Dr. Joshua Miller, Medical Director for Diabetes Care

[00:00:00] Rob Howe: What's going on everybody? I hope you are enjoying the first issue in the first volume of the Diabetics Doing Things Creator Zine. This is the final episode as a part of the zine. If you can hear my voice, I'm a little bit under the weather. But one of the things I wanted to touch on before we get into this interview with Dr. Joshua Miller is that over the years of doing this podcast, I have had the pleasure of being in rooms that I wouldn't have been in otherwise. A few times I've been fortunate enough to cross paths with Dr. Joshua Miller for the first time at ADA conference in 2018 and then again in 2019. And we were doing various interviews and panels and things of that nature. And I'm fortunate that I get to call him a collaborator and friend. And so I wanted to dig into something that we really haven't talked about on this podcast before. And it's a little bit more scientific. It's a little bit more clinical, a little bit more medical. and so I needed my friend who's the endocrinologist to come on the show and explain a few things to us. So Dr. Josh Miller is the medical director of diabetes care and a professor of endocrinology at Stony Brook Medical Center in Long Island and he's also lived with diabetes for just over 22 years. He was diagnosed in 1999. So what he and I do in this episode is actually pretty cool and a little bit of a, I was very nervous going into it because for the first time, I'm opening up my labs and blood work to the internet and to the community. So what we're going to review is my diabetes blood work and labs. And then hopefully I'll be able to teach you and Dr. Miller will be able to illuminate some of the information behind those blood tests and those blood work that we get ordered every three, six, 12 months, depending on who you are and what your doctor recommends. It's very important that this episode is not medical advice. I have to give that disclaimer. We do not give medical advice on this podcast. We never have. We never will. However, I felt that it was important that people with diabetes know how to talk to their doctor about their diabetes blood work in their labs and what they mean. So we're going to talk about a few different panels. We go through my fasting lipid, cholesterol panel, urine microalbumin, annual eye exam discussion, hemoglobin A1C, as well as AST and ALT ratio, which is used to detect liver damage or liver disease. So hopefully you'll come out of this episode with a little bit more insight as to what those tests mean, what your doctor is looking for, and what questions you might be able to ask if you want to help improve those or you want to get those numbers back into a range that you and your care team are more comfortable with. So again, disclaimer, this is not medical advice. What you're going to see here are my numbers and Dr. Miller's response to those numbers and what you and your care team can do to help improve those on your side. So I really hope you enjoy this conversation between three people with diabetes talking about diabetes blood work that we're all very familiar with. But we also touch on complications. And I think complications often are taboo. And we don't talk about them very often. But Dr. Miller does a great job of explaining that in 2022, if we do a reasonable job managing and controlling our diabetes, we have very minimal chances of gaining really bad complications from diabetes. So I want you guys to be encouraged by this episode and also get a little peek under the hood as to what's going on in my body and my blood work in my lab. So I hope you enjoy this interview with Dr. Joshua Miller. Hello and welcome back to Diabetics Doing Things. We are telling the amazing stories of people with diabetes from all across the world. And I'm very excited to introduce this very special episode as part of our Diabetics Doing Things Creator Zine that we are launching this year. So my very special guest this morning is Dr. Joshua Miller. He's the director of diabetes care at Stony Brook Hospital at Stony Brook University in Long Island, New York. So welcome to the show, Dr. Miller. Rob, nice to see you again. Thanks for having me back. Of course. And you're joined as always by our producer, Atreya Musa Khan. Welcome to the show as well. And Dr. Miller, you and I have spoken over the years. We've run into each other at American Diabetes Association on some Medtronic panels and things of that nature. And I'd love for you to sort of introduce who you are because you're more than an endocrinologist, you are also a person with diabetes. And I just find that

[00:04:13] Joshua Miller: intersection to be super important. Yeah, no, I happy to share Rob. So as you know, I have type 1 diabetes. I've had it now. I think I had a 22 year diaversary back in the fall. And having diabetes, living with type 1 certainly informs a lot of what I do professionally, certainly personally, you know, I wake up, check my own blood sugars, and then go to the office and help patients with theirs. That tends to be the paradigm that we think about. And as you know, as well, I have a very particular interest in technology and really more so quality of life, not technology specifically, but rather how can we use different paradigms of treatment prevention to help improve quality of life of people living with type 1 diabetes. And in many cases, technology can play a role. So I like to wear different pumps and sensors and get a flavor for what's out there. But my MO, if you were to ask me is helping people to have a better quality of life with type 1.

[00:05:06] Rob Howe: I love that. And you're right. I think the first time I met you, you were wearing not one, not two, but three different CGMs at once. And you were, and I think that is, you know, that locus or that lens for, you know, approaching care is one of the reasons that we're here today, because we're going to be talking about something that all people with diabetes who have lived with diabetes for a long time are familiar with. And that is labs and the blood tests that we get when we visit the endocrinologist. And what I have found, and this was sparked up from a, I had to do a life insurance exam. And they, you know, as a person with chronic illness who's applying for life insurance, there's few things in the chronic illness world that can be more triggering than somebody saying that your A1C of 6.0 is elevated. and is there, you know, and I think that there is a larger scale education piece that needs to happen there on behalf of the insurance companies, but we're not going to cover that today. But we are going to cover is what, how to look at the non A1C blood test results. And we'll look at A1C as well, because that's obviously very important, but how people with diabetes can read, understand, and take action if necessary on some of their labs. And we're going to do that through the lens of the American Diabetes Association guidelines. So for those medical advisory out there, we are going to stick to the book as much as possible. I like that. And I think

[00:06:26] Joshua Miller: that last point, Rob, is probably the most important to this conversation. It's what does the book say? What are the standards say? And as a subspecialist, I see patients from all parts of Long Island, all different walks of life, all different backgrounds. And we see a lot of variation in the community about how people with diabetes traverse the healthcare system and what different doctors in their lives do for them and with them. But we tend to focus as much as we can on the standards and really is how often does a patient with diabetes need to go to the lab and get blood work done? How often do they need to get their A1C done? And what will that data do to your life with diabetes and how is it going to inform how we help you to achieve your goals? There are some doctors who encourage slash force their patients to go for blood work every three months. I can't think of any standard, at least in the world of diabetes and its complications and preventing complications that would have a patient going to get blood work done every three months. So, you know, there's something to be said also for the cadence of the testing you're doing and specifically what type of tests you're being sent for. So I encourage patients to talk with their doctors about the testing they're being sent for to understand what that information will do to inform their care and how it's going to help them moving forward. And, you know, for those listening,

