Ologies with Alie Ward - Diabetology (BLOOD SUGAR) Part 2 with Dr. Mike Natter, MD

Episode Date: January 29, 2020

Diabetic diabetologist and wonderful person Dr. Mike Natter, MD is back 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 at Instagram.com/mike.natter or at Twitter.com/mike_natter A donation went to: JDRF.org Sponsor links: LinkedIn.com/ologies; HelloFresh.com/ologies10 (code: ologies10) More links at alieward.com/ologies/diabetology Transcripts & bleeped episodes at: alieward.com/ologies-extras Become a patron of Ologies for as little as a buck a month: www.Patreon.com/ologies OlogiesMerch.com has hats, shirts, pins, totes and STIIIICKERS! Follow twitter.com/ologies or instagram.com/ologies Follow twitter.com/AlieWard or instagram.com/AlieWard Sound editing by Jarrett Sleeper of MindJam Media & Steven Ray Morris Theme song by Nick ThorburnSupport the show: http://Patreon.com/ologies

Oh, hey, it's still your friend who looks at listings of houses she has no intention to buy. Hallie Ward, back with another episode of Allergies, part two of a two-parter. So the bookend on the beatus. And I'm going to keep this intro short, I'll keep it sweet, but we're back with part two of Diabatology 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 reined in my potty mouth for this part two and I uploaded a kid-friendly and swear-free version of Diabatology part one of last week's. It's on my website at alleyward.com slash allergies slash Diabatology.

Jarrett worked extra hours to 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 the show and makes things like that possible for everyone else. Thanks to everyone wearing gear from allergiesmerch.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 Foot 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 peace of knowledge and the gift of regular belly laughs. So hot damn. Thank you, Queets on Foot.

And also Juniper Dewdrop, 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 freaking 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. You ready to dive into some Patreon questions? 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. For example, there's gonna be a lot of scrolling, so just pardon. You scroll at your leisure. Okay. So as I pulled up your questions, Dr. Natter mentioned to say hi to editor Stephen Ray Morris and Jared Sleeper and how he wanted to hang out with them IRL. And I love watching cool dudes make pals. So I suggested that they go kick it without me.

Go get some pudding. I had some pudding in the hospital today. I 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 pudding. 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. Natter's blood glucose on this day? Well, with all that running around, it was low, it was dipping into the sixties. And the sixties, at least in blood sugar terms, are not groovy. Did you find that stress definitely impacted? Stress 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. Dilworth is awesome. I love her.

So yeah. Yeah. So when you have your hypothalamic pituitary adrenal axis kicked in, you are spitting out ... Well, from your hypothalamus, your hypothalamus is like, ah, like fight or flight. And then it goes to the pituitary, specifically the anterior pituitary because the pituitary is the master endocrine gland. And in terms of this fight or flight, your anterior pituitary is spitting out ACTH specifically. And that guy goes downstairs to your ... 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 like a gooey center called the medulla. And the gooey center secretes adrenaline, but we call it either norepinephrine or aperinephrine. And then those two hormones spin around the body and make everything go super fast. So they make your heart go bup, bup, bup, bup, bup, bup, and they make your blood flow and all the stuff. But the other thing to do is they kind of kick in a lot of glycogen breakdown.

Adrenaline is the storage form of sugar and your liver and your skeletal muscle have most of it, 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 bloodstream. 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 glove compartment and stress essentially screams, bust that sucker open, it's freak out time and I need to get juiced up. Anyway, that was an aside. We wouldn't put it in the side. No, I loved it.

I loved it. And so for you, because you don't have insulin to escort it into the cells, then it goes high and then it can do damage to your tissues, which is not good. 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 is serious stuff, but you can avoid it or stay on top of it. So let's learn how via your questions.

Jess Flowers wants to know, is it pronounced diabetes or diabetes or diabetes? I feel like it depends on your mood. I mean, Wilfrid Brimley would go with diabetes feels good to say diabetes. I say diabetes. Sometimes I call it the BDs or affectionately the sugars or the shugs, but it's, you know, however you want to, you know, everyone do it. Okay. PS side note.

I always figured diabetes, a pronunciation popularized by diabetic actor, legend and human walrus Wilfrid 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 Wilfrid, who was born vintage and has been playing lovable geezers since the 1985 Ripper cocoon is just saying it old school, but he's a good sport about people getting tattoos of his mustachioed face alongside the word BDs.

