October 14, 2025 • 43 mins
In Episode 56 of Think Like a Pancreas—The Podcast, Jennifer Smith, Director of Lifestyle and Nutrition at Integrated Diabetes Services, is joined by Gary Scheiner for a conversation on preventing type 1 diabetes.
With improved access to screening tools, they explore the implications for people living with diabetes and their families.
Gary shares the latest research and treatment options, highlighting how these advances can lead to better outcomes for those at risk of developing, or those diagnosed with, type 1 diabetes.
MEET YOUR HOST AND HER GUEST
Jennifer Smith, RD, LD, CDCES is the Director of Lifestyle and Nutrition for Integrated Diabetes Services. She is renowned for her expertise in nutrition, diabetes education, and athletic performance. With a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin, Jennifer is a Registered Dietitian, Licensed Dietitian, Certified Diabetes Care & Education Specialist, a certified trainer for insulin pumps and continuous glucose monitors, as well as a published author. Having lived with type 1 diabetes since childhood, Jennifer offers unique insight into day-to-day diabetes management, pregnancy, sports nutrition, and technology integration.
Gary Scheiner is an award-winning CDCES Fellow, Masters-level Exercise Physiologist who received his diabetes training with the world-renowned Joslin Diabetes Center. He serves on the faculty of Children With Diabetes and is an active volunteer for the American Diabetes Association, Juvenile Diabetes Research Foundation, Diabetes Sisters and Setebaid Diabetes Camps. Gary serves on the clinical advisory boards for several diabetes device manufacturers and pharmaceutical companies, while bringing together an incredible team of experts with his company, Integrated Diabetes Services.
WHAT YOU’LL LEARN:
✔️ Who should be screened for type 1 diabetes.
✔️ How you or your loved ones can be screened.
✔️ Beta cell bubble-wrap strategies.
✔️ Next steps after screening.
CHAPTERS:00:14 Welcome and introductions
02:00 Understanding the stages of developing type 1 diabetes
10:05 Who should be screened for type 1 diabetes?
14:15 The best age to consider screening
15:56 You’ve been screened for type 1 diabetes. What’s next?
21:33 Monitoring and insulin production preservation strategies
26:54 Medical intervention options to prevent stage 3, type 1 diabetes
35:43 To screen or not to screen is a personal decision
RESOURCES MENTIONED
Integrated Diabetes Services offers consulting services to individuals and families who test positive for antibodies. Call 610-642-6055 for details.
Most commercial labs such as Labcorp and Quest Diagnostics are equipped to perform antibody testing. Just ask your physician for a prescription the next time you have annual lab work.
At-home test kits can be obtained from TrialNet. Free screening kits are available at TrialNet sites or through the mail for first-degree relatives of people with T1D ages 2–45, or second-degree relatives ages 2–20. Call 800-425-8361 for details. https://www.trialnet.org/
ASK is a free T1D antibody screening service for children, available through the Barbara Davis Center for Diabetes: www.askhealth.org
For a variety of resources on the T1D screening process, visit www.type1tested.com
CONNECT WITH US🔵Website: integrateddiabetes.com
🔵 Follow on Social Media: @integrated_diabetes_services and @ integrateddiabetesservices on Facebook
🔵To work with the Integrated Diabetes Services Team , visit https://integrateddiabetes.com/how-to-start-the-process/ , or email info@integrateddiabetes.com
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Also, leave a review to let us know what you think, and share this episode with others who will enjoy it as well!
MORE GREAT EPISODES LIKE THISThe Quest for a Cure: A Diamyd In the Rough
Disclaimer
The information contained in this program is based on the experience and opinions of the Integrated Diabetes Services clinical team. Please discuss any changes to your treatment plan with your personal healthcare provider before implementing.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:14):
Welcome to Think Like a Pancreas,The Podcast where our goal is to keep
you informed, inspired, and a littleentertained on all things diabetes.
The information contained in thisprogram is based on the experience
and opinions of the IntegratedDiabetes Services clinical team.
Please discuss any changes to yourtreatment plan with your personal
(00:34):
healthcare provider before implementing.
Hello today I am super excited to be thehost of our wonderful podcast, Think Like
A Pancreas, and we're gonna be discussinga really, really important topic today.
Kinda the whys and hows ofscreening for Type one Diabetes.
And I am Jennifer Smith.
I'm Director of Lifestyle and Nutritionwith Integrated Diabetes Services.
(00:57):
And I'm glad to be joined by one ofthe people who knows an awful lot
about screening for T1D, Gary Scheiner.
Yay.
Hi Gary.
Hey Jenny.
I am thrilled to not have to host.
I love being a guest.
Uh, 'cause I don't have toremember or do anything special.
I can just answer questions.
My job's easy.
You got the hard job today.
(01:18):
Not really.
So, you know, it's all good.
I think a lot of people... we've had alot more information about screening--
I don't know, what would you say?
In the past five years?
It's become much more visible and thebenefits of it are being explained,
but I think something behind it, andthe reason for screening, really starts
(01:38):
with the stages of developing type one.
And we know that at, kindof the last stage is usually
the diagnostic stage, right?
Where we don't really know whatwas going on ahead of time.
And now with screening we have theability to actually see where are you.
What stage could you possibly be.
Tell us about the stages of screening.
(02:00):
How are the... even the stages ofdeveloping type one that kind of go
into, maybe where you're thinking aboutscreening your family member or child.
Yeah.
It's, it's analogous in many waysto doing checks for skin cancer.
Um, 'cause now when, you know, skincancer's caught very early on, it's
usually pretty easy to treat, right?
(02:20):
There's special procedures thatthey just remove a few of the upper
layers of skin in a local area.
It's, and it's gone.
Yeah.
Uh, you know, if it has a chanceto permeate deeper and spread,
it can be lethal, not just
Right.
Debilitating.
And with type one diabetes, there area number of antibodies that develop
and show up in, in the bloodstream
(02:42):
mm-hmm.
That are the precursor to developingsymptomatic type one diabetes.
Right.
There's, there's threestages to the development.
The first stage is just theappearance of the antibodies.
The blood sugar levelsare perfectly normal.
The pancreas still puts out areasonable amount of insulin.
So if you were to check yourblood sugar after eating a box of
(03:04):
Twinkies, it'll be perfectly normal--or a box of BooBerry, whatever.
So stage one is completely no symptoms.
You'd never know type one waseven in development if you didn't
know the antibodies were present.
And thus, if you're a family that doesn'thave type one at all, you wouldn't
(03:25):
even think about screening mainlybecause there would be no symptoms.
It's almost like an underlying coldwhere you don't really have the symptoms
yet, and then you finally do, andthen you really feel like crud, right?
Yeah.
Yeah.
That's something that's sortof in the mix, but you really
don't know until you do testing.
So.
Yeah.
(03:45):
Or in, in the skin issue, it wouldbe like having just a tiny freckle.
I mean, there's nothing to worry about.
It's normal.
You get these all the time.
Yeah.
Yeah.
So, so stage one, you know,you're, other than these antibodies
being in your bloodstream, you'reperfectly healthy and normal.
Nothing unusual.
So stage two is when the blood sugarlevels start to decay a little bit.
(04:08):
Uh, the pancreas is being attacked bythe body's immune system, and you've lost
some of the ability to produce insulin.
Mm-hmm.
But not enough for the blood sugarsto go super high and cause the
symptoms we're used to seeing.
So the only way to know you're at stagetwo is by doing blood sugar checks.
(04:29):
Sure.
I mean, whether it's a lab test, um,glucose tolerance test, or finger
sticks, or an A1C or even using aCGM, you'd have to be checking the
blood sugar levels, it's, in someway to know you're at stage two.
And typically at this stage, thefasting, the wake up readings might
just be a little above a hundred.
The after meal readings might be inthe mid to high hundreds, but then
(04:53):
they usually come back down again.
Mm-hmm.
So this is called a, astate of dysglycemia.
The blood sugars are not quitenormal, however, they're not so
high that the symptoms show up.
And that's stage three.
Stage three is when most peopleare diagnosed with type one.
They're already at stage three.
So you've gone from the point of a littlefreckle at stage one to kind of a larger,
(05:18):
odd shaped spot on the skin at stage two.
At stage three is when you have fulldeep skin cancer at, at that point.
But in this case, the pancreasnow just, it can't keep up.
It, it's unable to makenearly enough insulin anymore.
Mm-hmm.
Um, I mean, in percentages, youprobably lost at least 90% of your
(05:38):
insulin production capacity bythe time you get to stage three.
The hard thing about that is as you'recomparing it to like the development
of like a freckle into actual, likea nasty skin cancer, is that at least
skin cancer there is something visible.
Mm-hmm.
Type one development?
These stages really go unnoticed untilyou truly are at that stage three.
(06:02):
At stage three symptoms-- thirst, andgoing to the bathroom all the time.
For little, little kids, it's typicallylike many, many, many wet diapers compared
to what they normally would have, and likea thirst, or little littles who are just
irritable beyond anything that would benormal and there's no comforting them.
Yeah.
So I think that's, you know, infairness, it's like something that
(06:24):
has literally no visible outward--you don't get green spots or like,
you know, purple hair in your ear.
Yeah.
Until you hit, until you hit stage three.
You, you have no idea there'sa problem unless you've been
checking your glucose levels.
Sure.
And as you said, stage three, you start tourinate excessively 'cause when your blood
sugars hit, uh, you know, above 180 forperiods of time, now you start spilling
(06:48):
sugar in the urine and water's drawn withit, and you just pee your brains out.
Right.
