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- [00:00]
A
Welcome back, friends, to another episode of the Juice Box Podcast. If you're new to type 1 diabetes, begin with the Bold Beginnings series from the podcast. Don't take my word for it. Listen to what reviewers have said. Bold Beginnings is the best first step. I learned more in those episodes than anywhere else. This is when everything finally clicked. People say it takes the stress out of the early days and replaces it with clarity. They tell me this should come with the diagnosis packet that I got at the hospital. And after they listen, they recommend it to everyone who's struggling. It's straightforward, practical, and easy to listen to. Bold Beginnings gives you the basics in a way that actually makes sense. 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 Juice box podcast, type 1 diabetes on Facebook. Nothing you hear on the Juice Box Podcast should be considered advice, medical or otherwise. Always consult a physician before making any changes to your healthcare plan. Jenny, I'm going to spring this on you while we're recording.
- [01:33]
B
Yay. Which is not odd.
- [01:35]
A
No, it's not odd at all. But, you know, this one's a little out of left field. We're going to take a break this week from making Bolus four episodes, which, I have to tell you, people are really enjoying. So we're going to be making more of them. I saw the ADA guidance came out the other day.
- [01:48]
B
Yeah, the 2026.
- [01:50]
A
2026 guidance came out, and I have, like, in the past, I've always been like, whatever. Like, I don't really look at it too closely. But this year I thought, like, you know, everybody gets excited and is this marketing, this excitement or whatever. So I kind of dug into it a little bit, and it is a lot. It is a. It feels like a lot of nothing to me, and I realize that it's something that probably moves on very slowly, but I thought it would be interesting to look at it and to kind of look backwards a little bit, too, if you don't mind. Like, I'm gonna scroll back to 2022.
- [02:22]
B
Okay.
- [02:23]
A
Where the. Let's see how. How I broke it down here.
- [02:27]
B
Why 2022? I'm just curious. It's only four years ago. It's not like a round five number, so why that number? Why?
- [02:34]
A
I want to see if there's anything happening that just feels. I guess what I want to do.
- [02:38]
B
Is I want to show people significant enough indifference.
- [02:41]
A
Yeah. And I'd like to show people that something that came up in 2022, 2023, is slowly being adjusted going forward. It's not like. How do I mean this.
- [02:50]
B
Okay.
- [02:51]
A
A couple. Good.
- [02:52]
B
No, I was gonna say I. I have one that I. I know that we'll probably get into in terms of reviewing the current guidance that again just came out. And that slow progression to something finally being in a standardized guideline.
- [03:08]
A
Yeah.
- [03:09]
B
That technically, I feel like has already been standard in the crowd of people I tend to work with or that you tend to. In terms of who listens. Right.
- [03:22]
A
What throws me off about this. Yeah. I was prompted by. I'm not trying to out anybody. I was prompted by an email I got from a fairly big diabetes organization recently where they were like, oh, my gosh, look at how exciting this is. And they. Their news. I don't want to say even what it was because I don't want people to know what it was like. Like this amazing thing that's happening. Blah, blah. And I thought, I've been talking about that for three years.
- [03:45]
B
Right.
- [03:46]
A
Like, the mass of people see it like that. Even like going back to 2022. Right. ADA is like, screening is going to be very important. Screening, screening, screening. They've been talking about it now for, you know, a handful of years. And in my opinion, where we're at is, you know, we're trying to screen to see if people are, you know, eligible for TZeal. But the process of screening them is just. It's insane.
- [04:12]
B
Yeah.
- [04:13]
A
Going to get people who have not been diagnosed with type one yet early enough that they're eligible for T Z. And then if you find them, the answer is 13 infusions over 13 days. You might have to fly somewhere and live in a hotel to do it. And if we're lucky, this might stave off diabetes for a year or so. Like, wow. Like, what is so much effort go into something like that? Do you know what I mean?
- [04:36]
B
Yeah. I mean, I think in. In terms of these standards. Right. They are. I don't know. Honestly, it's a really good question. My thought is that from an organizational standpoint, it's almost like they're waiting to see enough momentum to be able to actually put it in there as a trusted, valuable standard that they can suggest to the greater. These standards are usually not even something people with diabetes look at.
- [05:06]
A
Right.
- [05:06]
B
They really are from a clinical standpoint of what should we as clinicians be looking at now as this is what we should talk to people about diabetes about, or this is what we should try to move to as the new guidance rule or the new medication and why it holds value when all the data has been building to that statement, but it's already been happening.
- [05:35]
A
Yeah. I don't say that people should run forward with their hair on fire and try everything that, like, randomly pops up in front of them. I think the screening thing going back this many years, because if you have any social media or you're around any contact with diabetes at all, you're going to hear, like, screening rhetoric being pushed at you. Right. Like, so what that to me means is that the machine thinks it's important. If the ADA thinks it's important, then I got to think whoever's supporting the ADA thinks it's important. I don't know anything about anything, but Sanofi paid a lot of money for that drug. So I got to figure there's some, you know, some push, some push from that. Yeah, I understand. I understand all this, but if that's how that works, then I want you to wonder about things like, I don't know, CGMs and GLP medications and microdosing stuff and, and thinking differently in general about things that you see in your life working. But then go out and say, the machine is not telling me that this is important.
- [06:36]
B
Right.
- [06:37]
A
I just think that it's. It's 20, 26. What's the guidance on a 1C right now?
- [06:42]
B
The guidance on a 1C? You tell me. I know you're looking at it.
- [06:45]
A
7.5 for kids. Right. And what is it for adults? 7.
- [06:50]
B
Under 7.
- [06:51]
A
Under 7. Okay.
