February 26, 2024 • 15 mins
Interview on diabetes technology and care in underserved patient populations with Anne Peters, MD, Professor of Medicine at the Keck School of Medicine of USC and Director of the USC Clinical Diabetes Programs
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
David Klonoff (00:15):
Welcome to Diabetes Technology Report.
This is the podcast that coversnew technology and profiles
leading doctors and scientistsin the field of diabetes
technology.
I'm Dr David Klonoff.
I'm an endocrinologist at UCSFand Sutter Health.
My co-host for DiabetesTechnology Report is Dr David
(00:37):
Kerr.
He will introduce himself andour guest today.
David Kerr (00:42):
Thank you, david, and good morning to everyone, or
good afternoon wherever you are.
It's a real pleasure to welcomeDr Ann Peters from Los Angeles.
Dr Peters is a world authorityon diabetes.
Ann, I'd just like to begin.
Some people would suggest youhave the dream job where on one
day you're looking after thestars and the next day you're
(01:04):
looking after I guess you couldsay the underdogs.
Was this by design or how didyou end up in this situation
where you have a whole crosssection of humanity with
diabetes that you're caring for?
Anne Peters (01:16):
Well, it was completely by design, but it
started because I knew I wantedto be a doctor by the time I was
five years old.
When I was six years old, infirst grade, my desk partner was
a black young man who hadtrouble learning how to read.
I realized his big trouble wasthat he was never in school
(01:40):
because he was always sick.
At that point I vowed that Iwould be a doctor who spent
their time helping basicallyeverybody.
I realized that there was thishuge need, which obviously was
not that well-formed at the ageof six, but I've always felt
that people deserve medical careand that, whether they're
well-served or underserved,there's something I can do to
(02:04):
help.
I've spent my life both doingvolunteer work as well as doing
my regular job.
David Kerr (02:10):
The current situation.
At the moment, you have aninterest in diabetes technology.
How excited have you been aboutthe progress, as you say it,
that we've made over recentyears and going forward?
Anne Peters (02:24):
My very first research with diabetes
technology might have been 20years ago.
I tried to do it in myunder-resourced population
because I've always wanted themto have a voice in all of this I
realized that I couldn't doresearch on technology with them
(02:45):
because the protocols and theinstruction manuals and
everything else weren't writtenat a level that would work for
them.
Then I became really obsessedwith trying to create tools and
approaches to help people whodon't have the same literacy and
numeracy skills as mybetter-served patients.
(03:08):
It's really worked because inthe beginning I thought that the
technology, the world oftechnology, was creating this
divide that was getting greaterand greater.
Then the pandemic changedeverything, because when the
pandemic happened, I was able toget technology for my
under-resourced patients BecauseI felt it was imperative to
(03:32):
their lives to use technology ina helpful way.
Because of telemedicine andaccess and everything else, I
really was able to work withtechnology in a way that made a
big difference.
Ever since, I feel that I'vebeen able to use technology in
my under-resourced populationalmost as well as in my
(03:52):
less-resourced population, withthe one caveat is that a lot of
technology requires that onehave a certain smartphone, which
my patients don't have.
I even give them thosesmartphones to use because I
want them to be able to usetechnology.
David Klonoff (04:09):
And how do you feel that technology supplements
or complements traditionaldiabetes treatments, which are
lifestyle, healthy diet, in somecases, medication?
Anne Peters (04:23):
Well for all patients that I have.
It helps them be more aware oftheir glucose patterns, and
becoming more aware, no matterwhat your skill level, is
something that people understand.
They can see that their glucosegoes up after they eat and that
maybe something should change.
And so I've been doing work inmy under-resourced population,
(04:47):
where I just give everybody CGMI don't care what treatment
they're on and we use it to helpwith diet, we use it to help
with oral medications, we use itto help with insulin, and
people respond.
And I think the thing that I'velearned the most is that I have
to do a lot more education upfront with my under-resourced
patients than I do with mybetter-served patients, who are
(05:07):
more familiar with technology.
But it doesn't matter.
I can get anybody to usetechnology as long as I have the
right educators.
And that's the most importantthing I can say is technology
plus education is everything.
David Klonoff (05:23):
And you work in Los Angeles.