And I remember when I was diagnosed,that's what was happening.
I, I couldn't drive 15 minuteswithout stopping my car and going,
you know, at a to a rest stopsomewhere and going to the bathroom.
Hundred percent.
You're thirsty.
You're thirsty, you're hungry.
I had lost a lot of weight too, becauseI couldn't burn glucose for fuel anymore.
(07:09):
It was just getting peed away.
Right.
What, what were your symptomslike when you were diagnosed?
No, I was gonna say the same thing.
I mean, I was an age where you don'treally like, you kind of are aware of
paying attention to things, but notso much that you're even gonna bring
it to the attention of your parents.
And I was, I couldn't wait between myclasses in school to run to the bubbler.
(07:34):
Okay.
Well, I live in the Midwest,so it's a bubbler here.
A bubbler?
It's, it's a waterfountain everywhere else.
Uh, but I couldn't wait between classesto actually run, get a drink before
I got like, into my next classroom.
Right?
And then I also couldn't wait for it toend because I had to go to the bathroom.
So it was like a decision.
It was like bathroom, stop at the at thewater fountain and then and then get to
(07:59):
class, and then at lunchtime, um, I had ahot lunch and would kind of encourage my
friends to take more than one milk becauseI was so thirsty and they were, you know,
happy friends, willing to do whatever.
Jenny just likes milk, and soI would consume like three or
(08:19):
four milk containers at lunch.
More than I would even eat myfood because it was so thirsty.
So, yeah and then, I mean, at thepoint that I was diagnosed, it was
the weekend of a dance recital.
And I again, was so thirsty.
I was chugging like gigantic,just containers of water.
I couldn't wait between our rehearsalsessions and everything and then the
(08:42):
morning of our actual dance, um, recital.
I woke up and my mom was like,there's clearly something wrong.
Like, I was so dizzy.
I was throwing up.
And so she called peds and theysent us right to the emergency room.
Um, my blood sugar was 865.
You remember the number?
I remember the number a hundred percent.
And you know, my only perceptionof diabetes at that point in
(09:05):
my life was my grandmother.
My mom's mom had type two.
She had been on insulin for a longtime, so had already seen somebody
taking insulin, but my very firstquestion to the doctors was, does
this mean I'm gonna look like grandma?
My grandma was a very large woman,also very tall, but just a very
robust woman and I thought thatthat was what diabetes looked like.
(09:29):
I was very worried that Iwas gonna look like grandma.
Right?
I dunno.
It's kind of a weird like, youknow, kid perspective on things.
Yeah.
So.
That's, that's the typical onsetof, of type one diabetes is
when all those symptoms show up.
Yeah.
And now, now we know moreabout how it develops.
We can identify these, not symptoms,but these characteristics earlier.
(09:52):
Right.
And yeah, I think you mentionedearlier on there hasn't been
much attention given to screening
No.
Until recently, 'cause therewasn't much we could do about it.
Right.
Well, and it kinda leads to like,who should be screened, right?
Mm-hmm.
Like who really, especiallyin the case of, you know, me.
I have nobody else in myfamily who has type one.
(10:14):
I don't know about you, butI'm the only, we have a host
of other autoimmune conditions.
We have rheumatoid arthritis.
We have a host of thyroid conditions,but no one else with type one.
So even, even at this day and age, Idon't know that my parents would've said,
Hey, let's screen for type one diabetes.
Because there was nohistory of it in our family.
(10:36):
Mm-hmm.
But it kind of leads the question of,like before understanding even what
it entails in terms of screening,like who should really be screened?
And I think because of the oddprevalence of it being in families
that have a history as well as a lotof people who don't have a history,
my personal and clinical is thateverybody should just get screened.
(10:57):
Like I don't think it's a hard thing tojust run a panel of antibodies and test.
Yeah.
There, there is a push on invarious medical associations to have
everybody screened for antibodiesthat cause type one diabetes.
And I should specify firstwhat those antibodies are.
Yeah.
The most common one is called GAD-65, GAD.
(11:19):
There's also one called a zinctransporter-8 antibody, and then
two others that are often found.
One is called insulin autoantibodies andanother is called insulinoma antigen-2.
So these all have acronyms that go alongwith them, but there's four primary
antibodies that tend to cause the body'simmune system to attack various aspects
(11:42):
of, of the insulin production process.
And I think of the insulin productionprocess, kind of like an assembly
line where you're building a car and,and if you pull one person or one
department off that assembly line, yougot cars rolling out that don't have
wheels, don't have a steering wheel,whatever, it's not a functional car.
Mm-hmm.
If you remove one aspect of how insulin isproduced or secreted, it's not gonna work.
(12:07):
So
Right.
Any of these antigens, uh, thatare present can lead to it.
So those, those are the four.
And you mentioned, yeah, it wouldbe nice if everyone got screened and
given the state of how health policyis leaning in this country right
now, it's very unlikely to happen.
Right.
So we're looking more at people who areat the highest risk, and if you have a
(12:30):
first degree blood relative with typeone diabetes, your risk is 15 times
higher to develop type one yourself.
15 times higher than inthe general population.
So it is absolutelyworth getting screened.
So that I would consider theprime population for screening.
And you mentioned other autoimmuneconditions, and that's a secondary.
(12:53):
So if you don't have a first degree familymember with type one, but you have other
autoimmune conditions like hypothyroid,hyperthyroid, celiac, psoriasis, vitiligo,
colitis, arthritis, there's a lot of otherhealth conditions that are autoimmune.
And autoimmune conditions tendto occur in packs, have one.
(13:16):
They like each other.
They do.
They like to hang out together.
So if you have one, you'relikely to develop more.
So that's a secondpopulation that's worth it.
If you have a family member withtype one and you also have an
autoimmune condition, you're just.
You're like a time bomb,you've gotta get screened.
Uh, they don't, they haven't calculatedthe actual risk, but it's really high.
(13:37):
Mm-hmm.
So we have a sense of, of whoshould be getting screened.
Ideally, it would be cost effective,I think, for everyone to get screened.
Just so we know and, and oncesomeone screens, if it's a child
and if they screen negative,yeah, they should probably get
rechecked in the next few years.
If it's an adult who, who screensnegative, they generally don't need
(13:59):
to be rechecked again unless theydevelop other autoimmune conditions.
Right.
So those are the populationswe're looking at getting screened.
And those are the antibodiesthey should get screened for.
Is there a, um, is there a beneficialage to consider screening relative to
understanding, as you mentioning age?
(14:21):
You know, kids at some point testnegative, they should probably at
some point get tested again, right?
Yeah.
With the consideration that,well, maybe they were negative and
maybe they will show up, right?
Yeah.
I think that's a, a hard and uneasyplace to kind of sit mentally.
Mm-hmm.
For many people because you think, oh,great, the tests were negative, but
is there still something that's gonnalike, almost like a switch that flips
(14:44):
and all of a sudden they're positive.
Yeah.
Versus the adults who maybe there isa long family history of something and
they get tested in their adulthood.
I guess, what's thedifference in age testing?
Yeah.
With kids, the most common timesfor type one to develop is between
four and seven, and again, betweenabout 10 and 12-- early adolescence.
(15:06):
Puberty.
Yeah.
Yeah, the, so even if you test negativeprior to those ages, you should get
screened again during those age groupingsjust to see if anything new has developed.
But don't forget, more than half of typeone diabetes is diagnosed in adults.
So adults need to be just as wary of this.
As parents of children do, so adultswho have a first degree relative,
(15:30):
whether it's a child or a sibling,or even a parent with type one,
should also be getting screened.
You could be 48 yearsold, have no symptoms.
But if you have a child with typeone or your brother has type one,
you should get yourself screened.
Right.
Because if those antibodies are presentnow you need to be on the lookout and
we'll talk, there are a lot of thingsyou can do to prevent it from developing.
(15:54):
Right.
So if you do, I guess, have somebodyin your family who has type one,
you now know about screening.
What?
What does screening involve?
What?
Who do you go to?
How do you do it?
What do you do with the information?
Like what are the steps involvedin the actual screening process?
Sure.
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And now back to our program.
Yeah, there's two differentways people can get screened.
Uh, one is just a blood test.
(16:56):
So when you have your annual lab workdone, you know, when they check for
cholesterol and all that other goodstuff, you know, just have them add
on these, uh, they call 'em isletantibody tests, the four antibodies
that they look for in most major labs.
You know, LabCorp Quest?
They all do this, uh, this testing.
So that's, that's the mostcommon way that it's done.
(17:18):
But there is also the possibilityof doing a home screening.
You can order kits from an organizationlike TrialNet or ASK (A-S-K).
They provide free homescreenings that people can do.
And it just involves doing afinger prick and following the
instructions that come with the kit.
You mail it in.
You get the results a few weeks later, butthe home kits aren't quite as complete.
(17:41):
They don't usually check all four.
They might check only two orthree, but it's, it's a still
relatively easy way to get it done.
My thinking is if you're gonna haveblood drawn anyway, just add it to
the list of things they're checking.
There's
yeah.
No harm, no foul in doing that.
It's no added inconvenienceor anything like that.
I think it also begs the, if you'regonna get it done through a lab, let's
(18:04):
say your doctor is willing to orderthe tests for you, I think it's really
important that that doctor then know howto talk to about what the results are.
Mm-hmm.
Right?
Because if you just have yourregular primary care doctor,
your regular pediatrician,sure they can write the order.
Maybe it gets covered by insurance andyou get them done, but then you get
(18:25):
these results and having somebody canreally talk to you and then direct you
in into the right next navigation point.