- [06:53]
B
I mean, it's. And that has, that has not changed at all. And then that's a standard. Right. We all have the knowledge as well, that it's, it's kind of a standard. That's not a hard box standard. It's a. There are wavy lines to it. If you have this type of situation going on, we might expand that. If you have, you know, hypoglycemia, unawareness, if you are over the age of such and such or under the age of, you know, whatever, then that gets a little bit wavy. But it's still. They have to have a hard set value to put into something like this. Again, from a medical, From a medical liability standpoint, there has to be something that medical clinicians are using as their, as their standard. It's their starting point. Right. I do think that the standards. And I actually looked at them when they came out for a couple of reasons. I think some of the new things on the list are important because they've again, been things clinically that I've seen have been pushed to the background. And so I think that standards like this, putting them more to the front ground and saying, hey, this is really important to pay attention to and this is why we know this now about this particular medication, it can impact this condition, which got kind of a second or a third notice comparative to just a 1C. Right. So the newer guidelines have things around. I think a big highlight is absolutely the GLP1s. There's a huge highlighted piece of that which most people with diabetes, especially with type 1 diabetes, have been hitting on and pounding their fist into the ground about being noticed for a while already. And yay, now the standards say, yes, there's value to these medications.
- [08:55]
A
Let me be cynical for a second.
- [08:56]
B
Sure.
- [08:57]
A
Isn't it possible, Jenny, that I'm not a genius and that three years ago when I was like, I'm going to give my kid a little bit of this GLP and see what happens, that maybe what was really going on when they were busy telling us, no, no, no, it's not for type ones, it's only for type twos. What they meant was, is we don't have production ramped up yet, so let's not everybody be dipping their toe into this pond yet. Like, I think that's the kind of stuff. I am not a conspiracy person. I just think that this is very, like, realistic to look at. Right. Like, and the reason I dislike it so much is because not only is that three years of people not getting support, maybe that would have been valuable for them.
- [09:33]
B
True.
- [09:33]
A
But it's three years of telling people, oh, no, this thing is not for you, and those people will never think about it again. Right. Like, that's the part I hate. Like, I hate when they tell me, like, if you tell a parent, A75A1C is a good target for your kid. I understand big picture. Everyone hears this. Everyone has different technology ability to, like, use tools, access the tools. And we want everybody to be safe. I don't not want everybody to be safe. Of course, I'm worried about all the people that heard the number and will move forward for the rest of their life going seven fives. Okay.
- [10:12]
B
That. That's the standard.
- [10:13]
A
Ye.
- [10:13]
B
Correct. And partially because nobody then clears it up. And once you've established that as your.
- [10:20]
A
Standard, then that's it forever and ever.
- [10:22]
B
Then that's it. Forever and Ever. Unless you're the type of person or personality that says, I'm going to do more research. Like, I was given that. Like, I think there are. There are several personalities within the scope of diabetes management. Some who are given a standard like that to begin with and. And go off and say, okay, yes, this is just it for life. I was told 7.5 or under. That is really great, fantastic. And they never ask more questions. But I think their doctors are also not providing enough either to make them think that there are additional things that could be done. And then there's the other avenue of people who absolutely take that as maybe this was the starting place because it was safe to begin with.
- [11:07]
A
Mm.
- [11:07]
B
But I know, and I think, especially because we have such a broad diabetes community in an online way that I did not have growing up. There was nowhere else to look, Right. Books that were on it. You had to go to the library or had to, like, order them from someplace. And there was not the Internet, nor the online communication that we have today to see that there is better, there can be better. And, gosh, I should be asking more questions to my doctor about why did you give me this? And why haven't we adjusted this now as things are changing?
- [11:43]
A
So I'm going to tell you a sad story that I don't know that I've ever told you before. And I'm sorry, but I. It fits here. And I've been thinking about it a lot lately, so it pops in my head initially, because Dexcom moves to the 15 day sensor.
- [11:58]
B
Yes.
- [11:58]
A
And everyone's like, mine doesn't even last 10 days. Now you're going to tell me it goes 50 and, you know, blah, blah, and everybody's complaining, right? And then you, you know, you try to parse it in your head. Like, really, the Internet is where people come to complain. My daughter wears an Omnipod right out. Or, excuse me, a Dexcom right out. 10 days, 12 hours, almost every time. Right.
- [12:18]
B
Which is awesome.
- [12:19]
A
It's lucky. I understand that. But at the same time, like, the Internet's not full of people who show up to go, hey, I just wanted to come by and say that my CGM lasts 10 days all the time. Right. So you get this feeling, you know, oh, gosh, it must not. A thing must not work. And then I saw somebody say something that really stuck to me, and it was more about the way they said it. And I. And I felt for them because I understand they're obviously either scared or having a bad experience or whatever, but, you know, why don't they fix the problems it has before they shove this down my throat and shove this down my throat is what stuck to me. And here's why. When I was getting ready to graduate high school, my best friend got diagnosed with type 1 diabetes. His name is Mike. Well, his name was Mike. And he was given regular and mph. And that was it. And my entire life, knowing and loving and being with Mike as a great friend, I thought of him as a person with kind of a strange temperament. He was lovely and sweet, but sometimes he'd get angry out of nowhere. And I never understood that.
- [13:20]
B
Right.