He retweets body art in his image. And yes, he has a Twitter. It's at real Wilfrid. And to patrons who asked about his impact, I'm looking at you, Ruth Anthony, Bernadocco, Edwards, Anna Suthime 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 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 dude's had it for decades and he's going strong. He's 85 right now. So follow the walrus.

Shay Littlepage 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? Yours, when you were hospitalized, was staggeringly high. I have to admit ignorance. I don't know what the record holder is for highest and lowest. The problem with lowest is that someone can technically be typically in the hospital during

what's called a code when someone's 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 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 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 A1Cs where I work. So A1C is a three month average of your blood sugar. A normal person's A1C is between like four and like 5.5-ish and that's a percent.

And what that really is is it's measuring the glycosylation of your red blood cells. So the sugar is sticky and so it's going to 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 of 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 a type above 6.5%. So if you're in technically, quote unquote, good control as a diabetic, you're less than 7%. And if you're not doing so hot, you're 8 or 9%. Even in the 10s, 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 kind of thing. Oh God. I had so many patrons. Kelly King, Heather Densmore, Deanne, Karen Burnham, Megan Johnson, Andrea Marsh, Ashley Hamer, Shay Littlepage, 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 have in 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. 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, than type one, but it's multifactorial and it's not like an autosomal dominant 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, 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, 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, it's not a sex-linked trait, but we just happen to see epidemiologically that type one fathers have more of a chance

of having a type one son. Oh, wow. Did anyone in your family have it that you know? No, no, no one in my family had it that I know of. The other thing is type one 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 degree relative 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 too in like the Netherlands and certain areas in that part of the world, very high predominance of type one diabetes. Oh. Yeah. So in part one, we talked about how folks in cold climates and in cold seasons tend to get diagnosed with type one 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 like, you know, back in the day, you know, my mom and dad would eat dirt and like, you know, 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 its immune system developed so that it creates plenty of antibodies and 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 kind of trained to be recognizing things that aren't foreign. And so then all of a sudden it starts looking at your own cells as foreign invaders. And so you start having autoimmune auto meaning self, immune your 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 Kruempens, Dominic Deck, Christian Bettner, and Rachel Ames.

Lauren Kruempens wants to know at what point does a pre-diabetic become a diabetic? And Dominic, I 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, that's a hard question to ask, but in general, pre-diabetes. Yeah. Well, let me just put a little preface in here. So I am a physician, I treat patients, I am a diabetic, but I cannot give individual medical advice like in this setting.

So I will speak in generalities. Don't sue. 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 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 pre-diabetic range. Okay. That's most commonly how I, and I think most clinicians will diagnose a pre-diabetic. 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, 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 126 in a fasting state, I think is also considered diabetes. And then you can also do like an oral glucose tolerance test where they make you drink this like, 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 5.7 to 6.4 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 of

auto-immunity or whatever, I'd want to get a couple of lab tests to make sure that they're not actually type 1 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 C-peptide or an anti-zinc transporter. And what these are, are basically kind of markers for auto-immunity amongst insulin or some of the beta cells.

And not every type 1 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 are type 1. 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. Natter 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-degree relics 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 eating for breakfast? What are you eating for lunch? What are you snacking on? How can we intervene, 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'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. It kind of gets into the idea of the pathogenesis of type 2. And we all assumed and in layman, in the popular culture, it's thought that, well, you ate

too much candy, you ate too much, you know, 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 2 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 lipo toxicity, lipo meaning 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. 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 postprandial absorption, so postprandial post meaning after, prendeal meaning meal. So postprandial absorption of sugar into the skeletal muscle and then impaired pancreatic glucoregulation of the beta cells. So yes, those saturated fats and the lipo toxicity 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 kind of happening because of inflammation, lipo toxicity, and it kind of 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 aioli, it's a bad idea. Well, it's delicious, but so, 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 and 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 IBs, you live to 120, but like, maybe you didn't really live, you know, if you eat a hot dog with a aioli 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 could eat? And the Luther burger side note, it's named for R&B legend, Luther Van Dros, who loved these cheeseburgers squished between two crispy cream donuts. Also, not to make this too real, but diabetes ran in the Van Dros 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 Shea Murphy, Madeleine Winter, Rose Presby, Samantha Galbraith, Moses Beebe, 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 tissues, like fat cells and skeletal muscle in a few other places. And when the pancreas or the beta cells of the pancreas secrete insulin in response to