Do you think that the problemswith diabetes that people face
in Los Angeles are differentthan in other parts of the
country, for example rural areasor other regions of the United
States?
Anne Peters (05:40):
My sense is that every area requires their own
solutions, so our population islargely Latino.
I have to have educators andpeople who work with me who
really understand that communityand are from that community.
I believe in usingcommunity-based help.
So we started working with someof the people in New York and
(06:04):
their population is similar butdifferent, and so we're each
finding our own solutions.
And I'm very proud of LosAngeles County because we have a
committee that works togetherand we now can get the
technology because we've reallyadvocated for it.
But I think that we can teacheach other.
But then we do a lot of focusgroups.
(06:24):
We do a lot of things to helpus understand the patients we're
treating.
David Kerr (06:31):
And just focusing in on continuous glucose
monitoring.
We're having conversationsabout trying to work out this is
really in the type 2 inpre-diabetes space the optimum
dose of CGM Was it in yourexperience?
How are you approaching this?
Because there's a healtheconomic perspective, who's
(06:52):
going to pay for it?
I mean, do you think peopleshould be on it all the time or
intermittently, and howintermittent is intermittently?
Anne Peters (07:02):
Well, I'm not a healthcare economist,
fortunately, but I'm all aboutthe patient and I can tell you
that I have patients in any partof town where I put CGM on them
, no matter what.
They have pre-diabetes diabetestreated with metformin, and
they love the CGM.
They feel that it helps guidethem with what they eat.
(07:24):
They feel that it helps themkeep a sense of control about
their blood sugars and I thinkif you want it, you should have
it.
I mean, I know this is noteconomic, but there are people
that in my under-resourcedclinic where they just can't,
they don't want to give it upand so it's really hard because
(07:45):
insurance isn't going to pay forit and they don't have the
money to buy it, but it just issomething that a lot of people
seem to just love.
There are other people and Ihave a lot of these people,
interestingly more on my WestSide practice, my more affluent
practice, where people don'twant to wear it all the time
because they don't want to bebothered.
For instance, my husband, whohas type 2 diabetes, who knows
(08:07):
what's going to happen when hesneaks candy, which he tries to
do all the time and he doesn'tlike the monitor beeping at him
that he's high, so he will wearit episodically, and what I tend
to do is have people wear CGMfor two weeks before they come
to see me, so I use it as a toolin my hands to retrospectively
look at what's going on.
(08:27):
But they're looking at it inreal time, so they get a sense
of it too, and I think thathelps them get better and then
helps us troubleshoot what needsto happen in the future.
David Kerr (08:38):
You said a really intriguing comment about
diabetes education and we findthat for the north here in
California, where we deal withHispanic Latino population, and
what's your thoughts on what'son offer traditionally in terms
of diabetes education, do youthink we've done a good job?
(08:59):
If so, fine.
If not, what needs to be donedifferently going forward?
Anne Peters (09:06):
Well, many things.
We need many, many, many, many,many more educators, because we
don't have access to enough.
So in the county of Los Angeleswe have very few actual
educators and I have my researchstaff, are my educators, but
I'm the one supporting them, notthe county, and we've been
(09:27):
doing this big project where wetake CGM and, as I said, we put
it on everybody who wants it andmy educators are there to train
people on the CGM and then tofollow up.
So when the connection getslost and they can't use it or
the thing falls off or theirlife is changing, and a lot of
these people, by the way, aredoing manual labor and that
(09:47):
makes them sweat, particularlyin the summer, and they come off
and we give them freeoverbandages.
We do whatever it takes, butit's not like you can say here,
watch a video where this and goout and use it.
So we need a lot more educationup front, but then it's ongoing,
and then what also needs tohappen is that it needs to
integrate in primary care, andso my educators use the CGM in
(10:09):
our patients and then they showme the tracings and then I give
recommendations to primary careand they're doing great, but the
primary care doctors don'treally have the resources to
start CGM.
They don't have the resourcesto do the prior or after CGM.
There's a whole list ofbarriers that make it hard with.
The educators say we don't haveenough, but then we need to
(10:32):
spill over for primary care.
So there are a lot of steps and, by the way I forgot to mention
, we need educational guides.
