Juicebox Podcast: Type 1 Diabetes

Episode #1722: DKA Has Been a Problem

Date: December 29, 2025
Host: Scott Benner
Guest: Roxanna, Pediatric CDCES, Type 1 for 10 Years

Episode Overview

In this engaging and insightful episode, Scott welcomes Roxanna, a pediatric Certified Diabetes Care and Education Specialist (CDCES) and ICU nurse living with Type 1 diabetes for a decade. The discussion centers on diabetic ketoacidosis (DKA)—how it can be missed, its long-term consequences, and the urgent need for improved screening and patient education. Roxanna shares her personal diagnosis story, the challenges of family genetics, her professional journey, and how bold education and new technologies are reshaping diabetes care for children and families. The episode is replete with practical strategies, candid confessions, and a focus on empowering both patients and providers to live better with diabetes.

Key Discussion Points & Insights

Roxanna’s Diagnosis & DKA Trauma

• Personal Story (03:14 – 05:28):

  • Diagnosed with Type 1 at age 36 while working as a pediatric ICU nurse.
  • She mistook her symptoms for the flu. Friends, concerned by her absence, initiated a welfare check. She was discovered in a diabetic coma with a blood sugar of 1200, septic, and hypothermic—“Almost died for sure.”
  • Her friends “definitely saved my life that day” (05:34).
  • For her, DKA was missed—despite being a nurse with experience treating DKA in children.

• Family Tradition of DKA Misses (31:00 – 34:55):

  • Later recognized symptoms of Type 1 in her niece. Despite warning the family, her niece was not tested until she was severely ill and needed to be life-flighted in DKA. The same happened to her nephew two years later.
  • Scott: "I'm underlining that for everybody...your brother didn't have to figure it out, someone told him and he still couldn't bring himself to make that leap." (35:12)

• Long-Term Impact of DKA (69:43 – 71:16):

  • DKA is not a one-off—its impacts can be lifelong, from cognitive issues to organ damage.
  • “DKA is a huge problem...it has lifelong impacts on a child or on an adult.” (69:43, Roxanna)

Diabetes Education is Broken—And Can Be Fixed

• Professional Perspective (17:49 – 19:15; 21:51 – 26:10):

  • Even as a nurse, Roxanna felt lost after diagnosis: “They...handed me two pens and said, ‘we’ll see you in a month.’ And I was like, wait, what? What do I do with this?” (18:27)
  • Formal medical/nursing education on diabetes management is minimal. “Nursing school does not prepare you for diabetes management at all. I don’t think med school does either...” (21:51)

• Endocrinology’s Gaps (23:48 – 25:15):

  • Many endocrinologists do not feel well-equipped and may have “imposter syndrome.”
  • Diabetes complexity means providers often rely on formulas that don’t reflect real life. Patients easily lose trust when protocols fail.

• Empowering Patients (43:39 – 44:29):

  • Roxanna encourages families: “Do not ask permission to change your carb ratio or your basal rate...I want you to understand why you’re doing it and how insulin works and all those things.” (44:06)

The Power of Community & Peer Resources

• Finding Support (16:33 – 17:24):

  • Roxanna credits the podcast with giving her both knowledge and hope: “I use the podcast as a resource or recommend it as a resource for a lot of our families...[they do] incredibly well for the most part.”

• Roxanna’s Practice (41:16 – 44:52):

  • Now a pediatrics CDCES, Roxanna integrates lessons from Juicebox and her experience into every new diagnosis class. She gives out binders with podcast resources and QR codes.

• Impact on Outcomes:

  • “Let’s go with 60%. 60%...have an outcome that makes me say, hey, they get this and they’re putting it to practice.” (44:47)

Screening for Type 1—A Message of Prevention

• Importance of Early Screening (36:27 – 38:24; 67:44 – 71:44):

  • Roxanna’s family had multiple autoimmune diagnoses; she’s now a strong advocate for antibody screening (TrialNet), pushing family and patients to get tested.
  • Screening is “the only way to prevent a traumatic diagnosis...[and] to identify candidates for new therapies and prevention trials.”
  • “DKA doesn’t have to happen. But you have to be screened and then monitored after and have this gradual introduction to education...” (71:16, Roxanna)

• Systemic Barriers (68:04 – 69:54):

  • Many families resist screening due to anxiety or thinking they’d ‘just know’ if another family member was getting Type 1. “Most of the time you don’t know. And I will tell that from experience.” (68:37)

Changing the System—Education and Technology

• Changing Education from Within (38:44 – 41:51):

  • Roxanna applied for her current educator position during COVID, seeing a need for real-life, practical training: “If I can do this, surely anyone can do it.”

