Ologies with Alie Ward - Diabetology (BLOOD SUGAR) Part 2 Encore with Mike Natter

Episode Date: August 15, 2023

Wrapping up our Diabetology 2 parter encore, diabetic diabetologist and wonderful person Dr. Mike Natter, MD is back with a little introduction covering some stuff that wasn't on the radar back in 2019, like what's the deal with this Ozempic stuff you've heard about, and then Natter from the past goes on  to answer all of your questions about blood sugar, the cost of insulin, pancreas transplants, keto, glucagon, how exercise can save your life, his most meaningful interactions with patients, pudding theft, and the best place to cry at work. Also: why you should always keep frosting in your purse.This episode is swear-free and okay for all ages, and a bleeped version of Diabetology Part 1 can be found at this link.Follow Dr. Mike Natter on Instagram and TwitterA donation went to JDRFMore episode sources and linksSmologies (short, classroom-safe) episodesSponsors of OlogiesTranscripts and bleeped episodesBecome a patron of Ologies for as little as a buck a monthOlogiesMerch.com has hats, shirts, masks, totes!Follow @Ologies on Twitter and InstagramFollow @AlieWard on Twitter and InstagramSound editing by Jarrett Sleeper of MindJam Media & Steven Ray MorrisTranscripts by Emily White of The WordaryWebsite by Kelly R. DwyerTheme song by Nick Thorburn

Oh hey, it's still your broken pancreas. And unfortunately I'm still not Alley Ward. But I am Mike Natter, happy to introduce round two of Diapetology. This again was filmed back in 2019. So things have changed a little bit. Here we are answering and talking about some questions from the Patreon page for allergies. And I did want to update a couple of quick things. We didn't talk at all in this episode

about GLP1 receptor agonist. These are things like ozempic and wigovii and manjara. And they've made a big splash right now, especially now in the diabetes world and the weight loss world. And I have to say I am using a lot of them with my patients, I am seeing a lot of benefit from them. But like every medication, there's indications

and there's always side effects and adverse events. So how do these things work? Well, GLP1 stands for glucagon like peptide one. Monjaro is actually two in one. It's GLP1 and GIP gastric inhibitory peptide. And our bodies make these water-known as incretens naturally from our small intestine. Once released into the bloodstream,

they talk to the pancreas, they talk to the liver, they talk to the receptors, and they make the body more prime to make insulin and be more receptive to that insulin. But they also talk to the part of the brain called the hypothalamus, and it tells the hypothalamus, hey, satiety center get turned on. You are now full.

So mentally you feel full. And it talks to our gastric tract. And the tract is making these kind of parasitaltic movements. It moves at a certain rate. It slows that rate down. So it's slowing that rate down. We're physically full. We're mentally full.

We eat less. One other thing I really wanted to talk about also was the price of insulin that we dive into. While a lot has changed, a lot is still the same. There is a movement now to make the copay for insulin no more than $35 a month, which is fantastic, but I have to tell you that only for folks who are insured. So those underinsured or have no insurance, they're still paying astronomically high prices for insulin and this really needs to change. Well anyway, I do hope you enjoy the encore of Diapetology Part 2. Allie, we miss you, we are thinking of you and we hope you feel better soon.

We all love you and I hope you guys all enjoy this second encore dropping of Diapetology. Be good. Oh, hey, it's still your friend who looks at listings of houses she has no intention to buy. Ali Ward back with another episode of Oligis. Part two of a two-parter. So the book end on the readers.

And I'm gonna keep this intro short. I'll keep it sweet. But we're back with part two of Diapetology in which we address all kinds of questions that patrons had about blood sugar and insulin and pancreatic matters. So if you haven't heard part one first, I am hereby inviting you and all of your glucose molecules to hop over to that first for a primer. And also, do you have little ones or grandparents, or perhaps curse a verse in your life who need to learn more about their blood sugar? Well, after I put up the first half, I thought, what if some people need to listen with kids who have diabetes?

So I've reigned in my potty mouth for this part two. And I uploaded a kid friendly and swear free version of Diabitology Part One of last weeks. It's on my website at alleword.com slashologies, slash diabitology, Jared worked extra hours, get that up quickly. There's a link just right in the episode show notes to take you right there in case you need to listen with little kiddos.

So you're welcome. Thank you to everyone on Patreon who supports a show. It makes things like that possible for everyone else. show notes to take you right there in case you need to listen with little kiddos. So you're welcome. Thank you to everyone on Patreon who supports a show. It makes things like that possible for everyone else. Thanks to everyone wearing gear from oligeesmarch.com. Thanks of course to everyone making sure you're subscribed and for rating the show. And of course reviewing, I read all your notes like a creep. And this week, thank you to Queets on Fudge, who says, we've ever felt afraid of the world

or overwhelmed by any facet of it. Listen, we fear the unknown, but allergies consistently brings me the piece of knowledge and the gift of regular belly laughs. So hot damn, thank you, Quiz on Fudge. And also, Juniper, do you drop special hugs to you and your fam? Okay, onward.

Diabetes and other such sugary stuff. So after our interview for part one, we had to dash off to a friend's dinner. So once he was back in New York, we recorded the second half. And it happened to be on World Diabetes Day of all things. And that day, thisologist had used his lunch break to speak into a megaphone on Wall Street,

advocating for a change in policy to make insulin more affordable. And then he went back to the hospital, saved some frickin' lives, finished up his shift, and hopped on a video chat to answer all of your Patreon questions. So sit tight for a healthy serving of answers from physician, type one diabetic,

and deeply lovely person, Dr. Mike Natter, MD. [♪ OUTRO MUSIC PLAYING [♪ Are you ready to dive into just a Patreon question? Oh my god, I'm so excited. I know, I sound too excited. Okay, well, let's start with some that aren't super specific first. Okay. For example, there's going to be a lot of scrolling, so just part out. You scroll as you're at your leisure.

Okay. So, as I pulled up your questions, Dr. Netter mentioned to say hi to editor Steven Ray Morris and Jared Sleeper and how he wanted to hang out with him, IRL. And I love watching cool dudes make pals. So I suggested that they go kick it without me. Go get some pudding. Yeah, I had some pudding in hospital today. Actually, ate, well, I ate it off the tray of my patient who wasn't eating.

I was dying. I didn't miss lunch today because I went to give that speech and I was like, I don't want this point. I was like, I'm gonna eat that. Am I allowed to put that in? Is that illegal? That's fine. I asked his permission. And how was Dr. Nader's blood glucose on this day? Well, with all that running around, it was low. It was dipping into the 60s. And the 60s, at least in blood sugar terms, are not groovy. Did you find that stress definitely impacted? It does impact it.

For most people, including myself, stress usually makes it go high. Because when you're stressed out, you activate your HPA axis. Oh my God, we can do one of these like harken back to your neurobiology talks with that wonderful woman. His name is escaping me. Oh my God, Dr. Dillworth is awesome. I love her.

So, yeah. So when you have your hypothalamic pituitary adrenal axis kicked in, you are spitting out, well, from your hypothalamus, your hypothalamus, like, like, fight or flight. And then it goes to the pituitary, specifically the anterior pituitary, because the pituitary is the master entrance and gland.

And in terms of this fight or flight, you are anterior pituitary, spitting out ACTH specifically. And that guy goes downstairs, so there's like this little beret that sits on top of your kidneys called the adrenal gland. And the beret has like a crusty out part called the cortex, and then like a gooey center called the medulla, and the gooey center secretes adrenaline, but we call it either no-opinephyr-aprinephyr-im. And then those two hormones spin around the body and make everything go super fast. So they make your heart go, bop, bop, bop, bop, bop, bop, and they make your blood flow

and all that stuff. But the other thing to do is they kind of kick in a lot of glycogen breakdown. Glycogen is the storage form of sugar, and your liver and your skeletal muscle have mostly liver. And so then you start breaking the glycogen down, which turns into glucose. And when glucose is basically sugar, and that goes into your blood chain.

And for you, if you're running away from a bear, great, because it's good for your muscles. For me, if I'm stressed out, I don't have insulin to then take that sugar that's in the blood and put it into the cells. So I go high. So thank you Adrenaline for reaching into our liver and muscles and cracking open that emergency sugar stash.