We need tools that patients canunderstand, that are written at
lower literacy levels and I'veworked on that and that is
beyond just CGM.
That's for pumps and otherautomated insulin delivery
systems, which are sort of evenharder to use in that way,
(10:55):
because you need a lot morefollow-up.
David Klonoff (10:59):
And could you say something more about pumps and
automated insulin deliverysystems?
Many patients start out withinjections, especially people
with type 2.
Do you think there's a role foreither pumps or AIDs in both
type 1 and type 2?
Anne Peters (11:16):
Well, I couldn't be a bigger advocate for using
automated insulin deliverysystems in anybody who's on
insulin.
And we've been doing researchwith the Omnipod 5 system in our
under-resourced population andI can tell you it's like magic
and I'm not that much a believerthat you can just fix
(11:37):
everything with one tool.
But we have our patients whoobviously want to come into the
research study, who've been onmultiple daily insulin
injections for a long time andtheir A1Cs are 12.
And these are people witheither type 1 or type 2.
And we put them on theautomated insulin delivery
system and they just get better.
I mean honestly, when thesepeople my patients are going
(12:01):
through their lives, their livesare so hard and they're working
three jobs and they've gotfamily members they're
caregiving for and all thisother stuff, and if they can
just push a button to givethemselves insulin before a meal
or there's automation overnightthat keeps them safe, it's life
changing.
And to me I don't differentiatetype 1 and type 2 on insulin,
(12:24):
especially on multiple dailyinsulin injections.
They all benefit from automatedinsulin delivery.
Again, it takes education toget them there, but I have so
many patients where we've madesuch a difference and these are
people who've spent years in ourclinics even in our diabetes
clinics, where we've been tryingto get them under better
control with multiple dailyinsulin injections, and it
(12:44):
hasn't worked.
So I couldn't be a biggeradvocate for automated insulin
delivery for both people withtype 1 and type 2 diabetes who
need it.
I mean, this isn't justeverybody if you're doing great
on whatever you're on, but Ihave so many patients who aren't
and they do so much better onthese systems.
David Klonoff (13:04):
Well, maybe the AID systems will be approved for
type 2 soon.
One treatment that we'rehearing a lot about now is use
of the glucagon-like peptide 1receptor agonist, so-called GLP1
receptor agonists.
They're used for type 2 andobesity.
What do you think about thosedrugs?
Anne Peters (13:25):
Well, I'm a great fan of incredent therapy, both
GLP1 receptor agonist and GIPGLP1 receptor agonist therapies
because they work so well atlowering glucose and obviously
I'm a diabetes doctor, so that'swhat is the most important in a
way.
But they also help with weightloss, and so I love that.
(13:47):
I can see people be successful,and one of the things that
happened when I did my studywith CGM is I identified a lot
of patients who, based on ourcountywide protocols, said that
they could be on somagelotide,on ozampic, if their provider
wanted it, and so I use the CGMto drive use of the GLP1
(14:10):
receptor agonist therapies and Igot people on lower doses of
insulin.
I got there when C is better.
The big thing that I use CGM todo was to help move use of the
GLP1 receptor agonist class andit really made a difference.
So I think that we can coupleusing CGM with understanding
(14:30):
what next therapies our patientsneed.
So I'm really a fan of thoseagents.
The problem, of course, is ifyou stop them, your glucose
levels go back up and the weightcomes back, and in a county
system where there's people whocome in and out of having health
coverage, then you run the riskof them only episodically
(14:51):
getting treatment, and thesepatients can't afford the
out-of-pocket cost for thesedrugs.
So you really have to be ableto make sure that the patients
you put on them can stay on themand really work with them to
continue the therapy.
David Klonoff (15:06):
And thank you very much for those comments.
I thought it was particularlyinteresting how you see the
similarities between treatingtype 1 patients and type 2
patients on insulin.
I'd like to thank you for beingon this podcast today Also,
thank, dr Kerr.
This diabetes technology reportis available at the Diabetes
(15:28):
Technology Society website andon Spotify and at the Apple
Store, and we look forward toseeing you and talking with you
at the next Diabetes TechnologyReport.
Thank you for listening.
