today. And I thought, you know, what are the reasons that you can't get this breakfast thing figured out? And I thought, well, maybe I need to adjust my Basal which I don't wait for my endo appointment to make changes to my pump settings. And my endo is fine with that she you know, she'll look at them. And only one time did she asked me to change something that she wasn't comfortable with. And it was because I had an overnight target of 90 and she wanted it higher. And I you know, she's she's so good and everything I said, Okay, how about if I make it 100? And she's like, Yeah, that's fine. So I did that. But the rest of my settings, you know, she she's okay with and I just changed it Sunday to increase my basil in the morning, because I did think well, maybe that's the problem. Maybe? Maybe it has nothing to do with what I'm eating. I'm not getting enough insulin, anyway.

Scott Benner 48:25
Yeah, no, I mean, that will be my first consideration. Do you go up in the morning if you don't eat? Well, I always eat. That's right. You said earlier, you're eating right.

Mar 48:36
I always, I always eat breakfast. That's my favorite meal of the day.

Scott Benner 48:40
Would you be willing on Saturday morning to have breakfast for lunch? Just to see what happens to your blood sugar if you don't eat in the morning? Oh, yeah, for sure. Give it a whirl. See what happens? Because maybe you're busy thinking? Well, first of all. First of all, pomp sight thing is worth thinking about. But if you're drifting up anyway, at that time of day, and you're just thinking about it as the food. Well, then that could be part of it, too. Yeah, you know,

Mar 49:10
so it could be because maybe that's not the issue,

Scott Benner 49:12
right? Maybe, well, maybe there's two things going on, and you're only looking at one of them. Yeah, right. So that's a possibility, too. You just need somebody to talk it through with like, that's the problem is that you, you get in your own head and it's hard to it's hard to flush the whole thing out by yourself. Sometimes.

Mar 49:31
It is 100% Yeah, and that's another reason like the podcast was you know, such a great fine because I don't have anyone to flesh it out with like, it's just me and I don't know anyone in real life that has this. And you know, again, the social media thing, you know, you can find good people, I found some really helpful people, but I also found some that were the complete opposite. And so after a while I quit asking questions.

Scott Benner 49:58
Yeah, it's tough because you just don't know What you're gonna get? Have you tried my private Facebook group? No, it's really good. There's like 24,000 people in there. And it's the it's the thing you hope Facebook would be?

Mar 50:10
Oh, I will. Yeah. How do I find that Juicebox Podcast

Scott Benner 50:13
type one diabetes. All right. And it's a private group, you'll have to answer a couple of questions to get in. That's how you'll know you're not just on the public page. Okay. Yeah, it's cool. Yeah. It's, it's just people who won't listen. It's still the internet, right? So it's people who listen to the podcast, mostly. But there are also a fair number of people in there who have just heard that the people in that Facebook group have a lot of success. So they they go there. It's interesting that every once in a while someone will just pop on and go, I feel so silly asking this. What is this podcast everyone's talking about? That made me mental in the beginning more, but I've let go of it. And I just know now that the Facebook page has sort of become its own thing. Yeah. And hopefully some people find their way from it to the podcast. But I mean, honestly, if the Facebook page helps them with their problem, then, you know, I think that's great. My honest opinion is you should listen to the podcast every day. And I know that's me sounding like I want you to listen to the podcast, but it keeps you in it. Yeah, like, think about it, you only really started wondering about why your breakfast isn't going the way you want. Because you were coming on a podcast to talk about diabetes. So you wanted to have some thoughts about it. Right? But why didn't you think about it six months ago? You know what I mean? And the answer is because you're living and you're alive, and it's going okay, enough. And when things start bleeding away from center, it happens so slowly, you don't notice your A once he goes, you know, go 66163 You're like, ah, six, three is fine, six, four, that's only one more than six, three, everything's fine. All of a sudden, it's six, eight, and you're like six, eight, still, in the sixes, you can you don't I mean, like you can rationalize almost anything. And that is a, that is a key building block of how human beings stay alive. By adjusting sub, like unconsciously to things. Just just so happens in this one area, you need to stop and focus sometimes and say to yourself, there's no reason why I'm six, seven now and I used to be six, two, I must be doing something different. And just and just not realizing it. i There's a great episode because way back years and years ago, where a mom has this realization while she's talking, where she's like, Oh, I've just become okay with 200. And she's like, I now think of 200 is not bad. And now I get what I expect. I expect 200 I get 200 I said yeah, move, move the alarms down, like just like you were talking about, expect 180. And then once you start getting 180, then try to expect 160. And then you'll see that most of the time you're under 160. And, you know, it's no big. I mean, it for me, I expect Arden to be between 70 and 120. That's all and most of the times that's what we get.

Mar 53:07
Yeah, see, that's that's where I want to be. I want to be in that range all the time. I mean, I don't want to have these highs when I eat something out. I mean, if I eat something, you know, sugar, then I know. But I hear you even talk about like our needs stuff like that. Yeah, and stays pretty steady.

Scott Benner 53:25
Yeah, she does. Well, yeah, I mean, Bolus for the right one. Yeah.

Mar 53:30
I think the most frustrating thing for me is like I haven't figured out when I'm not eating stuff like that when I'm just eating normal foods, and I still can't manage it. I don't always know why that's

Scott Benner 53:42
happening. Yeah, I I cut my teeth on bolusing for cereal. Like sugary box. Terrible for you not really food cereal. Like when I once I figured out a bowl of cereal. It just opens your eyes. It's like, it's like seeing the other side of the matrix. You're like, Oh, okay. And then you're just Okay, after that thing's news. The reference is so old now. I can't use it anymore. But, but I see diabetes, the way Neo saw everything once the bullet slowed down. Yeah, I just kind of look up and I go, Okay, well, let's move this over here and put this here and that'll do this and done. You know, but it takes it takes time and experience and a desire to. I mean, just a desire to fight through how hard it is to figure it out. Yeah, you don't I mean, it's just and you're we haven't mentioned it yet. But do you live alone? I do. So is that worrisome at night? No, no, you're okay. All right. Yeah, I'm fine. Yeah. You're like, Listen, my kidneys my thyroid, ra, whatever the hell that other thing is that I mentioned, you know, like,

Mar 54:51
No, I'm yeah, I'm never not living. I can tell you right now unless I mentally not, you know able to take care of Myself, I will not let. I'm just so used to living by myself.

Scott Benner 55:04
I was gonna ask if you wanted to be with somebody else and you're like, Nancy, I'm good like this. Thanks. No. Good. I was gonna ask you about like dating. I don't know if you're doing that or not. But now I just don't know how it is to bring another person into into this world and try to explain your health issues to them.

Mar 55:25
Yeah, I don't know. I most of the people that I know in real life don't know I have kidney disease. My brother's the only one who knows and then my best friend, but the rest of my family or they don't know, I couldn't think of a good reason to share that. Because it's only going to cause worry, and there's nothing I can do. I mean, I watch my diet I avoid you know, things that are high in sodium. I don't eat foods that come from cans or boxes or, or frozen, you know, things that have a lot of sodium. You know, but other than that, there's nothing, you know,

Scott Benner 56:02
get a t shirt made that said I had coffee colored P asked. asked me if you'd like to know more. But um, I mean, I would love to see who you'd meet. If that was your people. Like, I want to know about the coffee colored paper?

Mar 56:16
Yeah. coffee colored. Yeah. So weird. But yeah,

Scott Benner 56:19
it is. It's honestly, if it wasn't a morbid thing around like kidney disease. It could honestly be the episode title. I was fascinated by that description. I must. must have scared the hell out of you.

Mar 56:33
I mean, it didn't at the time because I knew I had been sick. And I was like I said, I had the flu. I was vomiting and diarrhea. I thought, Well, I'm just I'm just super dehydrated.

Scott Benner 56:42
Yeah. Does everybody remember the first time their poop came out? Green? You're like a kid. You're like, running through the house? That's like, everyone else.

Mar 56:54
I know. Right? Yeah. And I only mentioned it to her in passing. I did not think it was a big deal. I mean, yeah. So she, you know, thankfully,

Scott Benner 57:04
you've lucked into a couple of diagnosis is actually even with the calcium test for the Hashimotos. You know, when they palpated, your your thyroid back then did you touch it to

Mar 57:17
know I don't think I don't think I did. But they I didn't have visible tumors.

Scott Benner 57:25
like nothing's being out. But yeah, but yeah, when they feel that they can, I mean, they're doctors, they know where it is. I'm poking at my throat now as if I know where my thoughts I don't exactly know. And but it's it's interesting because I, during COVID. I watched somebody do that to my son over zoom. Oh, and like, had him get real close to the camera, like pull on his throat and push in places and swallow and stuff like that was really interesting. Oh, wow, that isn't just not fun. But interesting. Yeah. Anyway. All right. Well, we're coming up on an hour. We're not done yet. But I want to make sure that we're getting to everything that you wanted to talk about, because you wrote a fairly extensive note that I have mostly ignored while we were talking. So I'm wondering, I'm wondering how we're doing.

Mar 58:14
Now we're fine. I tend to be a little too wordy when I when I write or even when I talk. So I reread that last week I was cash. One, I mean, why don't you just sit down and like write a three page letter to this guy. It was so long,

Scott Benner 58:31
I ended up being people's therapist, sometimes.

Mar 58:34
I think, I think when I when I reached out to you, you know, I just was so like, happy to have this resource, honestly, that I just felt, you know, so great about, you know, tapping into this information. And I thought, well, I just have to tell this guy how great this is. And then it made me want to tell you, you know why I was listening and what was going on?

Scott Benner 58:55
I'm glad. Would you consider yourself a person who listens to podcasts outside of diabetes.