So just think your body hides glycogen like a snickers in a love compartment and stress essentially screams, bust that sucker open, it's freak out time. And I need to get juiceed up. Anyway, that was inside. We were even putting it inside. No, I loved it. I loved it. And so for you, because you don't have insulin to to escort it into the cells, then it goes high and then it can do damage to tissues. Correct. Correct. A long-term damage. So in the short term, you just feel like hot, sweaty garbage. But Dr. Natter reminds us that in the long term,

there are complications like blood vessel damage that can impact everything from your eyes to your kidneys, to your feet, serious stuff, but you can avoid it or stay on top of it. So let's learn how via your questions. Just flowers wants to know, is it pronounced diabetes? Or diabetes? Yes. Di diabetes or diabetes?

Diabetes or diabetes? I feel like it depends on your mood. I mean, well, for Brimley, we're going with diabetes. Feels good to say diabetes. I say diabetes. Sometimes I call it the beades or affectionately the sugars or the sugars. But it's, you know, however you want to, you know, however you want to do it. Okay, PS, side note.

I always figured a pronunciation popularized by diabetic actor, legend, and human walrus Wilford Brimley must be southern in origin, like some kind of Ozarks lilt. But I just read that it might be less regional and more temporal. So in the post-war 1950s, Americans apparently pronounced it diabetes, and then in the 1970s, alongside wide ties and sideburns, it shifted to diabetes, so Wilford, who was born vintage and has been playing lovable geasers since the 1985 Ripper cocoon, is just saying it old school. But he's a good sport about people getting tattoos of his mustachio face alongside the word Beatis. He retweets body art in his image. And yes,

he has a Twitter. It's at real Wilford. And to patrons who asked about his impact, I'm looking at you, Ruth Anthony, Veronica, McCall Edwards, Anastasem and Jess Flowers, this gentle mocking of his pronunciation has only up the profile of the disease. He's cool with it. And he said about diabetes. I would encourage people, especially people over 50 years old, to be examined to see if they've got diabetes. I would encourage people, especially people over 50 years old, to be examined to see if they've got diabetes. And not to be afraid of it, he says. It's not something that needs to scare you. It's not a death sentence necessarily, but that's up to you. You can

learn about your body, if you just pay attention, and then keep a log of blood glucose tests and carbohydrate intake like I do. And mainly, do not be afraid. The dudes had it for decades and he's going strong. He's 85 right now. So follow the walrus. Shay Little Page says, my dad has type one diabetes and wants to know, what's the highest and lowest blood sugar ever recorded

in a living person? He promises not to use this information on the edge. Do we have any idea? Like, yours when you were hospitalized was exactly on. I have to admit ignorance. I don't know what the record holder is for highest and lowest. The problem with lowest is that, you know, someone can technically be like, typically like in the hospital during what's called a code when someone's like kind of actively dying,

we get a lot of labs to see what's going wrong with them. And so we might get a sugar back that's like, you know, in the single digits, but they're technically dead. Oh, man, that's a bummer. So I don't know what the lowest would be that you could still be alive. I mean, I've seen people go into the 20s and then kind of recover. And then the highest, like you said, I think personally, when I was diagnosed, I was 1600, which is just disgustingly high.

And I think at the time, at the hospital, I was diagnosed in a New York city that I held the record, at least in the pediatric ER, for some time, I don't know if that's still the case. It's not a proud record to have, but yeah, I don't know. I've seen some A1C's where I work. So A1C is a three-month average of your blood sugar. Okay.

A normal person's A1C is between like four and like five point five-ish, and that's a percent. And what that really is is it's measuring the glycosolation of your red blood cells. So the sugar is sticky, and so it's gonna stick to your red blood cells, and so you can kind of get an average. And so what that does, and the reason it's every few months is

because your blood cells turn over in about 120 days or so. And so what that does is that kind of gives you an idea what your blood sugars are throughout those last three months. It's kind of like a report card. Here are your grades. So I've seen, so when you have diabetes, you're usually, technically diabetes is an A1C of above 6.5%. So if you're in technically, quote unquote, good control as a diabetic, you're less than 7%.

And, you know, if you're not doing so hot, you're 8% or 9%, even in the tens, it's not good. But I've seen folks in the 19%, 18%, and that kind of correlates to an average blood sugar of like 500 all day. Oh God. I did so many patrons. Kelly King, Heather Denzmore, Dianne, Karen Burnham, Megan Johnson, Andrea Marsh, Ashley Heamer, Shay Little Page, and April Perry. Also, first time question-asker, Amanda Mercer,

who says, is diabetes genetic? My great-grandfather and my grandfather were both diagnosed later in life and I was wondering how much of a chance I happened being diagnosed. So all those people are like, what's the deal? How genetic is it? So it's a really good question and it's not perfectly worked out yet, but the data suggests. So there's obviously there's numerous types of diabetes and there's type one and type

two. And in type one diabetes, it's most commonly thought, like, you know, laymen assume that type one is the genetic kind and type two is because you ate too much crap. And it's actually much more complicated than that. So what the studies are kind of finding out is that in terms of the genetics, there's a stronger genetic component with type two,

surprisingly, then type one. But it's multifactorial, and it's not like an autosomal dominance type thing where you're passing, you know, you're automatically passing on this dominant trait. It's much more complicated. So the data basically pairs out that in type two, if you have a first degree relative, then you just had a higher chance of having type two at some point in your life, not necessarily at all, but it's also environmentally kind of triggered. So there's this saying that I learned in, might have been an undergrad, that genetics will load the gun and environment pulls the trigger.

And so they're kind of intimately involved in type one, and this sucks for me, because I'm a dude, although I don't have kids yet, so maybe it won't be the case, but apparently there's an interesting correlation with type one fathers who have sons have a higher likelihood of getting type one, but there's no sex-linked trait that we know, like it's not a sex-linked trait,

but we just happen to see epidemiologically that type 1 fathers have more of a chance of having a type 1 son. Oh, wow. Did anyone in your family have it that you know of? No, no, no one. I only had it that I know of. The other thing is, type 1 is considered an autoimmune disease.

So autoimmune diseases like to come, they get lonely, they come in clusters and pairs and things. So if you have a first-reality that has any autoimmune disease, it does put you at a slightly higher risk of having an autoimmune disease yourself. There's an interesting demographic or geographic component to in the Netherlands in certain areas in that part of the world, very high predominance of type 1 diabetes. So in part one, we talked about how folks in cold climates and in cold seasons tend to get diagnosed with type 1 more often, but could there be anything else at play like just

bad luck or a witch's curse? Do you think that has anything to do with the hygiene hypothesis and immune systems and autoimmune issues? It's not known. So it's a really interesting theory. And just in case your listeners aren't familiar with it, it's a really fascinating theory. And the idea is that back in the day,

my mom and dad would eat dirt, and they'd roll around in the mud. And anytime you introduce pathogens or any type of kind of foreign invader into your system as a kid, your body then has a chance to have a immune system develop so that it creates plenty of antibodies in defense systems. So the theory is that, you know, us little snowflakes are growing up in this very clean world where you've never put like a twig in your mouth or a bug in your ear. Your immune system has not been trained to be recognizing things that

aren't foreign. Then all of a sudden it starts looking at your own cells as foreign or madeers. So you start having autoimmune auto-meaning self-immune immune system kind of attacking things. It's interesting. I don't know. Yeah. I'm sure in the future we'll know way more about it and think, holy smokes, we should have been eating more turnips straight from the ground. Oh, I was thinking just like worms and dirt, but turnips too. So many people had pre-diabetic questions like Laura Crompens, Dominic Deck, Christian, Bettner, and Rachel Ames. Lauren Cruppens wants to know, at what point does a pre-diabetic become a diabetic

and Dominica wanted to know, how concerned should you be if you can be considered pre-diabetic in terms of how to change your diet? That's a hard question. Ask Ben, in general, pre-diabetes. Yeah, well, let me just put a little crefus in here. So I am a physician, I treat patients, I am a type better, but I cannot give individual medical advice like in this setting. So I will speak in generalities.

Don't do. Okay. So let's first back up. And so, so what is pre-diabetes? And so pre-diabetes, obviously comes, it's like the before diabetes. And what that is is kind of like a little bit of a warning sign. It's like, hey, you're heading in a really not so hot direction. Let's take a good gander what we can possibly do. So what does it mean to be pre-diabetic? So if you go by the guidelines of the A1C that we mentioned before, the hemoglobin A1C, as I mentioned before, a normal range is 4 to 5.6%. So between 5.7 and 6.4% in America, we call that the prediabetic range. Okay. That's most commonly how I, and I think most clinicians, will diagnose a prediabetic. Once you get into the 6.5 and above range, you're technically considered diabetic.