an elevation of blood sugar, those little insulin pieces that kind of seem, they're kind of like keys. I'm oversimplifying, but they're kind of like keys. And the receptors on the adipose and the skeletal muscle are 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 insensitivity is a broken lock and we think this is because of this fat deposition and this mitochondrial dysfunction and this oxydestress 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's 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 and more called precision medicine or precise and individual. You can't just lump someone into one size fits all anymore and in 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 basically just get someone's height and their weight and the best example of how that doesn't fit into why it makes sense is because if you've got a very fit body builder 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 aside, 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. And we know where you carry the fat is also important. So central adiposity, so the beer belly is far more dangerous than carrying your fat on your butt or your thighs. And that's because the central adiposity is actually a surrogate marker for the fat that's inside and that is when you have your lipotoxicities, 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 attacks, 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 other reason then because and I tell them because I want them to live longer and healthier and feel good. A lot of folks actually asked about exercise and type one and type two. Michelle Phillips, Meryl 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 cells 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 and circulate 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 party or what? And glute 4 shows up the door and is like, huh, yeah, come in glucose, you seem cool. Now 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 want to let more glucose is 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 glute 4 receptors.

That's more likely what's going on so as I don't know if it's necessarily in 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, 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 like people that are very fit, that are marathon runners and they exercise all the

time, like their insulin requirements are probably a fraction of what someone who just sits on 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 going to 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 I started at like 70, rose to maybe 90, 110, and then crashed to 40. And I was like shaking, crying, 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 voracious 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 salad. 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, what causes gestational diabetes? How is it transient?

Well, regular diabetes is not. Type 1 diabetes is often kind of co-managed by a lot of the obigynes as well as endocrinologists. It's super important that when someone has gestational or just type 1 diabetes while they're pregnant to keep their blood sugars in extremely, extremely tight control because any kind of unfortunate high or low blood sugar is going to have potential really bad impacts on the child, significant if the blood sugars are really out of whack. So the endocrinologists and the obigynes 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 creates a really hyperglycemic state in the mom and it makes it very difficult for insulin sensitivity constantly having sugar around in the stream because the idea is that my theory or my understanding is that hypo 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 hypo-glycemic. So I think that's kind of maybe why these hormones are being secreted and 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. So if you are a person carrying a baby in your body, listen to your doctor.

Gestational 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 whopper 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 choosing and for part 2 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 all of these 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.

Chris Brewer 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 anytime 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 and if you do a really strict keto diet, you end up eating or like the Ackens 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. I think a plant-based diet, if it grows from the ground, greens, you want salads like all 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 healthier. 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 McGee 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. No. So she's given him a little influenza.

So yeah, poor guy. Oh, 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 it probably wouldn't work out. I'm not entirely sure. They're trained, it's a sense. My best guess is dogs have these phenomenal factory 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 high or 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 acetate 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 acidemic, which is bad and you don't like that.

And when your body or your blood is acidemic, your enzymes, your proteins, denature, things don't work and you can die. Oh, no, no thank you. So your body tries to compensate by blowing off the acid through your breath. So you breathe these, what's called kuzma breathing, you breathe very rapidly and shallow and you're trying to literally exhale acetate acetone and acetate 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 you're something is changed in your biology where you're breathing something that might be different, whether a little low or a little high, maybe that's what they're smelling. That's my best guess. I don't really know. Okay, two things. So your nose has about 5 million cent 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. Natter 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 and insulin? Karen Malines, Lynn Perry and Todd Peterson asked this, can you explain the dangers of diet soda? Todd Peterson said, I heard that aspartame release grows with your insulin levels and Karen Malines wants to know about stevia and artificial sweeteners, what that do to your 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 that stuff and the dyes and the synthetic stuff. It's just bad for you. It's just 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.

And so the most kind of interesting way that people have been hypothesizing that it can cause harm is that most people drink diet sodas because they're trying to be fit. They don't want 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 Diet Coke 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 how 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, it's technically we shouldn't raise your blood sugar. Things that raise your blood sugar are typically carbohydrates or 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 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? Langley Bradley, Madeleine Dunkel, Hannah M. Childers wanted to know what can you do if someone's in diabetic shock, if someone's hypoglycemic or hypoglycemic, 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, it's either going to be very low or it's going to be very high. So if you know which one that is, basically 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 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, the, 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 IM or intramuscular injection. Some people, not a big fan of the needles. I get it. It might be tricky.

They might not have the kit 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 hypoglycemic 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, Elise and Robert Bourne 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 that time was like super 80s, like very archaic. I had this, what looked like a brick of a glucometer.