Mar 59:01
Only just recently, like maybe a year ago. So what are these podcasts things that people are listening to? And it was not until the pandemic and I started working from home because I work from home four days a week that I started listening to podcasts while I work. Yeah. And prior to that, yeah, I didn't listen to them at all. And now I only listened

Scott Benner 59:26
to a few. Okay, yeah, I gotta talk to my wife about that, because she watches bad television while she's working. And I'm like, You should upgrade what you're she's like, I like how mindless it is. I'm like, I don't I don't know how she cares if a 21 year old kid is on a singing show. But my wife still really cares about it. So at least likes it his background. And so, anyway. Well, yeah, because I mean, 55 is, I mean, you're on the other side of what I you know, people expect for podcast listeners. Yeah. How did you so how did you find Did you Find. I'm trying to figure out how you found this.

Mar 1:00:03
I'm sure it was in one of the social media groups that I just remember thinking that I kept hearing the term that Juicebox Podcast. And I think I probably initially thought that it was for kids. And then I thought, well, I'll listen to it and see what it is. And I realized right away that it's for anybody who's dealing with insulin and diabetes. And I think you're right, I don't fit into that group that usually listens to podcasts. But if I have the TV on while I'm working, I can't pay attention to work. If I have the podcast playing in the background, I can somehow do both depending on the podcast, there are times when I have to rewind because I'm focused on what I'm working on. Or I you know, if I'm working on something, really, that really requires my focus, I'll shut it off. But, um, but yeah, I mean, it's just, you know, I listen all day. I'm home by myself. I listen all day while I'm working.

Scott Benner 1:01:04
That's lovely. Are you going to listen to this episode?

Mar 1:01:08
I don't know. Just because I'm sure that I will not like the way that I sound. And I will think, oh, cocky sounded so don't

Scott Benner 1:01:17
see, I'm always fascinated by that. Because a I don't sound the way I sound. Like when if I took off this head, these headphones. Because right now I'm hearing my voice in my own ears. And I do that so that you and I are the same level in the conversation. Like like his I'm hearing our conversation in my head. Which is, which is good. You kind of have to forget that the microphones here. But without this mic without these earphones. I don't sound the way you're hearing me right now. Exactly. Like I'm not like, I don't have like a squeaky Mouse voice. And I'm like, you know, masking it or something like that. But, you know, I don't like sound exactly like this. And I always think like, what did people like? What's their expectation of how they sound? Yeah, you know what I mean? And yeah, and then the other part is, you like the podcast, right? I do. You okay, do you? Generally speaking? You don't think there's like a like a real clunker in there? Right? Yeah. You don't get to one where you're like, Oh, God, this is terrible. Why am I listening to this? I mean, every once in a while, not your beer, your cup of tea, maybe or something? But you know what I mean?

Mar 1:02:22
Yeah, no, I agree. I listened to I'm trying to see what I was listening to it until our call, can't see what episode I want. Because I went back to the very first 000. And I've been working through them. That is

Scott Benner 1:02:34
what everyone should do, by the way. And, and because that's good for me. Just I mean, it might be it might be good for you. Actually, that's not true. You should because by episode four, I am already hitting my stride talking about diabetes. Like I'm, I'm going over things. And I mean, I think episode four episode 11 are really like pivotal to understanding how I think about all this. But but the My point was, is that I've never recorded an episode and just thought this is terrible. I'm not letting anybody hear it. So your episodes going to do something for someone else. Just like their episodes, or have done for you.

Mar 1:03:13
Yeah, hopefully. Yeah. Because I, I have gotten something out of all of them. I'm just looking at on episode 207. Look at your which is from February 19. So I'm getting caught up. But oh, this

Scott Benner 1:03:25
is super interesting. You know, a 210. The Pro Tip series starts you don't even know about that? Probably?

Mar 1:03:32
No, I've been listening in order. So no, I mean, and I do listen, like I said, if I'm focused on something that I'm working on, I'll back the podcast up because I didn't hear you know, what was actually being said it was just background noise. So I mean, it's taking me a while to get through them. But I do think that there's valuable information in each one, even if it doesn't pertain to me directly. So yeah, I haven't.

Scott Benner 1:03:54
Oh, Marla, you're doing pro tip. You're doing mid sixes. And you haven't been to the pro tips or the or the defining diabetes stuff or anything. Oh, yeah, you're a once he's gonna go into the fives.

Mar 1:04:06
Oh, I hope so. That's really what I want. Because honestly, Scott, I have all these other issues. That I feel like at some point, those things are going to come backing and I don't want to have major diabetes on top of every Sue's complications and then have those things come and have you know, whatever. How many ever years I have on this earth left? Hopefully a lot. I don't want that time to be you know, awful.

Scott Benner 1:04:36
Marla. I'm not even kidding. If you're definitely going to keep listening. When we're done here. We're going to talk about you booking to be back on like a year from now. Okay, because I'm sure I'd be super interested to see what happened to you after you got through that stuff.

Mar 1:04:55
Yeah, no, I definitely will keep listening. I mean, I'm lucky my job lets me work from home. I go to care. post like one day a week, the other four days I'm listening to the podcast. I mean, it's sometimes I'll take a break and listen to Smartlist because there's so funny. But the Jason

Scott Benner 1:05:09
Bateman one. Yes. Yeah, I've never heard it. But it's Bateman. Sudeikis and somebody else when Sean Hayes, I love that seems like something I should be listening to actually,

Mar 1:05:19
they're very funny. Yeah. And they have interesting guests. But most of the time, I'm listening. And then there's another one called spooked that I like because I like scary stories. But those are the three podcasts that I listened to yours. And those two. No,

Scott Benner 1:05:31
that's good company. I'll take it. Yeah. Thank you. Really, really cool. All right. Well, is there anything else that we should be talking about? Are we got?

Mar 1:05:40
Oh, no, I think I think we're good. I really appreciate you taking time to talk with me.

Scott Benner 1:05:45
No, I had a great time. This was was really interesting for me as well. And I appreciate you being comfortable laying out all the things that are happening so people can get a full picture. Sure. Yeah, that's really wonderful. Hold on one second for me. Okay, sounds good.

I want to thank Marla for coming on the show and let you know that I'm gonna have her back. I could wait about a year and then invite her back on I want to hear more from her. Thanks very much Mark. Also want to thank touched by type one, and remind you to go to touched by type one.org and find them on Instagram and Facebook. And of course, our new sponsor cozy Earth cozy earth.com. Then once you get everything in your cart, you know what you want to buy. Don't forget to check out to use my exclusive offer. Put in that juice box code, save 35% off and by the way that 35% off is sitewide when you use juice box, thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

If you're looking for community, please take a look at the Juicebox Podcast Facebook page. It's an absolutely private group has over 33,000 people in it. If you're using insulin, there's no better place to be Juicebox Podcast type one diabetes on Facebook. If you have type two or a lot or something like that, get in there. Big Family

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#836 Best of Juicebox: Explaining Type 1

Episode 371, Diabetes Pro Tip: Explaining Type 1 was first published on Aug 24, 2020.

You can always listen to the Juicebox Podcast here but the cool kids use: Apple Podcasts/iOS - Spotify - Amazon Music - Google Play/Android - iHeart Radio -  Radio Public, Amazon Alexa or wherever they get audio.

+ Click for EPISODE TRANSCRIPT

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

Scott Benner 0:00
Hello friends, and welcome to episode 836 of the Juicebox Podcast.

Today, we went back to the listeners and ask them for another episode for the best of series. And today I'm proud to present to you Episode 371, which you may have first heard on August 24 2023 71, is part of the Pro Tip series. And it's called diabetes pro tip explaining type one. This episode is going to help you to explain type one diabetes to friends, coaches, employers, and much more. And today I'm dedicating it to a young man who I was speaking to yesterday in the private Facebook group. While you're listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise. And in a second, you're going to hear me say that back in 2020, because this episode is presented exactly as it was. So the musical Come on, you'll get the introduction, and then the episode. Now if you're a person with type one diabetes, or the caregiver of someone with type one, please do consider going to T one D exchange.org. Forward slash juicebox. Join the registry take the survey takes 10 minutes. You can do it from wherever you're sitting right now. If you're walking, I mean I'd sit down first. I don't like you're looking at your phone while you're walking, you know, but you're gonna move diabetes research forward with simple answers to simple questions about type one T one D exchange.org, forward slash juicebox. There are of course, no new ads on this episode. But if you'd like to advertise the Juicebox Podcast, you certainly could buy one and put it on the next best of. But let me just do this for listeners. Right now. We have a new advertiser coming next week, I'm going to give you a little jumpstart on it. So for those of you who are already aware of cozy Earth and don't need to be told about it and filled in. Just maybe you need some sheets or pajamas or towels. Whatever you get from cozy Earth usually, here's the thing. Now when you buy from cozy Earth, you're going to use my code juicebox and save 35% on everything on the site. 35% And now I'm very proud to present you episode 371 diabetes pro tip explaining type one. Hello, everyone. Welcome to Episode 371 of the Juicebox Podcast. Today's show is a diabetes pro tip episode, mostly sort of, you'll see what I mean in one second.