- [13:21]
A
And later at night, there was always a rule. We didn't let Mike drive because he'd swerve and he wasn't like a great driver. And we just thought Mike couldn't drive. And, you know, that was just how we went along. And Mike went along and he got up in the morning and he did his, like, probably about this much injection and then we'd go eat breakfast and I'd see him do it again in the afternoon. We never talked about his diabetes. And it turns out that Mike didn't know much about his diabetes either. And neither did his doctor. And one day we're adults and we're married and moved on. Mike says to me, hey, I think my kidneys are failing and I'm going to go to the doctor today. And the next thing I know, Mike's on dialysis. And then Mike loses his job because he's always on dialysis. And then his doctor says to him, I'm not kidding. And this is only about six years ago. We should really try carb counting. That's when they moved Mike to Novolog and Atlantis. Yeah. Wow. And he's a bright guy. He was lovely. He had all kinds of interests. He would have been a real great addition to this world moving forward. And instead he started having seizures because he didn't know how to use his. His Novolog. He crashed his car because he tried to bolt like he was at a comic book store picking up his books and injected before he went to the diner, like he does all the time, except he used to inject a much slower acting insulin before. Onlooker said that my friend's car went down a private street between 80 and 90 miles an hour. It went into a cul de sac, spun in a circle before it crashed into a mailbox in somebody's house. Mike was lucky he didn't get hurt. A couple of months later, he fell out of bed having a seizure and broke his arm. And two years later, he was talking with his wife about what to have for dinner. They decided on what to have. He stood up out of his chair to go make it and fell forward on his face when his heart failed. Right. And I always think Sad that the MTs came and they saved him. And then three days later, I sat in a hotel room with my cell phone playing Mike's favorite music from when we were in high school. And he died the next day.
- [15:28]
B
I'm sorry.
- [15:29]
A
And I see that story as completely connected to this because at some point in Mike's life, someone said, this is how you take care of your diabetes. And he believed them. And then he moved forward and all this crazy stuff that happened to him we were all completely unaware of, as was he. Mike didn't think like, oh, I yell at people because my blood sugar's been high for three days.
- [15:51]
B
Right. He didn't make an association.
- [15:53]
A
No one knew. And I guess I'm asking everybody to say, what do you think might be happening to you right now that you're not aware of? Right. While we're slow walking telling people CGMs are important. I'm scrolling back now to 2018. CGMs for adults. Expand CGM recommendations to all adults 18 and over. Expand. Like my last thought here is, and then I really want to hear what you think about all this is that it's been about a year or so now. This very well respected doctor in the diabetes space was I'm going to make an announcement. I'm making an announcement, I'm putting up a video, I'm making an announcement. You should all be there. I went and looked and he said they've been doing research for 10 years now and he is confident and excited to tell us all that, you know, if you lower your alarm on your cgm, you'll have better outcomes. They figured that out. Jenny only took them about 10 years. So yeah, yeah, I'm saying this is great. I got nothing against the ada. I got nothing way the machine works. I understand slow, steady, make sure everybody's safe. But for the everyone else, pay attention, like follow your common sense a little more.
- [17:03]
B
Well, I think it also, what it highlights for me is also that and I don't know what kind of doctor your friend Mike was going to.
- [17:12]
A
I'm sure he didn't either by the.
- [17:13]
B
Way, if it right, he may not. Maybe it was a primary care and unfortunately primary care is like the Jack of all trades, right. They really know a little bit about a lot of things, but they are not They've not gone to schooling for a specialty. That's where endocrinology does shine. Whether you believe your endocrinologist is a great one or not, they still have a specialty in a lot of endocrine, not just diabetes either. So those are the doctors that I believe, really hope, I guess, are looking at more than just these standards.
- [17:57]
A
Yeah.
- [17:58]
B
It's the primary cares and the ones in the general public that I, I truly think should be the ones getting these standards and having to check it off. Almost like a continuing education that they have looked at it, that they now acknowledge the value to these things because they do see the larger portion of people with diabetes, not endocrinology. And again, for your friend Mike, my expectation is that he was probably going to a primary care or just a really bad endocrinologist who didn't know what they were doing with diabetes. Right. Because that endo six years ago. I mean, I've been using a CGM since 2005.
- [18:48]
A
Yeah. I looked the other day. I think if I got the. If I. It's now, it's in the back of my head, but I think there's been like over 10 iterations of like Dexcom CGMs over like 19 years or something.
- [19:00]
B
Yes. I didn't even start on Dexcom. I started on Abbott's Navigator, which was a phenomenal cgm.
- [19:08]
A
Kenny's like, why they take that Navigator from me?
- [19:10]
B
I loved it, it was awesome. But, you know, and then got kind of moved into Dexcom mainly because Navigator was leaving the US and they were no longer going to have it. So I have had almost all of the iterations of Dexcom and can say that it is an enormous reason that I no longer set an alarm overnight to check my blood sugar.
- [19:35]
A
Yeah.
- [19:35]
B
Prior to that. I mean, even my husband will tell you, like the 2am alarm, it went off every night and after a while, like he didn't even pay attention to it anymore because it was just the norm. Right. But once I got a cgm, my goodness, the value there and the value that it could have had for your friend Mike, I think that he probably could have even started making associations on his own. Even if no doctor told him anything about how to look at the data, he sounds like he was smart enough to probably start making associations of, gosh, my blood sugar is here and I start acting like a jerk.
- [20:14]
A
Yeah.
- [20:14]
B
You know what I mean?
- [20:15]
A
I thought about that a lot, honestly. Because like, where didn't. Where did someone fail him? And where did he not say, I gotta take care of this. But I don't, I just don't know. Like, you know, we talk about how blood sugars affect your personality and your ability to think and fogging. I just don't know where he was, you know what I mean? And that's the, that's why, that's why we made the Grand Round series. Because I want people to start with a good knowledge. Like it's why I talk about all this all the time. I mean, honestly, you guys probably don't realize it, but a lot of the reason why I come at this the way I do is because of Mike. I just don't talk about it because it seems distasteful. But his is an exploded example of what could happen. I'm saying like you don't have to end up, you know, with heart failure and kidney failure for this to be impactful on your life. You can have other small impacts along the way that you might not notice. And if you're counting on, if you're counting on guidance to get you there, I'm saying I don't think I would do that because it's going to lag behind. Look. How does that guidance impact something like insurance coverage? It defines medical necessity for technology. It sets prior authorization criteria, justifies coverage for off label use, preventative screening at zero cost lag time, commercial lag. It typically takes one to three years for a new ADA recommendation to be written into insurance, medical policies, policies.
