Episode 19: Mastering Diabetes with Exercise and DIY Technology

Welcome to Think Like a Pancreas, the podcast. Our goal is to keep you informed, inspired and a little entertained on all things diabetes. The information contained in the program is based on the experience and opinions of the Integrated Diabetes Services clinical team. Since this is a very individualized condition, please check with your healthcare provider before implementing any of the weird stuff we may happen to share with you today. I'm your host Gary Scheiner.

I'm owner and clinical director of Integrated Diabetes Services. And today we have the unique pleasure of spending some time with Kathryn Gentile Alvarez, who is our head of exercise physiology at Integrated Diabetes Services. So Kathryn, welcome. How are things in Florida today? They're beautiful. You know, I wonder if it's hotter here or hotter in Pennsylvania. I like to check that. It hit 98 in Philly yesterday. Yeah, it's crazy. It did not hit 98 here, but I'm in North Florida.

It's much cooler than it is in other places. It's only 82 right now. Yeah. I had the pleasure of attending Kathryn's wedding a few months ago, down in Jacksonville. That was quite an experience. That was the best day ever for me and Kenny. I just had the best time. You were a beautiful bride. Thank you. That was, and one of your patients even came for it. You're a popular diabetes clinician nowadays. Yup. Yeah. Well, I got the opportunity to meet her at a diabetes retreat and she's super fun.

So you've been with our practice a while, but you started out as an intern. Yes. You were working and for Acsensia, you were doing an internship.

Yeah. You know, this story is actually pretty funny. I should tell everybody how I landed at Integrated Diabetes Services. When I was an undergrad, I read Think Like a Pancreas and I was like, "Wow, I'm going to be just like Gary Scheiner." So that's why I'm an exercise physiologist. And then I got the internship at Ascensia. But before that, I sent an e -mail to Gary Scheiner, but it was the wrong Gary Scheiner.

He emailed me back and he's like, "Oh, I think you meant to e -mail the diabetes master," or something like that. Was it the guy in New York who works for the ad agency? I wrote to him because not many people, our name spelled the same and never wrote me back. Well, he wrote me back. He was very nice. He probably felt bad for me like, oh, this poor college student trying to e -mail her hero.

But really I got an internship at Ascensia through JDRF and I told Ascensia that I wanted to be just like you so they connected me to you. That's embarrassing. It really is. I think you should aspire much higher than that. No, you're, you're so awesome, Gary. I don't think you, you're so silly. See, this is why I hired you. You're very good for my ego.

Well, the crazy thing is like a lot of times you hear like never meet, you're like the person you most look up to, but you are everything I thought you were. I am recording this, aren't I? Yes, I am recording this. Okay. I'm going to play this back for my wife so she knows how wonderful I really am. There you go. Debbie likes to keep me in my place. You know that. Yeah. You have to have somebody that keeps you humble.

So when we met, you were still on injections. You weren't even on a pump at that point. Were you at least using a CGM then? Or were you still doing finger sticks? Yeah, I was. I was on the Dexcom G5 and the IN-Pen. The IN-Pen. Okay. Well, at least it was something kind of modern. And I think one of the first things we did is came to the conclusion pretty quickly that you needed to be on a pump. Yeah. What it really was, was I, so I was working with Alicia.

You paired me with Alicia and then it was awesome. I still find myself like quoting things that I learned from her in my appointment. But when I came, almost everyone at that point was still on DIY Loop. And I told Alicia, that's what I want to do. When I went to lunch with you, you were like, here, um, me bolus me for lunch. Look at my app that I use. And I was like, what is this? This is the coolest thing ever. That's why I wanted to be on a pump.

Yeah. I mean, interestingly, you've evolved to be, I think the most tech. savvy member of our team. And you know, most of the clients that we work with who need tech assistance, go to you.

You're the go -to person now for these higher level technologies. So what are you using now? What's your current platform that you're working? I'm currently beta testing trio. It's a different algorithm than what Loop is and it has a lot more toggles, I would say to it, like just way more settings, like on "preferences" that you're switching over to. Trio is kind of the new option. Yeah, I started looping probably about six years ago. I was on the JDRF board at the time.