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, it was kind of like the size of a game boy, like an old school game boy. 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, you know, roll with the cooler and the insulin and the syringes and it was 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 and it's very convenient. And the glucometers 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. 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 asked 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. It's a rapid acting insulin as opposed to what are known as basal insulins, which are kind of these long acting insulins 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 subq or 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 while it's in 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 100, but is it 100 and hanging out and chilling there? Is it 100 and dropping?

Is it 100 and rising? You don't know. You're in the dark. So now we have something called a continuous glucose monitor, CGM. And that CGM, usually I wear on my arm, a lot of people like to wear 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. There's arrows pointing up. I'm rising.

They've taken that data and they used like a radio shortwave 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 going to give Mike a little bit more insulin.

I'm going to increase his basal rate on its own. So overall, when you look at it from like the thousand foot 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 racquetball. Dr. Natter 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 had this question.

Emma Hawke Schneider, Christopher Rojo, Hannah M. Childers, Andrea Marsh, Lacey Gilbert, Monster Cat and Faisal's want to know what Andrea Marsh asks. Also, why can't the US 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 Faisal 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 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 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 there in America are only three major pharmaceutical companies that manufacture insulin and they have very proprietary patents and uses on their specific insulins. 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. Not too long ago, insulin was about maybe $35 a vial out of pocket or straight cash. And it is now closer to $300 a vial. How many vials does a diabetic person need per month? 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. So $600 a month.

A month. And now what you have to understand is currently you're living in a country where 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 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 insulins 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 run downtown to Wall Street

for a rally to talk about what it's like, A, to be a patient, but also to be a physician and see family members needing to decide if they're going to feed their family for the month or take the amount of insulin they need. And it's sickening. It's really sickening. 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 rein in this inflation that just continues to go up and up and up and up and up. And when you think about it, insulin, type 1 diabetics did nothing. They didn't smoke cigarettes and get cancer. This is not anything they did to themselves. 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 or about a hundred years and you're making it inaccessible and letting people die from that because of 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 medication for strep throat. Are people doing that? I don't know personally. I mean, I wouldn't be surprised if people do that. I mean, as a physician, I would 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, you know, I think you'd have to use syringes for it. I believe it's not the most rapid acting or the best basal insulin out there. But if nothing else, that's probably what you should be going for because it's better than getting black market stuff. Yeah. 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, Tyler Q., Colin 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.

You know, I saw him first when I was an intern. So two and a half years ago, this gentleman was wildly overweight. You know, 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. Like 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 weight room to grab him and I call his name and 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 percent, which is extremely high to less than 6 percent, 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 of call he needed. And so, 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, but any kind of weight loss is going to help and exercise is also very, 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 they've tried eating differently and it's just really hard. Are there any places to start?

It's tough. Everyone's so individualistic. 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 a medication. That's really the first place to start. But you have to kind of 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 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 sweetened drinks and the sodas and those things, you'll see a huge difference.

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. I've seen it myself. I used to drink a lot of diet soda and when I've read about how horrible it was, I stopped drinking it and I didn't drink it for years and then I had to drink or I had nap time. I was thirsty and that's what was in the hospital at the time so I had some and it tasted terrible. I felt it just didn't taste good and I realized that 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? No, I have the opposite problem with that. Oh no. Why did we break up? I know you're a softy. I am. It's terrible.

A ton of people wanted to know about importing a pancreas, essentially, Diana MS, Bob Carlton and Robert Bourne, want to know and Madeline Dunkel, will we ever get to a point where we can do pancreas transplants? What's up with that? So we do them now. Oh, what? Yeah, but we don't typically do them for diabetes 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 horrible. So you're on a lot of these steroids, you're on a lot of these tachrylimus and all these things that are suppressing your immune system. So you're kind of trading one malady for another oftentimes, but we're getting closer, 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 just like kind of hang out in the liver and do their thing. Wow. 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. Steph, Meryl Stark, Don Ewald, Megan King, Daniel Tipton, Helen Pang, 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 those. 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 glucagon, and there's data to suggest that we, as type 1 diabetics, over time don't have the same glucagon response. So they're making this dual chamber pump that has both insulin and glucagon that has a gas pedal and a brake pedal, which is the glucagon, and that's going to be a lot more physiologic, and I think that's going to be coming in the near future. It's coming out of Boston. To the folks working on the eyelet for beta-bionics, we see you.