I think that's very valuable.
Yeah.
And, and it's rare to find a primarycare provider, whether it's a
pediatrician or internal medicine.
They, they really don'tknow the nuances of this.
And the best they can do for youis just agree to order the tests.
(18:48):
Yeah.
And, you know, as, as patients, wejust have to demand it and say, I want
this test done, add it to my lab work.
Right.
Uh, but once that, you know, once youget tested, if you do test positive
for antibodies, you should ask fora referral to a diabetes specialist.
They're the people that can help.
Endocrin.
Yeah.
Um, and again, that might evenbe depending on where you are,
your area endocrine practicesare certainly shorthanded, um, in
(19:14):
terms of their time and ability.
So it is something that's importantto get in as soon as possible with
positive results of any of theseantibodies because time is kind of a key.
Mm-hmm.
In navigating whetheryou're positive or negative.
So
yeah,
negative, as we talkedabout before, great.
(19:35):
I was negative.
I might be, have been a kid, I'll getit tested again at some point, you know?
Mm-hmm.
I was an adult.
I'm negative maybe, or maybe not.
Will I ever test again, right?
Yeah.
And a negative test hasbenefits, you know, people
It does.
Are worried.
They're concerned.
Oh, is my child... is my,you know... ah my parent?
Are these people gonna develop Type one?
(19:56):
And as a person who's getting tested, youalso, you worry, am I gonna get type one?
Sure.
Testing negative for the antibodies?
It's a tremendous weight offyour shoulders 'cause it's very
unlikely it's gonna develop.
Not impossible, but it'svery unlikely at that point.
Right.
So there's a lot of value ina negative screening just for
peace of mind if nothing else.
(20:18):
What about the benefits of getting thescreening and the positive results?
What, like, what do youthink are the positives?
That's even, that's evenmore beneficial now.
Technically a positive screening means youhave two or more antibodies, not just one.
If you have one and you know,the titer is not real huge,
it could go away on its own.
(20:38):
Sometimes antibodiesshow up just temporarily.
They fade.
If you have two or more, thechances of you going on to develop
type one are very, very high.
And I'll, I'll share some ofthe stats with you about this
'cause it, it's astounding.
If you have two or more antibodies,I think the chances of you
developing type one within thenext five years is close to 50%.
(21:03):
And in 15 years it's, it, it'sapproaching a hundred percent.
It's, it's pretty much a done deal.
It's not, will it happen?
It's just, when is it gonna happen?
You're gonna develop type one.
So what that does is it empowers you.
So now it's like, all right,your, your dermatologist has
detected this potentiallyproblematic thing on your skin.
(21:25):
We can biopsy it.
We can see if it needs to be removed,and if so, it can be removed.
In the diabetes case, there are a,a multitude of strategies that we
can apply first to monitor ourselvesand catch it when it's starting
to progress to the next stage.
Sure.
Because, you know, youcaught it at stage one.
I mean, you're in a great position now.
(21:46):
You can monitor your glucose, whetherit's through finger sticks or using a
CGM once in a while, and, and some peoplecan even get over the counter CGMs and
use 'em maybe once every few months justto see what your patterns look like.
And you know, if you're starting tosee, you know, fasting blood sugars
creep in north of a hundred, or you'reseeing post-meal blood sugars that are
(22:08):
up in the above 140 on a semi-regularbasis, that means you're, you're in
stage two things have progressed.
Mm-hmm.
And you know, whether you're at stage oneor stage two, there's a lot of lifestyle
type things that a person can do.
Right.
And at stage two, there aremedications that can actually
be used to slow the progression.
(22:29):
And you're gonna love this sinceyou're a dietician, and I know
you're really into fitness, butthe things we do from a lifestyle
standpoint to delay the progressionof diabetes are the same things we
do for managing type two diabetes.
Right, they're.
These are things that I, I call thembeta cell bubble wrap strategies.
Yes.
These are things that ease the workloadon our pancreas that make our bodies.
(22:53):
More sensitive to insulin.
Mm-hmm.
That includes keepingour weight under control.
Yep.
Excess body fat causes insulinresistance, so losing some body fat helps.
And what adds to that?
Exercise or movement in your day, right?
Yes.
I mean, that's a big piece of it.
It's the most powerful way to improveinsulin sensitivity is physical activity.
(23:16):
Mm-hmm.
Cardio exercise in particular atthis stage is really beneficial.
Mm-hmm.
Strength training helps, but not asmuch as the cardio exercise does.
And from a food intake standpoint, justlooking at the nature of one's diet.
We don't have to avoid sugars.
We don't have to avoid carbs.
We wanna just try to modify or moderatethe amounts and not eat ex, you know,
(23:37):
huge amounts of carbohydrates andtry to choose the kinds of carbs that
are friendlier, that don't spike ourblood sugar all at once, but are more
slow and evenly digested and absorbed.
Right.
And your diet is full of those, Jenny.
I know that.
I try most of the time.
Yes.
And I, I think something that is behindboth of these pieces, these lifestyle
(24:01):
changes, is the ability to get in withsomebody who, at this stage can direct
you for how to make these changes, right?
It's not the rip-off page from justa doctor telling you to go take
a walk and stop eating sugar orputting it in your coffee, right?
Is really some very strategicand very individualized.
(24:23):
There's value to seeking out workingwith an educator even at this stage.
Because they could be somebody who helpsyou to preserve these beta cells even
more, sort of better bubble wrap, right?
Not the generic version, but the actualbrand name version of the bubble wrap.
And if you're, if you wanna get the mostbang out of this time period of delay
(24:47):
then working with somebody who can reallyindividualize and say, well, goodness,
you could stop drinking juice and havewater in the morning for breakfast, right?
You could change this up slightly.
You could make theseadjustments to things, um, even
oatmeal instead of BooBerry.
There you go.
Oatmeal instead of Boo-berry orFrankenberry or Choco, Count Choccula.
(25:08):
Right?
Exactly.
I mean, there are little strategicchanges that don't have to be major
in terms of the person's changes.
Yeah.
I learned that sweet potatoesare such-- so much slower at than
white potatoes at raising bloodsugar, that's a, a better choice.
And even the method ofpreparation of food.
I mean, you can get into the nitty grittyof discussion truly, but it is food and
(25:33):
activity are huge in terms of preservationand proper body metabolic response.
The better that you can do with realwhole unprocessed food at this stage?
The more potential preservationtime you're going to have.
And a lot of the things we teachpeople with type two to, to manage
better and avoid further, youknow, loss of their own beta cells.
(25:56):
You know, things like managingstress levels because stress hormones
kind of block insulin's actions.
They work against it.
Right.
Getting quality sleep canmake a big difference as well.
We produce, you know, cortisol,these other stress hormones
when we don't sleep well.
And, you know, avoiding, um, medicationslike steroid meds, prednisone,
(26:18):
cortisone, whenever possible.
If possible.
Those create tremendousinsulin resistance.
So, you know, just these kindalifestyle choices can make an enormous
difference in terms of, you know, howlong is it gonna take for the type
one diabetes to progress and developinto symptomatic type one that's gonna
require intensive insulin therapy?
(26:40):
And in some cases it's even possible--some people avoid it entirely.
It never develops.
Right.
So there is that opportunity as well.
So at this stage, is there ever aconsideration of using even a minor
amount of background, what we referto as basal long-acting insulin?
Mm-hmm.
For some people just to take alittle of the stress off of the beta
(27:00):
cells and preserve them longer too?
Yeah, that was studied decades ago.
They thought that, you know,bringing in the cavalry.
Let's bring some fresh outside insulin in.
Yeah, they actuallydidn't find that to help.
They didn't-- it didn't seemto slow the progression.
Okay.
But there are other medicationsnow they found that can.
These are medications thatare sometimes used in people
(27:21):
who receive organ transplants.
They help to suppress the immunesystem so that the beta cells aren't
being attacked so vociferously.
Sure.
It eases up on the attack.
And one of them, uh, it's calledTZIELD, generic, is called
tocilizumab, that's approved for usein stage two of type one diabetes.
The trial, the pivotal trials that wererun on that showed about a two and a half
(27:44):
year average delay in the developmentof type one from taking this medication.
It's not as, it's not as strong asthe doses and length that are used for
people who receive organ transplants.
People get organ transplants,they have to take high doses
of this stuff for a lifetime.
Sure.
In this case, the, the, the TZIELD's onlyadministered for two weeks, et cetera.
(28:05):
You know, relatively low dose.
But it's still, that alone had thepower to delay, by an average of two
and a half years, the progressionto stage three type one diabetes.
Has that been extended at allnow with, I mean, TZIELD has been
available now for a bit of time?
Has that like two, two and a halfyears, have they shown actual
(28:27):
progression for longer preservationand sort of delay in diagnosis?
It will.
They are doing ongoing studieson people and who are involved
in the research, okay?
They most likely will find alonger extension type delay,
but what they also have done isthey've studied it at stage three.
(28:48):
They studied it, people, okay,you're at stage three, you're
peeing, you're drinking, et cetera.
Let's do it now and see what happens.
And the studies, the publisheddata is very favorable.
It does preserve insulin productioncapability by the pancreas.
It's not yet approvedfor use in stage three.
That's still coming.
(29:09):
Sure.
But the progress is good.
And that's wonderful progressmainly because, if even diagnosis is
made, the potential of preservationmeans not as difficult to navigate.
Not as much insulin is needed.
More potential backgroundassistance from those beta cells.
(29:29):
I mean, there's even the long term,you know, we always talk about
complications and the prevention ofcomplications once you have diabetes.