There are other ways to diagnose diabetes. And so for instance, like a fasting blood glucose, so like a finger stick glucose of above 126, is also considered, I think it has to be twice though. I think not just one time, but twice above 26 in a fasting state. I think it's also considered diabetes. Then you can also do like an oral glucose tolerance test where they make you drink this like way too sweet

syrupy liquid and then check your venous blood sugar at different hours to see if you're metabolizing everything and making sure that you're dropping your sugars as they should. But I think the A1C is the most common and easiest way to do so. So once you're in that 5.76 point for a range, you're technically pre-diabetic. And then what you have to do is you have to look at why. And so the first thing I would want to say is, is this pre-diabetes for type 2? Most commonly, that's the case. But if someone's young and otherwise well, or maybe has a family history and just about immunity, or whatever, I'd want to get a couple of lab tests to make sure that they're not actually type one diabetics. Because that's something you can't miss, because they can get very sick, very quick, and you don't

want to miss that. So you might want to get something called an anti-gad 65, or CPEPPID, or an anti-Zinc transporter, and what these are basically kind of markers for auto-immunity amongst insulin or some of the beta cells. And not every type one will be positive for those, but at the very least it's good to screen for them because if they are positive then you know that they are going to be insulin-dependent and or type one. Okay, so to recap, fasting glucose over 126. A hemoglobin A1c, which counts how much sugar is sticking to your blood cells, over 5.7 is pre-diabetic. Over 6.5 is diabetic, but there are also tests to see if your hyperactive

immune system is helping you too much and accidentally killing the insulin or beta cells in your pancreas. So Dr. Netter has also had to counsel patients who might be most statistically at risk for type 2. And as a diabetic diabetologist, he wants to help them avoid the beast of the betas. Alternatively, if a patient has is overweight a little bit older, you know, has first-releas with type 2 diabetes is has what's called the metabolic syndrome where a large waist size overweight obese usually hypertensive hyperlipidemic or high cholesterol. Usually these are folks that are going to be type 2. And so the first thing to do is you could say we need to lose weight But that's not good enough to tell someone lose weight. You have to talk to them and say, okay, let's get granular here

What are you waiting for breakfast? What are you for, launch? What are you snacking on? How can we intervene in small steps? How can we get you exercising? And then if they are morbidly obese and they can't lose the weight, it's actually been found that weight loss surgery can halt and in many cases reverse type 2 diabetes. Wow. Why? how is that? How does that happen? So there's a lot of theories. And I don't, I think if someone tells you they know how, I think they're lying, because I don't think we know 100%.

So part of it certainly has to do with the losing of weight for sure. And then I think part of it has to do with the brain gut connection. I think there's a lot of feedback and connections that are happening there. And I think we's a lot of feedback and connections that are happening there. And I think we're still kind of not quite there in understanding all of it. But I mean, the easy low hanging fruit is, well, you just lost 100 pounds. And so therefore,

it's, you know, you've taken off all that weight. It's going to be easier for you to kind of regulate the glucose. But it kind of gets into the idea of the pathogenesis of type two. And we all assumed, and layman in the copy of the culture, it's thought that, well, you ate too much candy, you ate too much carbohydrates. But we're learning actually very recently that it has less to do, at least the pathogenesis, the etiology, the beginning stages of type two,

or why we get it. Have a little bit less to do with the carbohydrates up front and more to do with the saturated fats and the processed meats and all of the things that are processed and deep fried and high saturated fats and meats. And what's happening is those meats are causing or those chemicals are causing what's called a lipotoxicity, lipomeaning fat and toxicity meaning toxic. And we're getting this kind of accumulation or deposition of this adipose tissue in places that shouldn't be like the liver, like the pancreas, like the skeletal muscle.

And it's gumming up the works. It's causing mitochondrial dysfunction and oxidative stress and all these fancy words for like that. Okay. And that's going to in turn cause an insulin resistance picture. And what insulin resistance essentially is, it's kind of three categories. It's a dysregulation of glucoregulation. It's an impaired post-prandial absorption. So post-prandial post-meaning after,

prandial-meaning meal, so post-prangial absorption of the sugar into the skeletal muscle, and then impaired pancreatic glucoregulation of the beta cells. So, yes, those saturated fats and the lipotoxicity are messing up how your food is absorbed and how insulin, the hormonal key that lets sugar out of the blood and into the cells,

is able to work in the locks of those cells. But why do fats fudge up the works? Why are they such glucose coblants? So all of this is happening because of inflammation, lipotoxicity, and it spirals into this cycle of inflammation and high blood sugar, less insulin secretion, less insulin sensitivity to the secretion, and you kind of spiral into type two. So eating like a deep fried hot dog with AOLI,

it's bad idea. Well, it's delicious, but. So, yeah, but no, but you know, it's funny because like, you know, I think about this a lot, because I'm actually currently I'm on an oncology rotation in the hospital, I see a lot of terrible stuff, and it makes me think about kind of the quality of life. And I think everything in moderation is good because so you don't get typed to your

diabetes, you live to 120, but like maybe you didn't really live. And you know, if you eat a hot dog with a oily once a month, enjoy it, you know, do your thing. But maybe the rest of the month you're eating your salads, you know, it's kind of like a given to take So imagine your pancreas intense Negotiations with your mouth offering to trade like 4,000 salads for one Luther burger which is a dish I just learned about when I googled what's the least healthy thing you can eat and the Luther burger side note

It's named for R&B legend, Luther Vandross, who loved these cheeseburgers squished between two crispy cream donuts. Also, not to make this too real, but diabetes ran in the Vandross family and Luther himself perished from a stroke related to diabetes at the very young age of 54. So when Natter says avoiding insulin resistance and type two is worth the salad balance, he means it. What the hell is insulin resistance? A ton of people had this question, including shame or fee, Madeleine Winter, Rose Presby,

Samantha Galbraith, Moses BB, Lynn Perry, Rose Presby, said, can you explain insulin resistance and how it may differ between type one and type two? What the hell is it? There's insulin receptors that are typically found on adipose tissue like fat cells and skeletal muscle in a few other places. And when the bakery is with the beta cells of the bakery

is to create insulin in response to an elevation blood sugar. Those little insulin pieces that kind of see it, they're kind of like keys, I'm oversimplifying with they're kind of like keys, and the receptors on the adipose and the skeletal muscle kind of like the locks, they go in and they unlock the doors of those cells and the glucose goes in, everything is wonderful.

So insulin resistance or insulin sensitivity is a broken lock. And we think this is because of this fat deposition and this mitochondrial dysfunction and his oxytress that a lot of people lump into the term lipotoxicity. Again, type one, you're out of insulin which acts like a key. So you inject yourself with keys to open the locks on your cells and let sugar in. Now, type two, your locks are wonky. And when it comes to advising a patient and it comes to adipose tissue and BMI, there

are such a difference between weight and an unhealthy weight. Where do you as a doctor advise people in a way that isn't like moral or judgmental or that actually addresses the physical problem instead of something that we're used to being aesthetic or a certain aesthetic is frowned upon. You know what I mean? Yes, I think that's an excellent question. I think medicine is getting more precision medicine or precise and individual. You can't just lump someone into one size fits all anymore and medicine, that's very true.

And BMI is a great example of how BMI, I mean, the way we calculate BMI is very crude, you know, basically just like it's someone's height in their weight. And the best example of how that doesn't fit into why it makes sense is because if you got a very fit bodybuilder with a big muscle mass, who's maybe not that tall, they would technically be morbidly obese based on a BMI, and yet they have no body fat. So you're not taking into account a lot of factors, but those folks decide BMI can be helpful in steering a conversation because sometimes you need the objective data to say, you can always tie it back in medicine to, this is not reflective of a judgment, it's not reflective of an aesthetic. This is me being concerned about what's going on inside.