The Pro Tip series that exists inside of the Juicebox Podcast is mainly about management of type one diabetes. There's also some informative stuff like what can you do when you go to the emergency room to make your experience easier. And today, I'm going to be filling a need that's been presented to me by the listeners. So I don't know if this episode is for them to get ideas from or for them to share, or maybe both. But in this episode of The Juicebox Podcast, I along with Jenny Smith, Jenny of course has had type one diabetes for 32 years. She's a certified diabetes educator and an all around amazing person. And me Scott, who's you know, just the host of the podcast and the parent of a child with type one diabetes. So this episode is for people who need to understand type one diabetes more, or for those of you with type one who struggled to talk to those people about what type one diabetes is. See if you're like the school nurse or a teacher, maybe my boss, friend, and neighbor, somebody wants to have my kid over for a sleepover. This episode is for you to try to understand better what type one diabetes is and what your role in it can be. And if you're a person living with type one or the parent of someone living with type one, and you're struggling for how to talk to people about it, this will be beneficial for you as well. This episode of the podcast does not have any ads. But I do want to let you know that the Juicebox Podcast is proudly sponsored by Dexcom, makers of the G six continuous glucose monitor and Omni pod. The world's only to Bolus insulin pump. That greatest blood glucose meter in the world of my opinion that Contour Next One blood glucose meter. We're also sponsored by GE voc glucagon, Lily's chocolates touched by type one and the T one D exchange. There are links to all of the sponsors in the shownotes have your podcast player and at juicebox podcast.com. When you support the sponsors, you're supporting the show, but like I said, there's no ads in this episode. Because I don't know you're going to give this what to your kids, you know, baseball coach, and what's he going to do by an insulin pump. Having said that dexcom.com forward slash juice box my Omni pod.com forward slash juice box, contour next.com forward slash juice box touched by type one.org G voc glucagon.com forward slash juicebox. And if you'd like to get involved in some amazing type one diabetes research, T one D exchange.org, forward slash juicebox. Last thing before we start, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. Or becoming bold with insulin. and a huge welcome to those of you who don't usually listen to a type one diabetes podcast, those of you who care enough to try to learn a little more about type one so that you can be a better support system for the people you know, and love living with type one diabetes, this means a lot to them. I'm sure they're really, really excited that you that you took the time. So I hope we can make this informative and fun for you. I think we have, let's get started. I want to jump right into this because this has been interesting since I brought this up to you the other day, I I sat down myself and I thought who in my time have I spent? Have I had to describe diabetes to you know, when I started kind of making a list. And then I just a lot of people, a lot of people and then I went online and I said you know into the private Facebook group for the podcast. And I said hey, you guys, Jenny and I are going to do this thing. Who do you wish, you know, we could talk to and here's how the list came back. Grandparents, teachers, parents, babysitters, somebody who might have my kid for a sleepover, my child's friend's parents, a coach of a team, spouses or significant others, co parents, roommates, extended family, school nurse, coworkers, bosses, bus drivers, and, and and family of adults with type one. So people who are diagnosed as adults who then are around other adults who never get end up getting it. And then very much at the end of the list. Someone said, Oh, I wish you could explain to chaperones. And I started thinking everyone should have just answered with the same word, it should have said, people, because this is just, this is like everything else around diabetes like you like Oh, explain it specifically to a coach. So what I'm going to tell you is I think we're going to have a conversation, that whether you're one of the people I listed, or just a person who knows somebody with type one diabetes, when you're done, I'd like you to understand the basics of type one better, maybe a little bit of terminology. So things are happening, and maybe more so the mind of the person with type one, what's happening to them and how you could be supportive of them. I think that's the goal here like not to speak to like, like there was there in the beginning, I thought, oh, we'll do a couple of minutes talking to grandparents, and then a few minutes high. And I'm like, No, it's all the same thing. Really. Right? Yeah,

Jennifer Smith, CDE 8:23
it is. And it's really funny, you bring this topic up, because it's actually we do a monthly newsletter and my my article last month was sharing your diabetes. Okay. What it was kind of along this same line it was, how do you talk to other people about your diabetes and give them the baseline of what you need them to really know. Without like a textbook that's like 4000 pages long, overwhelming. It's overwhelming. And I know some of the big points were one set a time to discuss specifically diabetes, with these people, or this person or this culture, whoever it is, I like your term, just people in general, right? Pick the person. You need them to know this, this and this, these are the important facts. Because it's a lot easier if you've set a time for it, than if you go to the coach at the end of practice. And you're like, Hey, can you just take five minutes with me I really want to talk to about you know, Billy's like type one diabetes, and the coaches got like, you know, soccer balls over his trying to get home

Scott Benner 9:38
to go home and get yelled at. There's a lot going on in my life right now. Right? Right. So

Jennifer Smith, CDE 9:43
setting up a time and again, the timeline of what are the important things you want these people to know. Like you said the basics.

Scott Benner 9:51
Let me add this to that. The other things that people came back in their in their responses very overwhelmingly was I want this episode. be something I can text to somebody like a link and say, Please, can you listen to this and understand diabetes, because many of the people who came in to speak said, Look, I'm not very good at describing it like I can take care of myself. But when I start, there was an overwhelming feeling of when I start to explain it to somebody else, I either get frazzled or too detailed, you and Jenny do it. And I'm like, alright, well, we'll do it. So Jenny's after you listen to this episode, and you decide you really want to help a person you love with type one diabetes, or someone who's in your class, or because there was one very specific woman who said, I'm a college professor, I wish I could explain it to my students. Better, right. And so whoever you are, in this scenario, here's what I can promise you, Jenny, and I will not make this boring. And we will not make it overly, like taxing, it won't be so technical, you won't understand. And it should be a good runway up to you having that conversation that we just spoke about with this person in your life who has type one diabetes. So that's my overarching goal, Jenny, don't mess it up. Okay. I'm talking to myself, I don't want to mess it up. Do we start with? Well, we usually talk about diabetes in such a specific way. But why don't we start with just a really simple description of type one diabetes? You want to go?

Jennifer Smith, CDE 11:19
Yeah, absolutely. I mean, type one diabetes is the body's inability to create insulin, or to put it out into the body. And so without it, your blood sugar gets too high. So type one diabetes is a deficiency of insulin, it's specifically an autoimmune disorder, which means the person did nothing to cause type one diabetes. It's not because they sat and ate hohos for, you know, three years or whatever. So I think that's a, that's an important one to put out there. And just the simple explanation, because there is a lot of misunderstanding around just the term diabetes. Sure.

Scott Benner 12:00
So yeah, and it is a listen, it's a genetic issue, right. It's an auto immune disease, you know, you can use an example, my daughter was two years old, when she was diagnosed, she weighed 19 pounds, and I, you know, fed her the same stuff, all of us feed our kids. And, and her body just was like, you know, got confused one day. I mean, that's even that right? For these people listening, I don't know exactly what triggered my daughter's type one onset, what I can tell you is that testing can prove that you have markers, that that make you more likely to get diabetes. I don't know if my daughter had them, obviously, because no one ever checked her. But she got sick. And you know, it's always been my belief that her immune system got confused and instead of killing her virus went and killed her pancreas for the lack of a better term. And I want people to understand, too, that the advent of insulin is still fairly new 1921 one, right. So, for context, if my daughter's pancreas would have crapped out in 1919, she would have died in a couple of weeks, right? That's okay. The insulin is the only thing keeping people with type one diabetes alive. Otherwise, the first time your blood sugar starts heading up, it will just keep going up and never stop. That's right, right. And you'll slip into a coma and die. Okay, I told you this sounds like it'd be too technical. So so people are getting this insulin in, in a ton of different ways. And so I think that would be important. What are the different ways people get insulin,

Jennifer Smith, CDE 13:38
initially, and some people even long term after diagnosis continue to take injections. So the age old, you get a little like bottle or what we call a vial of insulin, they now come thankfully, and easily dispensing pens. And you dose it through the course of the day based on many factors. There's other ways such as an insulin pump, that you could take your insulin, kind of a fancy little pager size device that sort of drips it into the body through a tube or if you're using a tubeless one like Omni pod, then that would be another way to do it. So essentially, an injection or a pump, those are two ways to get in the body. Now there is one other way. I mean, if we wanted to be truthful about it, there's also an inhalable insulin called the Frezza. So, that's another way to use it.

Scott Benner 14:27
Most people inject insulin correct. And so inject like Jenny said, with a pen, which really is just a very fancy syringe, you might see someone do it with a syringe, you might see someone wearing a device on their body, or carrying a device that's connected to their body with a tube. There's different ways but in the end, you need to get that insulin under your skin, right. And this could happen for a number of reasons. It could happen because you're eating it could happen because your blood sugar just went up On its own, and you need to bring it back down. When it needs to happen, it needs to happen. And I want people to understand that asking a person with type one diabetes to go into the bathroom and extensively hide while they're injecting is not the right thing to do. So if please, there's, throughout this, I'm gonna tell you say things like, please don't ever say this, here's one of them, people around here might be uncomfortable with your diabetes, you can't do that to a person. If they're uncomfortable, they can leave, I need to give myself this insulin. So my blood sugar doesn't go up really high. And don't get me wrong, like not getting the insulin is not going to, you know, it's not going to kill you in the moment if your blood sugar is going higher, but here are a lot of things that could happen. They're thinking could become cloudy, right? Right, they could become agitated. So if you're a teacher, you don't want your kids blood sugar high, because they're gonna have trouble concentrating, thinking, they're not going to learn norming performing in all kinds of different ways. Same thing with sports, your blood sugar gets too high, you slow down your body has a difficult time, you know, I can see it my daughter's foot speed. If my daughter's blood sugar gets over a certain number high where it doesn't belong, I can literally see her slow down while she's running, she just can't go as fast. Right?

Jennifer Smith, CDE 16:22
It would be the same thing too. I think in like a corporate world type of setting where someone may feel like it wouldn't be acceptable in order to use their insulin or to respond to their pump, telling them to take the insulin or whatnot. And the same thing if they're being asked to present or to discuss something that's very, very important. They may not have the ability to do that in if their blood sugar is not in the right place. Yeah.

Scott Benner 16:49
So you need to give people the freedom to do what they need to do. If you want them to be themselves, or be able to do the thing you're asking them to do or hope that they can do, they need to be able to take their insulin and feel comfortable about it. It's difficult to have, this is a lifelong disease, like it's not going to, it's not going to get cured anytime soon, it's not going to, it's not going to go away, it's not going to one person said make sure people understand it doesn't just transform into type two diabetes, like it's a progression from one to two, right? Doesn't happen type two diabetes, completely different thing. Right. And so this person, it's hard, it's really difficult. Like I really want people to listen and think that every time you have a body function that puts pushes up your blood sugar. And so for people whose pancreas has worked fine, could be adrenaline, stress, pain, so many different things can make your blood sugar try to go up, when that happens to you out there. With a working pancreas, your pancreas just stops it, you don't even see it happen. Like if you were monitoring your blood sugar in real time, and you got some adrenaline like it might blip for a second, but it would come right back. A person who doesn't have that their blood sugar is going to shoot up and keep going or get too high and stay there. And then they need to put that insulin in into their body to bring it back down again. It's just it's 24 hours a day and to have somebody make it more difficult for you is is kind of terrible.