My understanding is also that the betterunderlying beta reserve, it's a reason
that people who are diagnosed as anadult often tend, with good management,
to not be as, I guess there's not asmuch potential for complications, right?
(29:54):
Yeah, that's right.
And we, Jenny, we both see, occasionally,we get lucky and get a patient
who's still in that honeymoon phase
Yes.
Of their diabetes and theirpancreas still produces even
just a little bit of insulin.
It makes their glucose managementa thousand times easier.
It does.
You know, they can usually just takea, a long acting insulin at a low
dose, maybe an occasional meal dose,but their blood sugars barely budge.
(30:18):
They stay within target zonespretty consistently without a
whole lot of work they have to do.
Yeah.
That's, that's the honeymoon.
It's a beautiful time.
I didn't get a honeymoonwhen I was diagnosed.
I had gone the entire summer just peeingand drinking and eating and losing weight.
My beta cells were dead on arrival and itwas a miracle I was not in ketoacidosis.
(30:43):
'cause most people are in DKA.
Oh, I was.
When they go that long at diag-- yeah.
And when you get to that point, you don'thave much beta cell function left anymore.
And I wish someone could have toldme months or years before that I
had the antibodies and this couldhave been happening 'cause I could
have had that prolonged honeymoon.
(31:04):
I
Sure.
And what happens is if people arediagnosed at stage three and they
still have a decent amount of, ofinsulin production in their body,
that honeymoon can go on for years.
You've seen cases where itgoes on almost indefinitely.
They, they just neverget past the honeymoon.
I mean, rarely that happens.
Now you marry somebody and thehoneymoon just lasts forever.
(31:25):
But yeah, that's not usually the case.
Usually, yeah, you get a week, amonth maybe, hey, wonder, everything's
wonderful, and then the reality of,of living with someone 24 7 kicks in.
But there are people who have thathoneymoon that just goes on and on and
on, and, and that's one of the benefits of
Sure.
Early detection.
You catch it early.
You do the things to keep the betacells functioning as long as possible,
(31:50):
and there's enough of them stillfunctioning even when you get to stage
three that they keep functioning.
Yeah.
And you have that easier managementthat that nice glucose control
that can go on for years.
Right.
And as you said, not only is lifeeasier, but you've just sharply reduced
your risk for long-term complications.
Yeah, no, it's, I mean, in terms of thepositive sort of results, I think there's
(32:14):
also the ability to prepare for what,you know, like it gives you educational
opportunities early on to dig forinformation, to look for even studies,
to look for things to be able to do.
And to prepare family members to beable to educate a little bit better.
And if it's for a child, getting themin on that education early and the
(32:38):
idea of what this might look like.
It's just a, it's almost like aneasing your way into rather than a very
rapid, emergent room kind of diagnosiswhere, oh gosh, here we're throwing
this all at you and you had no idea.
Yeah.
The incidence of DKA in people who gotscreened for antibodies is minimal.
(33:00):
Minimal.
It's very, very low.
It's close to 50% in peoplewho didn't get screened.
Yeah.
And DKA is no laughing matter.
It can be fatal.
And by that point you've destroyed, uh,you know, almost all your beta cell mass.
You're not gonna have much of ahoneymoon at that point, if any.
Like me, I had none whatsoever.
So, yeah.
(33:20):
The screening is extremely valuable.
It certainly sounds like it'sa, a good reason to screen.
I know that I talk about it withall of the clients that I have the
opportunity to work with you know,within the Integrated Diabetes practice.
Even a number of families who've had a--other children in their family screened.
Um, and you know, I think there'salso something to not only screening
(33:43):
and some of the therapies likethe Tzeild that you talked about.
Not everything works for everybody.
Right?
Right.
So there are these positive thingsthat could come from screening, but
there's also the consideration that...I've had one family who I worked with
for their younger child and theirolder, um kids also got screened.
One who was completely negative,the other one who had antibodies did
(34:05):
the Tzield, and it really didn't doanything in the preservation long term.
But what I do see is a difference inbetween those two kiddos was the one
that did do the Tzield despite not havinga delay in type one diabetes-- true
development, that's stage three, themanagement for that child is, as we talked
(34:27):
about, it, is so much easier than it isfor the younger child in that family.
So much easier.
And I expect that it is because theTzield had an impact on the betas that
were there, would be my expectation.
Mm-hmm.
And just gives an easieroverall navigation.
So again, all these therapies,they're not a hundred percent perfect
(34:49):
to any, everybody but... Yeah.
I recognize it's an emotional decision.
It is.
To have a blood relative screenedor if you have a blood relative
to get yourself screened.
Yeah.
It's an emotional decision.
Yeah.
Because you know you're finding outabout a potential serious health issue.
But that's why I, I like to put itin that skin cancer screening term.
(35:10):
Yeah.
Uh, if, if you get screenedand you're negative, great.
Relax, enjoy yourself.
Right.
If you do screen positive, you cantake pro, you can be proactive.
At that point, you're notsticking your head in the sand.
Right.
You can do things to keep yourselfhealthy and vibrant for a long, long time.
Even if it's just the lifestylestuff without any medical
(35:31):
true intervention, right?
Or or just monitoring yourselfonce in a while so you catch it
before it's at stage, you know?
Yeah.
Did you, I mean, you've got kiddos.
Did you and your wife decide to doany, they're adults now, I know.
Mm-hmm.
But did you when they were younger, orhave they decided now as more adults
(35:52):
on their own decision making tree?
Did they decide to do anything?
Well, when they were young enoughthat I had to some degree of control
over them, which I don't anymore, no,I didn't because I felt, well, what?
What do I wanna know for?
There's nothing I can do aboutit even if they test positive.
And when they finally grew up andnow they're all in their twenties,
(36:13):
and I have no control over themnow I want them to be screened.
So I provided them all with theinformation to get screened.
I highly recommended as in like, I'mcutting you out of the will if you
don't get screened, that sort of thing.
And it's up to them now.
I can't force them to, but I stronglyencourage them to get themselves screened.
Yeah.
(36:33):
I mean, my kiddos, um, were also,as I said before, like we're like
probably a few years, three tofive years, into really having some
viable options from what has comeout of the potential for screening.
So years ago when they wereyounger, we decided to not screen.
Right now we do very regular,like just finger sticks.
(36:56):
My kids actually like doing it.
They like to wait fortheir number to pop up.
Being an educator and knowing thesigns and symptoms very well, we
pay very close attention to anychanges or anything like that.
But because, I mean, it is actuallya conversation that we've had more
recently is at this stage there are somethings that we could potentially do.
(37:17):
My kids are old enoughfor some of these things.
So it is in the discussion of now,should we, and they're also of the age
of understanding what that might meanand to be able to have that discussion
and even changing, I mean, as adietician, I'm kind of like the mom
who doesn't let them do a lot of thethings that their friends get to do.
(37:39):
Like they don't get candy intheir lunchboxes and they don't
get a treat after dinner justbecause it's after dinner and
it's time for dessert or whatever.
Mm-hmm.
Like I'm that mom and I willentirely a hundred percent own
that it's keeping my kids healthy.
Mm-hmm.
But in understanding, if we did dotesting, the idea that they would, they
would need to understand what that means.
(38:00):
And then results, resultdependent, what that would mean
for some of those lifestylechanges that we may need to make.
I mean, my kids are active.
I don't think I could make them anymore active than they actually are.
I mean, you know how active my kids are.
Yeah.
I played soccer with your kids lastweekend, and man was I sore afterwards.
They ran me ragged.
(38:21):
Yeah, they're, um, they are just,they're just athletic, both of them
in their own way and, and food?
You know, we do a really greatjob outside of like the birthday
party or going on vacation wherethings get a little bit off.
In general, that part isalready really well navigated.
So again, from a testing standpoint,it's now there are things, so now
(38:44):
there's a bigger discussion foractually going forward with that.
Whereas before, I didn't.
I respect that.
I respect that entirely.
Now, this is a very individual, personal--it's type of a decision to make.
I just, I'm, I'm glad to have thisopportunity so that people who
listen can make an informed decision.
There's
absolutely.
I want to, I want to get around themisinformation that might be out there.
(39:06):
Let people know, we're letting peopleknow about the latest research,
the actual science behind this.
Uh, and
yeah.
There is a lot of potentialvalue to screening.
Mm-hmm.
And I think we went through prettyclearly, and, uh, I encourage
everybody to think, consider itand, and make an informed decision
that's in your best interest.
No, a hundred percent agreed.
(39:27):
I think I, it was greatto go over everything.
All of the available options.
What the testing, the screeningkind of looks like, because I think
even with it being very easy, soto speak, to access at this point.
Mm-hmm.
Understanding what would thescreening process look like,
and then what can I do about it?
Mm-hmm.
Who do I need to address?
If the results are positive,what would that mean?
(39:50):
And the individual nature ofdeciding it is and should be
a family discussion decision.
No one person in that family situationshould really make the decision because
then they may have to house thatdecision themselves, and that can be
very difficult for one individual.
So it has to be an agreed uponall around decision to go forward.
(40:12):
Agreed, agreed.
Understand what you're gonna do.
The re... the supportout there is not great.
I admit that.
I mentioned primary care.
They, they don't, they knowvery little about this and
Right.
Even in endocrinology care, there's,there's not a lot that really
understand this whole process and
No.
And testing and how to mitigatethe, the progression, et cetera.
(40:33):
So I have a batch of clients nowwho are family members of our
patients who don't have type one,at least symptomatic type one yet.
Right.