We know where you carry the fat is also important. Central adiposity, so the beer belly is far more dangerous than carrying your fat on your butt or your thighs. That's because the central adiposity is actually a surrogate marker for the fat that's inside. And that is when you have your lipotoxicity, your inflammation, your metabolic syndrome. And we know from years of data and from just seeing patients even in the short term,

that those folks that fall into those categories have far higher risk of heart attack, strokes, hypertension, diabetes, and all of those, that all the horrible comorbidities that bring with those things, especially diabetes. I've seen terrible things from that. And so I'm very keen to help my folks lose the weight, but not for any of the reason then,

because, and I tell them, because I want them to live longer and healthier and feel good. Mm-hmm. A lot of folks actually asked about exercise and type one and type two. Michelle Phillips, Merrill Stark, Evan Munro, Elise asked, what is the mechanism that lowers

the blood sugar of type one diabetics when they exercise without taking exogenous insulin? So how does exercise and blood sugar work? It's a very good question, very complicated physiology. And my understanding of it is a little bit crude. I don't know if it's been fully worked out. But the basic idea is that when you're exercising, you're using skeletal muscle.

And so typically, we can get really granular. So typically, if there's a rising blood glucose, the beta cell sense that they secrete their insulin, the insulin sits into the insulin receptor, and it actually stimulates something called a glute-4 transporter to come intercalate into a membrane and ferry the glucose across intracellularly. Okay. If you're like, huh? What?

Just think of glute-4 as the friend who gets a text from insulin. And insulin is like, hey, can you get my cousin glucose into this part of your what? And glute four shows up the door and is like, huh, yeah, come in, glucose. You seem cool. Now a side note, skeletal muscles and adipose or fat tissue needs a bunch of glucose. And hence needs insulin to text about getting the glucose in. But in type one, it's kind of like your phone died,

but your phone is your beta cells. Insulin can't text to get glucose in, but in type two, insulin is like texting and texting, but the cell is like, I don't wanna let more glucose in. I'm just over it. Also, if you use this flimsy metaphor on any entrance exams and you don't get in, I'm truly sorry. I don't know if it's been worked out or not that the Glute 4 transporter actually still

intercalates in the membrane in the absence of insulin. Or more likely is what happens is because you're using skeletal muscle while you're exercising and there's a higher demand of glucose because you need the ATP because once the glucose comes into the cell you go through all the glycolysis, you break things down so you get ATP which is kind of like the currency of the cell to have energy. There's a need for that energy. Therefore the insulin receptors may just be much more sensitive, and therefore whatever circulating insulin, however little it is, is just going to stimulate the glucore receptors.

That's more likely what's going on. So as I don't know if it's necessarily the absence of insulin, it might just be in the presence of very little insulin, you're going to get a robust response of those receptors. So when you exercise, the glucose party in your cells thins out. So when insulin says, hey, get my cousin into this party. The cells are really responsive. They're like, heck yeah, this party's dead, man. We'll let him in, which is why moving our booties is great for staying healthy and also just for keeping parties lively. Okay, so does it kind of retrain your body in terms of how it handles insulin?

I took a question. I mean, I think retraining would imply that then in the absence of exercise, you're just going to always be sensitive. And I think if you exercise enough, then yes, your insulin requirement, your exogenous insulin, oh, we should talk about that. Exogenous means the stuff you're injecting. Indogenous means the stuff you make on your own, just in case folks don't know. So people that are very fit, that are marathon runners and the extras all the time, they're insulin requirements are probably a fraction of what, someone who just sits in the couch all day would be as a type one diabetic, or even as a type two. But yeah, I think in that sense, you can train it, but I think if you ran a mile today, next week, I don't think you're gonna need less insulin.

The next day, you might, but not next week. Let's talk about hypoglycemia. Let's do it. Jordan wants to know, what is the deal with reactive hypoglycemia? And Christian Shoei says, does hypoglycemia mean you'll get diabetes later in life asking for me? I'm also asking for me,

as someone with reactive hypoglycemia, I've taken that test, that five-hour insulin test, and I was at show. So, like, started at like 70, rose to maybe 90, 110, and then crashed to 40, and I was like shaking, crying. Wow, it's so pretty. Yeah, it was not good. So in reactive hypoglycemia,

when you have sugar or carbs, you put out too much insulin and then too much glucose floods into your cells, leaving the glucose party in your bloodstream a little sleepy, which is why you can feel sleepy. Or cranky, or have blurry vision, or have a ferocious craving for more carbs, it's not your fault.

I'm talking to myself here. So what do you do, doc? So I think my understanding for treatment is a lot of frequent, small meals that are made up primarily of complex carbohydrates, the quinoa, the brown rice, those kinds of things, but mixing in vegetables, fiber, proteins, and good fats, like avocado, and that kind of stuff. Oh, I love a mix of it. I can stare at it for hours. Okay, let's talk about how babies can ruin your blood sugar.

What about gestational diabetes? Let's say you're cooking a baby, like Evan Jude, Marin Mossman, Jessica Chamberlain, Michelle Lee, all wants to know, like Evan Jude asks, Mossman, Jessica Chamberlain, Michelle Lee, all wants to know, like Evan Jude asks, what causes gestational diabetes? How is it transient while regular diabetes is not? Justational diabetes is often kind of co-managed by a lot of the OB-GYNs as well as endocrinitis.

It's super important that when someone has gestational or just type one diabetes while they're pregnant to keep their blood sugars in extremely, extremely tight control because any kind of unfortunate, higher low blood sugars going to have potential really bad impacts on the child, significant if the blood sugars are really out of whack. So the endocrinologist and the OBGYNs tend to be very on top of their diabetic pregnant ladies. But the understanding that I have of kind of why this is going on is because the placenta is a mofo. It spits out just like so much stuff, hormonal stuff, one of which I think is called placental

growth hormone called LPN. And it just, it creates a really hyperglycemic state in the mom and it makes it very difficult for insulin sensitivity, constantly having sugar around on the stream because the idea is that my theory or my understanding is that hypol or low blood sugar for anyone in the acute setting is far more dangerous than a little bit of hyperglycemia.

So I think the idea that evolutionarily, you never want the child to be without a source of glucose. So it's really scary if the mom were to become hypoglycemic. So I think that's kind of maybe why these hormones are being secreted in kind of wreaking havoc. It's not understood exactly why some women are more prone to getting gestational than others. If you are diagnosed with gestational diabetes, that may be transient, but you are at a higher, significantly higher risk of

getting type 2 diabetes later in life. Ooh, okay. So if you are a person carrying a baby in your body, listen to your doctor. Justational diabetes can become unhealthy for you and your little one. And if that is not incentive enough, untreated, it may lead to just a real wapper of a huge baby that you have to push out of your groin. So no thank you. Also, as long as we're talking about children's,

each week we donate to a cause of theologist using, and for part two this week, Dr. Natter would like a donation to go to jdrf.org, formerly known as the Juvenile Diabetes Research Foundation, which works with researchers from all over the world to fund more than 100 grants each year to reach more new breakthroughs, and their mission is very simple,

to find a cure for type 1 diabetes. So thank you, Dr. Natter, for pointing us in that direction. And allergies will be making a donation in your name for that. And thank you to sponsors of the show that make that donation possible. You may be hearing about them right now. Okay, let's get back to chewing the fat. What about chewing some fat? A ton of people, not a ton, handful of people.

CRISPR and Michelle Phillips wanted to know about the keto diet and if it's good for treating diabetes. That's a tough one. You can go on any blog and anecdotally there's going to be people that will swear by that. I think right now, in terms of the data, if I'm going to speak kind of from the empirical side, or like the evidence-based side, I think the plant-based diet is far better, not only for diabetics, but I think for everyone. I think any time you do an extreme diet where you kind of cut out one major food group, I do think that's dangerous.

I'm not a big proponent of that. I think it's also kind of difficult to sustain doing that. If you do a really strict keto diet, you end up eating or the the actins type diet or the paleo diet. You end up kind of eating a lot of meats and a lot of saturated fats. And if the data that's come out recently holds true, then you could actually be predisposing yourself to type 2 diabetes. So I think a plant-based diet, you know, if it grows from the ground, you know, greens, you want salads, like all of beans and lentils. And those things seem to have shown again and again that they're

good for not only your diabetic health but for cardiovascular health and stroke prevention and weight loss and overall health here. It's also really healthy for animals. I agree. Actually speaking of animal diabetes, Sid, Derek Allen, Alice Mouse, and Tara McGee asked, is there diabetes in cats and dogs? And Tara McNeigh wants to know how do diabetes service dogs work? What are they smelling? What's happening? Yes, dogs and cats can get diabetes. I am not a vet, so I don't know the details about it. I've heard about a lot of fat cats who get

diabetes. I haven't heard of too many dogs getting diabetes, and ironically my sister's poor dog was diagnosed with diabetes, so she's given him a little influence on that poor guy. Oh, both of you guys. Yeah, it's predatory. Diabetic alert dogs are awesome. Have you seen these?