Jennifer Smith, CDE 18:21
And I think in terms of even bringing up the technology that is available, such as an insulin pump in terms of delivery. I know that there's also the misconception even in our day and age right now. Oh, you've got a pump. It takes care of it all. Yeah, that's a that's not true. 100% not true at all, there is so much that the person with diabetes has to interact with in order for that technology to do what it needs to do for them. So just because they're connected to these devices can be helpful, but it's not doing anything without their interaction with it. Yeah.

Scott Benner 19:01
And it's, it's easy for people who don't understand to make an assumption, like, Oh, they got the machine, that machine fixes it. Right, right, or something like that. And I want to be really clear for everyone listening, like, I'm not coming down on you. There are plenty of disease states that I don't understand in any meaningful way. But what that does is it stops me from you know, saying things about it that I don't understand. And like there's a ton of different things you might think, Oh, this is helpful. Like, if you find yourself with a parent of a child with type one and they've just been diagnosed and you think oh, this parents so smart, or look how well they're handling it. It's not right to say to them something to the effect of you know, well God gave the child with type one diabetes to the right person because you can really handle it. Right really think about that sentence but you know when you're in it because it happens to a lot of people. No one's lucky that their kids got diabetes. Nope, no adult feels lucky. And no one walks around going thank God I'm a head screwed on straight kind of person and I'm the one who got to die. punk was Jimmy up the street hot mess. And if he would have gotten it, it would have been way worse for him. It's bad for everybody. Okay, it's just that's a. So be careful how you speak to people. Right? I think I think about a person who's been on this podcast before who had a child who passed away. And I asked like, what's the right thing for someone to say to you? And she's like, there is no right thing for someone to say to you. And, you know, anything you do is just going to, it's not going to make anything better. Unless you offer, like sincere, simple support. Hey, if there's anything you need, I don't know what to do. But if you tell me, I'll do it for you, that works with this as well. You know,

Jennifer Smith, CDE 20:41
I think it's I think it's along the same line as offering up information about your neighbors, grandma, who is something Something happened because they had diabetes, I same thing. It's like, don't, don't offer up in terms of like a connecting point. You know, if Sure, if you've got a cousin who has type one, or you know, an uncle who had type one, and you have a little bit of understanding that might even further your discussion in terms of what the person with type one talking to you could put back into the conversation. But unless you've really lived with it, or you have taken care of somebody with type one, please don't? Yes. Tell them about your neighbors, uncles, friends,

Scott Benner 21:28
Jenny's politely saying, don't look at somebody go diabetes. Oh, where have I heard diabetes from my grandmother? Oh, you know what? Oh, my grandmother had diabetes. They cut her leg off? That's not a good thing to say to somebody don't do it. Yeah. Right. And it just yeah, don't, don't do that. Okay, so keep keep those thoughts inside. Because that's not helpful. And it might have nothing to do with the person you're talking about your grandmother's situation, very well could be a ton different than this person situation. And that's important to understand, too, is that in this day and age right now, I know this sounds kind of strange. This is the best time in the in the history of the world to be diagnosed with type one diabetes. So people have a much greater chance of staving off, what could be long term complications, and they have a much better chance of managing day to day in the moment in a way that won't impact their lives too badly. Now, I feel strange saying this because on one hand, what I'm telling you is, these people need some leniency, they need some understanding, they need a little space, because they're making decisions about how their bodies are, you know, working. And at the same time, I want to tell you that they can do anything. And so don't limit them. You know, and that's hard to do, too, because you might not feel like you're limiting them, you may feel like you're protecting them. And correct. They don't need that. And if they do need that, they'll ask they'll ask you for it. Yes.

Jennifer Smith, CDE 22:52
Right, exactly. Which is part of this, you know, the purpose of this is understanding if they're having a conversation with you about what you need to know, the reason is because a lot of times they want you to know what to do in case they need help. Right? Some understanding about this is diabetes, this is what you might see me carrying such as the devices, this is I might make some noise, my products might be bit tight, or whatever, you know, but in case of this, this and this, these are the things that you could do to help me and this is how to help me right?

Scott Benner 23:27
Because they may at some point need that help. Right and so you understanding like say you're a teacher, you understanding like signs of visible signs of hypoglycemia, okay, so low blood sugar like sugar. And I'm gonna read your list, which I don't I'm not a big list reader on the podcast, but this person could feel shaky, be nervous or anxious. They could be sweating, have chills, feel clammy, irritable, impatient, confused, their heartbeat might pick up, they could feel lightheaded or dizzy, voraciously, hungry, nauseous. Their skin sometimes can get pale. They'll look tired or could feel tired, they could end up feeling weak. Their vision could get blurred or impaired. My daughter talks about her mouth gets tingly and numb if her blood sugar gets too low headaches, trouble coordinating themselves clumsiness. This is coming right from the ADA A's website, the American diabetes Association's Association's website, in their sleep, they can have nightmares or cry in their sleep. And if their blood sugar gets too low, they can and if it gets low enough, we'll have a seizure. And so they'd like to know if they're not making sense when they're talking so that they can take in some carbohydrates of some kind to bring their blood sugar back up. And so you being a person around them like like a coach and you have to figure out the line right because these things while they can happen, may very well not happen so they Think of the other side of it. You know? You've got a little girl on your soccer team and she's running around and every three seconds you're jogging next to her. Becky, do you feel okay? Thank you dizzy, you don't feel clammy, do you? Hey, Becky, Becky, Becky, Becky, you're ruining Becky's life when you do that, okay? Don't Don't do that. But at the same time, you could look over once in a while and visually, just, you know,

Jennifer Smith, CDE 25:24
evaluate the performance, if you're the coach, you know, how your kids usually perform, or do things, you know, how they interact with their other teammates and whatnot. So yeah,

Scott Benner 25:34
it may not be at all, a strange thing to say, like, look, we have a two hour practice. Everyone sits down, you know, halfway through and drinks water. I'd really like it. If Becky tested her blood sugar, then, you know, because I don't maybe you don't feel comfortable as the coach, like you don't want to be on the hook for like, seeing if this kid's about to fall over or not. Right, I get that. So talk to the parents and say, Look, can we just coordinate a blood sugar check, you know, at some point, you know, for safety, and then make it normal, don't call attention to it don't like it's happening. And everyone doesn't have to stare and people are going to stare in the beginning. But you got to just give the kid the the space to let it happen because everyone will get used to it. And I guess that's what I want to bring up with. When my daughter was very little the first day of school. I'd go in and it's and I would give a talk like to the kids like five minutes on the literally the first day. Hi, this is Arden. Arden has type one diabetes, her pancreas doesn't make insulin, once in a while you're gonna see art and pull out this thing and give herself insulin within her controller for her pump. Hey, you know what Arden is just like the rest of you. She doesn't need, you know, she doesn't need you to check on her constantly. But if she looks like she says he or she's not making sense, you know, it'd be nice to tell your teacher, right? But it still didn't stop this one little girl from mothering her. And so she came home one day, and she's like, this kid will not leave me alone. Like, like, and she goes, it seems really sweet. But she won't stop, I need this kid to stop. Like, leave me alone. So that there's, there's a balance in there somewhere where you can be supportive, and understanding without being a burden to them or making them feel different or looked at. And this is very important. Like it really

Jennifer Smith, CDE 27:33
goes across the board and what you're saying to not just the little kid component, but the teacher or the coach, like you said like bugging, bugging, bugging, are you okay? Do you feel okay? Do you need some more juice, you know, that kind of thing. Or you even goes cross crosses over into spouses, significant others. You know, especially and I would expect that later in marriage or later in partnership, you've had enough visualization to not be like bugging, bugging, but in newer relationships, I think an upfront important talk when you know that it's going a little bit further than just let's go out and get a drink or whatever, right? I mean, it's important to bring up this is how you could help me. Don't bother me, though, you know, don't. Don't tell me not to have the potatoes with my dinner when we go out for dinner. Because Oh, my goodness, they have carbohydrates in and the potato

Scott Benner 28:25
makes your blood sugar go up. Thanks. That's what I want you thinking about right now? Unless the person says, Look, I have trouble saying no to potatoes. So if you could like if they want it, that's different, right? It's good. You remind me not to do exactly. When I see the french fries, if you could just go hey, you told me last time I shouldn't get french fries to bring it up. I don't think anything that we've said the last couple of minutes about kids and coaches and teachers doesn't specifically apply to adults in adult situations, either. It's correct. It's all exactly the same. That's why I didn't want to break these up into like, Okay, now, here's 10 minutes for your boss. If someone's working for you, and they have type one diabetes, they're going to have some needs. And the most important thing is to support them and not make them feel awkward or odd about it. And I'll tell you why. And as a person who I'm hoping cares about other people who have type one, you know, you could create a, an eating disorder by telling someone don't, don't use your insulin here, because what you're saying to them is don't eat right now. And then they start associating the awkwardness of giving themselves the insulin with eating, and then they'll stop eating. And I know that sounds like oh, that won't happen, that happens a lot, or hide

Jennifer Smith, CDE 29:37
their eating right, or in an effort to not like show others. I mean, there there is it's I mean, it's a whole nother broad topic in terms of diabetes, the eating disorders that are associated with diabetes. I mean, food is a huge part of diabetes management. It is and so it's not odd that it can become an issue, but it certainly is something that in terms of being supportive for another person who has diabetes, you don't want to push the envelope that way.