[00:07:46] Rob Howe: be sure to review the disclaimer at the beginning of this episode, which we'll address to not make any treatment decisions without the approval of your doctor. And I am not a doctor. And even though Dr. Miller is, we are making sure to stick to the ADA guidelines as much as possible today. So one of the reasons, again, we touched on this already, you are a tinkerer with yourself. and you are curious about, you know, diabetes technology and its impact, you know, regarding through the lens of your own diabetes. So where should we start? You know, what should we measure and what should we be looking at when you're a doctor, you go to your endocrinologist visit, whatever cadence you may go, you may be, you know, at your particular stage of diabetes. For me, it's about once every six months. Generally, I go to my endocrinologist and I get a series of labs. So what are we looking to measure and what are you, you know, specifically with your patients looking to measure on a regular basis for people with diabetes?

[00:08:41] Joshua Miller: Yeah. So, right. It's a question of what the goal is in doing the measuring. So A1C obviously is a core component to people living with diabetes and clinicians who care for people with diabetes. Although even now, these days, I find myself not relying as heavily on A1C as I do, for instance, in time and range when using continuous glucose monitors and devices like that. So, you know, well we're doing in helping to control blood sugars and to help us to think about whether it's an insulin regimen or in someone living with type 2 diabetes, a medication regimen and the like. But the second component and really the largest component to why we do, in most cases, annual blood work for patients with type 1 diabetes is prevention, prevention, prevention. So ultimately, what are the types of complications patients with diabetes can develop? They don't always develop them, but what are the types of complications that people develop? And then how do we monitor for patients' risk of developing those complications? And then what do we do with that information? And really, in my mind, in living with a chronic disease, especially one like type 1 diabetes, the name of the long game is prevention, prevention, prevention. So, for instance, let's pick one of the labs that if you're living with type 1 diabetes at one point or another, your doctor has probably sent you for, which is a fasting lipid panel, a cholesterol cholesterol panel. So why do physicians send cholesterol panels in people with type 1 diabetes? And the answer is people with diabetes have a slightly higher risk of heart disease. And so longer term, how can you look at cholesterol to help lower someone's risk of heart disease? And many patients, not all, but it depends on the patient and what they bring to the table and their background and their other comorbidities and the like, many patients do require a cholesterol lowering medication, like a statin medication, looking at your cholesterol with your physician once a year helps you to understand your overall metabolic risk of heart disease. We look at LDL cholesterol, which we like to say is the bad cholesterol. We look at HDL cholesterol, which you like to say is the good cholesterol. But overall, it's looking once a year at your cholesterol panel to see, hey, what is my risk of heart disease with diabetes going forward? And

[00:10:48] Rob Howe: how can I mitigate that risk? You mentioned two things, the two C words that we talked about. We talked about comorbidities and we talked about complications. You know, taboo doesn't even really cover the word complications. And I think for many people with diabetes, they're rightfully so is a little bit of a stigma and fear around talking about the complications of life with diabetes. You mentioned at a higher risk for heart attack regarding the lipid panel and cholesterol and heart complications rather than heart attack. What are some of the other complications that, you know, just a long life with diabetes, leaves you susceptible to as a patient? Yeah, it's a great question. And you're right.

[00:11:29] Joshua Miller: It's a conversation or a subject rather that people don't like talking about. As a physician, it's a difficult conversation to have, but it's one that's so important to have because it helps patients to understand what I'm thinking about big picture long-term and why we do what we do. Also, it establishes, and I didn't coin this phrase, but I use it all the time, that diabetes is a marathon. It's not a sprint. So yes, we're focusing on today, tomorrow, next week, but I'm also focusing on next year, the next decade and beyond. So we generally think about complications of diabetes as falling into one of two big categories. One is microvascular disease and the other is macrovascular disease. In the microvascular disease category, I think about things like diabetic kidney disease, diabetic eye disease, sexual dysfunction, erectile dysfunction, gastroparesis, things that would result from damage to the small blood vessels. And then macrovascular disease would be things like heart attack and stroke. So those are the ways in which we study complications from diabetes as we categorize them based on those two big buckets. And then we think about how to lower someone's risk long term in each of those areas of complication. The other point, Rob, before we perhaps delve into some of the the granular details with the labs themselves is you know i get asked all the time from patients will i develop complications and the answer is no nothing is 100 ever we have some patients who are living for decades and decades with type 1 diabetes and they have perfect kidney function their eyesight is great they have no damage in the blood vessels in the backs of the eyes and the like and so you know their their their complication burden is very low. And I have other patients still who, unfortunately, they have exquisitely controlled blood sugar, they're exercising, they're fit, they're active, and they do go on to develop some microvascular disease. So, you know, we're understanding a lot more about risk of developing complications. But the number one thing that I say to every single patient with diabetes when they're first diagnosed is, in 2022, if you do a reasonable job controlling your diabetes, like a B minus C plus student, your chances of getting a complication from diabetes are less than one in a hundred thousand. That's something that was told to me many moons ago and framing the risk for patients with diabetes. So there's no definite in the world of complications, but we do as much as we possibly can to lower that risk over one's life living with type 1

[00:13:57] Rob Howe: diabetes. I'm glad you brought that up because I think too often we talk about diabetes doesn't look the same for everyone regarding carb counting, regarding insulin doses, regarding day-to-day management. But we don't often filter that through the lens of complications. And what we know about diabetes as people, you know, almost 60 years of lived experience here on this call today is that the only constant is change. And, you know, you can't really, you know, depend on, you can eat the same thing every day and use the same carb ratios at the same time and almost guarantee a different result. Through the lens of complications, how do you have those conversations with patients who have had a B minus, C plus or greater control and still deal with the frustration of micro and macrovascular complications?