We love you. Also, Dr. Natter asked me to add that clinical care of diabetes is a team sport. It includes clinical diabetes educators, nurses, dietitians, nutritionists, therapists, and they all rock. Okay. What else is on the horizon? There's going to be an implantable CGM that's coming out soon, which is going to be, because 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 the Nexplanon, which is a birth control rod, 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 LA ward stem cells and I put them in a petri 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 become 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 petri 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 hermetically seal them in these capsules, what I would describe as 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 kind of chunk of DNA or protein that's really kind of effing 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 there will be a cure for diabetes. And then what are you going to do? I'll draw books.

I thought there was going to be something on a beach. You'll draw books on a beach. Yeah. 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. I feel like that'd 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 pith helmet. So what does Dr. Natter like the least about being a diabetic, diabetologist? Okay, there's a lot. So let's, I'm not, you know, I'm going to be real with you. Diabetes sucks. It really sucks. I wouldn't wish it on my worst enemy. 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 like 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 finances and 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. Diabetes sucks because this is a 24-7 constantly on your mind, constantly needing attention thing. And at any moment, you are worried about, oh, I am going on this date with this cute girl.

Uh-oh, my sugar is low. And when your sugar is low, you act really 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 is 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, 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 and

that's some powerful stuff. And you know, 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. I cry so often.

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, so it's cancer and it is heavy. It is really heavy and it's, it's this weird dichotomy of, you know, it's like, you know, 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. And you just met them an hour ago and here you are kind of 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 know, then you go and you cry. So I definitely cried more 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? Like, do you know that there's like a supply closet that's good for it? Alley. Alley. Intern here, I scoped out all of the cry spots, don't you worry. There's, 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 and the space to do it. And then when you try and clean yourself up, you have like all the utensils you need.

You know, you got, it's a sink and you got, um, but then, then there's like the emergency cries where you're like, oh, I didn't think this was going to happen and it's just coming out like waterworks. Then you usually have to go to the top of the stairwell because if you go to the very top, then you'd like the likelihood that people coming down from there are slim. So you can like, but that echoes. So you can't ugly cry there. You can muffle it a little bit.

Most of the times I cry, it's not out of like pain. It's like, uh, it's more emotional. Like it's not really my own either. It's more like, um, like seeing other, other people. I guess I like, uh, happy cried in the sense of like, if I'm watching something, you know, sweet, you know, I'll get like the, with the single Obama tier, you know, that's how I like to cry. It's like that, that very manly, like that one tier and like stone faced, but, um, more

recently I've had the like crumpled up, like snot, you know, like heaving, heaving cry. That's been, it's been. Been there. Yeah. Been there, done it. I'm going to cross my fingers for, um, a cheaper generic alternative. And when that day happens, we will FaceTime and we will happy cry about it together. I like that.

I like that plan. But Dr. Natter wanted to leave us on a high note. So without diabetes, um, I don't think I would have gone into medicine. So I think there's, there's a silver lining in that respect. I think it helped me find my calling. So, um, 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, when my patients are struggling, um, with any chronic to illness, but especially diabetes, um, 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 it. I had a, I had a patient recently who was admitted to my service for an infection, but she happened to have type one diabetes and you know, the, being in the hospital, she was young and you know, being in the hospital is scary. And she was admitted overnight and it happened to have been, you know, there, um, ungodly hours.

And you know, she said, you know, she immediately felt comforted knowing cause she wore the pump in the C. Jim 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. Um, so for you to get admitted to the hospital, all of a sudden someone who you just met who doesn't really understand diabetes that well is saying, we're taking your pump off and I'm going to give you insulin. How I decide is, um, you know, John, so we, we, um, it was, it was really nice to, to

be able to share that with her and make her feel really comfortable. Fake red heads have the same nod. It's like I see you heavens 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 cause we're all going to die eventually, but you can delay that by asking questions. So to follow Dr. Natter, he's at mic.natter on Instagram or mic underscore Natter on Twitter.

We are at oligies on both. I'm at Ali Ward 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 oligies slash diabetology. Oligies merch is at oligiesmerch.com or at alleyward.com. Thank you to Shannon Feltas and Bonnie Dutch to wonderfully sassy sisters who run that and host the comedy podcast. You add that 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, Hannah Lipo, for all of your volunteer efforts over the last several years. And to 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 of the Mental Health Podcast, my good bad brain, did assistant editing. Thanks, of course, to the man and the mustache, Stephen Ray Morris, who hosts the kitty themed podcast and the dino pod, See 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 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 eeyore 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 crevasse 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. Did you promise? Yes? Okay. All right. Bye-bye. Diabetes.