Anne Peters (15:41):
Thank, you, anne, thank you.
Welcome to Diabetes Technology Report.
This is the podcast that coversnew technology and profiles
leading doctors and scientistsin the field of diabetes
technology.
I'm Dr David Klonoff.
I'm an endocrinologist at UCSFand Sutter Health.
My co-host for DiabetesTechnology Report is Dr David
(00:37):
Kerr.
He will introduce himself andour guest today.
David Kerr (00:42):
Thank you, david, and good morning to everyone, or
good afternoon wherever you are.
It's a real pleasure to welcomeDr Ann Peters from Los Angeles.
Dr Peters is a world authorityon diabetes.
Ann, I'd just like to begin.
Some people would suggest youhave the dream job where on one
day you're looking after thestars and the next day you're
(01:04):
looking after I guess you couldsay the underdogs.
Was this by design or how didyou end up in this situation
where you have a whole crosssection of humanity with
diabetes that you're caring for?
Anne Peters (01:16):
Well, it was completely by design, but it
started because I knew I wantedto be a doctor by the time I was
five years old.
When I was six years old, infirst grade, my desk partner was
a black young man who hadtrouble learning how to read.
I realized his big trouble wasthat he was never in school
(01:40):
because he was always sick.
At that point I vowed that Iwould be a doctor who spent
their time helping basicallyeverybody.
I realized that there was thishuge need, which obviously was
not that well-formed at the ageof six, but I've always felt
that people deserve medical careand that, whether they're
well-served or underserved,there's something I can do to
(02:04):
help.
I've spent my life both doingvolunteer work as well as doing
my regular job.
David Kerr (02:10):
The current situation.
At the moment, you have aninterest in diabetes technology.
How excited have you been aboutthe progress, as you say it,
that we've made over recentyears and going forward?
Anne Peters (02:24):
My very first research with diabetes
technology might have been 20years ago.
I tried to do it in myunder-resourced population
because I've always wanted themto have a voice in all of this I
realized that I couldn't doresearch on technology with them
(02:45):
because the protocols and theinstruction manuals and
everything else weren't writtenat a level that would work for
them.
Then I became really obsessedwith trying to create tools and
approaches to help people whodon't have the same literacy and
numeracy skills as mybetter-served patients.
(03:08):
It's really worked because inthe beginning I thought that the
technology, the world oftechnology, was creating this
divide that was getting greaterand greater.
Then the pandemic changedeverything, because when the
pandemic happened, I was able toget technology for my
under-resourced patients BecauseI felt it was imperative to
(03:32):
their lives to use technology ina helpful way.
Because of telemedicine andaccess and everything else, I
really was able to work withtechnology in a way that made a
big difference.
Ever since, I feel that I'vebeen able to use technology in
my under-resourced populationalmost as well as in my
(03:52):
less-resourced population, withthe one caveat is that a lot of
technology requires that onehave a certain smartphone, which
my patients don't have.
I even give them thosesmartphones to use because I
want them to be able to usetechnology.
David Klonoff (04:09):
And how do you feel that technology supplements
or complements traditionaldiabetes treatments, which are
lifestyle, healthy diet, in somecases, medication?
Anne Peters (04:23):
Well for all patients that I have.
It helps them be more aware oftheir glucose patterns, and
becoming more aware, no matterwhat your skill level, is
something that people understand.
They can see that their glucosegoes up after they eat and that
maybe something should change.
And so I've been doing work inmy under-resourced population,
(04:47):
where I just give everybody CGMI don't care what treatment
they're on and we use it to helpwith diet, we use it to help
with oral medications, we use itto help with insulin, and
people respond.
And I think the thing that I'velearned the most is that I have
to do a lot more education upfront with my under-resourced
patients than I do with mybetter-served patients, who are
(05:07):
more familiar with technology.
But it doesn't matter.
I can get anybody to usetechnology as long as I have the
right educators.
And that's the most importantthing I can say is technology
plus education is everything.
David Klonoff (05:23):
And you work in Los Angeles.
Do you think that the problemswith diabetes that people face
in Los Angeles are differentthan in other parts of the
country, for example rural areasor other regions of the United
States?