Scott Benner 30:06
And I know that people listening right now don't know us. And they are like, it's 2020. Like everybody seems super sensitive and social justice II and everything. We're not like that. Like, I'm not saying that at all, like, I, you can hear my terrible accent, I'm from the northeast, I'm good with like, Hey, get up, you'll be fine. I'm good with that I really am. But what I'm saying is, there's a real opportunity to mold a person in a positive way, or a negative way. And that goes for everybody I understand. But around this specifically, it does not take long to make someone feel different in a bad way. You know, and it'll stick with them, especially you teachers, who, you know, hear an alarm and are annoyed because you're trying to teach and it's alarming. Try to keep in mind that when that's happening, the student whose blood sugar is falling, who's now scared that they're going to pass out or die or something like that. They don't want this to be happening either. Correct. And you can't say, let me just finish this lesson. Or they need to address because we've talked about high blood sugars, but low blood sugars are more immediate, immediate, yes. Right. You can't just ignore because a blood sugar that's falling, could be falling quickly. And one of those issues could pop up out of nowhere. So if this kid's wearing a monitor that tells them live, Hey, your blood sugar is getting low, or they say I feel dizzy, I need to test or you know, like, you can't just say, Okay, well wait till after recess is over. Or as soon as I get done explaining this math problem, like they need to do it now. Which is another great reason to normalize it, let them take their meter out at their desk and check their blood sugar. It's not going to hurt anybody. And and they'll have an answer immediately about what to do next. But the five minutes you want them to wait could end up being much too much time for them. Yeah,

Jennifer Smith, CDE 31:58
yeah, absolutely. I mean, in terms of you know, even that also acknowledging what they're using to treat a low blood sugar is, is something that you also don't want to form any, like, wrong feelings about someone might use, you know, in terms of carbohydrate, it's just simple sugar that we really want to use to treat. So simple in terms of it could be juice, it could be Skittles, it could be something that we call glucose tablets, it could be honey, in there multiple things. And everybody seems to have a preference for what is great for them. And even flavor preferences. So just because the kid in your class is using like Skittles, and you're thinking, Oh, my goodness, Skittles, why are they so unhealthy?

Scott Benner 32:44
Right? Yeah, you don't understand what you're talking about, which is a good is a great example of keeping your mouth shut in that situation. Like, they're not eating Skittles, because you're, here's what's gonna happen you you don't know what you're talking about, the kid takes Skittles, and you think in your head, this is why they have diabetes, look how they eat, now, they need sugar to go into their body so quickly, that it can literally fight off this extra insulin and stop from making them too low. So know what you don't know, I think is important. And if you want to know find out more, but don't say silly things to people that, you know, it's not there. It's not their preference to have diabetes, the kids not looking for Skittles, you know, like, an adult doesn't want to get up in the middle of a business meeting and bang a Gatorade back. They're not like, oh, you know, what I want to do today in front of 30 people who I'm trying to get to take me seriously. And that's the other thing too, is that you have to understand that adults often are hiding their diabetes at work, because they don't want you to judge them and like and lose out on unprofessional opportunities,

Jennifer Smith, CDE 33:48
correct? Yeah, promotion and those types of things. And I think that's also in terms of people with diabetes. As I mentioned, initially, you have to really know who do you need to share your diabetes with who is really important as an adult, it might be your boss, it might be the co workers at the team members that you work with, as a child, it might be you know, your teachers, and hopefully your parents will help with that. Even some of your really good friends. I mean, I remember as a kid, when I was diagnosed, it was really helpful to have some of my really good friends know a lot, you know, in terms of like, their understanding language, teaching them things about why I was you know, doing a finger stick and all of that, but I think it comes down to defining who do you need to share with and what applies to this situation? You know, you're probably not going to teach your soccer coach about carbohydrate counting. I mean, that's, that's not purposeful. But you're going to teach them things like hypo awareness and you know what to do in case who to call emergency contact to there are defined pieces I think to teach everybody

Scott Benner 35:01
Yeah. And so it's also important to understand that diabetes is mostly an invisible disease meaning that the people around you unless you're having a struggle, aren't ever going to see it. As a matter of fact, I pulled this up here just so that people can have an idea. Former Chicago Bears quarterback Jay Cutler has type one diabetes. Bret Michaels has it Nick Jonas has it and rice the author has it. Mary Tyler Moore. My close friend of mine coaches for the Philadelphia Phillies Sam fold he has he used to play for the Oakland A's he was in centerfield had type one diabetes. There are plenty of people. The Justice Sonia Sotomayor, right. Right has type one. So you can do

Jennifer Smith, CDE 35:47
who's a baseball player? Atlanta.

Scott Benner 35:52
Oh, yeah. There's a guy. Well, there's a guy pitching for the Cubs. He's been on the show before. Brandon Morrow he has, I think the tight end of the Ravens has it? There's, there's nothing you can't do with type one diabetes. There's a there's a guy that I know really well, who's a four time Olympian who has it, right. So and, and the point is, is that you look at those people, and I don't tell you they have type one diabetes, and you're never going to know these people are. It doesn't mean it's easier for them. They don't have the easy diabetes, because you don't notice it. They work very, very hard. At their health. I know it's hard to imagine. But I the best I can say is imagine that you had to think breathe in, breathe out, breathe in, breathe out where you wouldn't breathe. Like that's what it feels like having type one, I'm going to eat something I need insulin, I'd has to be this much. Not that much. I don't want to get too high. I don't want to get too low. I can't have a bunch of insulin in me when I go for a run later. Because I might get low then he just like constant kind of tapping on the back of your head. You know,

Jennifer Smith, CDE 36:55
I call it diabetes inner monologue.

Scott Benner 36:57
Okay? See, Jenny, Jenny has had type one for 31 years now. 3232. Congratulations. And, and she can tell you that you Jenny's really, really good at managing her diabetes. But that doesn't make it so of course, but that doesn't make it not in her mind. And and so it's there, right? And an everyday conscious effort. Yes, it's so if you're a and I said that, so that you'd hear that. And so that if you are the spouse of a person who has type one, or your child has type one, but your spouse takes care of most of the management, you may not understand what's going into it on an emotional and physical and maybe sometimes lack of sleep level. It's really hard. It's incredibly hard to do well, it's also incredibly hard to do poorly. So if you're really great at managing or terrible at managing, that comes with different struggles, people who are great at it understand, you know, the timing and how to take care of things in a way that maybe some people don't get to understand. But the people who are struggling, are aware every moment of the day that they're probably on their way to complications that are serious because they can't figure it out, or because no one will help them. It's constantly in their head. Now, if you're co parenting, I can't tell you how many people come to me and say can you please find a way to talk to people who are like a divorced spouse or you know a step parent or somebody who's not for the lack of a better term in the fight constantly? Right? They only see a look, he's fine. Yeah, this isn't that hard, or as blood sugar just went up for seven hours. That was no big deal. It is a big deal. And and either you know I I don't normally get preachy, but either figure it out and help or get out of the way. But don't let your ego stand in the way of someone managing their health, which happens a lot. It may not be happening to you person listening right now. But it happens a lot more than you might want to think. Right you know. Anyway, I didn't mean to get like that. I just I know if you saw the notes from like my ex, you know, my kids blood sugar is terrific for a week and then they go to my exes for the weekend and his blood sugar's 300 all weekend long. So incredibly unhealthy. And and I

Jennifer Smith, CDE 39:29
see the same thing with you know, as good as family caregivers could be like you do the best that you can as parents and then you have a weekend away and you're like, Yay, we've got a weekend away but even in terms of those parents that weekend away is not free of diabetes thought right. You know, their thought has gone into prepping whoever the caregiver is prepping their child for they may not know this, so you know, text me if something comes up or you know, the grid And parents or caregivers or God parents or whoever they are, that's taking care of them thinking, well, can't they just have a little of this? Or can't we just give this to them, and we don't have to really worry about it, everything, everything is considered in diabetes. And as you said, you know, that couple of days that they're running now at 300, because you didn't follow the set of directions that you were given. That's making a difference in that person or that child's life.

Scott Benner 40:27
Yeah, no, and so that people can understand when your blood sugar is high, there's too much sugar in your blood and no way to release it, the insulin is what releases it, we're not going to get into super technical stuff. But when you hear later, you know, when you turn on the news, and some guy died of complications of type one diabetes, and you know, what they really died from was a heart attack or a stroke, or an aneurysm or something that comes from too much for the lack of a better term sugar scrubbing away, you know, in the inside of your body, is it going to happen today, if a kid's blood sugar goes up to 300 Watts, because you messed up the insulin? No. But if it keeps happening, it will happen very likely one day. And so you're making a decision today on Sunday, to maybe save someone's life 30 years from now, but that's, that's worth understanding, you know, and just because it's going to be later doesn't make it not super important. And don't forget to, you're helping them be clear minded, you know, thoughtful, being able to learn or perform like, a lot goes wrong inside of the functioning of your body when your blood sugar is high. It just, it's just very important. And the people who love you and are hoping you'll understand are, they don't know how to explain it to you. So they asked us to make this. I will tell you, Jenny brought something up a minute ago that I wanted to kind of like add on to if there was a super simple way to make it, okay. Everyone with diabetes would be doing it already. And you wouldn't have to worry about it. There's no shortcut to it. So if you're having a pool party, I think you really need to try to understand how terrible it is to not invite one kid, because you're scared or you don't understand, or you just don't want the hassle, like, just find some time talk to the parent come up with a simple plan that everybody can deal with, because that kid sitting at home, and they're thinking, I'm not at this pool party right now. I'm not allowed to sleep over right now. Because I'm a problem. That's how it feels to them. Right? I'm broken, and nobody wants me around. And you can't you can't be a part of making people feel that way.