I've heard about them, yeah. Oh my God, they're so cool. I want to get one really bad, but I live in New York, so my apartment is the size of a shoe box. So I probably wouldn't work out. I'm not entirely sure what they, they're trained, it's a sense. My best guess is dogs have these phenomenal olfactory bulbs

and they're just so amazing at what they can pick up that is outside the realm of what we can sense. And I think your breath changes odor when your blood sugar is either very higher, very low. I know for a fact that when you go into what's called diabetic ketoacidosis, which means like you're at the very other end, you're very, very high and you're going into like a coma state. Your body is breaking down because there's no insulin. Your body starts breaking down alternate forms of fuel, which typically is fats and lipids. And when those lipids are broken

down, the byproducts are acidic called ketones, specifically something called beta hydroxybutyrate and acetone. And your blood, which likes to live at a very neutral pH, 7.4, with all of these ketone bodies being dumped into the blood, it drops the pH down to much less than that. So you become acidic or acid-demic, which is bad, and you don't like that. And when your body or your blood is acid-demic, your enzymes, your proteins,

denature, things don't work, you can die. Oh, no, nothing, you... So your body tries to compensate by blowing off the acid through your breath. So you breathe these, what's called, cruise malbri, then you breathe very rapidly, and shallow, and you're trying to literally

exhale a sea to acetone. And a sea to acetone is nail polish remover. And so it smells like sweet. They call it the sweet breath, but it's like a fruity sweetness, but it's nail polish remover. So, I would imagine, you know, humans can smell this. I imagine that if you're even just a little bit high, maybe your something is changed in your biology where you're breathing something that might be different, whether a little lower,

a little high, maybe that's what there's knowing. That's my best guess. I don't really know. Okay. Two things. So, your nose has about five million scent receptors, but dogs have up to 60 times that. And they use those old factory talents to gather info about their environment

and their friends' butts. Now what are dads smelling when they're protecting their owners, though? Scientists are totally sure. It might be those ketones, or they may also be observing these subtle body cues like sweating or shaking, but in a 2016 University of Cambridge study, they found that hypoglycemic patients exhaled two times the amount of this compound called isoprene, which means that a low sugar breathalyzer could be the works in the future.

So will we still need dads? Well, okay. Studies have shown that diabetic-alert dogs, which can cost up to 20 Gs, fully trained, were slower and less reliable than a continuous glucose monitor, like Dr. Nader has. But patients who had diabetic-service dogs were overwhelmingly happy with the help that they provided. Even if it means some false positives and being nudged awake when their glucose was actually fine. So CGMs or continuous glucose monitors are cheaper,

more reliable, they don't require belly rubs. But on the downside, they are less fuzzy, which sucks. What about artificial sweeteners in insulin? Uh, Karen Malines, Lynn Perry, and Todd Peterson asked this, can you explain the dangers of diet soda? Todd Peterson said, I heard that Aspartane Malines grew with your insulin levels, and Karen Malines wants to know about stevia and artificial sweeteners, what that doodier insulin response, what's the deal with that? Well, first of all, sodas, diet or regular, both really terrible for you.

There's a lot of like phosphates and carbonation and all of that stuff in the dyes and the synthetic stuff. It's just bad for you. It's bad for your bones. It's just bad for everything. There's a lot of just not goodness in there. You deserve a cold, refreshing can of not goodness. So the most kind of interesting way that people have been hypothesizing that it can cause

harm is that most people drink diet so does because they're trying to be fit. They don't want it, the calories. So one theory is that when your tongue tastes the sweetness, it then kind of predisposes your brain to expect the caloric impact of that. And so when you end up just like pooping all of that out and not actually getting the caloric impact, your brain's like, wait, hey, I need more. I didn't get the calorie. So give me more, give me more, give me more. And so then you end up becoming kind of addicted

or looking for more sweetness. So you either continue to drink the gallons of diacoch, or you go searching for that donut that you told yourself you wouldn't have because you are not craving it. I think there's something interesting about that. I don't know if that's panned out in the literature or not, so that's one theory.

In terms of what it does to your insulin and glucose, my understanding is that it actually shouldn't have too much of an impact at all. If you know, in terms of diabetics, I got to, it's technically you shouldn't raise your blood sugar, things that raise your blood sugar or typically carbohydrates or you know, pure sugars.

So those technically don't have any and it shouldn't necessarily affect your blood sugars. Okay, this one is tricky, folks, because few studies have been done, and it's hard to separate the metabolic factors that cause folks to drink diet soda, like a predisposition to weight gain, with the effects of the diet soda.

And there was one in 2017, Oklahoma State Medical Association paper that cited a meta-analysis of a bunch of other studies and other than causing low blood sugar from the big bamboozle of zero-carb sweetness, nobody knows what the heck artificial sweeteners do to blood sugar. Now, what if you don't have blood sugar ish, but somebody around you does? Lately, Bradley, Madeline Dunkel, Hannah M. Childers, wanted to know what can you do if someone's in diabetic shock, if someone's hyperglycymic or hyperglycymic, what if there's a bystander, a loved one, how can you support them, what can you do in an emergency?

That's a really good question. I love diabetes awareness and obviously just saving lives is always a good thing. So there's two real diabetic emergencies and this is where it can get kind of tricky and you have to kind of tease out which one's which. So first and foremost, do call 911. That is always, always, always the first thing you do. Call 911. My friend's diabetic, he's unresponsive and you get the ambulance. That's always the first thing.

The next thing you can do is you have to, if you know that their blood sugar is low, is either going to be very low, or it's going to be very high. So if you know which one that is, basically, you know, if you happen to be with that person, and they tell you, I don't feel good, I think I'm low, and then they're not responsive, then we can say, okay, they're low. And what you would do in that case is you never, ever, ever want to like, you know, pour juice down their mouth or any of that. And so there's really two things.

Most diabetics have something with them called a glucagon kit. And what glucagon is, it kind of goes back to what we talked about in the pancreas. So the pancreas is this magical organ that wears two hats. That wears the endocrine hat and the exocrine hat. Those exocrine cells don't make insulin, but they make acids and enzymes that break down your salad or Luther burger. But then there's these little islands of cells that make hormones.

And so there's alpha cells, beta cells, delta cells, gamma cells. I think that's right. The alpha cells are making glucagon. Glucagon is a hormone that is kind of like the opposite, the yin to the yang of insulin. So, if you're not eating, if you're fasting and you are in fight or flight or you're starving, your glucagon is going to be very active. And what that's doing is it's telling the stores of sugar in your body to say, hey, let's release these and spit some glucose into the bloodstream because we need it now. And that usually happens in the liver. So if you're going to give exogenous

glucagon, you're trying to kind of utilize and mobilize that sugar that's already in the body. And so you can drop the syringe to glucagon and give it to that person. It's kind of difficult because you're giving them a pretty big I am or intramuscular injection. And some people, not a big fan of the needles, I get it, it might be tricky, they might not have the kid on them. The next best thing, and probably even better, if you're a bystander, is cake frosting. Pardon?

Okay. If you can take some cake frosting and you put it on your finger, and then you put it on the mucosal side inside the cheek, and you just rub it into their cheek. So that mucosal layer actually is very... you can really absorb a lot of sugar that way, and that might just be enough to kind of keep them alive until the paramedics come,

and that could save someone's life. Now, I need to preface this. This is only if you're pretty sure that this person is low or high-bokelycemic low. If by chance they've passed out because they have DKA or because they have super high blood sugar and you're certain of that, then again, you should not ever really administer insulin to someone in that case.

You should just get them to the emergency room as fast as possible. And now let's talk about how you're bionic. You have a pump, you have a meter, you're essentially you have an external pancreas. And Jesse Zoe Robertson, Merrill Stark-Tal, Alise and Robert Born, all had questions about monitors and pumps.

What are your thoughts on it? Yes, so I was diagnosed in 1984. In 1994, the technology for diabetes at that time was like super 80s, like very archaic. I had this, what looked like a brick of a glue cometer. So when you're diabetic, you have to do a few things. You have to take your insulin and you have to prick your finger and test your blood sugar on these little meters.