But they tested positive forantibodies, so we're, we're teaching
them all they can do to slow theprogress so folks can reach out to us.
Yep.
If they have questions or if they wantassistance, you know, they can contact
absolutely.
Integrated diabetes and we'llbe happy to work with them.
(40:54):
That's what we are absolutely here for.
So thank you so much.
What a really important topic todiscuss and be able to put out there.
I mean, we're almost, we'rejust the beginning of October.
National Diabetes Monthis November, right?
Yeah.
So hopefully more information, youknow, certainly will help within that
whole month of not celebrating, butreally highlighting diabetes navigation.
(41:17):
This is fantastic.
Again, if you are looking formore information, more handholding
through this whole process oftesting, understanding, maybe some
life changes, please let us know.
Integrated Diabetes Services hasa host of clinicians that... very
knowledgeable, can absolutely andvery happily help you on your journey.
Thanks for tuning in to ThinkLike A Pancreas, The Podcast.
(41:40):
If you enjoyed today's episode,don't forget to like, follow, or
subscribe on your favorite podcast app.
Think Like a Pancreas-- The Podcast isbrought to you by Integrated Diabetes
Services where experience meets expertise,passion meets compassion, and diabetes
care is personal because we live it too.
(42:00):
Our team of clinicians all livingwith type one diabetes understands
the challenges firsthand.
We're here to help no matterwhere you are in the world.
From glucose management to self-carestrategies, the latest tech,
sports and exercise, weight loss,type one pregnancy, and emotional
wellbeing, we've got you covered.
(42:20):
We offer consultations inEnglish and Spanish via phone,
video, chat, email and text.
Wanna learn more?
Visit integrated diabetes.com oremail info@integrateddiabetes.com
to schedule a consultation.
On behalf of Think Likea Pancreas, The Podcast.
I'm Gary Scheiner wishing you afantastic week ahead, and don't
(42:42):
forget to think like a pancreas.
Welcome to Think Like a Pancreas,The Podcast where our goal is to keep
you informed, inspired, and a littleentertained on all things diabetes.
The information contained in thisprogram is based on the experience
and opinions of the IntegratedDiabetes Services clinical team.
Please discuss any changes to yourtreatment plan with your personal
(00:34):
healthcare provider before implementing.
Hello today I am super excited to be thehost of our wonderful podcast, Think Like
A Pancreas, and we're gonna be discussinga really, really important topic today.
Kinda the whys and hows ofscreening for Type one Diabetes.
And I am Jennifer Smith.
I'm Director of Lifestyle and Nutritionwith Integrated Diabetes Services.
(00:57):
And I'm glad to be joined by one ofthe people who knows an awful lot
about screening for T1D, Gary Scheiner.
Yay.
Hi Gary.
Hey Jenny.
I am thrilled to not have to host.
I love being a guest.
Uh, 'cause I don't have toremember or do anything special.
I can just answer questions.
My job's easy.
You got the hard job today.
(01:18):
Not really.
So, you know, it's all good.
I think a lot of people... we've had alot more information about screening--
I don't know, what would you say?
In the past five years?
It's become much more visible and thebenefits of it are being explained,
but I think something behind it, andthe reason for screening, really starts
(01:38):
with the stages of developing type one.
And we know that at, kindof the last stage is usually
the diagnostic stage, right?
Where we don't really know whatwas going on ahead of time.
And now with screening we have theability to actually see where are you.
What stage could you possibly be.
Tell us about the stages of screening.
(02:00):
How are the... even the stages ofdeveloping type one that kind of go
into, maybe where you're thinking aboutscreening your family member or child.
Yeah.
It's, it's analogous in many waysto doing checks for skin cancer.
Um, 'cause now when, you know, skincancer's caught very early on, it's
usually pretty easy to treat, right?
(02:20):
There's special procedures thatthey just remove a few of the upper
layers of skin in a local area.
It's, and it's gone.
Yeah.
Uh, you know, if it has a chanceto permeate deeper and spread,
it can be lethal, not just
Right.
Debilitating.
And with type one diabetes, there area number of antibodies that develop
and show up in, in the bloodstream
(02:42):
mm-hmm.
That are the precursor to developingsymptomatic type one diabetes.
Right.
There's, there's threestages to the development.
The first stage is just theappearance of the antibodies.
The blood sugar levelsare perfectly normal.
The pancreas still puts out areasonable amount of insulin.
So if you were to check yourblood sugar after eating a box of
(03:04):
Twinkies, it'll be perfectly normal--or a box of BooBerry, whatever.
So stage one is completely no symptoms.
You'd never know type one waseven in development if you didn't
know the antibodies were present.
And thus, if you're a family that doesn'thave type one at all, you wouldn't
(03:25):
even think about screening mainlybecause there would be no symptoms.
It's almost like an underlying coldwhere you don't really have the symptoms
yet, and then you finally do, andthen you really feel like crud, right?
Yeah.
Yeah.
That's something that's sortof in the mix, but you really
don't know until you do testing.
So.
Yeah.
(03:45):
Or in, in the skin issue, it wouldbe like having just a tiny freckle.
I mean, there's nothing to worry about.
It's normal.
You get these all the time.
Yeah.
Yeah.
So, so stage one, you know,you're, other than these antibodies
being in your bloodstream, you'reperfectly healthy and normal.
Nothing unusual.
So stage two is when the blood sugarlevels start to decay a little bit.
(04:08):
Uh, the pancreas is being attacked bythe body's immune system, and you've lost
some of the ability to produce insulin.
Mm-hmm.
But not enough for the blood sugarsto go super high and cause the
symptoms we're used to seeing.
So the only way to know you're at stagetwo is by doing blood sugar checks.
(04:29):
Sure.
I mean, whether it's a lab test, um,glucose tolerance test, or finger
sticks, or an A1C or even using aCGM, you'd have to be checking the
blood sugar levels, it's, in someway to know you're at stage two.
And typically at this stage, thefasting, the wake up readings might
just be a little above a hundred.
The after meal readings might be inthe mid to high hundreds, but then
(04:53):
they usually come back down again.
Mm-hmm.
So this is called a, astate of dysglycemia.
The blood sugars are not quitenormal, however, they're not so
high that the symptoms show up.
And that's stage three.
Stage three is when most peopleare diagnosed with type one.
They're already at stage three.
So you've gone from the point of a littlefreckle at stage one to kind of a larger,
(05:18):
odd shaped spot on the skin at stage two.
At stage three is when you have fulldeep skin cancer at, at that point.
But in this case, the pancreasnow just, it can't keep up.
It, it's unable to makenearly enough insulin anymore.
Mm-hmm.
Um, I mean, in percentages, youprobably lost at least 90% of your
(05:38):
insulin production capacity bythe time you get to stage three.
The hard thing about that is as you'recomparing it to like the development
of like a freckle into actual, likea nasty skin cancer, is that at least
skin cancer there is something visible.
Mm-hmm.
Type one development?
These stages really go unnoticed untilyou truly are at that stage three.
(06:02):
At stage three symptoms-- thirst, andgoing to the bathroom all the time.
For little, little kids, it's typicallylike many, many, many wet diapers compared
to what they normally would have, and likea thirst, or little littles who are just
irritable beyond anything that would benormal and there's no comforting them.
Yeah.
So I think that's, you know, infairness, it's like something that
(06:24):
has literally no visible outward--you don't get green spots or like,
you know, purple hair in your ear.
Yeah.
Until you hit, until you hit stage three.
You, you have no idea there'sa problem unless you've been
checking your glucose levels.
Sure.
And as you said, stage three, you start tourinate excessively 'cause when your blood
sugars hit, uh, you know, above 180 forperiods of time, now you start spilling
(06:48):
sugar in the urine and water's drawn withit, and you just pee your brains out.
Right.
And I remember when I was diagnosed,that's what was happening.
I, I couldn't drive 15 minuteswithout stopping my car and going,
you know, at a to a rest stopsomewhere and going to the bathroom.
Hundred percent.
You're thirsty.
You're thirsty, you're hungry.
I had lost a lot of weight too, becauseI couldn't burn glucose for fuel anymore.
(07:09):
It was just getting peed away.
Right.
What, what were your symptomslike when you were diagnosed?
No, I was gonna say the same thing.
I mean, I was an age where you don'treally like, you kind of are aware of
paying attention to things, but notso much that you're even gonna bring
it to the attention of your parents.
And I was, I couldn't wait between myclasses in school to run to the bubbler.
(07:34):
Okay.
Well, I live in the Midwest,so it's a bubbler here.
A bubbler?
It's, it's a waterfountain everywhere else.
Uh, but I couldn't wait between classesto actually run, get a drink before
I got like, into my next classroom.
Right?
And then I also couldn't wait for it toend because I had to go to the bathroom.
So it was like a decision.
It was like bathroom, stop at the at thewater fountain and then and then get to
(07:59):
class, and then at lunchtime, um, I had ahot lunch and would kind of encourage my
friends to take more than one milk becauseI was so thirsty and they were, you know,
happy friends, willing to do whatever.
Jenny just likes milk, and soI would consume like three or
(08:19):
four milk containers at lunch.
More than I would even eat myfood because it was so thirsty.
So, yeah and then, I mean, at thepoint that I was diagnosed, it was
the weekend of a dance recital.
And I again, was so thirsty.
I was chugging like gigantic,just containers of water.
I couldn't wait between our rehearsalsessions and everything and then the
(08:42):
morning of our actual dance, um, recital.
I woke up and my mom was like,there's clearly something wrong.
Like, I was so dizzy.
I was throwing up.
And so she called peds and theysent us right to the emergency room.
