A (2:54)

And maybe we'll talk a little more about early testing right now and things that maybe can be hopefully done for type one before the complete onset.

B (3:03)

Yeah, that's what I'd hope to talk with you about today.

A (3:05)

Awesome. I'm trying to look here while you're speaking. I have you trying to see what we called your episode, because it's not up yet, but by the time people hear this, they will have heard it. I feel like I have it here somewhere. I think it's a Grand Rounds episode. I think that's what I did. I think I called it Grand Rounds. Inhaled insulin, I think I called it because you were so thoughtful. People can go find it. If they enjoyed you today after they heard this, they can go find more of you. There.

B (3:29)

It's perfect.

A (3:30)

Excellent. Before we started recording, I asked you if you saw this news story about something I saw recently about CRISPR genes and somebody having beta cells replaced. And I want to get back to that, but I don't think I want to start there. I want to say, at this point, I didn't have a podcast, so it was over 11 years ago, maybe more. I had this scientist on that the JDRF set me up with, and he went on and on and wax poetic about this pouch they were going to make. And the pouch was going to have cells inside of it, and they were going to open your body up, put the cells inside, give you this, you know, immune suppression, and this little wallet full of cells was going to act like your pancreas, and on and on and on. And all I really remember beyond that from that conversation is that I asked him, all right, let's pretend for a second you got it all figured out. It works. How long until I go to Target and get this for my daughter, you know? And he goes, oh, 15 years. And I was like, wait, what? And he goes, yeah. Like, if we had it worked out today, there'd have to be manufacturing. We'd have to get the cells. Like, he was going on and on to what would have to happen, right? And he's like, so if we knew how to do it today, it would be about 15 years before we could have a mass rollout of it. Does that timeline still work? If something was found today, do you still think it would take that long to get in the hands of an average person?

B (4:55)

It's hard to always predict what the regulatory pathway and timeline is going to look like. So I don't think they were that far off, sadly. I wish we could compress it a bit. I think it's likely that the timeline will continue to get compressed as more of these options for cell therapy come to be, and they're potentially even more effective. And you might get breakthrough status from the fda, but it's not a trivial thing to build up the machinery to manufacture these kinds of biomaterials and develop cells that are effective and then do the studies that are going to result in getting approved. But of course, it's a noble effort because for the 99% of patients with type 1 diabetes who are living past stage 1 or stage 2, where they don't need insulin, or past age 3, where they're early onset but still have a lot of beta cells left, we're going to need beta cell replacements to provide meaningful curative therapies for patients. So, undoubtedly, people will continue to do the work in that space to try to bring better things to the field as fast as we can. But, yeah, it's a slow process.

A (6:06)

We. When you hear people in your circles talking about all of this, is there ever any you want to get involved in something like, forget medicine for a second, like, you want to get a car that does this thing, or you want a new television and you think, well, I'm not going to buy it this year because I heard the one that's coming next year is going. Does that happen in medicine, too? Because it just occurred to me, if they figured it out today and they were like, hey, we can do it. Like you said, we're starting to build up infrastructure and all the other things that have to happen. Is it not in the back of somebody else's mind? We're probably going to figure out something better than this before we can get this working? And does that feeling slow people down from, like, rushing forward? Like, don't you have to be all in on what you're doing and see a pathway not just to getting it to people, but to, I'm assuming, make money with it so that somebody will actually get behind it. You know what I mean? Yeah.

B (6:58)

I think that's a good space to compare the difference between, you know, scientists and academics and the commercial aspects of these things. But obviously they have to work in tandem to ultimately get something to patients. You know, scientists are iterative people. They just like to keep doing things to learn and figure out how to do it better. And the notion of we're going to do it better at some point beyond, you know, the thing that I've developed tends not to bother the scientific community because I know that's the, the means to progress. It's a bit more challenging on the commercial side to your point, because of course people there have to be able to generate a return on their investment by way of profit of selling a device or a product or a drug. And so they are very much in tuned to is somebody going to have a better widget? The day after I spend 10 years of development to build mine, I write.

A (7:54)

You a $3 billion check and next week I find out I could have had something that faster, better, cheaper to production, et cetera. So on. Like how do I know when to jump in?

B (8:03)

Yeah, so I mean, I think that has been a challenge in the type 1 space, certainly on the immune therapy side, because there hasn't been a large number of therapies that have gotten a label. You know, at this point we have Duplizumab is the only FDA labeled immunotherapy for type 1. And there is Zimicells are the first cell therapy for type one to get a label mostly around the manufacturing process of that cell approach to islet transplant. But I think the technology space is probably a good example of where that can still be effective and provide patients fast access to new meaningful therapeutics or machinery to take care of their disease. Because there's a number of people in the space and all of them are trying to innovate to make a better system faster and there's room for everybody to both make profit and truly develop better pumps and better cgm. So my hope is that we get to a space in the immunotherapeutics or cell therapy world where that can happen too. I think we're just at the fair, we're sort of at the infancy of that with toplizumab getting across that first finish line, so to speak, but being nowhere close to the end of the race that we all want to achieve, which is having a handful or larger number of drugs or therapies that we can offer to people who might be at any stage of the disease that may offer something that you or somebody else's family would call a viable cure. And of course that may mean different things to different people. There are folks who would be happy with a pump and CGM style cure to their disease if it really meant they didn't have to think or worry about their, their diabetes. And they, they were comfortable and confident that it was going to take care of it. And there are others who I think very reasonably say, you know, nothing is a cure until I literally have nothing on my body. And my body works like it's supposed to, and I don't need insulin exogenously there too. I think that the two things are going to continue to be developed in, in parallel and hopefully complement each other. And I don't think there's a problem with that.