- [21:43]
B
Correct.
- [21:43]
A
Yeah, everything takes too much time. Your life is this long. That's a big picture thing and we should be doing that. The ADA's Thank God. Right? But like for you personally, inside of your life, you don't have the 300 years that they're mapping this out over. You know, you, you've got this time right now and I'm arguing you don't even have that much time because you're going to get set into some sort of a comfortable rhythm that you won't look up from and then It'll just be 10 years later.
- [22:14]
B
I mean the gist of it all is that it's too slow. These standard recommendations, they wait, they gather data, they gather more data, they gather more data and finally there's enough information for them to say, yes, we can now state that this is of value and a needed, you know, discussion or a needed reference or a needed medication. Even the, I mean if you look at the new, and this is the first time, if I'm remembering correctly, this is the first time that they're acknowledging the aid systems inclusive and their Value inclusive of the open source DIY systems. The first time. How long have I been using an open source system? I've been using one since early 2017. Yes, that is a long time. I have worked with person after person after person. I have talked to doctors. I did a presentation eons ago at a ADC ES conference about specifically the DIY open source aid systems. And what are you afraid of? Get your head out of the sand. Why are you not acknowledging this? And a lot of the problems at that time were. That came from the audience. It was. There are no standards around using them. We have not been educated on using them and we are liable if we recommend them in office. Those were the baselines. So until a standard comes out that brings it to the forefront within the medical community, there is a liability issue to a lot of this.
- [24:00]
A
Right. So you're not going to. Until this, until this guidance says, hey, do this, then doctors won't feel comfortable even if they know. That's why, by the way, this is partly why the podcast is so popular, because this is why you guys get grabbed in a hallway on the way out of an appointment. Somebody just whispers in your ear, just try the Juice Box podcast and they shove you out the door. Yeah. Have you tried. Did you read this book? Did you do this? Like, get out of here. Hurry up. Don't let anybody hear me saying this to you. My God, if you don't go do this, you're going to live like this forever. Kenny, if I.
- [24:29]
B
Go ahead. No, no, go ahead. I was gonna say there are. There are good doctors, there are good endos, there are good high risk doctors. You know, in the whole realm of pregnancy with diabetes, they are, they're too few and far between. Because the, the good doctors are willing to step outside of the box and say, while this is not the recommendation, there is value in trying this. Because I can see, I can see how this medication, for example, works. I can see how this system works. They're the ones that at night at. They're not sitting down and reading the next romance novel. They're actually online reading about open source. They're online reading about medications and expanding the use. And how could this actually work in the type 1 population despite it being a type 2 medication, but there aren't enough of them.
- [25:21]
A
No, the ones I meet are special. And yes, you know, they deserve a medal. If the guidance is there, then the insurance isn't going to cover it. If the insurance isn't going to cover it, then the device manufacturers aren't going to Push for it. Right, right. Like, so you're going to get slower. What, forward motion. With technology, with. With ideas. Because there's. There's no pressure to do it. If the guidance was there, then one company would stand up and go, oh, we're gonna do this. Which would make the rest of them go, oh, hell, we gotta do this now, too. And then, you know, and then you'd get your stuff more quickly, and it would. And I'm telling you, I think it would. It would value. It would add value to your life. I wish I could find. I can't even remember her name right now. I feel bad. One listener who reached out to me and was like, yo, your daughter should try a loop. And, like, I thought she was here right now. I'd kiss her on the mouth and buy her a car. Like. Like, I think I'd be dead, like, without that. Because of what you mentioned earlier. Like, I wasn't sleeping. Like, yeah, like, Arden was super healthy. I was awake 19 and a half hours a day. And, like, so. And there's that thing. Just, poof. All good. Here we go. And it works. And then you walk out in the world and all you hear is, oh, I don't know. I don't know. I don't know. And it's forever. And they're gonna. I don't know you. To death. To death is what I think. And it just. So I'm not picking on the ADA or the guidance. I'm just trying to show you how slow it is. Like, why did I go back, like, just a handful of years? Because if you go back a handful of years, what you see is not.
- [26:52]
B
A lot of motion, not much change. You know, I think the other really good thing that could come from the standards, and I said before, in general, I think these standards are really more for the medical community, truly. Right. But I do think that as a person with diabetes, it behooves you to also take a look at what they are on the continuum every single year when they come out. Mainly because if there are things that you have been trying to address and bring up with your doctor, they may pop into the standards. And if the doctor's still giving you pushback, you can bring it and kind of say, hey, look.
- [27:31]
A
Yeah, it's okay.
- [27:32]
B
This is part of the standards. Why are we not discussing this? I've brought it up for two years already.
- [27:37]
A
Yeah, that thing where you tell me the GLP is going to make me go into dka. We can stop saying that now, right? The paper says you don't have to say it to me anymore.
- [27:43]
B
And look at the other benefits that are coming out of it. The more research, the more information. The fact that, yes, gosh, it is very beneficial for those with type 1 diabetes. And yes, even the micro dosing was. Of those was something that was also not done in the typical endocrine practice. It was a. This is the dose. This is a standard starting dose. We titrate it this way, up, up, up, and see how you tolerate things. And again, the sort of. The gray area thinkers in the medical community were like, well, type one's very likely. And we can now see they do need a different dosing strategy than most type twos using these meds. But it doesn't mean we shouldn't use them. It means that we should figure out how to dose it better.