And at the time when I was diagnosed, the meter was not little, I was kind of like the size of a game boy, like an old school game boy. The meter was not little, so it was kind of like the size of a Game Boy, like an old school Game Boy. Okay. And it took like a decent amount of blood from your finger and it took a full 60 seconds to count down and tell you where you were. And the thing was pretty big.

In addition to that, you had vials of insulin and you needed to have insulin syringes and you needed to keep the insulin cold. So if you were going somewhere, you had a little cooler, and you'd roll with the cooler in the insulin and the syringes and there's a whole mess. Things have come a long way since then, and so from there they have these insulin pens that are these little disposable pens with these little tiny needle caps that you screw on,

and it's great, it's very convenient. And the glue cominers have become really teeny tiny. It takes five seconds to count down. It takes a very small sample of blood. And then things got really cool. So then, insulin pumps have always been around, but the technology has gotten better and better and better. And so now these insulin pumps, they kind of look

like a little bit of a pager. I typically get S, why I have a pager, and it makes sense because I actually have a pager for work. But now I also have my insulin pump. So insulin pumps only take one kind of insulin. I have a pager and it makes sense because I actually have a pager for work, but now I also have my insulin pump. So insulin pumps only take one kind of insulin. It's a rapid acting insulin as opposed to what are known as basal insulin, which are kind of these long acting insulin with no peak. This is a rapid acting insulin. So once it gets into your system, it works pretty quickly and it peaks and kind of comes out of your system. And you load up a reservoir of insulin into

the pump and you basically program what are known as basal rates into the pump. So you say, okay, from this hour to this hour, I want you to give me this fraction of a unit and you can get very granular and fine tuning it. And once that's programmed, you're done. That will basically pump it into you for the 24 hours as your background insulin. You don't have to think about it. And there is a little, what's called cannula that you kind of push in under the skin with a needle

and the needle comes out. And it's a subcutaneous, just beneath the skin, infusion then. So you have a little tube and some of them are tubeless, but mine has a little tube. And you have a little plastic cannula that kind of sits just under the skin. It doesn't hurt wilds end to put it in, you know, it's a little pinch and that's it. It's really not that bad. And it'll give me that kind of basal insulin throughout the day. When I go to eat something,

I have to say to myself, how many carbohydrates am I about to eat? What is my blood sugar right now? And how much insulin should I bolus or give a large amount at once in order to cover the amount of carbohydrates my body is about to see? And so it's kind of a little guess and check. But the technology has gotten even better because when you're testing your blood sugar, it's a data point in time. It's a fixed data point in time. So you could test your blood sugar right now and it could be a hundred.

But is it a hundred and hang it out and chill in there? Is it a hundred and dropping? Is it a hundred and rising? You don't know. You're in the dark. So now we have something called a continuous glucose monitor, CGM. And that's CGM. Usually I wear my arm.

A lot of people like to wear it on their arm. And it is a small strip of platinum that sits beneath the skin, and it sits in the interstitial space, which is the space between cells. And what it's doing is it's detecting flux of glucose. So as the glucose is going across it, it picks that up, and so you're actually picking up a derivative or the rate of change, which is exactly what you aren't getting when you break your finger. So now you have all of this data.

So now you know I'm 100 and there's arrows pointing down, I'm dropping or there's arrows pointing up, I'm rising. They've taken that data and they used like a radio, short way of radio waves. And so now it talks to my pump. And that's called a closed loop. And this is kind of brand new technology now. So what this is doing is this is taking a cognitive load

off of me, the patient, and it's saying, oh, your blood sugar is rising, but it's not quite high technically, but it's about to be, I'm gonna give Mike a little bit more insulin. I'm gonna increase his basal rate on its own. So overall, when you look at it from like the thousand foot view view, you're saying, I'm going to spend more time in range. My blood sugar is going to be less high and less low because of this system. And what that does overall is it drops my UNC into a better range.

And what that does in turn is it makes me essentially live a longer healthier life with less likelihood of complications. So let's say you have some activities that you'd like to not be wearing a small dangling machine off your body. Let's just say hot tubbing or nude racket ball. Dr. Netter says you could feasibly remove it for an hour or so without any dire consequences. And you don't have to take them off for airport screening. I just checked the TSA website and found a guideline that attached medical devices in sensitive areas are subject to careful and gentle inspection,

which sounds awkwardly romantic. But a lot of people have this question. Emma Hawke, Kushnider, Christopher Rojo, Hannah M. Childers, Andrea Marsh, Lacey Gilbert, Monster Cat, and Fisels. Want to know what Andrea Marsh asked. Also, why can't the U.S. get it together and make insulin affordable? Why is it so expensive?

Monster Cat says I recently heard a local news story about how a young man died trying to ration his insulin. And Fisels said, I've heard that due to the price of insulin, there are loopholes that people can use, and you can get animal insulin for a lot cheaper than the human insulin and use it for yourself, which probably doctors don't recommend. But what is happening with insulin? Why is it so expensive? It's really a problem. It's really sad. And it's actually ironic that we're talking today because today is National or rather rather world diabetes day. Oh my god. By total happenstance We recorded this on November 14th, which is the birthday of Canadian scientist Dr. Frederick

Banting and it's world diabetes day because today is when Dr. Banting, he discovered the therapeutic use for insulin. He was able to kind of distill it from, I believe, a dog's pancreas and use it in a young diabetic boy and save his life. And he sold the patent to the University of Toronto. Do you know how much he sold the patent for? How much?

A single dollar. And he said, insulin does not belong to me. It belongs to the people that need it, diabetics, and it should always be that way. And so now we've somehow come into this very unfortunate and corrupted place of capitalism where they're in America are only three major pharmaceutical companies that manufacture insulin and they have very proprietary patents and uses on their specific insolents. And through a series of really messed up capitalistic greedy type situations, insulin has risen more than 400% inflation over the last decade, maybe less. Oh my God. Not too long ago, insulin was about maybe $35 a vial out of pocket or like straight cash, and it is now closer to $300 a vial. So how many vials does a diabetic person need per month?

Like what's a monthly cost that people are looking at? Yeah, so it depends on their insulin requirements. I'd say on average about one to two vials per month. Like what's a monthly cost that people are looking at? Yeah, so it depends on their insulin requirements. I'd say on average about one to two vials a month. Yeah, so $600 a month. A month. And now what you have to understand is, we currently are living in a country where, I mean, most young people with type 1 diabetes

are otherwise healthy. So these people may not have insurance. They may not have good insurance. And they may not have insurance, they may not have good insurance, and they may not have a job that offers them insurance or a job that pays them enough where they can afford $600 a month. And what we're seeing now is insulin rationing, where people are taking less insulin than they're supposed to be taking, so that they have at least a little bit on board throughout the month. And we've seen people die. We've seen significant rises in preventable type 1 deaths

because of this problem. And it's horrible. So the pork insulin, so before the human insulin came out, I actually used pork insulin, because that was actually the standard. It was to use either pork insulin or some other type of animal-based insulin. And since those are no longer in use, people are still trying to get those and they're cheaper.

But as of today, in the New York Times, the WHO, the World Health Organization, just put out a statement saying they are going to basically somehow allow a generic push to allow someone, some pharmaceutical company to make a cheaper insulin to therefore undercut these three big pharma companies and try and drive the price down by using competition. And it needs to happen now or yesterday because there has been just like a horrible response. I was actually really fortunate. I was able to dip out of the hospital for an hour today and go to rundown town to Wall Street for a rally

to talk about what it's like A to B at patient, but also to be a physician and C family members needing to decide if they're gonna feed their family for the month or take the amount of insulin they need. And it's a seconding. It's really seconding. What can the general public do? Who can we yell at?

So I think lawmakers, I think it needs to come from a government kind of intervention at this point is I think the best way to go about it. We need to kind of reign in this inflation that just continues to go up and up and up and up and up. And you know, when you think about it, it's insulin type 1 diabetics did nothing, they didn't smoke cigarettes and get cancer, they didn't, you know, nothing, this is not anything they did to themselves. And very often these are children that are diagnosed that just happen to be inflicted for reasons that are outside their own doing.

And they are now dependent not on a medication, but literally on a hormone that they would otherwise be making themselves that they don't. And so you are restricting someone from what I wouldn't even call a medication, I would call replacing the hormone that their body stopped making, that we have and know how to make cheaply for over a hundred years, and you're making it inaccessible and letting people die from that because of money. Money.