A (10:09)

I think you said two really interesting things are the first idea that, you know, using the, like a pump or a CGM manufacturer as an example, like, they're in the game already, so they need to keep iterating because I think we've seen how society works with like a phone, for example. Like, nobody's happy until the new one comes out. And you haven't gotten to. I still have to touch all this a number of times. Like, I just, I told you before we got. I was 2 minutes late jumping on because my daughter's rushing around. She's a little late for school, and she's like, can you please bring me a pod? Because I got to change my pod. And like, you know, until those, like, those touches go down, you know. Right. You're still there. But maybe that's why we should be happy that it's Sanofi. Right. They bought Tamazipob from Prevention. So, like, we should be happy that somebody threw their hat in with their wallet because now they're going to keep pushing their pot committed now.

B (10:59)

100%. Yeah, use that exact phrase all the time when I'm talking to patients and families. They are pot committed. You know, companies don't commit that number of dollars unless they do see a way forward that can generate a return on their investment. It all but forces their hands to continue to innovate and develop new therapies. So to their credit, Sanofi has a number of promising immune therapies in the pipeline that are in clinical trials as we speak that hopefully will complement teplizumab, maybe be better than toplizumab, may work better for certain patients. And so again, that may get us to that space where it feels like it feels with pumps and CGMs now. And you have some choice and you can advocate for yourself and decide which one of those things makes more sense for you or your patients.

A (11:46)

There's a framework that can be built on hopefully that somebody's. They're in already. They're not going to stop now. You don't lay out 3 billion and then go, hey, you know what? Forget it.

B (11:56)

Exactly.

A (11:57)

Yeah, you'd push good money after bad before you just gave up. So hopefully that, that keeps the process going and maybe you'll find out that maybe that drug will lead to something for people who don't have diabetes, like who knows what. I certainly don't understand the, the mechanism of the molecule, so. But I'm hoping they do or they wouldn't have bought it. That's my hope there. The reason I bring this up, I'm going to kind of fold together with this next thought and then we can move forward. I see a lot of conversations online around stuff like this, right? And people either they kind of lean one of two ways that. And the one way they'll lean is like, it's coming. They fixed it. I saw there's a lady in China, she doesn't have diabetes anymore. Like, you know, I saw this here. They did it. It's coming. Like they're either way too enthusiastic or the opposite of it. And I think we've gone over the first part. I want to ask you about the latter. Just your personal opinion. What would you say to somebody at a cocktail party, for example, who said, yeah, yeah, no one's ever curing this. There's no money in it. They want to keep me sick. It's more viable for them financially that way. And then they tell you the story about the light bulb that doesn't burn out and they got the guy in the room and took his patent and his light bulbs and burned all the stuff. And like you hear all those kind of those stories after that. Like, I would tell you that if you asked me to. Just, you gave me money and you said, Scott, you got to bet this one way or the other. I'd bet that if something comes up, it'll make. It'll. It'll see the light of day and people will say it. They'll at least know it exists. I don't know if that means money will get behind it or not, but how do you feel? This episode is brought to you by Omnipod. Would you ever buy a car without test driving it first? That's a big risk to take on a pretty large investment. You wouldn't do that, right? So why would you do it? When it comes to choosing an insulin pump, most pumps come with a four year lock in period through the DME channel and you don't even get to try it first. But not Omnipod 5. Omnipod 5 is available exclusively through the pharmacy, which means it doesn't come with a typical four year DME lock in period. Plus you can get started with a free 30 day trial to be sure it's the right choice for you or your family. My daughter has been wearing an Omnipod every day for 17 years. Are you ready to give Omnipod5 a try? Request your free starter kit today at my link omnipod.com Juicebox terms and conditions apply. Eligibility may vary. Full terms and conditions can be found@ omnipod.com juicebox find my link in the show Notes of this podcast player or@juiceboxpodcast.com I used to hate ordering my daughter's diabetes supplies. I never had a good experience and it was frustrating. But it hasn't been that way for a while. Actually for about three years now because that's how long we've been using USMED usmed.com juicebox or call 888-721-1514. USMED is the number one distributor for Freestyle Libre Systems nationwide. They are the 1 specialty distributor for Omnipod Dash, the 1 fastest growing tandem distributor nationwide, the 1 rated distributor in Dexcom customer satisfaction surveys. They have served over 1 million people with diabetes since 1996 and they always provide 90 days worth of supplies and fast and free shipping. USMED carries everything from insulin pumps and diabetes testing supplies to the latest CGMs like the Libre 3 and Dexcom G7. They accept Medicare nationwide and over 800 private insurers. Find out why US Med has an A plus rating with a Better Business Bureau at usmed.com juicebox or just call them at 888-721-1514. Get started right now and you'll be getting your supplies same way we do.

B (15:57)

Yeah, no, it's a common question and parents and families ask it all the time. I'm of the opinion, I think like you, that if you really had a therapy, a biologic approach that was curative, you as a company could name your price. And the example I'll give of that is gene therapies. Right now. You know there are gene therapies on the market that cure awful diseases. They cost 3, 4, 5 million dollars a patient. Why? Because the return on that investment is well worth it. And insurance companies are paying it because if they don't, that patient's going to cost them significantly more. When you look at the lifetime cost of living with diabetes, and I mean all costs, both for buying all the equipment and medical complications down the line and the quality of life years added, there's no doubt that a therapy that really was a cure could be a profitable therapy for somebody. Now will that put other people out of business? Yes. But that's true of lots of things in the history of Innovation and medicine is a reason why people should continue to strive for that and why I don't buy into the notion that somebody is hiding a cure somewhere. That just isn't the way scientists work, certainly. And even though there might be companies in pharma that would benefit from things being slower to getting to patients than others, eventually things that work are going to find their way forward.

A (17:26)

I would also be inclined to be a little more cynical but hopeful at the same time by saying that the person looking for the quote, unquote cure is not the person selling you insulin or pumps or whatever else you're buying. Where people think like, ah, they want us to keep buying this stuff, that's another person. Like, there's an ice cream shop on the left side of the street and I'm going to open up one on the right side of the street. My ice cream is better than your ice cream. I'm going to put you out of business. That's kind of my point is that if someone came up with a cure, they would get financial backing from a group of people who are not involved in diabetes. And those people would look at that as a way to get wealthy off of curing your diabetes. Like, I don't know why.