- [28:27]
A
It's the crazy leap that I never understand, right? Like, it's. Oh, well, it's. There's a label warning for type ones because they go into DKA Woods. And so I said to somebody, I'm like, wait, so GLPs cause DKA and type 1s? And they go, well, no. And I'm like, well, what's the problem then? Well, GLPs make it so that some type ones need so little insulin, they don't take enough insulin, and they go into DKA because they're not eating. And I went, oh, well, that's not the same thing. Like, like, you're.
- [28:55]
B
There's a big difference.
- [28:57]
A
You're fixing the problem in an unnecessary way. Like, yeah, and so it's. It's the baby with the bathwater thing. Like, just don't throw the whole thing away because you bumped into the first problem. Like, you know what I mean? Like, oh, no. You know, we gave glp, because these are studies, we gave GLP to people with type 1s. Some of them went to DK. So now there's a label warning about it. That's a big leap, you know, because the GLP lowers my daughter's insulin needs by like 30%.
- [29:24]
B
Yes.
- [29:25]
A
Yeah. She's not in DK. She's good.
- [29:28]
B
She's good, right, because you've also. You also know enough about titrating insulin, right? I mean, if you look at.
- [29:34]
A
That's the fixable problem, not the. You know, I'm sorry I cut you off. Go ahead.
- [29:37]
B
Oh, no, no, no. I was actually just going to compare it to. It's a major problem. Because if you compare it even to all of the pharmaceutical ads, which I would 100% be the one that's like, we gotta get them off the television. Right. But, like, if you look at any of them at the end, there's always a host of. It could cause this. Cause your toe to turn purple and fall off. But that's just a potential side effect. Right, but they have to list side effects. Yeah, but if you look at that from a medical perspective, doctors are still prescribing these for the value of what they're prescribing them for. And often they don't even talk about the side effects. But when it comes to something like diabetes and the value and the very low chance of any of the side effects, and if doctors were actually reading the research the correct way, they'd actually see that things like DKA with type 1 and the GLP1s, there's a. There's a path to that happening.
- [30:34]
A
Yeah.
- [30:35]
B
And if you educate your patient the right way, that's. It's not going to happen. And it isn't 100%. It's. It's utterly ridiculous.
- [30:43]
A
And it le. Here's what it leads to. It leads to me or somebody like me, you know, stepping like, Jenny, I've said this a thousand different ways, but the way that it sticks to me the most is that when I started talking about GLP medications, some parts of the Internet came after me with a hot poker and tried to shove it right up my okay. And I was like, no, you guys are like, you're missing the boat. But how does that happen? Because the ad says, you know, be careful. Blah, blah, blah, blah, blah. And then somebody hears that, and then you say online, like, hey, you know, I was. I've been doing this. It's really working. Look into it if you want to. You're gonna kill people that makes this happen. I know a person who was in the hospital and their guts were turned into a knot. And like, okay, yeah, I'm not saying that it doesn't happen to some people, but there's also millions of people it's not happening to.
- [31:30]
B
Like, correct.
- [31:31]
A
It's fascinating. And it goes back to. You're not going to remember this, but, like, when we recorded that Pro Tip series in, like, 2020, you didn't even know me that well then. And I was like, jenny, listen. I'm like, I am tired of, like, common denominator teaching for people. Like, I know there's 20 kids in the class, and two of them are really having trouble, but why are we teaching to them all the time? Like, can't we teach to everybody else and protect them? At the same time.
- [31:58]
B
Right.
- [31:59]
A
Humanity doesn't work. There they go, nope, sorry, we can't. We'll all just pretend that that's the level that we're all working with. And the rest of it will just sit around and pretend it doesn't happen and it doesn't exist. I'm not down for that anymore. So.
- [32:11]
B
No, Yeah. I mean, there are many. If I was writing the standards and this is where nobody would live in Jenny's world, but, I mean, there would.
- [32:20]
A
I'm trying. Before you say that, I'm trying to imagine a world where you have a child with type 1 diabetes and someone tells you to keep their A1C at 7.5. And it was a. They'd be like, oh, you're doing great. You're almost at 7.5. That would happen, wouldn't it?
- [32:32]
B
No, no, no. In fact, I'd have many words. Many words as well as. I mean, you know me, you see me all the time when we. When we do this, right. You know that I have literally no poker face. Like, I do not play cards. I have no ability to hide. It just shows on my face. And I'm quite sure the doctor would be like, what do you. What, really? You don't believe me? I, like, have no problem voicing my opinions there.
- [32:57]
A
By the way. There's a drift that happens. If you tell somebody 7.5, then 8.2 doesn't seem that far from 7.5. And then next week, you know, or next month or three months from now, we come back again and into eight. Five, you go, that's not bad. It only went up 0.2, 0.3. You're doing great. We'll try again. Like, you know, and you just zoom.
- [33:17]
B
And what you're bringing in is also a slower drift. Right?
- [33:20]
A
Yeah.
- [33:21]
B
Most people have ups and downs in their life, variables that impact things. And let's say 7.5 has been your gold standard because that's what you've been told. And now you're at 7.6 or 7.7 Again, the drift is so small that you have just a concept with those numbers. That's not a big change. Whole number value is going from 7.5 to 8.5, I think is a very visible, larger jump that somebody would probably acknowledge and say, well, gosh, absolutely, something major has changed. But anytime there's a little decimal drift, we don't really acknowledge it. And I mean, point 1.2 again, it really is.
- [34:02]
A
I don't care if your blood Sugar, if your A1C moves around. But I'm saying that you get lulled into, like, complacency entirely.
- [34:08]
B
And so then 7.8 becomes 7.9 becomes 8.1 becomes 8.4, and that drift continues. But because it's so slow, you don't acknowledge where you started and how much you've drifted over a time period when the drift didn't have to happen if you knew what to do.