What about people who are trying to access medications that would be used for pets on themselves? I mean, I've heard of people who have taken literally like fish antibiotics because they don't have insurance to get, you know, medication for strep throat. Are people doing that? I don't know personally. I mean, I wouldn't be surprised at people. I mean, I would, as a physician, certainly not recommend doing that. Right now, the best option is Walmart has probably the cheapest insulin you can get, which is very reasonably priced. It's not the top of the line stuff. It's still, I think I believe you'd have to use syringes for it.

I believe it's not the most rapid acting or the best basal insolence out there. But if nothing else, that's probably what you should be going for because it's better than getting black market stuff. In terms of type two, if you're not insulin dependent yet or if you're type two and maybe you can take some measures that aren't exogenous insulin like cat, tylercute, colon croft, Lynn Perry, Roxanne Parker, Shea Murphy, Jessica Davis asked, what can you do to try to reverse type two? Yeah, I mean, it's kind of what we spoke about.

Basically, the idea is diet exercise, losing weight, that's key in more extreme cases, these weight loss surgeries, do see really dramatic results. I actually anecdotally, I have a patient who's like the most amazing human being. I saw him first when I was in interns, so two and a half years ago, this gentleman was wildly overweight. He wasn't taking care of himself. He wasn't taking his insulin. And one day last year he came to see me and he just looked terrible and I had to admit him to the hospital. I said, you're really sick.

I need to admit you to the hospital and then when he came out of the hospital, I had to talk to him and I said, your kidneys are failing. I need to put you on dialysis. And we had a real kind of come to Jesus moment and I said, you know, this is because of the diabetes. We need to figure this out. And more recently I saw him and I saw him on my on my list on the on the computer and I went to go to the waiting room to grab him and I call his name and I I don't see him

anywhere. And this guy is walking up to me and I was like, oh no, no, sir, you're not next. I need to find this guy. He had lost 230 pounds and he was a totally different man. And he, you saw the life in his eyes and he no longer had diabetes. His A1C went from 16%, which is extremely high to less than 6% which is normal. And that's because he gave up all the things he was eating that he knew were no good for him.

He exercised and he had a new lease on life, granted he had to be on dialysis which is not easy. But that's the wake up call he needed. So weight loss is huge and a significant amount of weight loss can definitely help. And it's not easy to do it. And his guy is really on another level. And any kind of weight loss is going to help and exercise is also very helpful. Do you have any strategies that you give to your patients if they have tried weight loss, they've tried exercise and they've tried eating differently? And it's just really hard. Are there any places to start? It's tough. Everyone's so individualistic. I mean, there are some medications that have been

proven to be somewhat helpful in weight loss. I don't like using medications ideally for anything. You can consider what you eat in medication. That's really the first place to start. But you have to find out what about someone's life. So what is it that they can't give up? If there's a guy or he needs to have his morning donut no matter what, you can't give that up. He's pre-contemplative. He's not even ready to think about giving that up.

You say, okay, so you eat that donut. But then where can we trim the fat elsewhere? Can you not have the fries with your meal and can you get rid of this bun and trade it out for brown rice? And you look for substitutions, you look for small things, and then you make these small steps that hopefully add up, but you want to make these small steps because those are the ones that they can continue to do. Can you get off the subway a stop early and walk? Can you take the stairs instead of the elevator? Can you park your car a little farther away from where you need to go so you can walk? These things in folks that are otherwise sedentary and overweight, you actually see a really, really big production from that.

They'll shed pounds, and if they give up the sweeten drinks and the sodas and those things, you'll see a huge difference. And so those are the first places to start. And I think you break a cycle because there's an addictive quality to some of these, and in those things, you'll see a huge difference. And so those are the first places to start. And I think you break a cycle because there's an addictive quality to some of these beverages and sweetened drinks and foods. And I've seen it myself.

I used to drink a lot of diet soda when I have read about how horrible was I stopped drinking it. And I didn't drink it for years, and then I had to drink, or I hadn't after. I was thirsty, and that's what was in the hospital at the time, so I had some. And it tasted terrible. It just didn't taste good and I realized that like I had an addiction to it and when I stopped drinking it I realized how awful I actually felt

when I drank it. It's the same thing with breaking up with people and then you look at them later and you're like wow what was I thinking. Oh I have the opposite problem with that. Why did we break up? Why? I know you're a softie, what was I thinking? No, I have the absolute problem with that. Oh, no. Why did we break up? Why did I know you're a softie? I am a terrible. A ton of people wanted to know about importing a pancreas, essentially, Diana MS, Bob Carlton, and Robert Born, want to know, and Manel and Dunkel,

will we ever get to a point where we can do pancreas transplants? We'll solve that. So we do them now. Oh, what? Yeah, but we don't typically do them for diabetes. Okay. Because you have to understand when we do

these pancreas transplants and really with any transplant, there's so much anti-rejection medication that you need to take, which in and of themselves is like horrible. So you're on a lot of these steroids, you're on a lot of these like, tach on a lot of these, like, tactile limes and all these things that are suppressing your immune system. And so you're kind of trading one malady for another oftentimes.

But we're getting closer, you know, a lot of folks that have pancreatic cancer, oftentimes they're starting, a lot of stuff is going on at Hopkins actually. It's actually a really amazing thing that they do. What they do is when they do something called a Whipple procedure where they're basically cutting out the pancreas because there's cancer there. But the parts of the pancreas that they cut out that aren't cancerous, they digest out the beta cells and the hormone producing cells. And they then re-inject them through the portal vein in the hope that they'll kind of like

take homage in the liver and they'll kind of like take uh... homage in the liver and just like kind of hang out in the liver and do their thing. Well, what they're doing is they're because otherwise they would have made these people diabetic and they're basically making them cancer-free and not diabetic all in kind of one-felt swoop, which is really impressive. A ton of people had questions about the future. really impressive. A ton of people had questions about the future. Steph, Merrill Stark, Don Ewald, Megan King, Daniel Tipton, Helen Peng, David M. Williams, want to know what technology like CRISPR is on the horizon for treatment of type one and

two diabetes. Like, is there going to be a cure? What about vaccine as cure trials? Like, what's coming up? There's a lot of really exciting research. I don't think that there's a silver bullet because I still don't think that we truly understand the multifactorial etiology,

but I think we're getting close and I think we're getting close. So right now, I would say we have as close to a mechanical cure as you can get with a closed loop system. We're getting closer and closer to fine tuning. There's something called the Bionic Pancreas Project, where if you think about insulin as a gas pedal, an insulin pump only has insulin in it, but a pancreas has insulin and glucogon. There's data to suggest that we, as type 1 diabetics, over time don't have the same glucogon response.

They're making this dual chamber pump that has both insulin and glucogon response. So they're making this dual chamber pump that has both insulin and glucogon that has a gas pedal and a brake pedal, which is the glucogon. And that's gonna be a lot more physiologic. And I think that's gonna be coming in the near future, it's coming in at a Boston. To the folks working on the I-let for beta-bionics, we see you, we love you.

Also, Dr. Nader asked me to add that clinical care of diabetes is a team sport. It includes clinical diabetes educators, nurses, dieticians, nutritionists, therapists, and they all rock. Okay, what else is on the horizon? There's gonna be an implantable CGM that's coming out soon, which is gonna be, cause right now I have to change out the CGM every five days

I have to change out my pump every three or four days There's going to be an implantable CGM that will last for six months to a year and that is kind of similar to like the next Planon which is a birth control rod with a progesterone that they inject they put in the arm for a period of time very similar procedure That's exciting. There's always a lot of stem cell research. So stem cells are what are known as kind of pluripotent cells, meaning they could become any cell in the body. So if I took a little swath of alley-word stem cells and I put them in a peachy dish and I put the growth factors around them and kind of coerced them and whispered to them at night and said, hey, you should make them beta cells.

Let's eat beta cells. And I grew your own beta cells. Then here we go. We have functional beta cells, which we've been able to do in the lab. Then the problem becomes if your type 1 diabetes is because of an autoimmune disease, then how do I put back your beta cells? I just grew in this peachy dish and make sure they don't get attacked by your immune system again.

So there's a lot of data or research looking into that. There's some research trying to like, hermetically seal them and these like, capsules, what I would describe is like a Trojan horse. So they're invisible, like, an invisible cloak to the immune system. So there's a lot of really interesting stuff going on. CRISPR is interesting. The problem is we don't have one specific gene or, you know, kind of chunk of DNA or protein that's really kind of f-ing things up.