B (18:08)

Yep.

A (18:08)

Yeah, it seems simple to me.

B (18:11)

And I mean, they're real world examples of that even now. So look at the one you just gave with Sanofi. They make Atlantis, you know, arguably the, the highest selling in terms of dollars, I think, insulin in the world still. And yet they're in the space of trying to prevent or delay the disease. The world's market for type 2 diabetes and insulin is still huge. And so they can continue selling insulin for a long, long time in that market. Even if there are biological therapies for type one.

A (18:40)

Sure.

B (18:40)

And similarly, Lilly, you know, other major producer of insulin is now in the immunotherapeutic space as well because they have a therapy, baricitinib, that looked really good in a trial done in Australia called Bandit. And they're moving forward to do a stage two and stage three study for potential labeling in the US internationally. So I think there's places for companies, even single companies, to be in both spaces and essentially be diversified so that they can have opportunities down the road. Again, I'm not a business guy, so that's not the way I think, but I think that that's a reasonable way for people to the space and try to avoid the sort of conspiracy theory mindset that somebody is going to keep something that's going to Help people and patients locked away.

A (19:31)

Yeah, I appreciate you going over that for everybody out there who's worried about it. Go find Bigfoot or something. Turn that energy on, something important. As to whether or not there's really UFOs.

B (19:40)

Need pictures of Nessie too.

A (19:41)

Yes. Listen, I run a very small business compared to the business that someone's going to run one day if they come up with a cure for diabetes. But if you handed me the cure for diabetes right now, I know how I would market it. You know what I mean? And I'm not a business mind. I'm assuming that smarter people than me can figure it out. By the way, I want to say, I don't think they just see dollar signs. I also think that people really motivated people like that. I think they would enjoy having their name attached to something that changed the world that way. Like, right, Michael? Like, wouldn't you want your name on that? You know what I mean? Like, if you had that kind of thing, I'd want people to know I did that. I'd want people to. I'd want people to know that somebody figured it out, that science figured it out, that maybe you guys should get out there and work on something else. Because look what we figured out, you know, we.

B (20:26)

Yeah, absolutely.

A (20:27)

Yeah. It's only been what it said 100 years or so since they came up with insulin. That's the other thing that cracks me up. Like it's been forever. Like it's been a hundred years. That's not long. This episode of the Juice Box podcast is sponsored by Eversense365 and just as the name says, it lasts for a full year. Imagine for a second a CGM with just one sensor placement and one warm up period every year. Imagine a sensor that has exceptional accuracy over that year and is actually the most accurate CGM in the low range that you can get. What if I told you that this sensor had no risk of falling off or being knocked off? That may seem too good to be true, but I'm not even done telling you about it yet. The Eversense 365 has essentially no compression lows. It features incredibly gentle adhesive for its transmitter. You can take the transmitter off when you don't want to wear your CGM and put it right back on without having to waste the sensor or go through another warmup period. The App works with iOS and Android, even Apple Watch. You can manage your diabetes instead of your CGM with the Eversense365. Learn more and get started today at eversensecgm.com Juicebox 1 Year 1 CGM it really isn't.

B (21:44)

It is sort of amazing when you step back and think about where we've come in 100 years from an insulin at all to all these analog insulins and pumps and CGMs that were purely science fiction are now reality and they're only going to get better. So, yeah, I think the pace of discovery is accelerating and I think there's lots of reasons to be hopeful rather than pessimistic. But at the same time, you have to be a realist and know that unfortunately, the cure is not tomorrow or even next year. It's still a ways away.

A (22:20)

So then I'll share with you and I'll ask your what you tell people, but I'll share with you the when someone asks me directly, Scott, what do you think about there being a cure for type 1? I will tell them the same thing over and over again. I live, hopefully. But we're pragmatic. So day to day we act like it's never going to happen, like that. Arden's health, long term is focused on us doing a great job day to day, hour to hour, sometimes. Right. Like it's never going to happen. So we need to keep her as healthy as we can for as long as we can. But I'm also not, not hopeful. And I do think all this stuff is incredibly interesting. Like, am I going to see it in my lifetime? I'd bet against that. I'm in my mid-50s. I'd bet against that. Right. If it happened, I'd be thrilled. What I hear is that if somebody came up with it Today, I'd be 69 by the time maybe they could get it to market. I'm also listening to stories about how AI is changing every three months. So in my mind, medical research is going to probably get more and more, I don't know, hopefully faster with the help of, you know, baby, like instead of bench doctors and people sitting down, taking notes and keeping spreadsheets and hoping to find, you know, a connection between this and that, maybe I'll get better and better. They'll all dump their data into it and the thing will go, hey, I can't believe you haven't noticed this. You know what I mean? Like, and maybe that will speed things up.

B (23:49)

Yeah, I agree.

A (23:50)

Yeah.

B (23:51)

And I think that's an appropriate and reasonable way to think about progress. I also am a big believer in having hope, am optimist. But the thing that drives me nuts is false hope. And there are a Lot of people out there who unfortunately are peddle it constantly. Loyal salesmen peddling misinformation. And all that does is serve to upset people further. It's like the whole notion of the decade of a cure and just it's right around the corner. I think that's not being fair and transparent.

A (24:25)

Right.

B (24:25)

And realistic for people. That just sets the field back. So I will never give people a timeline either because I just don't think that's right. I don't think we really know, so why suggest that you do? But I do think we're every day making progress towards it.