[00:14:49] Joshua Miller: Yeah, so the question that I ask myself every night before I go to bed and one that I think is important to answer together with a patient in the office is, am I doing everything I possibly can to live a long, healthy life with diabetes? Am I doing everything I can alone and with my clinical team to lower my risk of complication long term? Or if God forbid I develop a complication to lower the impact of that complication as much as I possibly can to prevent further decline, further progression of that complication? And if the answer to those questions is yes, then I can go to sleep at night feeling comfortable that I've done what I needed to do. The inevitability of change in this disease is, of course, a constant. And that is a reality every single day. I see it in the office. Someone comes in, you know, Dr. Miller, I check my sugar. You know, at the agreed on frequency, I exercise regularly. I'm taking the same meds. My diet is as good as it's ever been. And yet my A1C today is nine and it was six last year. what changed? Well, your diabetes changed. Maybe your insulin resistance changed. Maybe the amount of insulin your pancreas is making changed, depending upon the type of diabetes, of course. So, you know, I think change in this disease is constant. A mentor of mine used to say diabetes is a disease in evolution. It always changes and you always have to be ready to anticipate that change. Preventing complications, delaying complications, I think is a big part of that conversation. It's important to have it with your doctor because if not, then it's constantly going to be the elephant in the room that you're thinking about, he or she may be thinking about, but if you're not able to gel on that topic, it's going to hold you back from achieving your goals,

[00:16:27] Rob Howe: in my opinion, at least. Yeah, really well said. I think, you know, the challenging part about, like, and the reason I think that these types of discussions are a little bit taboo is that we have to sort of admit that we don't have total control, right? And that, like you said, diabetes is a disease in evolution, and it doesn't look the same on day one as day 100, day 1000. And I At the same time, you know, I think that this has been a recurring theme for us here on the podcast this year is we're all on borrowed time. If we were if we were born almost any other time in human history, we wouldn't be able to live the lives that we are living today. And, you know, that is that is a gift. And that's a perspective that I think we're taking here at the podcast. But also understanding that, you know, longevity with with diabetes and complications and challenges are just sort of part of everyday life with a lifelong chronic illness. you know, that, you know, and at the same time, we're at this great place where you like you said, people who have lived with diabetes for more than 20, 30, 50, 60 years, in some cases, are living the lives that they wanted to live. And, you know, with relative, you know, and it's not doesn't look the same for everyone, but with relatively complication free, or, you know, high focus on being able to be grandparents or be able to have great careers and family life that people want. And that is encouraging. And at the same time, there are complications and there is risk of complications. And so we've got to make sure that we're, like you said, before we go put our head on the pillow at night, are we doing everything that we can today to minimize complications

[00:17:57] Joshua Miller: tomorrow? And that's right. Part of the conversation that you should be having with your clinical team about the testing that we do and at what cadence and what you do with that information. So I'll give you an example. I think any patient living with diabetes at one point or another had to give the lab a urine collection, right? So we do, and the standard is you're supposed to check a urine microalbumin once a year. So microalbumin is a small form of protein that really should never be in the urine. So if you provide a urine sample and the lab runs the test and they find that there's a little bit of protein in the urine, what does that information tell us, it tells us, it can tell us that there's been a little bit of damage to the filtering apparatus in the kidney. And at its earliest, earliest stages, when there has been some damage from either blood sugars or blood pressure, which I'll explain in a second, you can start to see a little bit of protein in the urine. And it's that urine microalbumin to creatinine ratio that allows us to determine if there's this concern for damage in the in the kidney filtration apparatus for someone with diabetes so the two leading causes of kidney damage in the western world are uncontrolled diabetes and uncontrolled high blood pressure hypertension and we know that when blood sugars and blood pressure are reasonably controlled again not perfect but reasonably controlled you can prevent kidney disease from high blood sugar and high blood pressure so once a year we do a urine microalbumin, knowing that if someone is spilling a little bit of protein in the urine, that may give me some information about their risk of developing diabetic kidney disease, and how I use that information to helping patients continue to remain complication-free is going to be vital. So, you know, when I sit back and I look at a urine microalbumin that turns positive, I sit with the patient and say, listen, this is what it means. You know, you've lived with type diabetes for 15 years, for instance, your blood sugars are reasonably well controlled, you have a little bit of protein in the urine, how do we cross that bridge together of what this means longer term? And how do we prevent, God forbid, further damage to the kidneys? Hard stop. That's the conversation we like to have. Now, in the world of protein in the urine and diabetic kidney disease, there's a class of medications that physicians will sometimes use. They're called ACE inhibitors, that in addition to sometimes helping with blood pressure, they can also help to decrease the amount of protein in your urine and decrease some of the risk of damage to the kidney. So, you know, if you do make some protein in the urine, that may be a conversation to have with your doctor. And the doctor may come to you and say, hey, you know, Josh, you have a little protein in the urine. We may want to start a low dose of an ACE inhibitor to prevent further damage. There are some things that we do in response to that information. Again, I get back to, you know, what role is that information providing and helping you to achieve your goals and what are your goals long term. I'll pick another example as a little bit of a paradigm shift for what we look for in the blood work. So we oftentimes will send a metabolic panel once a year. So that looks at your liver function and your kidney function, your electrolytes. On the kidney function front, again, those blood tests allow us to understand how well someone's kidneys are functioning and filtering the blood and liver function. Similarly, how well the liver is functioning. Are there any changes to the liver function enzymes and the like. In the case of certainly type 2 diabetes, and in certain cases with type 1 diabetes, some of the medications we use are actually metabolized by the liver. So it is important pretty regularly to take a look at your liver function, make sure if your liver can continue to tolerate some of the medications we use. More common, again, in type 2 diabetes in patients taking multiple pills, oral agents to control their blood sugars, but still important to people with type 1, you want to make sure that the the liver function is doing what it needs to do, same with the kidney function. I would say, in addition to some of the blood work we discussed, so the fasting cholesterol panel, look for risk of heart disease, urine microalbumin to look for, God forbid, risk of damage to the basement membrane of the kidneys, and liver kidney function to make sure that you know, your body's able to process things correctly. The number one preventive piece of information that I probably glean the most insight from for people type 1 diabetes, especially is an annual visit to the eye doctor. Similarly, so why am I being sent by my endocrinologist to my eye doctor every six to 12 months, depending? It's for the eye doctor to look in the backs of the eyes, do a dilated exam and tell me, God forbid, have they seen any preliminary damage to the blood vessels in the eyes from my diabetes. How does that information change things? Well, if God forbid there is some damage, it may compel me to have a more significant conversation with an endocrinologist about my blood sugar control. Also in the world of diabetic eye disease, we know from the eye doctors that the earlier you intervene and recognize any damage in the backs of the eyes, the better people do longer term with their vision. So that's again, part of primary and secondary prevention and just understanding trajectory overall and how you might be able to change and impact that trajectory with your doc. So let's talk about this for a second,