Um, my blood sugar was 865.
You remember the number?
I remember the number a hundred percent.
And you know, my only perceptionof diabetes at that point in
(09:05):
my life was my grandmother.
My mom's mom had type two.
She had been on insulin for a longtime, so had already seen somebody
taking insulin, but my very firstquestion to the doctors was, does
this mean I'm gonna look like grandma?
My grandma was a very large woman,also very tall, but just a very
robust woman and I thought thatthat was what diabetes looked like.
(09:29):
I was very worried that Iwas gonna look like grandma.
Right?
I dunno.
It's kind of a weird like, youknow, kid perspective on things.
Yeah.
So.
That's, that's the typical onsetof, of type one diabetes is
when all those symptoms show up.
Yeah.
And now, now we know moreabout how it develops.
We can identify these, not symptoms,but these characteristics earlier.
(09:52):
Right.
And yeah, I think you mentionedearlier on there hasn't been
much attention given to screening
No.
Until recently, 'cause therewasn't much we could do about it.
Right.
Well, and it kinda leads to like,who should be screened, right?
Mm-hmm.
Like who really, especiallyin the case of, you know, me.
I have nobody else in myfamily who has type one.
(10:14):
I don't know about you, butI'm the only, we have a host
of other autoimmune conditions.
We have rheumatoid arthritis.
We have a host of thyroid conditions,but no one else with type one.
So even, even at this day and age, Idon't know that my parents would've said,
Hey, let's screen for type one diabetes.
Because there was nohistory of it in our family.
(10:36):
Mm-hmm.
But it kind of leads the question of,like before understanding even what
it entails in terms of screening,like who should really be screened?
And I think because of the oddprevalence of it being in families
that have a history as well as a lotof people who don't have a history,
my personal and clinical is thateverybody should just get screened.
(10:57):
Like I don't think it's a hard thing tojust run a panel of antibodies and test.
Yeah.
There, there is a push on invarious medical associations to have
everybody screened for antibodiesthat cause type one diabetes.
And I should specify firstwhat those antibodies are.
Yeah.
The most common one is called GAD-65, GAD.
(11:19):
There's also one called a zinctransporter-8 antibody, and then
two others that are often found.
One is called insulin autoantibodies andanother is called insulinoma antigen-2.
So these all have acronyms that go alongwith them, but there's four primary
antibodies that tend to cause the body'simmune system to attack various aspects
(11:42):
of, of the insulin production process.
And I think of the insulin productionprocess, kind of like an assembly
line where you're building a car and,and if you pull one person or one
department off that assembly line, yougot cars rolling out that don't have
wheels, don't have a steering wheel,whatever, it's not a functional car.
Mm-hmm.
If you remove one aspect of how insulin isproduced or secreted, it's not gonna work.
(12:07):
So
Right.
Any of these antigens, uh, thatare present can lead to it.
So those, those are the four.
And you mentioned, yeah, it wouldbe nice if everyone got screened and
given the state of how health policyis leaning in this country right
now, it's very unlikely to happen.
Right.
So we're looking more at people who areat the highest risk, and if you have a
(12:30):
first degree blood relative with typeone diabetes, your risk is 15 times
higher to develop type one yourself.
15 times higher than inthe general population.
So it is absolutelyworth getting screened.
So that I would consider theprime population for screening.
And you mentioned other autoimmuneconditions, and that's a secondary.
(12:53):
So if you don't have a first degree familymember with type one, but you have other
autoimmune conditions like hypothyroid,hyperthyroid, celiac, psoriasis, vitiligo,
colitis, arthritis, there's a lot of otherhealth conditions that are autoimmune.
And autoimmune conditions tendto occur in packs, have one.
(13:16):
They like each other.
They do.
They like to hang out together.
So if you have one, you'relikely to develop more.
So that's a secondpopulation that's worth it.
If you have a family member withtype one and you also have an
autoimmune condition, you're just.
You're like a time bomb,you've gotta get screened.
Uh, they don't, they haven't calculatedthe actual risk, but it's really high.
(13:37):
Mm-hmm.
So we have a sense of, of whoshould be getting screened.
Ideally, it would be cost effective,I think, for everyone to get screened.
Just so we know and, and oncesomeone screens, if it's a child
and if they screen negative,yeah, they should probably get
rechecked in the next few years.
If it's an adult who, who screensnegative, they generally don't need
(13:59):
to be rechecked again unless theydevelop other autoimmune conditions.
Right.
So those are the populationswe're looking at getting screened.
And those are the antibodiesthey should get screened for.
Is there a, um, is there a beneficialage to consider screening relative to
understanding, as you mentioning age?
(14:21):
You know, kids at some point testnegative, they should probably at
some point get tested again, right?
Yeah.
With the consideration that,well, maybe they were negative and
maybe they will show up, right?
Yeah.
I think that's a, a hard and uneasyplace to kind of sit mentally.
Mm-hmm.
For many people because you think, oh,great, the tests were negative, but
is there still something that's gonnalike, almost like a switch that flips
(14:44):
and all of a sudden they're positive.
Yeah.
Versus the adults who maybe there isa long family history of something and
they get tested in their adulthood.
I guess, what's thedifference in age testing?
Yeah.
With kids, the most common timesfor type one to develop is between
four and seven, and again, betweenabout 10 and 12-- early adolescence.
(15:06):
Puberty.
Yeah.
Yeah, the, so even if you test negativeprior to those ages, you should get
screened again during those age groupingsjust to see if anything new has developed.
But don't forget, more than half of typeone diabetes is diagnosed in adults.
So adults need to be just as wary of this.
As parents of children do, so adultswho have a first degree relative,
(15:30):
whether it's a child or a sibling,or even a parent with type one,
should also be getting screened.
You could be 48 yearsold, have no symptoms.
But if you have a child with typeone or your brother has type one,
you should get yourself screened.
Right.
Because if those antibodies are presentnow you need to be on the lookout and
we'll talk, there are a lot of thingsyou can do to prevent it from developing.
(15:54):
Right.
So if you do, I guess, have somebodyin your family who has type one,
you now know about screening.
What?
What does screening involve?
What?
Who do you go to?
How do you do it?
What do you do with the information?
Like what are the steps involvedin the actual screening process?
Sure.
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And now back to our program.
Yeah, there's two differentways people can get screened.
Uh, one is just a blood test.
(16:56):
So when you have your annual lab workdone, you know, when they check for
cholesterol and all that other goodstuff, you know, just have them add
on these, uh, they call 'em isletantibody tests, the four antibodies
that they look for in most major labs.
You know, LabCorp Quest?
They all do this, uh, this testing.
So that's, that's the mostcommon way that it's done.
(17:18):
But there is also the possibilityof doing a home screening.
You can order kits from an organizationlike TrialNet or ASK (A-S-K).
They provide free homescreenings that people can do.
And it just involves doing afinger prick and following the
instructions that come with the kit.
You mail it in.
You get the results a few weeks later, butthe home kits aren't quite as complete.
(17:41):
They don't usually check all four.
They might check only two orthree, but it's, it's a still
relatively easy way to get it done.
My thinking is if you're gonna haveblood drawn anyway, just add it to
the list of things they're checking.
There's
yeah.
No harm, no foul in doing that.
It's no added inconvenienceor anything like that.
I think it also begs the, if you'regonna get it done through a lab, let's
(18:04):
say your doctor is willing to orderthe tests for you, I think it's really
important that that doctor then know howto talk to about what the results are.
Mm-hmm.
Right?
Because if you just have yourregular primary care doctor,
your regular pediatrician,sure they can write the order.
Maybe it gets covered by insurance andyou get them done, but then you get
(18:25):
these results and having somebody canreally talk to you and then direct you
in into the right next navigation point.
I think that's very valuable.
Yeah.
And, and it's rare to find a primarycare provider, whether it's a
pediatrician or internal medicine.
They, they really don'tknow the nuances of this.
And the best they can do for youis just agree to order the tests.
(18:48):
Yeah.
And, you know, as, as patients, wejust have to demand it and say, I want
this test done, add it to my lab work.
Right.
Uh, but once that, you know, once youget tested, if you do test positive
for antibodies, you should ask fora referral to a diabetes specialist.
They're the people that can help.
Endocrin.
Yeah.
Um, and again, that might evenbe depending on where you are,
your area endocrine practicesare certainly shorthanded, um, in
(19:14):
terms of their time and ability.
So it is something that's importantto get in as soon as possible with
positive results of any of theseantibodies because time is kind of a key.
Mm-hmm.
In navigating whetheryou're positive or negative.
So
yeah,
negative, as we talkedabout before, great.
(19:35):
I was negative.
I might be, have been a kid, I'll getit tested again at some point, you know?
Mm-hmm.
I was an adult.
I'm negative maybe, or maybe not.
Will I ever test again, right?
Yeah.
And a negative test hasbenefits, you know, people
It does.
Are worried.
They're concerned.
Oh, is my child... is my,you know... ah my parent?
Are these people gonna develop Type one?
(19:56):
And as a person who's getting tested, youalso, you worry, am I gonna get type one?
Sure.
Testing negative for the antibodies?
It's a tremendous weight offyour shoulders 'cause it's very
unlikely it's gonna develop.
Not impossible, but it'svery unlikely at that point.
Right.
So there's a lot of value ina negative screening just for
peace of mind if nothing else.
(20:18):
What about the benefits of getting thescreening and the positive results?
What, like, what do youthink are the positives?
That's even, that's evenmore beneficial now.
Technically a positive screening means youhave two or more antibodies, not just one.