Jennifer Smith, CDE 42:35
No. And if you don't know, like you said, it's ask, you know, a lot of the kids that I work with, that's one of the big things I bring up with a parents, you know, it's if there's going to be a sleepover or something they've been asked to, again, defining a time to sit down with those parents, or even the good, the good friends, parents, and make sure that they have a basic baseline kind of understanding. But I think it also takes from the standpoint of not not being the parent with a kid with type one or not being you know, the employer who has type one or any experience with it, it takes asking, really just I mean, don't be afraid to ask any question is a really good question. As long as it's not, I guess derogatory? No, it doesn't come out as what should you really be doing that? You know, I don't know very much about this. But should you be doing that I

Scott Benner 43:27
know, a lot of people have type one diabetes, don't ask them if they should be eating something that really doesn't sit well with them, you know, they'll, they'll, they can eat anything they want if they know how to use the insulin to manage it. And and so in the end, it's just that idea of, of being supportive. And like Jenny said, If you don't understand, try to find out and understand that when you go to find out, it's very possible that the person you're going to ask the mother of a kid who's had diabetes for six weeks, she might not understand yet either. You know, and so her her instructions might seem like a lot or babbling like, or I've babbled a lot of people when my kid first had diabetes, I'm like, Listen, you don't understand, she can't get high, she can't get low and you start rambling. And before you know it, you're like, Oh, great. I'm the crazy person in the room.

Jennifer Smith, CDE 44:15
You get the glazed over eyes, and they're just like, I always imagined

Scott Benner 44:19
that there are somewhere between like, I'm so glad this didn't happen to me, and why won't they shut up, but they won't shut up because they're scared, right? Because this stuff as much as it seems like, you can make it seem mathematical. diabetes is not like I take a pill every morning, and I'm okay. It's very fluid. It changes pretty consistently depending on a ton of factors. And the people who really understand it, or the people who are living with it are just sort of struggling moment to moment because they don't know what's going to happen next. It feels like you're running for your life in a disaster movie. And you know, you're like a bridge collapses underneath of you and you pull your stuff up on the bank. And then as soon as that's happening, a zombie bite your leg in a building falls on your wife, you know, like, you're just like, Wait, When is this gonna slow down? You know? And at the same time, I know, I just said that, and it's true. This is gonna sound crazy. Don't treat people like they're running through a disaster movie, because they're trying to find some normalcy. And you could be a big help in that.

Jennifer Smith, CDE 45:23
And I think sometimes, within that understanding, let's say you're the teacher, or you're the boss, or you're the coach, and you've, you've been schooled, right? Somebody sat down with you, and they've given you information. They're like, this is the plan of action. And then next year, they come to you, and they're like, Okay, do you understand everything? And you're like, Yeah, I got it, you gave me this whole, like, you know, our long, entire, you know, information session, you're like, okay, but this year, this is a little different, right? This is what we're experiencing now. So know that life with type one diabetes also kind of, it's a little bit more fluid, there's, there's change that ends up happening, you know, last year, to juice boxes at the middle session of a soccer match, might no longer need to be there. This year, the reaction is a little bit different. So, you know, also continue to ask questions along the way to say, well, has anybody anything changed for you? Or you know, is it is it still the same? Do we need to consider anything different? I think that's why, in the beginning of the year for kids, especially, there's always a, there's a point at which you need to go in and you need to re establish that care plan for this year, what's going what needs to be different, what needs to change? Because Because life changes,

Scott Benner 46:38
and seriously, because your grandmother or your aunt or your uncle has type two diabetes, you don't understand type one at all. There's nothing about that, that translates over to this in any meaningful caregiving kind of a way. I remember just recently, we were having a conversation before a school year. And one of the teachers, you know, my daughter's information about her blood sugar is on her cell phone, right, which is really cool. And so the teachers like, well, we take the cell phones away at the beginning of the class, and I laughed, and I was like, that's fine. Arden's not going to be giving you her cell phone, she needs to, you know, make life and death decisions. And she's very good with their cell phone. She's not going to abuse it and everything like that. She was well, what do I tell the other kids? And I said, I swear I said this in a roomful of about 10. Teachers said, tell them if they want to get a lifelong incurable disease, then they can keep their cell phone on them to, otherwise they should shut up. And like, and you have to have the nerve to do that, like you shouldn't to turn to 20 other kids and go, Listen, her situation is different than yours. I don't even care if you but just stop, you know, like it's a it's a big deal. Imagine wanting to use someone's diabetes as an excuse to keep your cell phone or to be a malcontent for a second, and then you as an adult, don't just shut that down right away. Instead, you're like, Oh, well, you know, Kim does have a good point. It's not fair. Of course, it's not fair. It's also not fair that my daughter's carrying a juice box with her and like, something called glucagon in case she passes out to somebody could stick it in her leg. It's not fair either, you know. So just think I'll tell you a common sense, is, is a huge help with diabetes. It really is, and especially about being around them. But let's look, I think everybody understands now hopefully, why don't we drill down a little bit more about how in a situation whether you're a teacher or grandparent who's babysitting or something like that, or a, you know, a boss who's trying to, you know, keep somebody healthy? Like, let's give them more nuts and bolts of what goes on in the day of a person with type one diabetes, and how they may be able to be helpful in those situations. So, I mean, but before we do that, Jenny, I'm sorry. Can you explain to people what it feels like to be high and what it feels like to be low? For you personally, it's gonna be different for some people. But yeah,

Jennifer Smith, CDE 49:01
so lows. As I said just a bit ago, low symptoms for the person can change through the course of life with type one too. So my lows now, I feel as though I have like these racing thoughts. I feel like things are going really like exponentially fast. But I feel like I'm moving through mud. Like I feel like I just can't get there. Even though everything in my brain feels fast. I feel like I'm just moving at like a snail's pace. It feels horrible. I also for a long time it started in college and I didn't have this symptom before but kind of like you mentioned that like Nam with Arden, I have like this numb, tingly tongue kind of feeling for low blood sugars. And I've never Thankfully, knock on wood, I've never gotten to the point of needing glucagon, I've never had to use it in my 32 years of life. Nobody's had to give it to me, I have had to have assistance for treating a low. But, you know, sometimes I've, I've liked started talking kind of weird, like, not really what the whole conversation was about or like mumbling and sort of rambling. And my husband said, like, think your blood sugar's kind of low. And this was before CGM, like we're married early on. Yeah. You know, he knew some of the things to watch for. So I mean, those are my lows. Now, when I was younger, I definitely was shaky. I mean, it was very visibly, my blood sugar was low. And again, that was a time when there were no continuous monitors and pumps were not really beneficial. So but highs, highs, I get really, like tired, and really kind of, like more annoyed, I don't get annoyed, I don't get that like irritated angriness with lows like many people can get, I get that more when I'm high. And I feel like I just can't put a lot of really good, like thoughts together, they're consistently I feel slow,

Scott Benner 51:16
so hard to put the effort in for anything. And it's not something that you can just fight through. It's not like that. It's not, it's not like I didn't get enough sleep last night, but I need to be at work. It's an absolutely physiological issue that is limiting you. So for people listening it sugar glucose is the is the energy your brain runs off of. And having the right amount of it is perfect. Having too little of it, you know, is goes the way we've discussed and having too much of it does something to your body with a working pancreas just keeps you in a great range all the time. So you don't experience all of these things. But a person who may be could do something so simple as let's see, let's say you have a kid in your class who says I have to give myself my insulin right now, because I'm eating in 10 minutes. And you say no, no, no, we're gonna finish this first, don't do that. I don't want you giving yourself insulin in front of all these people. Well, you've now missed time, their insulin with the impact that the foods going to have on their body, which will very likely drive their blood sugar higher and cause what Jenny just described. Similarly, if they say I put my insulin in 10 minutes ago, and I know you want to talk for five more minutes, but I have to start eating now. You can't say no, because then their blood sugar could go the wrong way the the insulin will continue to pull the sugar out of their blood, it doesn't know how to stop like, like a healthy body does,

Jennifer Smith, CDE 52:38
it's expecting there to be food there to work with. Yes,

Scott Benner 52:41
and when that foods not there, they can get awfully low and all the way up to like I don't want to, like, you know, I don't want to make you feel like I'm trying to be dramatic, but you could kill them. And you know, anywhere from shaky to not making sense to angry to seizures to passing out to dying, like if you take too much of that sugar out of their blood. That's like taking electricity away from a light bulb, and you can't turn it back on again, by putting the sugar back in after it's off. So it's really important. And at the same time super important not to make people feel like pariah and and not to give them long term, serious psychological issues around this thing that they you know, I I'm gonna say this, but I don't think it matters. They have nothing to do with getting it. But even if they did, why would you? Why would you want to make them feel that way? You know, and I think that's important. And I don't think any of the people listening to this want that? I think it's just it don't know what they're talking about. And then you make assumptions. You know, I don't know, a lot of the things that we think are is anecdotal, you know, kind of went over like, oh, diabetes, that keys off. My grandmother had diabetes. I understand diabetes, I live with my grandmother for three years. No, that's different. That's probably type two diabetes. And your grandmother probably took a couple of medications and, you know, different thing. But the person who says that I don't think they say that out of malice. I also don't think the person who tells you you're so strong. Thank God, this happened to you. And not me. I don't even think I don't think that person means that with mouth. No, you know, they're in any conversation.

Jennifer Smith, CDE 54:16
We're always trying to find a connecting piece, you know, I mean, communication is that it's a give and take between two people or six people or whatever. But if you're in the, if you're the person that doesn't know, then asked more than talking. Yes. Right. It's it's always, oh, goodness, I you know, I didn't know that you had type one diabetes, tell me what that's like. I mean, that's a very easy, simple, you know, and if the person really doesn't want or need to share with you, maybe they would just say well, you know, I manage it and it's okay, but if they're if you're sharing with them for a reason, then continue to really be more the ask the questions, but don't share too much unless you truly have some experience to share.