A (24:37)

And I appreciate that people need to fund their labs, but every time you save a mouse from something, maybe don't make a press release because there's. Every time you do that, it finds somebody whose kid was just diagnosed 10 minutes ago, and they think, oh, listen, it happened to me 2007. My daughter had had diabetes for less than a year. And I woke up one morning, I was reading the news, and there it was. Somebody cured a mouse from type 1 diabetes. And I actually said to my wife, I can't believe how lucky we are. Artem was diagnosed with type 1 diabetes right before they cured it. And that was 19 years ago. And I was really heartbroken when I realized when my poor wife had to pull me aside, she's like, listen, dummy. And she explained it to me, but it's how emotional I was at the time.

B (25:21)

Yeah, it's hard. You can't ignore those things. And fortunately, there are great discoveries made in the lab on a regular basis. But. But I agree with you. I hate that the press and sometimes even the investigators over promise.

A (25:36)

Yeah.

B (25:36)

And then ultimately under deliver when people finally realize, oh, well, that was the 500th experiment, the Nod mouse that was curative. Obviously none of those have translated yet to humans in a very meaningful way.

A (25:51)

If you look at those, Michael, the conclusion you come to is that we'd be better off trying to turn people with diabetes into mice because apparently we know how to.

B (25:59)

We're really good at curing mice. We're fantastic at that. But I could give, you know, I don't care much about. About the mice. I care about kids and people living with type one. And so, yeah, that's why I tell patients and families all the time, it's just to start a model. It's proof of concept. And to your point about AI, we are now building and have used these in silico models where we dump in all the data from all the clinical trials of type 1 in people and try to model what might happen with different therapies. So you're right. I think we will get faster and better and smarter and hopefully have more personalized approaches as we Understand that type 1 diabetes is really 1000 different diseases with different flavors. And some patients are going to need a certain therapy and others a different one. And so hopefully as we continue to get better and better at that, we can, we can really provide meaningful therapy to more people.

A (26:49)

I genuinely don't remember where I heard this the other day, but some guy running a lab somewhere, I don't even know what they were researching. And he says because of AI, he was able to, I guess fire a lot of his staff because the AI is doing the work that the staff was doing. And I thought, oh great, he'll cure the disease so that people have more time to sit around and not do anything because they, they won't have a job. You know, at least we'll all be alive. So anyway, all right, so right now, September 2025, what's the best thing we have going? Where should people be focusing and is there something they could be doing for themselves or for loved ones? What is real and tangible?

B (27:25)

Yeah, you know, I think the lowest hanging fruit, silver lining kind of stuff is around screening people for risk for type one and identifying the ones who are unfortunately going to develop the disease early. Now we know that the community rate for diabetic ketoacidosis at diagnosis is between 30 and almost 50% in some communities. And fortunately we do a far better job of treating DKA analysis that the fatality rate is low, but it's not zero. And it's devastating when we lose a kid because of a previously undiagnosed case. And DKA, on the other hand, if we're screening effectively and identifying people early and getting them enrolled in follow up and early stage clinics, that DKA rate goes down to less than 1%. And we convert a traumatic diagnosis story with an ICU admission and parents not knowing if their kid's going to survive to still a terrible diagnosis, but one that is far more gentle and safe and allows people to transition to the the idea of now I got to live this life with type 1 diabetes. And even there we're doing a pretty poor job of screening everybody who is at high risk. One in 300 people in the US at least kids get type 1 diabetes, so it's not a particularly rare disease and that number is 1 in 20. When you start talking about first degree relatives of people with type 1 and last time I checked, everybody had a mother and a father and most people have siblings in this country. And so there are tons of people living with type one whose first degree relatives are not being screened. And it's really a shame that we're not doing that because that's not a research question anymore. It was when we first started doing the diabetes prevention trial and trying to figure out could we pick up who are the people who are going to eventually be the type 1 patients of the future. That question of equipoise is a research question, is answered and it's now something that should be standard of care. And every pediatrician and family practice doc and internal medicine doc who has patients with type 1 diabetes should be reminding them. And if they see their siblings or their parents or their young nieces, nephews, cousins should be reminding them, telling them that they should be getting screened for type one antibodies. And the hope there is, if we identify all these folks and we develop better therapies that will convert type 1 diabetes from an insulin managed disease to the immune mediated disease that it is, and pick up these folks and treat them, to delay their disease and hopefully one day be able to prevent it entirely.

A (30:12)

So, first of all, I think that's awesome, but I have a kid with diabetes and there's autoimmune stuff in my family and I look up at my extended family and I see autoimmune in them that they don't want to hear about. You try to tell them and they ignore it. Nobody wants to hear. So let's say I actually do get them to go to the doctor. How do I get them to a doctor that doesn't just go, you don't need a screen for that, you're fine. Because you're gonna like it. Seems like there's so much, I'm gonna use the word ignorance. There's so many, so much ignorance on this path. Like, right, like we're counting on me or somebody like me to say to somebody else, hey, you know, I think you ought to look into this. If you're lucky enough to talk them into it, they're gonna go to a doctor who's very likely gonna tell them, nah, you're fine, don't worry about it.

B (30:54)

No, you're absolutely right. I was just at a diabetes camp weekend, family weekend this weekend. A lot of nuance at families. Then I asked them, how many of you had your endocrinologist, this is your endocrinologist, not even just their general pediatrician mention that your family members should be screened for antibodies and the response rate was abysmally low. I think it's just a failure of education, of our ability to frankly do a marketing job of telling people there's so much out there to know in terms of medical knowledge and practice. So you can't know everything. But this is something that's pretty darn simple, requires just ordering the four biochemical antibodies that are in everybody's electronic medical record system to order now and getting folks to do it. So there's this we call therapeutic inertia that exists until it becomes standard of care meaningfully, even though it's written in the guidelines now, it's just not yet something that everybody is practically doing. And changing people's behavior is hard. So we got to start by educating, educating, educating, and get people to be aware. And then they start to do it, and once it becomes habit, and then it will spread. So that's what we really need to be working on.