- [34:27]
A
It works the same way in your mind as gaining weight, not cutting the weeds around your house or something. You just accept more and more of something that on day one, you weren't excited to accept.
- [34:37]
B
Absolutely.
- [34:37]
A
Right. Now, listen, this year there's some. I think they made some really nice improvements this year. First time GLP receptor agonist are explicitly listed as recommended treatments options for obesity in people with type one. That's a great step for you.
- [34:50]
B
100% awesome.
- [34:52]
A
Great step. New recommendations state that there should be no requirement for C peptide levels present of antibodies or duration of insulin use before initiating an insulin pump or an aid system. That's a really good one.
- [35:04]
B
It is huge. Yeah, absolutely.
- [35:06]
A
This one's nice. Workplace advocacy. New guidance explicitly states that adults using diabetes technology like pumps or CGM should receive reasonable accommodations in the workplace. Now, that's nice, but it took us till 2026 to say that, like, that one, one we could have slipped in 10 years ago. You know what I mean?
- [35:22]
B
Like, here's a great percent.
- [35:24]
A
Hospital safety. A new safety standard mandates that hospital policies must ensure basal insulin is never held for people with type 1 diabetes. That's a great one. I clap for that 100%.
- [35:34]
B
And that should be something that. In bold type red, when somebody comes in to the emergency department, right, and they acknowledge type 1 diabetes highlighted in red blinking lights. As soon as they acknowledge it comes up in the system is another statement. Don't hold insulin.
- [35:52]
A
Yeah. It's just. It's insane. My point over. I would say to whoever added that this year, congratulations. Where the hell was that before? Like, you are in charge of what the hospitals think about when you. So when you. When people say all the time. I just had Dr. Beach Jim on a while ago.
- [36:07]
B
Yeah, I love her.
- [36:07]
A
She was lovely, right?
- [36:08]
B
She's great. Yeah.
- [36:09]
A
As I'm talking to her, like, she says this one thing that, like, strikes me is like, look, we follow the. Like, there's guidelines. We. We have protocols. Those protocols come from stuff like this. So you're telling me that you could have added this 10 years ago, and then for the last 10 years, the people went to the hospital type 1 diabetes wouldn't have their pumps taken from them or have their blood sugar shot way up and treated like they were type 2 and just on vacation, like, because that is really what kind of happens, right? I go back to 2025 like here, I mean, it's more about screening toplizumab, but sleep cannabis warnings. What are you making? Cannabis warnings. A new specific recommendation to avoid cannabis use in people at risk for DKA to the risk of cannabis hypermyc syndrome. Come on. Kidding me. Whole world's high.
- [36:59]
B
Jesus.
- [37:00]
A
You ever walk outside, go, what is that I smell? It's weed, Jenny. It's everywhere. Okay. No, not for type ones. You guys can't have.
- [37:10]
B
We can't have it.
- [37:11]
A
No, it's going to make cannabis hypermycis. I don't know what the. That says. Like, like it just.
- [37:17]
B
That's a good job trying to read it.
- [37:19]
A
This one, I think. No, no, no, you go.
- [37:22]
B
I think some of the, the newer things that are in this, you already mentioned in terms of just GLP1. That takes a heavy hit of explanation in many different categories. Things like kidney health and heart health, Cardiovas, Vascular, GLP1s are mentioned in many different places, which is thankfully, again, slow. But it is continuing to highlight the value of what they're finding. And as we all know, research takes a long time to put together enough sort of quantifiable information that suggests to the positive before any broad statement can be made. Right.
- [38:07]
A
Yeah, it just. I, I interview. I was didn't interview the other day with a guy who makes a GOP one podcast and he was talking about all the things that, you know, they know it's helping with and all the things that they're wondering if it's helping with and testing to see it looks like it is if you look at the population. And he got done and I joked about it, but I said, I feel like what you just told me is I'm gonna live forever. And like. And I know that's not, it's not what. It's not really true, but if all these little things are happening behind the scenes in your body and now they're happening at a lesser degree and it's going to, it's going to increase your longevity and. But back to the original point, we've demonized GLPs for so many years now that there's now going to be a whole generation of people who will never try them because they have an idea in their head or it's that, oh, that's the thing. You cheat with to lose weight or you do. No. How about that's the thing that'll make my kidneys work better or my fatty liver go away. Right?
- [39:04]
B
Right.
- [39:04]
A
How about my cytokines are going down? How about that? Yeah.
- [39:08]
B
Look at you. Big words.
- [39:09]
A
I know a couple of words, Jenny. I used apoplectic in an episode the other day, just so you know. Yeah, damn right. I've heard words before.
- [39:20]
B
You're fun.
- [39:20]
A
Yeah. Oh, please. I guess that I would ask you. I'm gonna put. I'm gonna put that crown back on you for a second. Right.
- [39:27]
B
Oh.
- [39:28]
A
If you were in charge, what do you want people doing? Looking at, Thinking about. How do you want them measuring? Like. Like, what's a big picture way people should be thinking about this for themselves? It's a big question, but I think you can answer it.
- [39:44]
B
The big question about how they should be looking at the standards for themselves.
- [39:48]
A
Is that, like, how should they be running their lives? Like, what did they get up in the morning and say to themselves? Like, this is what I should be trying for. Like, I'm not saying you're gonna get it every day, but, like, let me rephrase it. In a world where this amount of Insulin keeps my A1C at this level, and a greater amount of insulin would keep it lower, right? And we know that the only fear is that people are like, oh, you're gonna get low. That's it. Like, what do you think people should be? And I'm not telling. Like, I'm gonna cover your ass for you before you start talking. Oh, no. I know some of you don't want a pump. Some of you don't want a cgm. Some of you can't afford of it. I'm. I'm talking about perfect world.