• Group Education & Challenges (48:11 – 53:28):

  • Every newly diagnosed family must attend her three-hour class before seeing a provider—this allows for a baseline of understanding.
  • Scott suggests bigger symposium-style interventions; Roxanna sees both promise and challenges in terms of engagement and customization.

• Tech for the Unengaged (53:33 – 55:13):

  • The iLet pump is offered especially to families struggling with management. “If you will just put this pump on and keep it charged...That’s all I expect from you. I don’t even care if you bolus...Those kids do really well.”
  • Technology isn’t a panacea, but can bridge the biggest gaps for unengaged or overwhelmed patients/families.

AI, Tech, and the Future of Diabetes Care

• Artificial Intelligence (74:07 – 77:59):
  • Roxanna sees promise in using AI (like ChatGPT) to interpret CGM graphs or help patients problem-solve management: “AI is going to play a large role...it will help a lot of people much better than endocrinologists can.”

Notable Quotes & Memorable Moments

• “I had taken care of hundreds of kids in DKA and did not recognize it in myself. I just knew I felt badly.” (04:41, Roxanna)
• “Almost died for sure.” (05:26, Roxanna)
• “You handed me two pens and said, ‘we’ll see you in a month.’...I have no idea.” (18:27, Roxanna)
• “Nursing school does not prepare you for Diabetes management at all. I don’t think med school does either...” (21:51, Roxanna)
• “DKA is a huge problem...it has lifelong impacts on a child or on an adult.” (69:43, Roxanna)
• “Do not ask permission to change your carb ratio or your basal rate... I want you to understand why you’re doing it and how insulin works and all those things and the possible variables that could be in there.” (44:06, Roxanna)
• On families missing diagnosis despite warnings:
  Scott: “Your brother didn’t have to figure it out, someone told him and he still couldn’t bring himself to make that leap.” (35:12)

Timestamps for Key Segments

• Roxanna’s DKA diagnosis story: 03:14 – 05:51
• Family history, denial, missed diagnoses: 07:20 – 08:35; 31:00 – 34:55
• Knowledge gap in healthcare education: 21:51 – 26:10
• Role of the Juicebox Podcast and peer support: 16:33 – 17:24; 27:29 – 28:32
• Changing diabetes education as CDCES: 38:44 – 44:31
• Screening advocacy and barriers: 36:27 – 38:24, 67:44 – 71:44
• Technology for disengaged patients: 53:33 – 55:23
• AI in diabetes management: 74:07 – 77:59

Tone & Style

The episode is characterized by a blend of candor, humor, empathy, and hope. Both Scott and Roxanna approach personal and systemic shortcomings with honesty but focus steadfastly on practical solutions and empowerment. The conversation often moves from deeply personal (and sometimes painful) anecdotes to actionable strategies and policy insights.

Takeaways for Listeners

• DKA is often missed, even by experienced healthcare professionals and family members—but it’s preventable with screening and awareness.
• Education for both patients and providers is deeply lacking; real progress starts with practical, lived-experience guidance.
• Families should be empowered to make safe management decisions without waiting for provider approval.
• Bold use of technology—including AI—can bridge gaps for the disengaged, the underserved, and the overwhelmed.
• Screening for type 1 and other autoimmune risks in families is critical and should become routine.
• Diabetes care requires hope, patience, real-world strategies, and the courage to be "bold with insulin."

For more resources and support, Roxanna recommends checking out JuiceboxPodcast.com and the podcast’s private Facebook community. She also encourages all families with any family history of autoimmune issues to pursue antibody screening.