And I ran into Aaron Kowalski, president of JDRF. And he had just started it. And he since he and I were the two Type 1s at the meeting, we were just comparing notes and it looked interesting. I know if Aaron can do this, I can do this. So I did give it a try. And it was tough for me to build that original version of Loop because I never use Mac computers. I only use PCs. So I had to borrow a Mac computer. And the user interface is so much different.

It took me a while to actually get that up and running. But it finally did. And I haven't looked back. I've been using Loop. I've been very happy with it. When it comes to our staff, all of our clinicians, live with Type 1, we'll experiment. We'll try things like Trio. And we'll try any product that comes out, any meds that come out, we'll try them. When it comes to our clients though, we're a little more cautious.

We're generally not gonna recommend things that we don't feel are gonna be safe for them. So you made multiple transitions. You started out just on a basic pump. Was it an Omnipod you started with? Yep. All right. What pumps have you tried? I've worn the tandem. I've worn an old mini med to try out like a extended wear infusion set. So yeah, that's it. I don't have like 100 pump lists like you do, Gary. We've just got reps calling on us all the time here. So what's your favorite?

The pod with Loop though. When I used the Omnipod 5, it definitely was not the right system for me. So I did use it with the Omnipod 5. I feel the same way, but I'm curious, what was it about Omnipod 5 that came up short for you? Just the customization, it wasn't there. The activity mode and the adjustment of target and correct above blood sugars just wasn't what I already had had with Loop.

So it's not like my management when Omnipod 5 was like a disaster or dumpster fire, but it was not even close to comparable to what I was able to achieve on loop. One of the things with Omnipod 5 that I struggled with, I'm one of those people who has a really significant peak and the valley to my basal rates, and something the Omnipod 5 does, which is the same as what Medtronic does, is it creates what they call an adjusted basal rate.

It's just a flat basal rate based on your total insulin use, and it adjusts from there. So it waits until you start rising or falling to make an adjustment. But by then, sometimes it's a little too late. What I had to do was take that breakfast insulin to carb ratio way lower than what it actually is on a standard pump, and I'd have to dose as soon as I was getting out of bed to cover that huge increase in basal needs that it wasn't going to cover. And if you sleep in, what happens?

Well, you know, going up It goes up, right. And then eventually the algorithm kicks in and fixes it. But, you know, the young people you work with, you know, children, the teens, they usually get a basal peak in the evening, around bedtime. And in almost every one of them, their glucose shoots up at that time. So unless they're giving a meal bolus beforehand, where we can compensate, their sugar climbs at that time of day.

Yeah. And then they totally tank out like 2:00, 3:00 AM Every data I go into, they get that big growth rise and then low blood sugar around 2:00, 3:00 AM. Yeah. So again, these, the DIY, they're not really do-it-yourself anymore. There is a lot of support. What kind of support is available to people who go on something like Loop? Well, the biggest support is the community.

And honestly, I would argue that the community is much better customer service than you're going to get with your FDA approved systems. People on Loop, they go in different, either different channels or on social media platforms. So the big one, we have Discord. And then we have like the Facebook groups is the most popular ones where people go for help. They post their question and the community jumps in to help them out.

And then there's moderators to make sure that the advice and everything doesn't go way off basis and they get some craziness. So they're not going to ask everybody, so what was your last blood sugar? Which and where are you wearing your infusions? You know, they're not going to ask all the list of questions. You follow all the correct steps. The company tech support when you call the toll free. Yeah. No scripted thing that they're reading. Yeah. All the bull crap questions they get.

go through just to get to the point that you want help with. Yeah, that is annoying. So of the open source systems that you have experience with, do you find certain ones are best for certain people or do you think there's just one that's best?

It definitely varies person to person and that's with every system. I think there's a right person for all of the different options that we have. Yeah, I'm finding Trio is it's really, really great. But for a lot of people, it's going to be way too complicated. There's just too many things within the like setup for from like a dialing in setting standpoint. And it's just too overwhelming for a lot of people. But for the people that it's not, it's going to work really, really great.