- [40:27]
B
Sure. In a perfect world, it would be an option for all people to have access, right? So that they could have enough information to say, this is where I am. So the starting point of, okay, I've been told a 7.5. I've. I've recently learned I should technically be lower than that. It is a lot about insulin knowledge. And so my, I guess standard would be teaching people enough about knowing their insulin and how it works for them so that as they're looking at their numbers, whether it's just a finger stick or their cgm, they can say, okay, well, this is my base. As you were getting at, like, this amount of insulin is keeping me here, but if I'm really aiming here now, how do I get there? It is about sometimes lifestyle stuff. But it is also about insulin. And gosh, I've got a base that's holding me here. I want to be 20 to 30 points lower. What if I just add a little bit more insulin? And again, I always encourage you to talk to your medical provider. Don't just dial things up by 30 extra units. But even little titrations, let's say a meal is consistently sending you high and you're using three and a half units. Well, goodness, three and a half up to four if you're on three units already for a meal is half a unit is not really gonna. But it is gonna help to move you forward. So I think standards should go in the direction of teaching people how to move where they want to get to, if they even know in the broader population of people, again, think doesn't know enough. And that makes me sad.
- [42:13]
A
Yeah, no, I'm with you.
- [42:15]
B
So if you have standards, I think it's the people who are already looking for more that are going to look for these standards as, again, a way to bring into their doctor to say, hey, look at this. Like, we've never talked about this. I've been talking about it. It's now a standard. But other people are hoping that their clinician, who has the white coat on and has gone to school for 8, 10, 12 years, that they should know these things and that they're bringing it into the practice and helping them.
- [42:45]
A
But those people are waiting for the buttonless pumps, which I think are probably coming, but they're not going to come as quickly as you hope.
- [42:54]
B
And there are years until that point of which there's stuff going on in your body that, I mean, we've talked about it before. Like, the incremental little things that end up happening aren't like, gosh, I have diabetes and three days later I have heart disease. That's not how this works. It's incremental and it's unfelt. You don't feel, nor do you see the internal stuff that is going on until you get to the point of. I mean, again, you brought up Mike.
- [43:25]
A
You stand up to make dinner.
- [43:27]
B
Yeah, you stand up to make dinner. The doctor says, hey, your urine sample shows that you're spilling such and such. I think you've got kidney disease. Mike didn't feel anything going on.
- [43:36]
A
Nope. He had no idea. He really didn't. Diabetes is not a cross. We'll cross that bridge when we come to a situation like, you need to be. You need to be thinking about it every day. And I even take that. Not everybody's going to. And that's fine. But I really do want to repeat again to anybody listening who makes a decision if the island's on fire and there's only so many boats, we still tell people the island's on fire so they have a chance to get away.
- [44:02]
B
Correct.
- [44:02]
A
Right. You don't get to make the decision about whether or not I die in the island fire. Right. Like, so I'd be looking for the.
- [44:09]
B
Largest branch to float on. If the boats were full, man, I'd be looking for the door or whatever.
- [44:15]
A
You got to give people a fighting chance.
- [44:17]
B
You do.
- [44:17]
A
If your argument is, well, everyone's not going to understand, everyone's not going to have the bandwidth, everyone's not going to have access. So we just won't tell anybody. That's a terrible perspective to have. Right.
- [44:28]
B
It's also judging somebody from what you think you've gathered out of a 10 or 15 minute office conversation with someone.
- [44:36]
A
Which isn't that funny considering that when I scroll back through this document, the ADA is always worried about people being treated properly.
- [44:45]
B
100%. It's in the. It's in these. It's one of the things that. Treating people with individualization and empathy and, and all the wordage that they can possibly use. But let's put it into effect.
- [44:57]
A
Yeah, let's not then tell them a seven fives. Okay, that's hilarious. Like, everyone deserves to be treated well. Blah, blah, blah. And now you know, you know what it takes me back to. I was at a blogging conference one time and I got caught in an elevator with a person who conference. I was, there was a blogging conference for people with type 1 diabetes. I don't know what to tell you. They used to exist. I got into an elevator with a person who I was like, oh my gosh. This person was like, like one of the gold standard people in the space. And I had gotten to over a couple of days watch them and I was like, this person really knows what they're doing with their diabetes. But public facing it was a lot of like, woe is me and isn't this hard and blah, blah, blah. And I was like, oh, you understand this one way, but you talk about it another way. And I did at some point say to them, like, why don't you talk about it more like this? And so I'm not getting involved in that. Oh yeah. And those same people told me I can't do what I'm doing. And I've complained about it enough. I don't want to Complain about it again. But when I started doing this, I got pulled aside by people who were like, you can't tell people how you manage your daughter's diabetes. And I was like, why not? I was like, it's just what we do. And they're like, yeah, you're going to hurt someone.
- [46:09]
B
It's like having a conversation with somebody you run into at the coffee shop. Right. Who wants to tell you about how they manage the exterior of their vehicle. Well, you know what?
- [46:20]
A
If you want, Jenny, they can't see the big picture. I'm just telling you. Okay.
- [46:23]
B
Yeah, yeah. I don't. You know, and what you were talking about as well, I think you were seeing somebody as the front face of. Of, like, what they were spilling out into the community, but you also saw behind the scenes the fact that they were doing something different on a personal level.
- [46:44]
A
Yeah.
- [46:45]
B
When I went into this field, specifically, I thought about eons ago when my parents got married, my dad was a smoker. My dad went to his primary care doctor and his doctor told him to stop smoking, that it was going to be detrimental. This was obviously at the point that that was coming to be breaking news. Right? Breaking news. And so, you know, he goes home thinking about this, blah, blah, blah, whatever. And out in public, my dad sees his doctor smoking, and he's like, what the. And I remember that story because when I went into doing something that is so. It has become very visible now, especially, I don't want to tell someone one thing and not do it in my own life. I don't think that's fair.