If you have one and you know,the titer is not real huge,
it could go away on its own.
(20:38):
Sometimes antibodiesshow up just temporarily.
They fade.
If you have two or more, thechances of you going on to develop
type one are very, very high.
And I'll, I'll share some ofthe stats with you about this
'cause it, it's astounding.
If you have two or more antibodies,I think the chances of you
developing type one within thenext five years is close to 50%.
(21:03):
And in 15 years it's, it, it'sapproaching a hundred percent.
It's, it's pretty much a done deal.
It's not, will it happen?
It's just, when is it gonna happen?
You're gonna develop type one.
So what that does is it empowers you.
So now it's like, all right,your, your dermatologist has
detected this potentiallyproblematic thing on your skin.
(21:25):
We can biopsy it.
We can see if it needs to be removed,and if so, it can be removed.
In the diabetes case, there are a,a multitude of strategies that we
can apply first to monitor ourselvesand catch it when it's starting
to progress to the next stage.
Sure.
Because, you know, youcaught it at stage one.
I mean, you're in a great position now.
(21:46):
You can monitor your glucose, whetherit's through finger sticks or using a
CGM once in a while, and, and some peoplecan even get over the counter CGMs and
use 'em maybe once every few months justto see what your patterns look like.
And you know, if you're starting tosee, you know, fasting blood sugars
creep in north of a hundred, or you'reseeing post-meal blood sugars that are
(22:08):
up in the above 140 on a semi-regularbasis, that means you're, you're in
stage two things have progressed.
Mm-hmm.
And you know, whether you're at stage oneor stage two, there's a lot of lifestyle
type things that a person can do.
Right.
And at stage two, there aremedications that can actually
be used to slow the progression.
(22:29):
And you're gonna love this sinceyou're a dietician, and I know
you're really into fitness, butthe things we do from a lifestyle
standpoint to delay the progressionof diabetes are the same things we
do for managing type two diabetes.
Right, they're.
These are things that I, I call thembeta cell bubble wrap strategies.
Yes.
These are things that ease the workloadon our pancreas that make our bodies.
(22:53):
More sensitive to insulin.
Mm-hmm.
That includes keepingour weight under control.
Yep.
Excess body fat causes insulinresistance, so losing some body fat helps.
And what adds to that?
Exercise or movement in your day, right?
Yes.
I mean, that's a big piece of it.
It's the most powerful way to improveinsulin sensitivity is physical activity.
(23:16):
Mm-hmm.
Cardio exercise in particular atthis stage is really beneficial.
Mm-hmm.
Strength training helps, but not asmuch as the cardio exercise does.
And from a food intake standpoint, justlooking at the nature of one's diet.
We don't have to avoid sugars.
We don't have to avoid carbs.
We wanna just try to modify or moderatethe amounts and not eat ex, you know,
(23:37):
huge amounts of carbohydrates andtry to choose the kinds of carbs that
are friendlier, that don't spike ourblood sugar all at once, but are more
slow and evenly digested and absorbed.
Right.
And your diet is full of those, Jenny.
I know that.
I try most of the time.
Yes.
And I, I think something that is behindboth of these pieces, these lifestyle
(24:01):
changes, is the ability to get in withsomebody who, at this stage can direct
you for how to make these changes, right?
It's not the rip-off page from justa doctor telling you to go take
a walk and stop eating sugar orputting it in your coffee, right?
Is really some very strategicand very individualized.
(24:23):
There's value to seeking out workingwith an educator even at this stage.
Because they could be somebody who helpsyou to preserve these beta cells even
more, sort of better bubble wrap, right?
Not the generic version, but the actualbrand name version of the bubble wrap.
And if you're, if you wanna get the mostbang out of this time period of delay
(24:47):
then working with somebody who can reallyindividualize and say, well, goodness,
you could stop drinking juice and havewater in the morning for breakfast, right?
You could change this up slightly.
You could make theseadjustments to things, um, even
oatmeal instead of BooBerry.
There you go.
Oatmeal instead of Boo-berry orFrankenberry or Choco, Count Choccula.
(25:08):
Right?
Exactly.
I mean, there are little strategicchanges that don't have to be major
in terms of the person's changes.
Yeah.
I learned that sweet potatoesare such-- so much slower at than
white potatoes at raising bloodsugar, that's a, a better choice.
And even the method ofpreparation of food.
I mean, you can get into the nitty grittyof discussion truly, but it is food and
(25:33):
activity are huge in terms of preservationand proper body metabolic response.
The better that you can do with realwhole unprocessed food at this stage?
The more potential preservationtime you're going to have.
And a lot of the things we teachpeople with type two to, to manage
better and avoid further, youknow, loss of their own beta cells.
(25:56):
You know, things like managingstress levels because stress hormones
kind of block insulin's actions.
They work against it.
Right.
Getting quality sleep canmake a big difference as well.
We produce, you know, cortisol,these other stress hormones
when we don't sleep well.
And, you know, avoiding, um, medicationslike steroid meds, prednisone,
(26:18):
cortisone, whenever possible.
If possible.
Those create tremendousinsulin resistance.
So, you know, just these kindalifestyle choices can make an enormous
difference in terms of, you know, howlong is it gonna take for the type
one diabetes to progress and developinto symptomatic type one that's gonna
require intensive insulin therapy?
(26:40):
And in some cases it's even possible--some people avoid it entirely.
It never develops.
Right.
So there is that opportunity as well.
So at this stage, is there ever aconsideration of using even a minor
amount of background, what we referto as basal long-acting insulin?
Mm-hmm.
For some people just to take alittle of the stress off of the beta
(27:00):
cells and preserve them longer too?
Yeah, that was studied decades ago.
They thought that, you know,bringing in the cavalry.
Let's bring some fresh outside insulin in.
Yeah, they actuallydidn't find that to help.
They didn't-- it didn't seemto slow the progression.
Okay.
But there are other medicationsnow they found that can.
These are medications thatare sometimes used in people
(27:21):
who receive organ transplants.
They help to suppress the immunesystem so that the beta cells aren't
being attacked so vociferously.
Sure.
It eases up on the attack.
And one of them, uh, it's calledTZIELD, generic, is called
tocilizumab, that's approved for usein stage two of type one diabetes.
The trial, the pivotal trials that wererun on that showed about a two and a half
(27:44):
year average delay in the developmentof type one from taking this medication.
It's not as, it's not as strong asthe doses and length that are used for
people who receive organ transplants.
People get organ transplants,they have to take high doses
of this stuff for a lifetime.
Sure.
In this case, the, the, the TZIELD's onlyadministered for two weeks, et cetera.
(28:05):
You know, relatively low dose.
But it's still, that alone had thepower to delay, by an average of two
and a half years, the progressionto stage three type one diabetes.
Has that been extended at allnow with, I mean, TZIELD has been
available now for a bit of time?
Has that like two, two and a halfyears, have they shown actual
(28:27):
progression for longer preservationand sort of delay in diagnosis?
It will.
They are doing ongoing studieson people and who are involved
in the research, okay?
They most likely will find alonger extension type delay,
but what they also have done isthey've studied it at stage three.
(28:48):
They studied it, people, okay,you're at stage three, you're
peeing, you're drinking, et cetera.
Let's do it now and see what happens.
And the studies, the publisheddata is very favorable.
It does preserve insulin productioncapability by the pancreas.
It's not yet approvedfor use in stage three.
That's still coming.
(29:09):
Sure.
But the progress is good.
And that's wonderful progressmainly because, if even diagnosis is
made, the potential of preservationmeans not as difficult to navigate.
Not as much insulin is needed.
More potential backgroundassistance from those beta cells.
(29:29):
I mean, there's even the long term,you know, we always talk about
complications and the prevention ofcomplications once you have diabetes.
My understanding is also that the betterunderlying beta reserve, it's a reason
that people who are diagnosed as anadult often tend, with good management,
to not be as, I guess there's not asmuch potential for complications, right?
(29:54):
Yeah, that's right.
And we, Jenny, we both see, occasionally,we get lucky and get a patient
who's still in that honeymoon phase
Yes.
Of their diabetes and theirpancreas still produces even
just a little bit of insulin.
It makes their glucose managementa thousand times easier.
It does.
You know, they can usually just takea, a long acting insulin at a low
dose, maybe an occasional meal dose,but their blood sugars barely budge.
(30:18):
They stay within target zonespretty consistently without a
whole lot of work they have to do.
Yeah.
That's, that's the honeymoon.
It's a beautiful time.
I didn't get a honeymoonwhen I was diagnosed.
I had gone the entire summer just peeingand drinking and eating and losing weight.
My beta cells were dead on arrival and itwas a miracle I was not in ketoacidosis.
(30:43):
'cause most people are in DKA.
Oh, I was.
When they go that long at diag-- yeah.
And when you get to that point, you don'thave much beta cell function left anymore.
And I wish someone could have toldme months or years before that I
had the antibodies and this couldhave been happening 'cause I could
have had that prolonged honeymoon.
(31:04):
I
Sure.
And what happens is if people arediagnosed at stage three and they
still have a decent amount of, ofinsulin production in their body,
that honeymoon can go on for years.
You've seen cases where itgoes on almost indefinitely.
They, they just neverget past the honeymoon.
I mean, rarely that happens.
Now you marry somebody and thehoneymoon just lasts forever.
(31:25):
But yeah, that's not usually the case.
Usually, yeah, you get a week, amonth maybe, hey, wonder, everything's
wonderful, and then the reality of,of living with someone 24 7 kicks in.