[00:23:15] Rob Howe: because I think, you know, this is why they put me in the seat to ask the dumb questions is, you know, it seems like, and I understand on the laboratory scale, we look at the heart, we're looking at the kidneys, we're looking at the liver, all vital organs. And obviously, at any baseline level of human science, you understand that these are critical for you. And I think looking at like, oh, the pancreases and the endocrine system's effect on everything close by obviously is important. Now, let's put it through the real lens of a person living with diabetes. They've already overcome the balancing of going to the endocrinologist to do the blood work on a six month, 12 month, three month, whatever is their care team has provided cadence. And then there's another step, which is, Hey, you need to go to the eye doctor, the ophthalmologist to make sure that your eyes are healthy. And oftentimes it's a pretty simple, they just dilate your eyes. They look at the back and they make sure that everything's okay. And in some cases, like you said, if there's a need to take action many times, the earlier they catch it, the easier it is. I think Atreya, you can maybe speak to this a little bit. I know that you've

[00:24:23] Atreya Khan: dealt with some of this as well uh yeah mine was a little different i had floater in my eye so like i just like i actually had they had like a bad migraine in that day and suddenly i had a floater in right eye so i went to my eye doctor and he was like oh no you need to go see go see a special and i think it was the owner that like freaked me out because he's like there's no there's nothing to do here you got to go see like a real doctor um and i went to go see a retinal special um dr k here in Irving, Irving amazing. And, uh, I ended up having to do like, uh, type type of laser in my eye. So they would like numb my eye and basically what I would think the word is categorized. Like they would burn the bleeders because I had a few, um, and I went like three, three times, uh, the first time I got a shot in my eye and the two times after your laser, uh, that pretty much kind of saw the problem. And now I still see him once every three months, just like make sure there's no further complications or anything like that. But yeah, I mean, it was scary. I didn't enjoy it. I thought I was blind.

[00:25:33] Rob Howe: Well, let's focus on that too, because it is scary, especially when you find something, but it's also, you know, another step, another, you know, thing to think about, another thing to balance in your head and the great, you know, sort of diabetes, anxiety, and we can talk a little bit about mental health later if we have the time, but taking that extra step and going to another doctor just to see if we had uncovered something. And thankfully, you did that and you uncovered a very treatable complication. So I guess, Dr. Miller, for you, when you're having conversations with patients, we run the labs like, hey, now you have to go to another doctor. You have to go do another test. How do you find that people respond to that? And what would you say to a patient who's like, well, you know, all my other labs are in order. Maybe I can skip the ophthalmologist this year because that's where my brain might go. Yeah. You know, and I think it

[00:26:24] Joshua Miller: gets back to overall philosophy of what we're sending a patient to do, whether it be a blood test, a urine test, what type of specialist or subspecialist I'm referring the patient to. The fundamental question with any of those referrals or testing strategies is what information am I going to glean that's going to impact you living with diabetes? And what information can that specialist or subspecialist provide us is going to impact your overall life with diabetes. So in terms of seeing an ophthalmologist, you know, this happens all the time where I'll have a patient sees an optometrist to get their contact lenses checked right. And the optometrist looks and sees some changes to the lens of the eyes and says, you know, maybe you need to see an ophthalmologist, a physician who cures for the eyes. Patient goes to see the ophthalmologist. They dilate the eyes. They look in the backs of the eyes at the blood vessels. They see a little bit of bleeding. And so then they send the patient to the retinologist, which is a subspecialist type of ophthalmologist that only deals with the retina. And then the retinologist goes in and they see some bleeding vessels and they may cauterize them or inject them with a medication to stop the bleeding. What that did for the patient is first off, gave them quite a bit of information about what their overall state is in terms of risk of complications in the eyes. And, And, you know, hey, have I had any damage to the eyes in my life living type 1 diabetes? And then two, OK, God forbid I have some damage. What do I do to prevent further damage and how to maintain my eyesight? Hard stop. And that's where the referral process, it sounds like, did what it was supposed to do for you. But I hope that people along the way explained, right, why you're seeing so and so, why we're referring to a subspecialist. And, you know, same with me as a subspecialist, subspecialist. you know, it still happens from time to time where a patient ends up in my office and I ask them, hey, what are you here to talk about your new patient? And they say, I don't know. I was sent to see you. My doc said he was concerned about something. You have to know, right? Why am I being referred to someone? What is this consultation for? What am I trying to get information about? And that in and of itself, for me, at least, then I have a shared partner with the patient, right? Then it's not just me asking another doc, what do you think about Josh? It's me and the patient working to get that answer. And when you have that teamwork in place, then you're not necessarily at much at the sort of, you're not at the will of the healthcare system to get you where you need to be. You were given a referral to see your eye doctor and then a subspecialist. You went, you got the information you needed, you got treated, thank God, you're going to go back to your primary doctor and have that conversation about that. And then you're continuing that maintenance, that surveillance every couple months to take a look to make sure everything is still okay. That sort of trajectory is far more meaningful than saying, you know, Josh, go talk with so-and-so and let me know what they say. That's not shared decision-making as to