A (32:07)

Yeah, the pathway to it seems. I mean, full disclosure. I did ads last year for screen for Type 1, and even I was, as I was making the ads, and I was like, God, this seems like this isn't going to work. There's a lot there. And then I've seen how they've kind of gone this year with the. I'm going to get. I'm going to guess the Chrissy Teigen People magazine article has something to do with it. Right. Like in that kind of stuff. But that's not. I don't know, it just feels to me like you just maybe got to go to the doctors and say, like, look, just take a family history and just. You need to be the one to say to them, like, hey, why don't we screen for type 1 diabetes while we're here? Because, I mean, because that's cutting out a number of steps. And I mean, it would seem to. If you're going to, like, I don't know, it just seems. It seems like a lot to me to. For me to have to talk a family member into believing in the family member, into being lucky enough to find a doctor that's in on this whole thing, and then even if they are for that doctor to then know what to do, you know, afterwards is the leap. Again, I think the education doesn't lie with the public. I think the education lies with the physician that could order the test. That's just my opinion.

B (33:12)

Yeah, I completely agree with you. I think the, you know, the screen for Type 1 program, which is supported by, you know, Sanofi, is really focused on general population Screening and guidance because ultimately 90% of new onset patients don't have a family member. So just screening family members is going to not give you the biggest overall yield of future type 1 patients. But my counter to that is always, well, we're not even doing that low hanging fruit of screening all the family members of people who do have Type one. So we should crawl before we walk and run. And you're absolutely right. I think the focus needs to be on educating the providers. They're the ones who have to click the boxes to order the labs. And if they don't even know the names of the labs, they're certainly not going to do that. So we have to educate them, make it easy for them to do, make sure they get appropriate reimbursement for when they're spending time talking about counseling and screening for autoimmune disease and type 1. And so those are things that we're actively doing. In Florida, for example, we had some funding from the state this year to expand screening programs for Type one. And so we're doing exactly that. We're doing educational sessions, providing continuing medical education for providers, going to providers clinics to literally show them how to order antibodies and what their options are for doing it with either point of care collection kits or sending patients to commercial labs, or doing it through a research assay. So I think all those modalities have to be used and have to be optimized. Optimized before we're going to see the real large number of folks being screened for the 60 something thousand new onsets a year in the U.S. it's only a tiny, tiny fraction of those that knew that they were going to progress and had antibodies measured before the disease. And that's a shame. Many of those folks we could have picked up if people were screening family members.

A (35:17)

Can I thank you for a second? Because I sat in a number of meetings saying this and people looked at me like, oh look, podcaster boy thinks he knows what he's talking about. Thank you for agreeing. That's all I wanted to say because I feel vindicated. I feel vindicated because I felt. Listen, Michael, and between you, me and everybody listening, I took their money and I made the ads. But I first tried to tell them, like, I don't think this is where you should be putting the effort. Like I've been in this space a long time. Like, I think you want to go this way. I, I was, I think I did an interview once and I've said it to them privately too. Beta bionics with eyelet I was like, I don't know what you're doing for marketing, but skip it and go right to PCPs, because those are the doctors that are helping people with type 1 who don't go to endos, who very likely do not have good outcomes. Start slapping your eyelet pump on those people. That's gonna help them. Like, you're gonna take people with 10, 11, 12, A1Cs, put their A1C in seven. Like, come on, like, that's a no brainer. But those are the people you're trying to find. Like, you're talking to me, you're on a podcast. I'm talking to people who are on the razor's edge of their diabetes care. These are people who are forward thinking out in front, putting a ton of like, effort into trying to figure out how to get a 6, 5 AC1C down to 5, 9. They're trying to get their time and range from like 80% to 85%. They're not, they're not trying to turn a 12, a 1C into a 7. Like, you're looking in the wrong places.

B (36:37)

The marketing for the 1 percenters is different than the folks who are.

A (36:41)

No one listens, Michael. No one listens. I sit here, get frustrated sometimes with this screening thing again. Like, you know, I guess I'm never going to get an ad again. But you guys are going about this all wrong. The lady on the peloton, that's not going to do it for you. Okay, like, come on, who's watching peloton videos? Michael? You know what I mean?

B (37:05)

I can't disagree with you. All screening is good in that we identify more people. Yeah, it does seem like they kind of jumped steps one, two and three and went straight to sort of step four when they, when they could have gone with, with a lower hanging fruit.

A (37:23)

So espn, whose wife or daughter or somebody has type one, I'm like, oh my God. Like, you got to get your head out of New York and the marketing scene there and like, see what it is you're trying to really accomplish here. You know, are you trying to put together a marketing campaign that looks awesome or are you trying to actually reach these people? Anyway, I said that in a meeting, so I'm not afraid to say it here. I. They never called me back, so I don't think they agreed with me.

B (37:46)

But you know, I've done some advisory boards for companies too, and I'm not shy about sharing my opinion, but sometimes that means I don't get invited back to it.

A (37:56)

Oh yeah, they're not calling me again.

B (37:58)

Yeah.

A (38:00)

And. But they. You know what the funny thing is, is that they should. They really should. I mean, you. Other people like me, like, I've been around this for so long. Like, I know how it goes. You can't just hire a marketing team who. No one has diabetes on the team. They don't know anything about it. They spend the first 30 minutes of the phone call asking you to explain the drug to them. Like, you know what I mean? And then. And then suddenly I see all this money goes out the window and there's taglines and colors and websites. And I was like, this isn't going to get seven people screened. I would actually like to see people get screened because I've interviewed people who have used that drug and their kids are not developing diabetes. I've interviewed the people who, you know, actually put that pouch into them. You know, for science, maybe this getting screened thing will or won't lead to you having some benefit, but it's definitely going to lead to somebody having a benefit 5, 10, 15 years from now. Like, if we all don't, like, do a bit. This ain't going anywhere. Like, everybody's got to do their part to make this move forward. You're not just sitting back waiting for the people or the guy or the lady with the thing to do the thing. It's not like that. Like, everybody's got to get involved, you know, or it ain't going to go anywhere.