Scott Benner 55:01
I feel like before we go over nuts and bolts like management ideas that people will have to intersect with, I think what we should really be saying here is, in case you haven't been paying attention for the last 49 minutes, this is about communication. And most people are terrible communicators. And it's because they don't listen enough, and they interject their thoughts. And it's a very human thing to feel like, you know, but you don't like I could sit here for the rest of my life and make a list of things I don't understand. You know, but I'll tell you what, put me in a situation with one of those things. I probably puff up a little bit, start reaching into my common sense, or, you know, a little bit of my anecdotal information I have. And I started saying, no, no, I know what's up here. You know, it's, it's like talking about, I know, we're recording this during Corona, but like, it's that thing when people step up, they go, Oh, no, no, you know what you have to do you have to do this. How do you know that? Is it because you're a Harvard researcher? Or is it because you heard a guy say a thing, and now two people said it, you're like, oh, that must be true. And that's just how our brains operate. And it's very valuable day to day, it's not very valuable when you're trying to talk to somebody about something important like this, that you don't understand. And they very well may be struggling with as well. You know, so anyway, all right, I'll start you jump in. Okay, I'll do breakfast, you do lunch, and we'll, we'll go from there. My daughter gets up in the morning. And if we're lucky, her blood sugar's been stable overnight. But if she's been low, overnight, we may have had to take away some insulin, or give her food, she could wake up a little higher. Because of that, it could throw off the timing of her eating, she might end up being late for school. Because of that. She may end up being a little rundown, you can wake up if you have a bunch of low blood sugars overnight, you wake up with, but people some people call a low blood sugar hangover. Yeah, right. And so that could be that. So you got to give these people a chance to get their lives moving. And then they've got to get to work. And what if I get myself insolent or on time and I have to get my car then and drive to work. And now I'm scared, I could get low while I'm driving like these poor people, or you're just eating, you got a pancreas, it works. You get up, you make some eggs, you throw them in your face and run out the door. And it's all good. People with diabetes are already 45 decisions into life. And it's 730. And they haven't been in the shower yet. So they so they get that together. My daughter, you know, heads off to school and, you know, half an hour, 45 minutes later, she needs to know what her blood sugar's doing. So she's gonna have to look. So you see, my daughter looked down at her phone in the first in first class, she's not ignoring you, she's making sure that her blood sugar doesn't get out of whack. And then she's got to start thinking about like, Oh, I'm getting low. And I have gym two hours from now. And, and lunch is gonna be in three hours. And, you know, I have to give myself insulin during social studies so that it's working for, you know, all that stuff, right? And they have to count their carbohydrates and their food. So I'm gonna ask Jenny to explain like, what they're doing. They're around their meals.

Jennifer Smith, CDE 58:05
Yeah. So I mean, carbohydrates are is just a big word for sugar, right? I mean, all all carbohydrate foods, like starchy foods, fruit, even vegetables have some kind of carbohydrate or sugar in and when we take insulin, insulin is meant primarily to cover the impact of carbohydrates. So timing is really important around that in terms of like you said, she might need to take her insulin and social studies so that by the time she gets to lunch, the insulin is already there, the way that our insulin today works, it's meant to meet with food in the system. But our insulin has to actually do what we call peaking, kind of get in get working get circulating in order for food, carbohydrates was which digest really fast. Once they start, you know, getting into the stomach, that insulin has to meet it at the right time. And so when we count our carbohydrates, it's a certain amount that goes along with a certain amount of insulin, so that our blood sugar doesn't get too high after that might involve looking at a food label that might involve looking up information on your phone. So that maybe you're you know, visiting an app that's got a calorie or a carb counter in it. You might see somebody again on their phone or their device looking something up, and I guarantee with diabetes that fits around a mealtime. It's not that they're ignoring you or trying to be rude. It's likely that they're looking for information or maybe that they're telling their pump to do something important. Coming into that mealtime.

Scott Benner 59:37
And if you stand in their way of doing that than most people to feel like they fit in next time won't do it, then you'll make their insulin late and they're gone and their blood sugar is going to be higher. Not everybody is me. I don't care what people think I would just do whatever, you know, and I've raised my daughter that way. I'm like, Oh, don't worry about them. Just do what you need to do. But you have to understand that many, many people can't over or come social pressure. And so you pressure him even on the way you don't understand, you may send them in another direction. So they count all these carbs that give themselves their insulin. Now they're not sure if it's going to work, their blood sugar might go up and might go down. Now they might have to have their meter out to check their, you know, they might have to poke a hole in their finger, make some blood come out, check it with a test strip, some people might be wearing a glucose monitor that's feeding their, their blood sugar live to them on their cell phone, there's a lot of gear they have. It's not, you can't restrict their access to their gear is is a big thing. Because I've seen people say like, oh, just leave your bag here. Like I need that bag. I can't just leave it here. And that might mean if you're a teacher, that at recess for this year, you're gonna be wearing some kids bag over your shoulder at recess, and just I know, it sucks, but just do it. And that's it. For for, for I was Go ahead, please.

Jennifer Smith, CDE 1:00:53
Oh, I was gonna say along with that, like in terms of like, what do you have to leave your bag here, whatnot, I've worked with quite a number of adults, especially who are government employees who aren't allowed to run their phones aren't allowed to have certain devices like a phone or whatnot within their government building. And I think the important thing, I mean, if you are certainly, you know, within the realm of being an employer, for people with type one i policies need to change, then that's the biggest thing that I can say, because while the device itself might have pieces that you don't want within the building, you're really restricting their ability to have a healthy life in terms of also what you're asking them to do performance wise on the job, things

Scott Benner 1:01:34
change. And that goes right to what I was gonna say with like school nurses, like, I know, You've been a school nurse for 25 years, and no kid here has ever died from type one diabetes, except the way that you took care of it 15 years ago, it's not the way people take care of it anymore. It's much more fluid, it's, it's, it's better. It just it really is and saying to somebody, Oh, it's okay. Or I'd rather their blood sugar be high than low? No, you wouldn't rather their blood sugar be high than low, you'd rather the blood sugar be normal normal than either of those things. Stop finding either ores in your head, I don't want to go down the wrong road away from away from diabetes, but everything's not black or white. It's not this or that. There's all kinds of other options and gray areas. And just because your brain picks, I'd rather be high than lie rather than behind the load. That doesn't make you right. And that doesn't mean that's the only option. There are a ton of options. Kids having to leave class to go to the nurse to do diabetes related things. That's bad. Okay, I know, you think it's Oh, they need to be around me. So they do it right, you need to everybody needs to teach them how to handle it on their own. Because losing five or 10 minutes of math when you're too, you know, in second grade is one thing, but losing 10 minutes of advanced trigonometry is another thing. You know, like or may miss a whole concept. Yes, and it's gone. And, and if you learned how to manage on your own in the moment, you can just kind of find a need meet the need, keep going instead of wait till the needs a problem. Go to the nurse spend a half an hour getting out of the problem going back much better to be proactive than reactive. And the going to the nurse thing all the time is reactive, it's waiting for a problem. These things can can be done in classrooms. Technology is amazing. My daughter has been managing her blood sugar through text messages with me for a decade. Right and she does no lie. Since the last day of second grade. My daughter who is a junior in high school has not been to the nurse's office for anything diabetes related in all that time.

Jennifer Smith, CDE 1:03:44
Well, even in terms of like safety to, you know, I know that there are a number of schools and families that have worked with well, they have to send my child to treat the low blood sugar to the nurse's station. It's down three levels and across the building and whatnot. And like the blood sugar is low, they need to treat it in class. There's no reason that you're you're sending a kid whose blood sugar is dropping, you know, for a five minute walk through the halls in order to go suck some juice down and a nurse so they can watch and make sure they drink the whole box. That's ridiculous. Like

Scott Benner 1:04:14
they're like, well, we'll send a kid with him like, Oh, great. So there'll be another eight year old there because I am always putting eight year olds in charge of important things. You know, hey, listen, you just go with Jenny. And if she passes out, you know what to do your age. Right? Exactly. 20 year old wouldn't know what to do. We'd be like, Oh, what happened? Jenny fell over. We left her there. And she died. Like, you know, like, you just don't put kids in charge of stuff. It's weird. Like I get if it's a little like, Oh, she just wants to have somebody to go down with and it's all nice, but the nurse's office is for emergencies. And here's the crazy thing. Having type one diabetes is not an emergency. It's just, it's just an extra thing you do during the day, so stop treating them like they're sick time. Stop treating them like they're broken. They're, they're just, they're not, you know, and so and so listen, that they're gonna have to get on the bus where you have to drive home from work. And you're still thinking about your blood sugar. And so if someone comes to you and says, Look, I need you to watch my kid tonight for a couple of hours, or you're the babysitter, or a grandparent, it's very doable, someone's gonna say to you look, eight o'clock, test their blood sugar, you know, text me the number, I'll help you do what you do, if you know if the numbers in this range, that's cool, give him this much insulin, let him eat this snack, you know, and here's what the snack is. Just follow the instructions, the person giving you the instructions is fairly confident that they're that they're right. And questioning them all the time is bizarre, you have any idea how many school nurses fight with parents, like I've been taking care of this kid for 10 years. And you want to tell me how to do it now. Because that's how we've always done it here. Very strange way to come at something. I get that you don't want to get into a long conversation with a family who maybe doesn't understand and maybe, least common denominator, it might make it easy for people who don't know, but instead of doing that to them, like what if you said to them, Hey, I think there's a way we could do this that your kid could be healthier, or you know, that kind of thing. And, and I want to say to I'd like to give Jenny a chance here to talk about what it would feel like if her spouse had those kinds of like anecdotal thoughts and was leaning on her all the time. First of all, I'd be dead. She'd bury him somewhere and so over, she wouldn't take it. But But like, what would it be like for another adult who you respect in all other things, to suddenly have thoughts about your health that that aren't warranted or founded?