[00:29:21] Rob Howe: why you're going in that direction. So I'm glad you brought this up because we're going to cover this in a little bit when we review my blood work and the questions that me as a patient, I can ask to my care team because you hit on something really important is the relationship between you as the patient, me, Rob, me, Atreya, me, Josh, and my care team and my role as part of that. And I think that we hit on a very, we talked about diabetes isn't the same for everyone earlier. Also, treatment doesn't look the same for everyone and not everybody's care team. This occurred to me in college where I thought as a young person, oh yeah, every person that's authority over me is like the best in their craft and at the top of the game. And, you know, it only takes a little bit of lived experience within any profession to learn that, you know, not everybody is in the top 5% of practitioners or anything. So if you don't have that, or if you are newly diagnosed, or if you maybe just aren't as confident, or this is a very soft spot for you personally to discuss, how do you, you know, what steps would you recommend discussing with your care team to kind of help you get more information, arm you with more, even just strategies of how to speak to different providers or, you know, when you get referred to a specialist, what questions should you be asking or how can you, when you see, you know, when you're getting a referral, what questions can you ask your care team to prepare you for that interaction?

[00:30:50] Joshua Miller: I think that's probably the singular most important thing in terms of clarity for a patient to get to, to be their best advocate. So, you know, if and to your point that you sort of scratched the surface of it, didn't dwell on, but I can because I'm a physician. Right. You know, what do they call the student that graduated last in his or her medical school class? They call them doctor. Right. So there are phenomenal, amazing diabetes doctors out there. And I'm humbled by their care and commitment to patients every single day. And there are others that perhaps don't do as much of their due diligence in helping patients along their journey. I think every patient, regardless of disease, and in this case, diabetes, is seeking a care team that makes them feel supported and that shares in their journey. Whether it's a diabetologist, a primary care doctor, a nurse practitioner, a nurse diabetes educator, or Certified Diabetes Care and Education Specialist (CDCES), yes. I think anyone can play that role. But it's that shared commitment to my patient's journey that I think, at least for me as a patient, has been the most meaningful. I've had docs in the past that were seemingly judgmental and very matter of fact. and then others that clearly took the time and interest in making sure that I was achieving my goals. So the first sort of do not pass go unless you've addressed this with your doctors across the board that I would offer any patient and family member is what are your goals, right? And understand that your goals as a patient may be fundamentally different from your endocrinologist goals. It's not that he or she does not value what you want to do as a patient. It's that I think it's a recognition of both sets of goals. For many patients, I would like them to to take a cholesterol medicine, but for the patient, maybe they're laser focused on making sure they don't bottom out in the middle of the night with low blood sugar. Well, okay, so I'm gonna triage the cholesterol conversation over here for a little bit. We're gonna get back to that, but let's focus on low blood sugars in the middle of the night. Let's tackle that together. And then once we've tackled that, let's get back to the cholesterol part of medication. There's no absolutism in cultivating relationship with your care team over time. In my mind, it's sharing your goal setting and helping them to understand what's important and meaningful to you and helping you to understand what the data shows that I should be doing as your endocrinologist to decrease your risk long term, to help you live that high quality of life that you very much want to achieve. You know, we moved away and continue to move away from this sort of paternalistic approach to health care. You know, I'm not the boss in my patients' lives. My patients are. I will be very forthcoming and transparent and proactive about helping to steer patients with the information they need to make the decisions they should be making. But ultimately, as a patient, it's so important that you share with me what your goals are and let's achieve those together and then continue the conversation holistically about the other items that we also need to tend to.

[00:33:55] Atreya Khan: so as we talk about complications and we kind of address a little bit the stigma and maybe those bad feelings how do those conversations happen in your office with patients who are maybe feeling really really guilty I know that when I found out I was having some issues with my eye I literally I thought I was going blind and I just thought it was completely my fault and when I finally saw the red not the fee guy he was like no you're just in a race against the clock. So how do those conversations happen in your office? And what would you say to patients who have maybe developed some complications and are feeling really guilty? Yeah. So Atreya,

[00:34:30] Joshua Miller: I'm glad you used the word, the G word, which I use all the time. And I ask my fellows and students this all the time as well. You know, yeah, we talk about, and I started by talking about micro and macrovascular complications from diabetes. When in point of fact, I find that the most significant complication of living with diabetes, whether it be type 1 or type 2, is guilt. It's that we can behave in a way that is identical to our peers, and yet we are at greater risk of developing complications and may, in fact, despite that good behavior, still end up with a complication. And I have this conversation with patients with type 2 diabetes. I have patients who go to McDonald's seven days a week and maybe don't make the best choices, but their blood sugars are perfect, their cholesterol is perfect. And then I have other patients who they eat the best diet they can and exercise five, six days a week, and their numbers are falling apart a little bit. And there's this sort of, well, why do they get to do that? And what did I do wrong to develop a complication, God forbid? I think that in and of itself is the biggest stereotype that we need to continue to chip away at. There's no guilt here. There's no what could I have done differently? And it's as much as we can focusing on the positives, as recognizing the importance of addressing the negative. So, okay, I may have some bleeding in my eyes. What do I do now? Am I, is it going to derail all my progress on, I get up every day, I check my sugars, I exercise, I go to work, I lead a functional, productive life every single day. I live life to my fullest. I go to sleep at night answering the question, yes, have I done everything I can today to take care of myself? And okay, I have some bleeding in the eyes. And despite all of that, I still develop bleeding in my eyes. what do I do here? Is this my fault? There's never any fault. When a patient comes into my office and the first thing they say or they're compelled to say is, doc, I've been bad, I stop them hard in their tracks. There's no bad or good. You made a decision and that decision worked for you. Let's figure out how we can support you in that decision. It's not, you know, I had pizza Sunday night and my blood sugars fell apart. No, you wanted to have pizza because it's your kid's birthday party. So next time, what strategy can we use to help you enjoy the pizza and not feel so guilty about it. I think that's a big part of the conversation to me. And so it's not, you're going to go see the retinologist and get a laser, a quadurai, whatever the guess may be. And how did you get to this point? And I told you, if you don't control your sugars, you're going to end up, I mean, that's an awful thing, an awful thing. And I would compel any patient who's in that situation where they're being made to feel shameful or guilty, falling into that stereotype of a complication from diabetes to push back a little bit and make sure you have a meaningful conversation with the care team to explain how that makes you feel. Because how awful of a situation would that be if you find yourself feeling more shame and guilt about something that you really had little to no control over? And that's the truth.