It's multifactorial, and in some cases it might be mostly environmental. So we can't really necessarily use CRISPR per se, but I think we're... I'm optimistic that in my lifetime I will be put out of business because it will be a cure for diabetes. Oh, and then what are you gonna do? I'll draw books. Cool. I thought there was gonna be something on a beach.

Go draw books on a beach. Yeah, well I was, you know, I often fantasize in residency if I were to quit, what would I do? And I think about maybe being like a mailman in Hawaii. Feel like that would be fun. You can come, you get these little cool shorts with those stripes on the side, you know? I'll take it. I'll take a pit helmet.

So what does Dr. Natter like the least about being a diabetic diapetologist? Okay, there's a lot. So let's, I'm not, I'm, you know, I'm gonna be real with you. Diabetes sucks. It really sucks. I wouldn't wish it on my worst enemy. And what about being a doctor?

I don't like how much of it is a business. I don't like treating my patients like customers. I don't like rushing them out of my office or in the emergency room or in the hospital. I don't like discharging them because we have to turn over beds for money. I don't like that. I don't like that most of my day, unfortunately, is maybe 10% of it is done doing real medicine, and the rest of it is done doing

what feels like bureaucratic nonsense. And I know I'm a resident, but I think a lot of that's still the case as an intending, and that bothers me a lot. So that sucks about medicine as a whole. Obviously the finance is in the business of it and the insurance sucks. And the access to insulin and other medications that my patients need and are struggling to get really sucks.

Diabetes sucks. So diabetes sucks because this is a 24-7 constantly on your mind, constantly needing attention thing. Constantly on your mind constantly needing attention thing and At any moment you are worried about oh, I'm going on this date with this you girl. Oh, my sugar's low And when your sugar's low you act really well wonky and you stumble and you stutter your words and you feel The cold sweats, you know, and well, that's not very sexy. Or, you know, your blood sugar's high and it stays high. And no matter what you're doing and you're doing everything right, it's high and you don't understand it. And you know that if it stays high, you might

get complications and you worry about having kids and passing it on and you worry about going blind and losing limbs and losing fingers and losing your kidneys. I mean, it's a lot to deal with. So that sucks. Yeah. Understood. It's like your pancreas is out to lunch and in its place, you have a screaming baby that needs your attention at all times. That is exactly what it is.

We took out your pancreas, we replaced it with a screaming infant. Oh, thank you. Okay, go about your life. So kind. What is your favorite thing about being a physician or about talking to patients who have diabetes? So, you know, I mean, this is the flip side.

This is why I still do it. And this is why I went into it is because I like people. And I think when you wake up in the morning to go to work and know that you have the potential to help someone at the very least and at the very best, you can save someone's life. I mean, that's some powerful stuff. And it makes these long days and these 24 hour shifts and all this stuff and all the decades of schooling.

It makes you feel like, okay, maybe this is worth it. I like connecting with people and I like connecting with people on a deep level, and I like being able to help people. How do you not cry on the job? I cry so often. Thank you. I cry so, I mean, I am an emotional, sensitive man, maybe more so than most.

And so as I think we were chatting before, like my, I'm currently on an oncology rotation since cancer and it is heavy. It is really heavy. And it's, it's this weird dichotomy of you have this like weird privilege and this weird honor to be literally at the bedside with someone who's dying and talking to their family and walking them through it. You just met them an hour ago. And here you are guiding them through

the most human process that anyone and everyone goes through. So it's really something special, which I love. But I then take it home with me, which is not healthy. And so then you go and you cry. So I definitely cried more of this rotation than I think any other. But usually, like you learn as an intern, you could become very efficient at crying because what you do is you used to come home, cry, then shower, then have a drink. So now what I do is I cry in the shower while having a drink, and just kind of get it all done at once. You learn efficiency.

Is there a good place in the hospital that you cry? Do you know that there's a supply closet that's always good for it? Allie. Internia, I scoped out all of the cry spots, don't you worry. There is, in one of the hospitals I work, there is these great single bathrooms where you can do like the ugly cry because like you have all the time in the space to do it.

And then when you try and clean yourself up, you have like all the utensils you need. You got, it's the same thing you got. Yeah. But then there's like the emergency cries where you're like, oh, I didn't think this was gonna happen and just coming out like water works,

then you usually have to go to the top of the stairwell because if you go to the very top, then you like the likelihood that people coming down from there are slim, but that echoes. So you can't ugly cry there. You can muffle a little bit. No. Most of the times I cry, it's not out of pain,

it's more emotional. It's not really my own either. It's more like seeing other people. I guess I like happy cry in the sense of watching something sweet. I'll get the single Obama tier. That's how I like to cry. It's very manly, that one tier and like stone faced. But more recently I've had to like crumpled up, like snot, you know, like heaving, heaving cry that's been, it's been, been there, been there,

done it. Well, I'm gonna cross my fingers for a cheaper generic alternative and when that day happens, we will FaceTime and we'll happy cry about it together. I like that plan. But Dr. Natter wanted to leave us on a high note, so. Without diabetes, I don't think I would have gone into medicine. So I think there's a silver lining in that respect. I think it helped me find my calling. So if I could be appreciative to diabetes for anything, I think it's that. Has it brought you closer to other people who have it, obviously? Yes, and I think as I kind of alluded to before, when my patients are struggling with any chronic illness, but especially diabetes, I love when they catch a glimpse of my pump

and then we have that moment of like, oh, wait a minute. Like you get, I had a patient recently who was admitted to my service for an infection, but she happened to have type one diabetes. And being in the hospital, she was young and being in the hospital was scary. And she was middle of her night and it happened to have been there on godly hours. And she immediately felt comforted knowing,

because she had wore the pump in the C-GIMP that I got it because not everyone in medicine understands how these things work as a diabetic. You're very kind of protective and know your diabetic care better than anyone else. So for you to get admitted to a hospital, it's someone who you just met who doesn't really understand diabetes that well saying, we're taking your pump off and I'm going to give you insulin how I decide is, you know, a jargon. So we, it was, it was really nice to, to be able to share that with her and make her feel

really comfortable. Fake redheads have the same nod. It's like I see you. It happens all the time. So essentially I've lived your life and I get it. Oh, thank you so much for doing this. So once again, ask nice, sweet doctors, stupid questions, because we're all going to die eventually.

But you can delay that by asking questions. So to follow Dr. Natter, he's at mic.nader on Instagram or mic underscore.nader on Twitter. We are at allergies on both. I'm at alleyward with one L on both links to JDRF.org and the sponsors are in the show notes and they're also up at alleyward.com slash allergies slash diabetology. Oligies merch is at allergiesmarch.com or at alleyward.com. Thank you to Shannon Feltis and Bonnie Dutch to wonderfully sassy sisters who run that and host the comedy podcast. You are

to check that out. And happy slightly belated birthday to Aaron Talbert who runs the oligies Facebook group, which is a job in and of itself. Thanks so much Emily White who organizes all the transcriptions. Thank you patrons for allowing me to pay them for that hard work. There are links to bleeped episodes, including part one of this episode in the show notes. Jared Sleeper did assistant editing. Thanks, of course, to the man and the mustache. Steven Ray Morris, who hosts the Kitty-themed podcast and the dyno pod, C. Jurassic Right, for putting all the parts of this episode together. Nick Thorburn wrote and performed the theme music. He's in a band called The Islands,

very good band. And if you stick around to the end of the episode, you know I tell you a secret. And this week, as long as we're talking hormones, I have to take a bunch of hormones because my ovaries are just like, bye-bye, we're out of here. And one of them I take is like a progesterone. And it bums me out so much. I'm supposed to take it regularly, but I just get so eore on it. And I'm only telling you this because a, the first few times I took it, I had no idea what was going on. And I thought I was losing my marbles fully. I didn't know that that can happen to some people when they take it. And also because as long as we're talking about the wonders of the American healthcare system, I told my latest doctor about it and she said, well, I have to put you on it again and

feel like you want a crevice of the earth to open up and swallow you. And then your insurance will approve something that doesn't do that to you. Anyway, so, progesterone dudes and ladies and everyone who's neither. Thank you for ducking into my secret hut and listening to these things. Okay, please take care of yourselves. Do you promise? Yes? Okay.

All right. Bye-bye. Mediology, Nephology, Syriology, Nephology. Diabetes.