- [47:40]
A
Yeah.
- [47:41]
B
I think that if you put something out there, then you should absolutely hold that as something that's also important for the value of your own life. And I think that it's just being truthful, in my opinion.
- [47:56]
A
I've said a thousand times. I don't know how I was supposed to know all this and then just not tell anybody about it.
- [48:03]
B
Pretend.
- [48:04]
A
Yeah. It was ridiculous. That person was having great outcomes and was, you know, really on the ball. And then when they talked to people, it was always like, oh, I know it's hard. It's okay. And yo, 250, you're fine. Like, I'm not saying your blood sugar might not go to 250 once in a while. I'm saying don't set that in people's minds as expectation. Like, it's okay to say this is going to go wrong sometimes, but here's our goal. Like, there's. And if you don't make the goal, it's not a failure. It's just like, don't act like that's not the standard we're looking at.
- [48:36]
B
And noting that the goal can shift. Sure. Right.
- [48:39]
A
Yeah.
- [48:39]
B
You. You have somebody who starts with an A1C of 8.5, and you say, well, the initial goal is 7.5, but this is a moving goal. Eventually we want to get down here, and eventually we want to have an average more around this. Eventually. We don't want your. Your numbers to look like the Rocky Mountains. We want it to be a little smoother. Eventually. Eventually. And they are. They're baby steps for some people.
- [49:04]
A
Other people.
- [49:05]
B
No, not at all. And some people gather all the information you want and they apply it and they go home and they change everything.
- [49:10]
A
I get those notes. Those notes are crazy great.
- [49:13]
B
Yeah, yeah, fantastic. But you have to have. Also from a clinical standpoint, you have to have the vision of, where could somebody get to if I just give them this little nibble of information that could help right now.
- [49:25]
A
Right. But I've spoken to clinicians who will tell you that there are people that come into their office that they don't even try to talk to because they've decided ahead of time they're not going to figure it out. I think I've had a conversation with somebody with an IQ from like, 80 up to 170, and they all have the same concerns. They all have the same roadblocks to understanding. And there's. And by the way, I use the same language to get them all to a place where they can figure it out. I have an example right now that I'm incredibly proud of, but I won't. Like, I don't want to embarrass anybody, but there's a person listening to this podcast right now that really is limited, and they're still doing well for themselves. And so everyone gets to know what happens when the island burns down. It's up to them what they do with it. It's not up to you as to whether or not they die without ever having fought for themselves.
- [50:14]
B
That's how I feel also, what they can use. Right, right.
- [50:18]
A
Don't stop them from. I can't get a C peptide test until. What was it? And so I can't have a. Or I can't. Like, that's insurance. Like, don't.
- [50:26]
B
100.
- [50:27]
A
Yeah, yeah, yeah. Don't. I mean, don't try to pretend like that's some sort of rule. There are so many rules around life and diabetes, more specifically, that have nothing to do with anything. And I Try so hard. Like, you know, I. Like, I'll be like, oh, it's the pot roast story about the short pan. I'm trying just trying to get you to think, like, oh, maybe there's no reason I have to do this, right?
- [50:49]
B
My pan is big enough. I don't have to cut the ends off anymore.
- [50:52]
A
I get a bigger pan. Like, how about I do something for myself? There's no. And listen, some of you are rule followers and God bless you. I don't know what your illness is, okay? I was like, but, like, I'm not some crazy podcast. You guys have been listening to me long enough now. This just seems like common sense to me. I'm not saying you all need to be on a jlp. I'm not saying you all need to be doing anything. I'm saying, like, don't limit yourself to me. I've been having the same conversation about thyroid for eight years. That the amount of people who are not medicated well for their thyroids and how horrible it's impacting their lives is unconscionable. Like, it's so simple to figure out. And still. I talked to a woman the other day, Jenny. I said, list all your issues. She listed them. She got done. I went, you have graves. She goes, well, no, they said that my test is like 0.1 or something on the wrong. I'm like, no, you have graves.
- [51:42]
B
Please find a good clinician who, when.
- [51:44]
A
A goiter pops out of the side of her head or her eyes fly forward, they'll go, she might have graves. Great. All right, listen. Go fight for yourselves. Stop it. Jenny. Thank you. Of course, I'm all upset now. My Diabetes Pro Tip series is about cutting through the clutter of diabetes management to give you the straightforward, practical insights that truly make a difference. This series is all about mastering the fundamentals, whether it's the basics of insulin dosing adjustments or everyday management strategies that will empower you to take control. I'm joined by Jenny Smith, who is a diabetes educator with over 35 years of personal experience. And we break down complex concepts into simple, actionable tips. The Diabetes Pro Tip series runs between episode 1000 and 1025 in your podcast player, or you can listen to it@juiceboxpodcast.com by going up into the menu. You okay? Well, here we are at the end of the episode. You're still with me. Thank you. I really do appreciate that. What else could you do for me? Why don't you tell a friend about the show or leave a five star review Maybe you could make sure you're following or subscribed in your podcast app. Go to YouTube and follow me. Or Instagram TikTok. Oh gosh. Here's one. Make sure you're following the podcast in the private Facebook group as as well as the public Facebook page. You don't want to miss please. Do you not know about the private group? You have to join the private group. As of this recording, it has 74,000 members. They're active, talking about diabetes, whatever you need to know. There's a conversation happening in there right now, and I'm there all the time. Tag me. I'll say hi. The Juice Box Podcast is edited by Wrong Way Recording wrongwayrecording. Com. If you'd like your podcast to sound as good as mine, check out Rob at wrongwayrecording. Com.