Once you get all of those things toggled incorrectly. Loop, there's not so many buttons to push and settings that you have to have dialed in, but your settings are really, really important with Loop. Whereas with Trio, they're not quite as important. Can you still do kind of custom temp overrides in Trio? Yeah. And the really nice thing about those, so they have profiles and temp targets with Trio.

And the thing that really stands out to me, so with Loop, let's say you have your high-fat override on, and maybe you increase your overall insulin needs by 150%. So we have that set for a specific duration, but if you go into the bolus calculator, it's also going to impact that carb ratio dose. So you have to tap the override off, deliver your insulin, and then put it back on and adjust the time.

Trio, you have these additional options where you can turn off the impact of affecting the carb ratio. You can also turn off the impact of it affecting ISF (insulin sensitivity factor). So you can have it like just change the basal profile and that's it, which technically you can do in Loop too. If you just go under the pod and you do like a temp basal, but then you're not in fully closed loop. So it's not fully.

Yeah. I imagine the people who are writing the code for Loop can update that as well, make an option that it would only adjust the basal and not the bolus if you choose that. Yeah, definitely. I think an important option that would be great to have in Loop. Something I've always liked about the open source systems is how adaptable they are. Someone has an idea that makes a lot of sense is going to help a lot of people. They write the code for it. It's up, it's available. You can install it.

I remember when the ultra-fast insulins like Fiasp came out. It took years before the pump companies were able to, and some of them haven't even updated the insulin on board algorithm to work with those ultra -rapid insulins but Loop had it within weeks. It was really quick. Yep same with like the new CGMs and everything I mean, G7 in no time you could use it with Loop Exactly and I used the the temporary overrides a lot for different types of workouts.

So, if I go to the the weight room I just have to make a slight adjustment to my insulin delivery if I work out in the morning I don't have to make any adjustments but if it's a cardio workout I have to lower my insulin quite a bit and if I'm gonna play basketball for a few hours I have to lower it while I play but then again overnight otherwise I tend to drop but those temp overrides, those custom ones give me a lot of flexibility to manage those.

So as, as the exercise physiologist and IDS, you and I are in that unique position of kind of working with people who are involved in a lot of sports and recreational exercise, what are you doing to stay in shape these days? Any sports that you've gotten into? Um, I'm playing, eh, so, pickleball is huge here. I think it's becoming big everywhere, but I like to play some pickleball now. Sometimes I'll do some tennis because the pickleball courts get loaded. But I do a lot of bike riding.

How does your blood sugar respond to pickleball? Pickleball lowers it. I have to reduce insulin needs on an override. Now with, I do a profile with Trio for it. Yeah. I find sports where there's a mental and a physical component, blood sugar seemed to drop a lot more than if it's just purely like a cardio workout. So once you get your brain involved. Uh, you're burning even more glucose.

I mean, every once in a while I'll get an adrenaline rise because like, you know, I just get that super competitive nature. I really like to win. So that's a tough, tough matchup. I honestly, I've not played pickleball yet. Although, you know, the gym where I play basketball, they, uh, set up pickleball courts there, so I'm tempted to pick up a racquet one day and just give it a try. Yeah. You got to do it.

We were kind of ahead of the trend on it a little bit because they had it at the Spooky Nook. So we used to just kind of casually play there and then it became super big. How many days a week are you working out now? Uh, six. Yeah. Cool. Me too. Yeah, it's usually one day a week where I just can not get the work out of it just because of the usual stuff, but I try to work out.

And I am, I'm a night guy, not getting up early morning and getting to the gym or doing anything about going out for early morning is when you were here at the office, you might remember when I'd come in first thing in the morning, I was not like Mr. Happy, so. Yeah, well, remember, I'm not either. I'm not a morning person or a night person, which I just, I like to sleep. I used to do the morning workouts though.

