In this episode, Jake Kushner, pediatric endocrinologist specializing in helping people with type 1 diabetes and Medical Director of McNair Interests, discusses the best strategies to live and thrive with T1D, especially as it relates to diet and exercise. We also discuss why many patients who control their blood sugar with high amounts of exogenous insulin are at a substantially higher risk than people who can control their blood sugar at lower levels of insulin. This concept has great implications for non-diabetics as well considering the increasing prevalence of diseases related to insulin resistance. We also cover some of the basics, the history, the increasing prevalence of type 1 diabetes, and more importantly, what we can do to help kids with this disease, and their families.

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We discuss:

How Jake became interested in type 1 diabetes [5:30];

The pathophysiology of type 1 diabetes, the increase in prevalence, and the role of beta cells [17:00];

The role of body weight and BMI in the risk of developing T1D [27:00];

Genetics of T1D and the risk of inheritance [32:00];

Hemoglobin A1c [36:15];

Insulin: the amazing story of its discovery, its effect on cellular metabolism and IGF-1, and why the hell it’s so expensive [39:15];

Diabetes Control and Complication Trial: blood glucose and the complications associated with diabetes [54:45];

Cognitive impairment, epigenetic changes, and other dangers associated with high, peak blood glucose, and big swings in blood glucose levels [1:09:15];

Depression, anxiety, and other challenges of living with T1D [1:15:30];

Jake’s realization that the current standard of care of T1D is inadequate [1:26:15];

Managing diabetes with exercise [1:30:15];

The Bernstein method, and protein’s impact on glucose and insulin [1:36:15];

Jake radically changes his approach to treating patients [1:45:00];

What other tools are there for controlling T1D? [1:49:45];

Is the ketogenic diet appropriate for those with T1D? [1:52:45];

The most important lessons that can be applied by the non-diabetic population [1:59:00];

The two dream measurements Peter wishes were available [2:04:00]; and

More.

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How Jake became interested in type 1 diabetes [5:30]

Peter and Jake had dinner one night in Houston, Texas

Jake was the first person to introduce Peter to the CGM

Advisor for Sanofi

Working on the exciting drug sotagliflozin ⇒ a new class of drugs that will hopefully benefit people with type 1 diabetes (T1D)

Peter says, “Super interesting, not just for type 1 diabetes, but potentially Type 2. And frankly if you subscribe to the idea that lower levels of glucose and insulin are just better overall, there may even be other applications.”

Jake’s path to becoming a pediatric endocrinologist

Trying to decide in between being a pediatrician and being a molecular biologist

“I thought I would do that and the classical path as an endocrinologist is to go and find a rare disorder and discover the molecular basis for it and find some unique product that you could then replace and provide it”

Was also interested in pediatrics

undergraduate at Berkeley working continuously in basic science research labs

Several years afterwards as a research technician, first at UCSF and then Oregon.

Medical school at Albany Medical College in New York

Pediatric resident at Brown University

Enamored by endocrinology in general, so he applied and got fellowship at Children’s Hospital Boston

Also served as a research fellow at the Joslin Diabetes Center at Harvard Medical School

How Jake became so interested in type 1 diabetes

“As a first year endocrine fellow, we’re running around an incredibly busy service, and we’re interacting with families of children who are newly diagnosed with type 1 diabetes. And I just thought, ‘Wow, this is really an amazing and challenging problem.’ And it has so many aspects of medicine that I appreciate. It has, most importantly human elements, but there’s also basic science.”

Jake saw the toll it took on people and especially parents

He also saw how often is was either completely missed or a misdiagnosis was given About 30% of the kids that are diagnosed present with diabetic ketoacidosis (DKA) which implies that they’ve had the illness for quite some time “When they present with diabetic ketoacidosis, it means that they have somehow managed to slip through the cracks. Nobody’s figured out that their glucose level is through the roof, or that they’re becoming acidotic or do these other things. And what actually brings them into the hospital is a septic-like situation.”



Onset of T1D in adults

The presentation of DKA is less frequent in older people, who generally become diabetic at a slower pace which is known as cryptic type 1 diabetes

In these people… they probably have autoimmune antibodies, and they have some degree of loss of beta cells ⇒ “and this phenomenon explains some of the adult onset diabetes that you just don’t quite understand”

How many people in the United States have type 1 versus type 2?

So Type 1 is approximately one in 300 people

The typical age of onset is around nine years old

And they live into adulthood, and many can survive into their 80s

“It’s the most common life threatening, medication requiring, illness of childhood.”

“And when you’re working in a fancy medical school, it’s quite sort of tempting to focus on a rare, unique condition that most people don’t get a lot of exposure to, and bypass the really common things. But for me, type 1 diabetes was the elephant in the room. It was just so compelling and I ended up being the first clinical fellow at Boston Children’s in 10 years to go into type 1 diabetes.”

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