Jennifer Smith, CDE 1:06:45
It would be it would, it would feel horrible. I mean, this fact that somebody that, like you said, you care so much about and that you have a lot of good rapport, and almost every other thing that you talk about and live with and decide about together? I mean, it would make you feel kind of countered, honestly, in terms of what you've been doing. And also like visually how you feel like they're now seeing you. Like, is it all about this? Is this all they see now? is are they really gosh, they're they're really worried about this, or they feel like they don't have any, there's no confidence there. And what I in what I'm able to do for myself, you know, I've been managing this for 30, some years. They feel like, I can't do it anymore, that they're constantly asking, like, are you okay? Or did you just check your blood sugar before bed tonight? Because, you know, I heard your Dexcom last night or whatever.

Scott Benner 1:07:38
Feeling like feeling like someone looks at you and sees diabetes, not you. Is is is kind of crushing. You know, and that's another great little tool you're looking for a tip don't lead with how's your blood sugar every time you see somebody, something else first, how's the day? Isn't it sunny out, blah, blah, blah. Like, even if you're the school nurse, like just walking in there. It's a drudgery for kids to do that.

Jennifer Smith, CDE 1:08:00
Like it's very rare for my husband to actually like, ask, even if he hears like my Dexcom making a noise or something. It's very rare for him to ask I he does have the follow app on his phone. And even with that, he never I think it was maybe a month ago that he texted me to ask, you know, I've gotten these like urgent, low alerts. He's like, you know, and I've gotten a couple of them like, are you okay? Is kind of all he asked or, you know, and I was like, Yep, it's a sensor. That's totally off. I was like, I just restarted it this morning. Difficulty? Yeah, I actually texted him a picture of like, my actual like, finger stick. I'm like, I'm like, 92. Totally fine. He's like, Okay, I just wanted to make sure that he's like, because I keep getting them. And I just wanted to make sure that everything was okay. But other than that, usually it's not, you know, it's not even something.

Scott Benner 1:08:55
But it wouldn't be pleasant if if he was constantly.

Jennifer Smith, CDE 1:08:58
No, in fact, usually my my late native work, in which he doesn't work, he usually makes dinner. And he'll actually usually text me and ask, you know, hey, I was going to make this this evening, you know, this is how much carbs in it because he knows that I need to Pre-Bolus Or he'll have measured something for me. And this is how much was in it? Or, you know, when do you think you're going to be done? Because he knows that the Pre-Bolus component is really important. So those kinds of pieces are really helpful. They're not like, annoying,

Scott Benner 1:09:31
too good example. It's a good example of him. Like, look, what are we saying, listen, talk, ask questions, be empathetic, do things that are actually helpful, not that you think are helpful. I learned that from being married, by the way, that the things that I think my wife wants aren't necessarily the things that she wants, and that you know, and that I would be much more helpful if I did the things that would actually be beneficial to her and not the things that I feel would be beneficial, right. So listen, talk, ask questions, let them talk realize it's hard for them as well. And like Jenny said, at the beginning, set a time to sit down and talk about this. And if you don't understand, keep asking and understand that things could continue to kind of morph and grow and change and that what you know, today to be true very well may not be true a year from now. Right, you know, you've no idea how things evolve and change hormones and kids are huge stress is, is can sometimes be hard on your on your diabetes, but I really do want to make sure that no one leaves this feeling like oh, well, people with type one diabetes, I shouldn't hire them. I shouldn't put them on my kids baseball team. It's not the case, with with good support and understanding. I mean, this, okay, you guys are listening. Because somebody sent you this episode, you don't know this podcast, you don't know me. I've met 1000s of people with type one diabetes in my life. And overall, some of the kindest, smartest tuned in people that I've ever met in my life, like, imagine how tuned during you are when you have to understand the inner workings of your body constantly. You want these people on your side, like they're, they're great teammates, they're there, they're great coworkers, there's just a little bit that they need you to understand. And then you'll find a rhythm, that's the other thing is like, this isn't forever, you'll find a rhythm together, whether you're you know, a, you know, the parent of a friend of a kid or something like that, or whoever you are, in the scenario, you do this, at times, it won't be a thing anymore, you'll just you'll have it, you know, and it's worth doing because you're gonna get to know some great people who otherwise may be marginalized. And I don't know, just think about it, like you have an opportunity to put in a little bit of effort to figure something out. And keep a kid from being a kid who's not invited to a birthday party, or a person who loses a job that they're completely qualified for, because they got low at work, and nobody knew how to help them that made all of you nervous, you know, that sort of thing. I want to say to that, if you really want to dig in more there episodes of the podcast called defining diabetes. And they're very short. And they, they define very specific things. So like, if we set a word here, like Bolus or Pre-Bolus, that you didn't understand, it will explain that to you very simply. And if you really want to dig down deep and understand what people are thinking about when they're managing their blood sugars, there's an entire series of episodes called diabetes pro tip, right? So it's diabetes pro tip Pre-Bolus diabetes, pro tip, something, there's maybe 20 of them by now, if you really want to understand what people with type one diabetes are thinking about. Those episodes will take you well inside. And same thing for people listening who were like, I can't make anybody understand Pre-Bolus Sing like just you could send them one of those. So yeah,

Jennifer Smith, CDE 1:12:51
I was actually going to mention that too. So yeah,

Scott Benner 1:12:53
thank you very much. And this is the first episode that Jenny and I recorded with her new microphone. And I have held in my excitement about how good she sounds the entire time we were doing this. So for regular listeners to the podcast, you're there. All right now going like Kenny sounds so much better. And for everybody else. They're like, huh, I didn't know that was a big deal.

Jennifer Smith, CDE 1:13:13
I asked Scott, if it was actually going to get rid of my Wisconsin accent. And he's like, yeah, probably not. No, it'd be so much clearer.

Scott Benner 1:13:19
You talked earlier about the night, your husband, you work late, and your husband cooks. And there were four words that if I hadn't spoken to you so much, I don't know that I would have known what you were saying. Oh, really. But that's right. I said water a couple of times in here. So everybody who's not from Philly is like, what is wrong with this guy, thinking I'm having a stroke, probably. Anyway, I really hope this was valuable. I know, it's not possible for us to cover everything. But the goal was for you to be the person who's in some way supporting someone with type one diabetes or wants to understand better. And I hope that by listening to this, you have a better understanding, I think you will.

Jennifer Smith, CDE 1:13:58
And also know that you are really important in terms of the person's like feelings about things and that background support piece, you're a really important part of that as long as you understand things in the way that you need in order to provide that support. So

Scott Benner 1:14:16
I think in the last thing, I think I want to say is that as my dog barks, that you don't want to separate yourself from a person's life because you're scared of their thing. Like that hurts like it might because I talked about co parenting earlier and spouses who aren't as involved. I believe sometimes they just don't want to mess up. So they step back but you end up alienating the person with diabetes and stranding the person who's trying to help them and and I know it's a lot to figure out but you could like Trust me I know as you're listening you don't know me, but I am. There's nothing special about me and I understand diabetes really well. And everything I know about it and Jenny knows about it. We put into those pro tip episodes. So you If you're just a dad or a mom, or you know who's like, I don't want to get involved, because I'll mess it up. You know, you're doing other things that I think you don't mean to be doing in your relationships. And if you understood it better, I think you could do better it would help. Yeah, it really would. Anyway, I could keep talking about this forever. So let's just stop. Jenny, thank you very much for doing this with me, of course. This is usually the place where I thank the sponsors and the guests, but instead, thank you for listening. Thank you for wanting to know more about type one diabetes, for spending the time to try to learn. If you have more questions, you can look for episodes of the show called defining diabetes, or other diabetes pro tip episodes. Just look right there and your podcast player and check it out. And if you're looking for a place to pick around even a little further, there's a blog at juicebox podcast.com. Thanks so much to Omni pod Dexcom touched by type one, that Contour Next One blood glucose meter. Lily's chocolates, G Vogue glucagon T one D exchange. It think that's it. Those Those all the sponsors. We have a lot of sponsors. Thank you for being sponsors. Seriously. Get a free no obligation demo of the Omni pod tubulin and tubulin tubeless insulin pump at my Omni pod.com forward slash juice box. Their demo is absolutely free and has zero obligation. Learn more about the Dexcom G six continuous glucose monitor@dexcom.com forward slash juice box. Get what I think is the best blood glucose meter on the planet at contour next one.com forward slash juice box. lend your voice to insanely incredible diabetes research. T one D exchange.org. Forward slash juice box. You want to pre mixed prefilled glucagon it even comes in a Hypo pen. It's amazing G voc glucagon.com forward slash juice box no more mixing up your glucagon people and lilies chocolates make some great chocolate with far less sugar in it than you expect. Their ads will begin in the second half of 2020 and they will be accompanied by a savings coupon so you can try some lilies and save some money that's coming soon. Check out my absolutely favorite diabetes organization at touched by type one.org. I know this episode didn't quite fit in with the other diabetes pro tip episodes. But I do think this is the place to put it. As I think about everyone learning about their type one at some point part of it becomes talking to other people about type one diabetes. So this is where this belongs. Thanks so much for listening. I'll see you soon.

I hope you enjoyed this best of the Juicebox Podcast episode. We enjoyed bringing it to you. Number of people suggested episode 371. But I want to shout out Willie as a specific person who who threw this one out there. Appreciate you guys listening check out the private Facebook group. If you want to know who's picking these episodes. The people inside of the private Facebook group for the Juicebox Podcast. It's called Juicebox Podcast. type one diabetes has over 33,000 members right now. Great conversations happening there's something in there for you. The podcast is supported of course by sponsors like Omnipod Dexcom, the Contour Next One blood glucose meter, G voc hypo pen, Athletic Greens makes ag one and cozy Earth now who else? Sorry, advertisers touched by type one T one D exchange not an advertiser, but we love it when you help them out. Because it helps us out too. I think I got everybody us med get your diabetes supplies from us, man. Anyway, there are links in the show notes of this episode, and links at juicebox podcast.com to all of the sponsors. Check them out. And of course don't forget cozy earth.com 35% off with the code juicebox thank you so much for listening. I'll be back very soon with another episode of The Juicebox Podcast.

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