B (39:11)

Yeah. And I think that's where maybe the pharma folks are hoping that they're seeing 10 years down the line where we really are doing general population screening, and it's standard of care. And every single kid who comes through the pediatrician gets antibodies screened. And they're not wrong in that that's what it will ultimately take to identify every single one of those 60,000 kids who's going to progress before they progress. But some of our group's counterargument has always been, that's nice, but there's all these folks over here that are much higher yield on the per patient ratio that we're not doing a very good job of yet, either. Or yet. And we should probably focus on those folks first.

A (39:51)

Yeah. Well, listen, again, I want to thank you because sometimes I feel insane in those conversations. And. And it's not lost on me. Listen. For people listening. It's not lost to me. I'm a guy that makes a podcast. I have no degree. I have no background. Like, Michael, you went to more school the first day of college than I've gone to my entire life. Okay, sure. I mean, this is obvious and somehow it's not obvious to the people who are making the decisions half the time. And that's, that's upsetting to me because I really do think the screening would be beneficial. But anyway, good luck, everybody. All right, so let's pretend they actually get somebody to get screened. They find a doctor who's willing to screen them. What's the process like? What do they expect to have happen next?

B (40:29)

Yeah, so I think we're just trying to give people choice providers, namely choice in how they do this and make it easy for them. You know, there's the point of care collection kits enable biosciences. There's point of care collection kits from the Ask Study run out of the Barbara Davis Center, Colorado. There's even home kits that we provide capillary collection through trialnet. And then there's sending people to get a Venus straw at Quest or LabCorp. And I think proponents of screening in high risk populations, we just need to make it as easy as we can so that there's no, no other inertia creating barriers for folks to get it done, because there's always a reason, excuse to not do something when it's not an emergency in the person's eyes. So that's what we've been trying to do. And certainly awareness campaigns and education campaigns for the doctors helps. And then the next step, of course, is when they get somebody who's positive. We have to make it as easy as possible for them to do the right next thing, which is first confirm the antibody status. I'm somewhat surprised by the number of folks who get a single antibody test and then label themselves as having early stage diabetes without a confirmatory antibody, which that should be done for sure. But then when somebody is identified with multiple antibodies and confirmed with antibodies, they need to be followed up in an early stage clinic. All the data that I spoke of before that shows reduced DKA rates. That wasn't in the vacuum of somebody just being told you're antibody positive and walking away you're antibody positive and we're going to follow you with metabolic testing and remind you of your risk for type one every three to six months in a study setting. And that's where we saw the decay rate go so low. So we want to make all those things easy for providers. So we, Florida, our team here has set up an early stage clinic where most of what we do is guidance and education. And because of that, we're able to serve People throughout the entire state because we do it through a telemedicine clinic. So if you're a doc in Key west or you're a doc out in the panhandle and anywhere in between, you can call us and we can set up a telemedicine visit with the family to talk through what it means to have antibodies and what their child's risk really is and what we should be doing to monitor them. And then that allows us to talk through all their choices and options. Do you want to be in trial net and have follow up that way and be offered studies, or do you want to just have clinical follow up and be a candidate for teplizumab? And I think the most difficult thing is talking to families after the fact when they're diagnosed, and they say, oh, I wish I had known about all these opportunities. And they just, you know, they just didn't get that opportunity because in their world, their circle, there, there weren't people who, who knew about the. The notion of screening and follow up.

A (43:38)

Yeah. Yeah. Well, Michael, the. The amount of I wish I would haves in the world are, Are great. Right? I wish I would have wore my seatbelt. I wish I would have stopped smoking. I wish.

B (43:46)

They're endless. Yes.

A (43:47)

Yeah. It's usually when it's too late is when you're flying through the air thinking, maybe I shouldn't have brought a motorcycle. I feel like we're talking to. I don't know if you're aware of this, not Michael, but a lot of physicians and. And clinicians listen to the podcast. So I, I really feel like we're making a bigger picture argument to people out there to get screened. But at the same time, I hope who we're really talking to are the people who could actually maybe make a difference on this. So for those of you listening, here's an example. I interviewed a woman not so long ago, and her kid was misdiagnosed a couple of days at a time. And then there was a person who was supposed to call and tell her to go into an er, but went home from the doctor's office without making all their calls that day. And, you know, some days later, her daughter's in the hospital throwing up what they described initially as black tar. And eventually, and I forget what it is, it's not common. Okay, but it happened to this kid, her esophagus and like that. Trust me, the details are lost on me. Go find the podcast episode. But it was like, from the dk, like it was rotting inside. Like she was throwing up her flesh. And that is not a thing that's gonna reverse for her. And now the rest of her life is impacted by this. And literally, somebody just had to say, like, why don't we do a finger stick? Why don't you go to the hospital? And so many people dropped the ball along the way. And I'm not saying this happens to everybody, but it happens to more people than you think. And some of those.

B (45:15)

Yeah, no, it's a common experience, again, just at this family weekend to ask people to tell their diagnosis stories. And invariably there's 1 out of 15 or 20 that was seen by a handful of providers in the weeks prior to their diagnosis with symptoms and signs that should have been plainly obvious. And like you said, all they needed to do was a finger stick or even a urine dipstick, and the diagnosis would have been made prior to the kid or adult getting particularly sick.

A (45:47)

And it's good that you bring up those numbers, because I do think that, generally speaking, most physicians, clinicians, etc, like, do a great job for people. Like, I'm certainly not, you know, yeah, it's not.

B (45:58)

It's. It's not the majority of people, but it's still too many. You know, one's too many. So it happens. Absolutely.