Anne Peters (05:40):
My sense is that every area requires their own
solutions, so our population islargely Latino.
I have to have educators andpeople who work with me who
really understand that communityand are from that community.
I believe in usingcommunity-based help.
So we started working with someof the people in New York and
(06:04):
their population is similar butdifferent, and so we're each
finding our own solutions.
And I'm very proud of LosAngeles County because we have a
committee that works togetherand we now can get the
technology because we've reallyadvocated for it.
But I think that we can teacheach other.
But then we do a lot of focusgroups.
(06:24):
We do a lot of things to helpus understand the patients we're
treating.
David Kerr (06:31):
And just focusing in on continuous glucose
monitoring.
We're having conversationsabout trying to work out this is
really in the type 2 inpre-diabetes space the optimum
dose of CGM Was it in yourexperience?
How are you approaching this?
Because there's a healtheconomic perspective, who's
(06:52):
going to pay for it?
I mean, do you think peopleshould be on it all the time or
intermittently, and howintermittent is intermittently?
Anne Peters (07:02):
Well, I'm not a healthcare economist,
fortunately, but I'm all aboutthe patient and I can tell you
that I have patients in any partof town where I put CGM on them
, no matter what.
They have pre-diabetes diabetestreated with metformin, and
they love the CGM.
They feel that it helps guidethem with what they eat.
(07:24):
They feel that it helps themkeep a sense of control about
their blood sugars and I thinkif you want it, you should have
it.
I mean, I know this is noteconomic, but there are people
that in my under-resourcedclinic where they just can't,
they don't want to give it upand so it's really hard because
(07:45):
insurance isn't going to pay forit and they don't have the
money to buy it, but it just issomething that a lot of people
seem to just love.
There are other people and Ihave a lot of these people,
interestingly more on my WestSide practice, my more affluent
practice, where people don'twant to wear it all the time
because they don't want to bebothered.
For instance, my husband, whohas type 2 diabetes, who knows
(08:07):
what's going to happen when hesneaks candy, which he tries to
do all the time and he doesn'tlike the monitor beeping at him
that he's high, so he will wearit episodically, and what I tend
to do is have people wear CGMfor two weeks before they come
to see me, so I use it as a toolin my hands to retrospectively
look at what's going on.
(08:27):
But they're looking at it inreal time, so they get a sense
of it too, and I think thathelps them get better and then
helps us troubleshoot what needsto happen in the future.
David Kerr (08:38):
You said a really intriguing comment about
diabetes education and we findthat for the north here in
California, where we deal withHispanic Latino population, and
what's your thoughts on what'son offer traditionally in terms
of diabetes education, do youthink we've done a good job?
(08:59):
If so, fine.
If not, what needs to be donedifferently going forward?
Anne Peters (09:06):
Well, many things.
We need many, many, many, many,many more educators, because we
don't have access to enough.
So in the county of Los Angeleswe have very few actual
educators and I have my researchstaff, are my educators, but
I'm the one supporting them, notthe county, and we've been
(09:27):
doing this big project where wetake CGM and, as I said, we put
it on everybody who wants it andmy educators are there to train
people on the CGM and then tofollow up.
So when the connection getslost and they can't use it or
the thing falls off or theirlife is changing, and a lot of
these people, by the way, aredoing manual labor and that
(09:47):
makes them sweat, particularlyin the summer, and they come off
and we give them freeoverbandages.
We do whatever it takes, butit's not like you can say here,
watch a video where this and goout and use it.
So we need a lot more educationup front, but then it's ongoing,
and then what also needs tohappen is that it needs to
integrate in primary care, andso my educators use the CGM in
(10:09):
our patients and then they showme the tracings and then I give
recommendations to primary careand they're doing great, but the
primary care doctors don'treally have the resources to
start CGM.
They don't have the resourcesto do the prior or after CGM.
There's a whole list ofbarriers that make it hard with.
The educators say we don't haveenough, but then we need to
(10:32):
spill over for primary care.
So there are a lot of steps and, by the way I forgot to mention
, we need educational guides.
We need tools that patients canunderstand, that are written at
lower literacy levels and I'veworked on that and that is
beyond just CGM.