[00:37:28] Rob Howe: And that's the truth. Well, and it comes back to what you mentioned earlier as well. Diabetes is a marathon, not a sprint. And, you know, they're, you know, I've never run a full marathon, but even in a half marathon, you make little optimizations. You don't want to dig too deep into one problem because it's a long race. And I think that's, I would echo that sentiment as well. And those are hard conversations to have. I think it takes a lot of courage for somebody to speak up and say, I want to change the way that we're talking about me and the way that we're talking about my performance, relatively speaking, revolving around diabetes. Because like you said, hey, I had a tough quarter. It was my kid's birthday, or I was graduating from high school or college, or I was focused on something at work or the global pandemic and bad news all around, anxiety, depression affecting my life. I think those are very human responses, regardless of whether you have diabetes or not. And I think, but again, it takes courage to have those conversations. So I hope if somebody's hearing that, you feel a little spark in your heart to advocate for yourself in that way as well, because you are a person with diabetes. You're not just an experiment. Okay. I want to shift gears a little bit because I want to be conscious of your time. So I broadcast this episode as a chance for us to review my and put me in the test, in sort of the test tube, so to speak, to look at some labs and how we might have a conversation in a care team scenario. So I have now, we've shared the screen for those of you guys who can't see us and I've got some labs pulled up and I'm going to scroll through here. I see some cholesterol here at the top. Where would you like to start with these labs, so to speak?

[00:39:11] Joshua Miller: So we can start up top and we've already had this conversation, but for the purposes of your audience, I'm not your physician. I'm not providing you bona fide medical advice, but I'm going through these labs with you to help you to understand what we look at. So, you know, yeah, so we're looking at a fasting cholesterol panel. And I think the first thing I would tell patients in general is, you know, when you should ask your doc when you're being given a prescription for blood tests, when you need to be fasting versus not and why. And for me, the fasting criteria is really only specific to your lipid panel. And the reason for that is that diet, especially the meal the day before can impact how your cholesterol panel appears when they actually run the testing. So, you know, were you actually fasting for this test, Josh, when you had the blood done? So for you, but then when you break down the actual indices within the panel, I actually really love this cholesterol panel, Rob. So the first thing I look at is your HDL cholesterol, which as I said before, is your good cholesterol. What we know from tons of data in the research world is that the higher the HDL is, the more protective that cholesterol is at helping for heart health long-term. So HDL is great. And HDL, you know, there are a few medications that we use to drive up the HDL to have a significant impact. Really the main thing that causes a high HDL is physical fitness. So the more lean muscle mass someone has, the more physical activity they're pursuing, not just cardio, but also strength training, the better your HDL will be. And that in and of itself is very protective, which is great. The LDL cholesterol, which we sometimes coin the bad cholesterol, that also from years and years of data shows us that the higher the LDL cholesterol is, the greater the patient's risk of cardiovascular diseases. Because LDL cholesterol is a surrogate for the cholesterol that collects in the blood vessels and that can cause those cholesterol plaques, those lipid plaques that can, God forbid, cause heart attack or stroke. And it's interesting. So the standards for LDL cholesterol in patients living with diabetes versus those without are actually a little bit different. So for those without diabetes, and you see it there, the reference range of 50 to 130, we generally recommend an LDL cholesterol less than 130, less than 120 or thereabouts. But for someone living with diabetes, the recommendation is to try to get the LDL cholesterol to below 100 if you can, and sometimes closer to 70. So there are some cardiologists who would say that an LDL cholesterol above 100 for someone living with diabetes is no good. I tend to look at the entire context of the patient and the entire context of the lipid panel, that HDL being so high and so protective, in many cases counteracts the LDL being over a hundred. So I love this lipid panel. I don't think necessarily that you would be on a cholesterol medicine, given that you're very young, but it is certainly worth the conversation with your doctor to say, Hey, you know, I, as I understand it, people with diabetes should have a relatively low LDL cholesterol. What can we do about my LDL of 116? And what do you think about it? Oh, and, you know, is the HDL cholesterol here helping me, which I believe it is your triglycerides are very low. So that tells me at least in the days preceding your test, you didn't have fast food or French fries or anything like that because your triglycerides are low, which is wonderful. Usually people who consume a very, very high fat diet, high saturated fats and the like, their triglycerides are very, very high. And there's also a familial component there as well. We see it in patients both with type 2 and type 1 diabetes where triglycerides can be too high, can also increase your burden of cardiovascular disease. And this is, you hit on a really

[00:42:58] Rob Howe: important point that you don't, you didn't know about this, but for me, my family, uh, you know, heart disease, I have a history of family history of heart disease in my family. So this is something that, you know, is worth spending a little more time on and looking at for me as I get older, like you said, right now, 33, uh, physically fit, able to get and do the, the, the activities that I want to do. Um, and, you know, eat, uh, I watch my diet. I'm very disciplined about my exercise right now, which is something I'm very proud of. Good, good, go me. But yeah, it's always good to have more information there. And, you know, again, unless you spend time going over these results with your care team and ask these questions, you know, it may spark ideas or adjustments you can make