I used to wake up, go to CrossFit first thing in the morning, and it's so nice for blood sugars to be able to do that. And then going to the gym now, I'm going in the evening, like six o 'clock, and it is so packed full. Gives me a little bit of social anxiety, but it's okay. Come on, you're in good shape. You used to tell people, wait til you meet Kathryn, she'll bench press a Buick. You're always taking good care of yourself. We try to walk the walk around here. Absolutely.

Blood sugar wise, not always, but that's par for the course for everybody. When it's like to do all the right things and still have blood sugars that suck for a while, it just happens. Yeah, yesterday I had a high blood sugar and for whatever reason, it made me very mad and I rage bolused. I was like, I haven't done rage bolusing for a very long time. I don't know why I hit myself so hard. Did you pay the price for it? I sure did.

Yeah. Once in a while those rage boluses turn out okay and you're thinking, wow, I'm on to something here. Yeah, no, it did not turn out okay. Yeah, it will get you in some trouble.

You had a little addition to your family. Is she around? Yeah, Miss Gravy. She sure is around and she just ate a box. Here's the box that she ate. Come here, Gravy. Come here. Hi. Hey, Gravy. Gravy, eat food. Food is for eating, not boxes and batteries and clothing. And worse things that we put her in the doggy hospital. What are some of the areas you feel like you have this best expertise?

So definitely the DIY section and especially getting started, the build process really stresses people out. So I can do a lot of hand-holding through that and then just getting started, how it works and everything. Also exercise and sport, working through that. And then I have a lot of firsthand experience with very young children with Type 1. So working through the ins and outs of your toddler refusing to eat the meal that you just dosed him for and running around like a mad person.

Those fun things that come with it.

So I was going to do this battle of the exercise physiologist thing and see if I can ask a question to stump you. If somebody is exercising. The body's cells can absorb glucose, even without insulin present. What are those little thingies called that transport glucose into the cells that don't require insulin? Uh...That transport glucose into the cells that don't require insulin? Uhm... Glucose -like receptor? {Eeeeeeeent} Incorrect. It's GLUT4. Oh yeah, GLUT4. Oh yeah, GLUT4.

This is the stuff they don't teach you in grad school. G-L- is so GLU. I was on to it, Gary. You were. Yeah. Yeah. Sure you were. No, we didn't do that in grad school. That was undergrad. Oh really? Hmm. Okay. Let's see. What does MET stand for? M-E-T.

And don't tell me it's the baseball team from New York No like exercise METs um like on a treadmill um I should have provided these questions in advance Yeah, so then I could have uh all right I'm gonna put up on google but No no no no no no no no just because you're tech savvy doesn't mean you can do that Um uh okay what does it stand for? METs = Metabolic Equivalents so like you know baseline is one Okay well what does one net equal?

That's your metabolic rate that's just energy expenditure at rest. Yeah right That is right yeah I remembered that you got one from me? Um what does EPOC stand for? Now you can't ask me anything that was taught after 1993, all right? Um I don't think it was taught after EPOCs? Yeah EPOC = E-P-O-C Does it have something to do with glue? No Oxy?

No EPOC Oxy = oxygen Yeah I know oxygen's in there somewhere... ep... E-P-... energy No Damn um give me another hint Um well you had oxygen Oxygen consumption yes all right ep After you finish exercise think about like Recovery... recovery... What is it? Excess Post exercise Oxygen Consumption There's an extra "E" in there. I thought it was E-P-O-C? It is E-P-O-C. I guess they just combined the two. Epeoc is harder to say. Yeah, that doesn't sound good.

If I'd known about that extra E, I would have had it like that. Well, we learn a lot from each other, and I do appreciate that. But I mean, when it comes to the tech stuff, Kathryn , you're my go to person, you hope you'll be working with us for a long time, at least till we have a cure, right? Yeah. What are you going to do if diabetes is cured? We've all got to find different lines of work. Oh, yeah, we do. I think I'll just work as an exercise physiologist.

Kathryn, thank y ou for spending some time with me and all of our listeners. You are a true treasure. I'm so glad you're part of our team and glad I met you all those years ago. I'm glad too. On behalf of Think Like the Pancreas the podcast, I'm Gary Scheiner. Have a great rest of your day.