A (46:03)

When it happens, it happens. You have no idea how many people come on this podcast, they start talking about their health, and I'm. I want to be 100 clear, Michael. I think the number was 56 days. That's how many days of my senior year. I didn't go to school of high school, okay? Because I was poor, and I went to my job at a. My uncle's sheet metal shop to make $4.50 an hour, okay? And so I would go to work instead. I was not a good student, and I still graduated, and I went along the way and blah, blah, blah. And now here I am making this podcast, and I realize you all probably wish it was somebody else whose diabetes podcast got really popular, but you're stuck with me. It was mine. Here I am interviewing somebody, and they're talking about their life. Ten minutes. I'm like, hey, you're anemic. And they go, what? I'm like, you're anemic. You have hypothyroidism. No, I don't. No, no, you do. You just described it to me. My point is, I know when people describe it to me, how the hell does a doctor not know? Like, this woman's describing her kid who went through this dk, and the whole time she's Talking, I'm thinking like, the kid's got type 1 diabetes. Like, no one notices this when it happens to somebody. Again, I don't think it's a lot. I don't think it's everybody. There's a ton of you out there doing a great job. No one's talking to you. But every once in a while we're going to hit a clunker. And some people hit a couple clunkers in a row, they go to an urgent care, they don't get a good answer, they go to a doctor, they don't get it, oh, you got the flu, blah, blah, blah. Next thing you know, you're throwing up your esophagus. Like, that kid's got a real lifelong problem now that a week earlier didn't exist in them. If somebody would have just said, hey, it sounds to me like you might have type 1 diabetes. And my point is, is if a guy that skipped his senior year of high school to cut sheet metal could figure it out, I guarantee you that a doctor could figure it out too. Like, it's just something's wrong along the way. I don't think we're gonna fix that bit, I guess, is my other point. You know what I mean?

B (47:48)

Well, despite your, despite your lack of formal schooling, clearly you are gifted in the art of observation and talking to people. This is why your podcast has been so, so successful. And good physicians do exactly that. And unfortunately, the current American healthcare system has disadvantaged providers in practicing the art of medicine. And they don't always take the time to sit back and recognize what is fairly obvious to others. Hindsight always being 2020. So it's easy to Monday morning quarterback it. But to your point, those kinds of misses are still far too often and easily could have been avoided if we did a better job of educating those providers about early signs and symptoms of type 1 and at least made sure it was somewhere in the back of their mind so that when the next kid comes in vomiting and losing weight in the middle of flu season, they don't just write it off as being flu or gastroenteritis and send them home.

A (48:52)

I'm sure this makes some people upset and who are scared of AI and me. You could probably mark me as somebody who's scared about what might be able to. What might happen too. But I do have this like, I am 100% certain I've settled on here so many times. I hope somebody just steals the idea because I don't certainly have the capital to get it started. But I think that it would be incredibly valuable if people had an app on their phone that they spoke to and just told it how they felt that would iteratively keep all of their conversations and complaints and continue to look at them. Because that's, to me, is the way that you're gonna diagnose things in the future. Because even if you get a good doctor, you're counting on, I mean, Michael, you know this, right? You're counting on the person to come in and actually say all the things and not to mislead you with their theories about what's going on. And then you have to. You're also arguing with your wife, and you got a kid who's like, you know what I mean? Like, everybody's got a life. There's a lot going on in people's heads. If you had a simple personal AI that you said, like, hey, I woke up this morning and my knee hurt, like, anteriorly, just right here, Like, I don't know, it's only happening when I'm driving and, you know, this happened to me, and my bowel movement was kind of runny today and blah, blah, blah. Eventually you'd say enough to it that it would go, hey, you should look into this. Because that's really what you're asking of a doctor, but you're asking them to do it ten minutes at a time, three times a year. And I really.

B (50:12)

I'm bought into the use of AI to take care of patients already. I mean, I have many times put symptom complexes or patient complaints in to see if it broadens my differential or reminds me of something I didn't know before. And my philosophy in teaching has always been you don't memorize stuff, understand it, and it just makes that so much easier. Now, you don't have to memorize every single pathway or every single name of a drug, but if you at least can give a large language model like ChatGPT, the right information to go find will make it far more efficient for you. So you can get back to that art of medicine of really observing and talking to patients and families. And that's what I think the future is. I don't think AI replace doctors, but I don't think there'll be any doctors, successful ones, who don't use AI.

A (51:02)

Right.

B (51:03)

That's just. That's just the way it's going to be. So you can either choose to adopt that technology and let it help you take better care of people, or you can become a dinosaur.

A (51:12)

Yeah. And it'll stop people from having to send A bunch of people into DKA to learn their lesson as a physician. Because that is really what happens. Right. Like, it's trial and error like everything else. Like, you keep having experiences till one day your brain just goes, oh, that's this. Like, I've now seen that enough times that it just pops into my head. It's not lost on me. You can't teach somebody everything they need to know to be a doctor in medical school. Like, I get that.

B (51:37)

Yeah.

A (51:37)

You know, and that there are some people out there who want to be great doctors or some people out there, they're like, hey, my mom told me to be a doctor. I'm a doctor. And, you know, I, I, yeah, right. Like, so there's a, there's a, you know, a mix of, of situations you're going to run into. But going back to the person, the, the person who's sick, they don't know who they're going to go talk to. They don't know if you're about to walk in with a doctor who's been at this for three days or 30 years. Like, you know what I mean? Are you the one they're going to send into DKA to learn their lesson? Like, that's, that doesn't need to be like that anymore. I think at this point, when I go to a physician now or if I send my kids, I know with reasonable certainty what's going on before I get there. But everyone's been directed, don't say it out loud. Keep it in your, Keep it inside. Let them do their job. And if they don't get to what you're thinking about, that's the time to lay your breadcrumbs out and say, well, I also saw this and this and this. I was wondering if maybe it could be that and let them think about it. Because I find that if you go in and say your thing, then they don't do their process, and you don't want to take them out of the loop. You'd like to hear what they think and what they, what their, you know, thought is here. But you also don't want to walk in and walk out when you're 99% sure this is the problem. So, I don't know, like, I hope everybody. I know people say advocate for yourself. It's. I hate that. Honestly, I hate that word. I hate the idea that you need to do that. I hate the idea that there's possibility that I'm going to run into a physician who, you know, if I don't advocate for Myself isn't going to help me think. You have to arm yourself with as much knowledge as you can. Let the physician do their job and then fill in where you don't hear back from them. But you got to do it in a way that it doesn't rub people's egos wrong or come off like you're telling people. It's. It's a, it's a dance. It really is. You know, it's. It's hard to go to the doctor is what I'm saying. You know, there's too many people walking around, Michael, with a TSH of 4, being told they're fine. They've got six different things they're struggling with. It all point to hypothyroidism. Like that just happens all day long to people. How does that happen, by the way?