[00:43:38] Joshua Miller: longer term. So I like that lipid panel. I'm actually a little bit jealous of it. So let's see here. I see a diuretic screen, beta screen. I actually don't know what that test is. I guess they were looking in your urine for a diuretic. We tend not to do that, but the doc's panel may be a little bit different, so we can go down a touch. So, you know, what the lab here has done is they've bundled a couple of different tests under the category of kidney and bladder so you can understand what they're talking about. Creatinine is one lab index that we look at pretty regularly for all patients as a good, reliable surrogate for kidney function. Creatinine is a protein in the blood. And again, when the creatinine level is very, very elevated, it can imply kidney damage exists. And the range there, as you see, 0.5 to 1.4, you know, we generally look for creatinine in most healthy men and women of around 0.9 to 1 or thereabouts, depends on the lab, depends on the patient age and whatnot. But your kidney function based on those lab tests looks quite good. What you may also, I get asked this question all the time, you know, you get your results back and something is a little bit off and it can be concerning, you don't know what it means, the BUN, blood urea nitrogen in the blood, sometimes can be elevated when you're fasting. So if you're fasting and dehydrated, you might sometimes see the BUN high or a high BUN to creatinine ratio. It's nothing to worry about necessarily. In patients with known kidney disease, you can see elevations to the BUN and creatinine together. But in someone who's gone for routine morning fasting blood work, and I see the BUN is a little bit high. I'm rarely too concerned about it if I know that they were fasting and maybe didn't have a lot to drink in the morning. Going on in your testing, it looks like someone may have done a urinalysis, which you don't need as someone living with diabetes. They looked in your urine to look for leukocytes and evidence of blood or white cells in the urine. If, God forbid, you had symptoms of a urinary infection, those tests would be useful. But really, the only urine test that I'm particularly interested in patients with diabetes and one that adheres to the standards is the urine protein, specifically the urine microalbumin. Here, they've included your urine albumin, which is great, but microalbumin, the smaller form of that protein is really what's key. I may be down further, I don't know. But urine albumin of negative, and it just may be the way this lab reports it is what you want to see. So if you see urine protein, urine microalbumin, urine microalbumin to creatinine ratio, if you see elevations, any of those three, it may be worth asking your doc, you know, I see a little bit of protein in my urine. What do you think about that? But you don't have any, which is great. Great news. Love that. And then here again, the lab has sort of bundled the lab indices that map back to, in this case, liver function. These are enzymes and proteins that are found in the liver that contribute to being able to filter the blood and the like, and your numbers are excellent. So AST and ALT are transferase enzymes in the liver. They can be elevated when there's been damage to the liver. So they can be elevated in someone who has a very high fat diet, high alcohol intake, and those enzymes can be elevated. Sometimes in patients with diabetes type 2 type 1 you can see what's called fatty liver where there's high cholesterol and fat and high blood sugars and all those contribute to a little bit of damage inflammation in the liver and as i said sometimes patients who drink alcohol very heavily you can see abnormalities in the ast and alt but in this case your liver enzymes are really spot-on perfect and excellent looks like they screened you for hiv and then they went down and again they've I've not seen this before, but I guess it's kind of neat where they bundle different tests under their own categories. This is pancreas. So let's start with A1C first, and then we'll talk about the glucoses themselves and why I care, but sort of don't care. So, you know, A1C, I think is hard baked into any conversation related to diabetes. And don't get me wrong, A1C is very important. Why is it important? So it is a three-month measure of blood sugar control. And, you know, in broad brushstrokes, very simply put, if your hemoglobin is bathing in a lot of sugar, it's going to get glycosylated. It's going to have that sugar attached to it. And you could measure that in the form of a percent. So the less amount of sugar that your hemoglobin is bathed in, the lower your A1C will be. Why do we still focus on A1C? Well, we know from many, many years of data that A1C is very closely correlated with risk of micro and macrovascular disease, more micro than macro. But even still, we know that as A1C climbs significantly above 7%, a patient's risk of developing diabetic kidney disease, diabetic eye disease is much, much higher, similarly with heart disease. So that's why we still look at A1C. And that's why I still do rely on it to help us to sort of think about that long-term risk. With that said, if you were to ask me, would I, you know, do I have the choice, if I have the choice rather of looking just at A1C or looking at a CGM time and range, I would probably choose the CGM between the two because I think the CGM provides more actionable data in terms of pattern recognition and what the day-to-day life is for someone with diabetes and how we can tweak perhaps insulin regimens and the like to improve time and range. But there is a high correlation between time and range and A1C. As far as blood glucose, it's a random snapshot. I don't care as much about a serum glucose on the chemistries. It just happens to tell me that that morning your sugar is 121. If your A1C is 6.1 and your sugar is 300 that morning, yeah, I mean, the sugar is too high, but I do know that it's an outlier because the A1C is relatively low, although A1C is an average. But the blood sugar itself, out of context of A1C, is a little bit less actionable. I can look at an A1C and not see the blood glucose and do just fine and helping patients to understand their blood sugar control. Um, but to look at a blood glucose without the A1C or without the CGM, it's not very actionable. I agree with you at the same time as

[00:49:57] Rob Howe: a person with diabetes, who is, uh, a little bit of a control freak. Uh, I think about, you know, when I get my sugar tested, uh, you know, even in the days before I wore CGM, a little bit of the sweaty palms of, Oh, what's my doctor going to say if my sugar is out of range in this moment, even if I have a good A1C. And, you know, I think that that is just more of my healthy anxiety contributing to that conversation. My care teams have always been really supportive. So, but yeah, I guess it's nice to hear that if you have a number that's even a high outlier or low outlier, it's okay. We're looking at the bigger picture here, marathon, not a sprint.

[00:50:36] Joshua Miller: It's all about big picture. And yes, I mean, it's been ingrained in our heads that we should be perfectionists and that our blood sugar is really sugar, sugar, sugar should be perfect, perfect, perfect. But, you know, yeah, I mean, if your blood sugar was 300 on your chemistries, I might ask you, hey, what happened the night before the morning of your lab test to give you the sugar 300? Oh, you know, I was fasting and I didn't bolus to correct in the morning because I didn't want to bottom out when I got my bloods done. And so, yeah, my sugar is a little bit high. Okay, fine. Your A1C is 6.1, no worries. The urine glucose, similar, but also different. So, So when I'm teaching students and residents and fellows, I always ask them, why do we care so much about urine protein and urine glucose? Why do you want to not see glucose and protein in the urine? And the reason for that is evolutionarily, if you think about the way the body developed over time, many thousands of years, we didn't always have the ability to go to the local grocery store to get our food and to get our nourishment. And so the kidneys evolved over time to hold on to what I call expensive molecules that the body produces and needs, among them being protein and among them being sugar. So the kidneys spilling sugar tells you that the sugars are too high in the blood and they're not able to hold on to that sugar in the kidneys. Same goes with the protein. The body spends a lot of energy to create albumin, to create protein. And if you're spilling that protein in the urine, it tells you that some damage to the kidneys that's allowing the protein to get through. So the body is designed to hold on to those very expensive molecules. Glucose and protein are the two that I think about. You don't want to see glucose in the urine. And just as a side note, if you do consistently see glucose in the urine, it tells you that on average, the blood sugars themselves, the blood sugars are above 180 to 200. So it's that threshold above which the kidneys are not able to hold on to all the sugar when they're filtering the blood. And that's when you start to see what's called glucosuria, glucose in the urine or urine glucose that's positive.