That's for pumps and otherautomated insulin delivery
systems, which are sort of evenharder to use in that way,
(10:55):
because you need a lot morefollow-up.
David Klonoff (10:59):
And could you say something more about pumps and
automated insulin deliverysystems?
Many patients start out withinjections, especially people
with type 2.
Do you think there's a role foreither pumps or AIDs in both
type 1 and type 2?
Anne Peters (11:16):
Well, I couldn't be a bigger advocate for using
automated insulin deliverysystems in anybody who's on
insulin.
And we've been doing researchwith the Omnipod 5 system in our
under-resourced population andI can tell you it's like magic
and I'm not that much a believerthat you can just fix
(11:37):
everything with one tool.
But we have our patients whoobviously want to come into the
research study, who've been onmultiple daily insulin
injections for a long time andtheir A1Cs are 12.
And these are people witheither type 1 or type 2.
And we put them on theautomated insulin delivery
system and they just get better.
I mean honestly, when thesepeople my patients are going
(12:01):
through their lives, their livesare so hard and they're working
three jobs and they've gotfamily members they're
caregiving for and all thisother stuff, and if they can
just push a button to givethemselves insulin before a meal
or there's automation overnightthat keeps them safe, it's life
changing.
And to me I don't differentiatetype 1 and type 2 on insulin,
(12:24):
especially on multiple dailyinsulin injections.
They all benefit from automatedinsulin delivery.
Again, it takes education toget them there, but I have so
many patients where we've madesuch a difference and these are
people who've spent years in ourclinics even in our diabetes
clinics, where we've been tryingto get them under better
control with multiple dailyinsulin injections, and it
(12:44):
hasn't worked.
So I couldn't be a biggeradvocate for automated insulin
delivery for both people withtype 1 and type 2 diabetes who
need it.
I mean, this isn't justeverybody if you're doing great
on whatever you're on, but Ihave so many patients who aren't
and they do so much better onthese systems.
David Klonoff (13:04):
Well, maybe the AID systems will be approved for
type 2 soon.
One treatment that we'rehearing a lot about now is use
of the glucagon-like peptide 1receptor agonist, so-called GLP1
receptor agonists.
They're used for type 2 andobesity.
What do you think about thosedrugs?
Anne Peters (13:25):
Well, I'm a great fan of incredent therapy, both
GLP1 receptor agonist and GIPGLP1 receptor agonist therapies
because they work so well atlowering glucose and obviously
I'm a diabetes doctor, so that'swhat is the most important in a
way.
But they also help with weightloss, and so I love that.
(13:47):
I can see people be successful,and one of the things that
happened when I did my studywith CGM is I identified a lot
of patients who, based on ourcountywide protocols, said that
they could be on somagelotide,on ozampic, if their provider
wanted it, and so I use the CGMto drive use of the GLP1
(14:10):
receptor agonist therapies and Igot people on lower doses of
insulin.
I got there when C is better.
The big thing that I use CGM todo was to help move use of the
GLP1 receptor agonist class andit really made a difference.
So I think that we can coupleusing CGM with understanding
(14:30):
what next therapies our patientsneed.
So I'm really a fan of thoseagents.
The problem, of course, is ifyou stop them, your glucose
levels go back up and the weightcomes back, and in a county
system where there's people whocome in and out of having health
coverage, then you run the riskof them only episodically
(14:51):
getting treatment, and thesepatients can't afford the
out-of-pocket cost for thesedrugs.
So you really have to be ableto make sure that the patients
you put on them can stay on themand really work with them to
continue the therapy.
David Klonoff (15:06):
And thank you very much for those comments.
I thought it was particularlyinteresting how you see the
similarities between treatingtype 1 patients and type 2
patients on insulin.
I'd like to thank you for beingon this podcast today Also,
thank, dr Kerr.
This diabetes technology reportis available at the Diabetes
(15:28):
Technology Society website andon Spotify and at the Apple
Store, and we look forward toseeing you and talking with you
at the next Diabetes TechnologyReport.
Thank you for listening.
Anne Peters (15:41):
Thank, you, anne, thank you.
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The World's Most Dangerous Morning Show, The Breakfast Club, With DJ Envy, Jess Hilarious, And Charlamagne Tha God!
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.