But there are people who have thathoneymoon that just goes on and on and
on, and, and that's one of the benefits of
Sure.
Early detection.
You catch it early.
You do the things to keep the betacells functioning as long as possible,
(31:50):
and there's enough of them stillfunctioning even when you get to stage
three that they keep functioning.
Yeah.
And you have that easier managementthat that nice glucose control
that can go on for years.
Right.
And as you said, not only is lifeeasier, but you've just sharply reduced
your risk for long-term complications.
Yeah, no, it's, I mean, in terms of thepositive sort of results, I think there's
(32:14):
also the ability to prepare for what,you know, like it gives you educational
opportunities early on to dig forinformation, to look for even studies,
to look for things to be able to do.
And to prepare family members to beable to educate a little bit better.
And if it's for a child, getting themin on that education early and the
(32:38):
idea of what this might look like.
It's just a, it's almost like aneasing your way into rather than a very
rapid, emergent room kind of diagnosiswhere, oh gosh, here we're throwing
this all at you and you had no idea.
Yeah.
The incidence of DKA in people who gotscreened for antibodies is minimal.
(33:00):
Minimal.
It's very, very low.
It's close to 50% in peoplewho didn't get screened.
Yeah.
And DKA is no laughing matter.
It can be fatal.
And by that point you've destroyed, uh,you know, almost all your beta cell mass.
You're not gonna have much of ahoneymoon at that point, if any.
Like me, I had none whatsoever.
So, yeah.
(33:20):
The screening is extremely valuable.
It certainly sounds like it'sa, a good reason to screen.
I know that I talk about it withall of the clients that I have the
opportunity to work with you know,within the Integrated Diabetes practice.
Even a number of families who've had a--other children in their family screened.
Um, and you know, I think there'salso something to not only screening
(33:43):
and some of the therapies likethe Tzeild that you talked about.
Not everything works for everybody.
Right?
Right.
So there are these positive thingsthat could come from screening, but
there's also the consideration that...I've had one family who I worked with
for their younger child and theirolder, um kids also got screened.
One who was completely negative,the other one who had antibodies did
(34:05):
the Tzield, and it really didn't doanything in the preservation long term.
But what I do see is a difference inbetween those two kiddos was the one
that did do the Tzield despite not havinga delay in type one diabetes-- true
development, that's stage three, themanagement for that child is, as we talked
(34:27):
about, it, is so much easier than it isfor the younger child in that family.
So much easier.
And I expect that it is because theTzield had an impact on the betas that
were there, would be my expectation.
Mm-hmm.
And just gives an easieroverall navigation.
So again, all these therapies,they're not a hundred percent perfect
(34:49):
to any, everybody but... Yeah.
I recognize it's an emotional decision.
It is.
To have a blood relative screenedor if you have a blood relative
to get yourself screened.
Yeah.
It's an emotional decision.
Yeah.
Because you know you're finding outabout a potential serious health issue.
But that's why I, I like to put itin that skin cancer screening term.
(35:10):
Yeah.
Uh, if, if you get screenedand you're negative, great.
Relax, enjoy yourself.
Right.
If you do screen positive, you cantake pro, you can be proactive.
At that point, you're notsticking your head in the sand.
Right.
You can do things to keep yourselfhealthy and vibrant for a long, long time.
Even if it's just the lifestylestuff without any medical
(35:31):
true intervention, right?
Or or just monitoring yourselfonce in a while so you catch it
before it's at stage, you know?
Yeah.
Did you, I mean, you've got kiddos.
Did you and your wife decide to doany, they're adults now, I know.
Mm-hmm.
But did you when they were younger, orhave they decided now as more adults
(35:52):
on their own decision making tree?
Did they decide to do anything?
Well, when they were young enoughthat I had to some degree of control
over them, which I don't anymore, no,I didn't because I felt, well, what?
What do I wanna know for?
There's nothing I can do aboutit even if they test positive.
And when they finally grew up andnow they're all in their twenties,
(36:13):
and I have no control over themnow I want them to be screened.
So I provided them all with theinformation to get screened.
I highly recommended as in like, I'mcutting you out of the will if you
don't get screened, that sort of thing.
And it's up to them now.
I can't force them to, but I stronglyencourage them to get themselves screened.
Yeah.
(36:33):
I mean, my kiddos, um, were also,as I said before, like we're like
probably a few years, three tofive years, into really having some
viable options from what has comeout of the potential for screening.
So years ago when they wereyounger, we decided to not screen.
Right now we do very regular,like just finger sticks.
(36:56):
My kids actually like doing it.
They like to wait fortheir number to pop up.
Being an educator and knowing thesigns and symptoms very well, we
pay very close attention to anychanges or anything like that.
But because, I mean, it is actuallya conversation that we've had more
recently is at this stage there are somethings that we could potentially do.
(37:17):
My kids are old enoughfor some of these things.
So it is in the discussion of now,should we, and they're also of the age
of understanding what that might meanand to be able to have that discussion
and even changing, I mean, as adietician, I'm kind of like the mom
who doesn't let them do a lot of thethings that their friends get to do.
(37:39):
Like they don't get candy intheir lunchboxes and they don't
get a treat after dinner justbecause it's after dinner and
it's time for dessert or whatever.
Mm-hmm.
Like I'm that mom and I willentirely a hundred percent own
that it's keeping my kids healthy.
Mm-hmm.
But in understanding, if we did dotesting, the idea that they would, they
would need to understand what that means.
(38:00):
And then results, resultdependent, what that would mean
for some of those lifestylechanges that we may need to make.
I mean, my kids are active.
I don't think I could make them anymore active than they actually are.
I mean, you know how active my kids are.
Yeah.
I played soccer with your kids lastweekend, and man was I sore afterwards.
They ran me ragged.
(38:21):
Yeah, they're, um, they are just,they're just athletic, both of them
in their own way and, and food?
You know, we do a really greatjob outside of like the birthday
party or going on vacation wherethings get a little bit off.
In general, that part isalready really well navigated.
So again, from a testing standpoint,it's now there are things, so now
(38:44):
there's a bigger discussion foractually going forward with that.
Whereas before, I didn't.
I respect that.
I respect that entirely.
Now, this is a very individual, personal--it's type of a decision to make.
I just, I'm, I'm glad to have thisopportunity so that people who
listen can make an informed decision.
There's
absolutely.
I want to, I want to get around themisinformation that might be out there.
(39:06):
Let people know, we're letting peopleknow about the latest research,
the actual science behind this.
Uh, and
yeah.
There is a lot of potentialvalue to screening.
Mm-hmm.
And I think we went through prettyclearly, and, uh, I encourage
everybody to think, consider itand, and make an informed decision
that's in your best interest.
No, a hundred percent agreed.
(39:27):
I think I, it was greatto go over everything.
All of the available options.
What the testing, the screeningkind of looks like, because I think
even with it being very easy, soto speak, to access at this point.
Mm-hmm.
Understanding what would thescreening process look like,
and then what can I do about it?
Mm-hmm.
Who do I need to address?
If the results are positive,what would that mean?
(39:50):
And the individual nature ofdeciding it is and should be
a family discussion decision.
No one person in that family situationshould really make the decision because
then they may have to house thatdecision themselves, and that can be
very difficult for one individual.
So it has to be an agreed uponall around decision to go forward.
(40:12):
Agreed, agreed.
Understand what you're gonna do.
The re... the supportout there is not great.
I admit that.
I mentioned primary care.
They, they don't, they knowvery little about this and
Right.
Even in endocrinology care, there's,there's not a lot that really
understand this whole process and
No.
And testing and how to mitigatethe, the progression, et cetera.
(40:33):
So I have a batch of clients nowwho are family members of our
patients who don't have type one,at least symptomatic type one yet.
Right.
But they tested positive forantibodies, so we're, we're teaching
them all they can do to slow theprogress so folks can reach out to us.
Yep.
If they have questions or if they wantassistance, you know, they can contact
absolutely.
Integrated diabetes and we'llbe happy to work with them.
(40:54):
That's what we are absolutely here for.
So thank you so much.
What a really important topic todiscuss and be able to put out there.
I mean, we're almost, we'rejust the beginning of October.
National Diabetes Monthis November, right?
Yeah.
So hopefully more information, youknow, certainly will help within that
whole month of not celebrating, butreally highlighting diabetes navigation.
(41:17):
This is fantastic.
Again, if you are looking formore information, more handholding
through this whole process oftesting, understanding, maybe some
life changes, please let us know.
Integrated Diabetes Services hasa host of clinicians that... very
knowledgeable, can absolutely andvery happily help you on your journey.
Thanks for tuning in to ThinkLike A Pancreas, The Podcast.
(41:40):
If you enjoyed today's episode,don't forget to like, follow, or
subscribe on your favorite podcast app.
Think Like a Pancreas-- The Podcast isbrought to you by Integrated Diabetes
Services where experience meets expertise,passion meets compassion, and diabetes
care is personal because we live it too.
(42:00):
Our team of clinicians all livingwith type one diabetes understands
the challenges firsthand.
We're here to help no matterwhere you are in the world.
From glucose management to self-carestrategies, the latest tech,
sports and exercise, weight loss,type one pregnancy, and emotional
wellbeing, we've got you covered.
(42:20):
We offer consultations inEnglish and Spanish via phone,
video, chat, email and text.
Wanna learn more?
Visit integrated diabetes.com oremail info@integrateddiabetes.com
to schedule a consultation.
On behalf of Think Likea Pancreas, The Podcast.
I'm Gary Scheiner wishing you afantastic week ahead, and don't
(42:42):
forget to think like a pancreas.
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