B (53:39)

Yeah, well, that's a, that's a good example of one that the, the data don't really support there being much that should be treated with a TSH that's in that range. But lots of people come in with the symptoms and it is hard for physicians to differentiate the ones that may really have symptomatic hypothyroidism that needs to be treated with a high normal reference range TSH from those who have very valid complaints, but they're coming from other things. So it's not all black and white in medicine for sure.

A (54:10)

Yeah. So you need people who have been through it enough times to say, look, I see the symptoms. Well, I'm gonna get you some medication.

B (54:16)

We'll.

A (54:16)

We'll see what this does here. And yeah, I mean, that's just. That one's a. Is a thorn to my side because it, it, it really like derailed a large portion of my wife's younger life, you know, like walking around unfortunate. Yeah, it's just, it's, it's upsetting. And so, and now since then, I've had tons of doctors on who talk about it differently. There's a great thyroid series on the podcast if you really want to understand it. Like Dr. Bonito comes on and talks about. She'll medicate you 2.1 or higher with symptoms. You're. You're going to get a thyroid replacement from her.

B (54:49)

Interesting.

A (54:50)

Yeah. And she helps people at an incredible. She's one of those doctors you can't go see anymore because too busy, you know. Do you think that it all ends up going that way one day? Are the ones that really know what they're doing just gonna open their own practice and be cash pay.

B (55:07)

Oh, I hope not, just because I think that will result in only a small portion of people having access to the best of care. I mean, it's tempting for physicians to do that because it just gets rid of all the middlemen and logistics and allows people to spend a lot more time with their patients and provide care that way. We here at our institution, at least in our clinic, we're about 60% Medicaid. So we would immediately be leaving almost all those patients without access to endocrinologists if we did that. I think we just need to do better jobs of. Of improving the system so everybody can have access to. To good docs.

A (55:44)

Yeah. Is there anything that we didn't talk about that you wanted to.

B (55:47)

That was a lovely conversation, Scott. I appreciate it.

A (55:49)

Thank you. I'm going to keep bugging you to. Come on, Mike. You're. You're great to talk to. Thank you.

B (55:53)

Sure. Anytime.

A (55:54)

I appreciate your time. Hold on one second for me, okay? Okay, thanks. The podcast episode that you just enjoyed was sponsored by Eversense CGM. They make the Eversense 365. That thing lasts a whole year. One insertion every year. Come on. You probably feel like I'm messing with you, but I'm not. Eversensecgm.com juicebox A huge thanks to my longest sponsor, Omnipod. Check out the Omnipod 5 now with my link omnipod.com juicebox you may be eligible for a free starter kit. A free Omnipod 5 starter kit at my link. Go check it out. Omnipod.com Juicebox terms and conditions apply. Full terms and conditions can be found@ omnipod.com juicebox A huge thanks to US Med for sponsoring this episode of the Juice box podcast. Don't forget usmed.com juicebox this is where we get our diabetes supplies from. You can as well use the Link or call 888-721-1514. Use the link or call the number, get your free benefits check so that you can start getting your diabetes supplies the way we do from usmed. Thank you so much for listening. I'll be back very soon with another episode of the Juice Box podcast. If you're not already subscribed or following the podcast in your favorite audio app like Spotify or Apple Podcasts Podcasts. Please do that now. Seriously, just to hit, follow or subscribe will really help the show. If you go a little further in Apple Podcasts and set it up so that it downloads all new episodes, I'll be your best friend. And if you leave a five star review. Ooh, I'll probably send you a Christmas card. Would you like a Christmas card? If you're looking for community around type 1 diabetes, check out the Juice Box Podcast. Private Facebook Group juice box podcast type 1 diabetes but everybody is welcome. Type 1, type 2 gestational loved ones it doesn't matter to me. If you're impacted by diabetes and you're looking for support, comfort or community, check out juicebox podcast type 1 diabetes on Facebook. If you're looking to meet other people living with type 1 diabetes, head over to juiceboxpodcast.com juicecruise because next June. That's right, 2026 June 21st. The second Juice Cruise is happening on the Celebrity beyond cruise ship. It's a seven night trip going to the Caribbean. We're going to be visiting Miami, CocoCay, St. Thomas and Saint Kitts. Yeah, the Virgin Islands. You're going to love the Virgin Islands. Sail with Scott in the Juice Box Community on a week long voyage built for people and families living with type 1 diabetes. Enjoy tropical luxury, practical education and judgment. Free atmosphere. Perfect day at Coco Bay Saint Kitts, St Thomas. Five interactive workshops with me and surprise guests on Type 1 hacks and tech, mental health, mindfulness, nutrition, exercise, personal growth and professional development. Support groups and wellness discussions tailored for life with Type one and celebrities. World class amenities, dining and entertainment. This is open from every age. You know newborn to 99. I don't care how old you are, come out. Check us out. You can view staterooms and prices@juiceboxpodcast.com JuiceCruise the Last Juice Cruise just happened a couple weeks ago. A hundred of you came. It was awesome. We're looking to make it even bigger this year. I hope you can check it out. The episode you just heard was professionally edited by wrong way recording wrongwayrecording.com.