[00:52:37] Rob Howe: I know we're short on time, but I want to ask just ideologically, is that where that sort of time and range high end threshold? Is that the reason for 180 to 200 that we consider a higher elevated blood sugar?

[00:52:49] Joshua Miller: To a certain extent, right? So the standards for time and range, I think, are evolving a little bit over time as we all as a diabetes community gain a better appreciation for how impactful CGM can be in helping patients to achieve their goals. But yes, what you'll notice in looking back historically at a lot of the data suggesting complication risk based on blood sugar threshold, that's both in the four walls of the hospital amongst hospitalized patients, as well as outpatients in longer term studies. It is that number above 180 that tends to cause greater, it's the number above which you see the inflection of greater risk. So consistently above 180, A1C consistently above seven, you're going to see risk of microvascular disease. Same goes for the inpatient setting as well. But what I'm referring to for glucose in the kidneys is what's called a transport maximum, the number above which the max has been exceeded and the kidneys can no longer hold on to glucose and you end up spilling a little bit of glucose in the urine. So, you know, the fact that you have that they've grouped blood glucose, urine glucose and A1C together, I think it's great. Of the three numbers, the one I care the most about, of course, is the A1C, urine glucose a little bit less. If I were specifically interested in risk of kidney damage, the urine microalbumin and the creatinine are probably the two more useful lab indices I would use in discussing that with the patient. Well, thank you so much,

[00:54:21] Rob Howe: Dr. Miller, for digging into some data. And for everybody, if you ever wondered what my real numbers were, uh, you'll get to see them now. So, uh, peeling the curtain back a little bit, so to speak. Um, Dr. Miller, I know we're short on time and I want to make sure to be respectful of your, of your time. You've got patients to see, um, 22 years with diabetes, looking back, uh, if you could transport yourself back to 22 years ago, uh, what would you tell younger Dr. Miller about your life with diabetes and what advice would you give yourself?

[00:54:50] Joshua Miller: Yeah. I mean, I think ultimately, especially at or near a time of a new diagnosis, the whole process of understanding the impact of that diagnosis long term is very very very overwhelming and I would probably sit down with my 19 year old self and say you know what everything's going to be fine right I think that all too often especially amidst what is a particularly scary diagnosis to receive and everyone's got their own story about how they were diagnosed and who they saw at the time and where they were, were they in the hospital, were they home, etc. But I think the universal there is people are scared. And I would go back and give myself a hug and say, you know, everything's going to be fine one way or another. And understanding that there is a pathway forward to leading a healthy, God willing, complication-free life. And I think establishing that framework at day zero is so profoundly important because blood sugar control, medication management, all these things are vital. But if you don't help patients to realize what the long game is and share in that long game and crafting a strategy to getting there, the other stuff matters far less. And you get caught up in the weeds. So, you know, yeah, I give myself a

[00:56:06] Atreya Khan: hug and say, everything's going to be okay. Man, I couldn't have said it better. That was so wholesome. When you said, give himself a hug. Oh my God. I would. I mean, it's, you know, it's,

[00:56:19] Joshua Miller: a scary time in anyone's life with diabetes. And I diagnosed people, I diagnosed a gentleman in his 60s last week with type 2 diabetes. And the fear behind his eyes was no different and no less than in the eyes of a 16-year-old that we diagnosed. So, you know, I think everyone's unique, but recognizing that there's a shared set of challenges and circumstances that we all have. And it does take a village and it is a marathon, not a sprint, and everything's going to be okay. I think that's important. You know, beyond that, hopefully, Rob, someday, sooner rather than later, we'll have a conversation about closed-loop therapy and me being able to put on a device and not have to worry about bolusing and all these other things. But how you get from here to there, I think, is the journey that's probably the most significant for patients. So I hope I was able to share a little bit of information about labs. And I will say I'm exceedingly jealous by your lipid panel and by your A1C. I, of course, won't be sharing my A1C with you, but you're doing an extraordinary job. Seriously. Excellent. You should be commended.

[00:57:23] Rob Howe: I appreciate it. And again, this is not for me to flex my numbers. I also, I think what you've said about all of the emotions and all the feelings around the numbers and around the care team discussions are what's most important. And I just, I feel that people with diabetes are going to feel very seen by this, by this conversation to hear an endocrinologist who lives with diabetes, to speak to the holistic approach of emotions and, uh, you know, different points in your diabetes journey and, you know, what you would tell your younger self, as well as how to have proactive conversations about longevity, uh, because this is a marathon, uh, not a sprint. And, uh, again, I'm grateful to live in this time of history where not only can I have the tools, uh, you know, and we need to work on accessibility, but the tools are out there for us to live well with diabetes. And the technology, like you said, is getting better. I'm very excited to have that conversation with you, hopefully in the near future as well. But thank you, Dr. Miller, for giving of yourself for people with diabetes and for having this very human conversation, you know, with a little bit of science sprinkled in. So I'm very grateful. Thank you very much.

[00:58:29] Joshua Miller: Thanks for inviting me, Rob, for the time. Atreya, it's nice to meet you. Thank you also for sharing your journey. And anytime I can help your listeners and readers, it's my pleasure. It's really great chatting with you guys.

[00:58:41] Atreya Khan: Thank you.