Dr. Mike C. Riddell - York University

[00:00:00] Rob Howe: Welcome to Diabetes Innovators, a special series from Diabetics Doing Things covering the 85th Scientific Sessions. We're held in June 2025 in Chicago, Illinois. You're going to hear interviews from leaders of tech companies, people with diabetes, diabetes creators, researchers, and more on this podcast. If you want to learn more or hear more from this series, visit DiabeticsDoingThings.com slash Diabetes Innovators. Enjoy the episode. Okay, let's talk about our partners who help support this podcast. Today, I'm going to talk about Type Zero, which is typezerohealth.com. It is a business run and founded by a person with type 1 diabetes, John Jensen, who's been on this podcast a couple of times. I've been using this product since 2018. I started training for a half marathon, which I ran in Dallas in December 2018. I was looking for a workout supplement, a pre-workout that I could trust not to spike my blood sugar. 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[00:04:27] Mike Riddell: Hi, I'm Dr. Mike Riddell from the School of Kinesiology and Muscle Health Research Center at York University in Toronto, Canada.

[00:04:33] Rob Howe: We were just talking about you were on the planning committee for ADA Scientific Sessions. So now here at the event, all that work sort of coming to fruition. Yeah, it's amazing. My first experience on

[00:04:43] Mike Riddell: the planning committee, I'm in charge of all the exercise-related content of the conference, but I'm also, it's fun to meet people who are doing research and cures and innovations and technology, but it is a ton of work, but now it feels like it's worth it because I get to see all

[00:04:58] Rob Howe: the action here live. Yeah, it's doing this series basically to talk about all the diabetes innovations. And I'm excited to hear, like you, I'm excited and have a vested interest in anything cure-related or therapy-related. But on the diabetes and exercise side, I'd love to know what are the big innovations that you're seeing around diabetes and exercise or what are the

[00:05:16] Mike Riddell: sort of themes at this year's scientific sessions? In the type 1 space, we are seeing lots of studies related to try to minimize hypoglycemia with exercise. We know that exercise can kind kind of increase your insulin sensitivity and cause your blood sugars to drop, often causing low blood sugar, as you and I both know firsthand. Yeah, all too. We're seeing that there are strategies that use different AID settings, so changing insulin delivery that's better for when you're active compared to when you're sedentary and doing. That requires innovation in bioengineering, but also sensing when people are exercising using wearables. We're seeing that here. We're also seeing some different nutritional strategies. There's a great poster I just was at looking at whey protein as a supplement prior to exercise. You know, we often gravitate to carbs, but it looks like some branched-chain amino acids are improving glucagon's response to exercise and allowing our blood sugar to be in better balance. We are seeing strategies around exercise education to break down some of the barriers and fears that people might have if they're on insulin to exercise. Our friend and colleague, Dessi Zaharieva, is here with Diabetes Wise, and they're presenting stuff on the educational modules and how they're making newly diagnosed young people with type 1 a little less fearful to exercise for health reasons. I think that's great.

[00:06:30] Rob Howe: Well, I think you touched on a couple of really big things, like hypos and exercise. They go hand in hand, right? And especially if you're just getting started. I try to remember so much of my life in general has been influenced by sport and exercise and being an athlete. And my life with diabetes is no different because from the beginning, I was exercising, you know, strenuously with diabetes and got to learn about it there.

[00:06:52] Mike Riddell: Right. And your story is neat to me because you adopted technology soon on after your diagnosis, but you were still doing very competitive athletics. You could say that the pump was great in some situations like overnight, but you still realize that exercise gave all sorts of challenges. It was tricky. Even with the best technology.

[00:07:09] Rob Howe: And, you know, with no CGM at that time, widely used. Today, I think about what it would look like being on an AID system and competitive college athletics would be very, very interesting. At least you'd sleep better, probably. For sure. For sure. My mom would probably call me less. Yeah, mine too. I think, though, for people just getting started with exercise, like hypos, like you said, insulin sensitivity or they've got insulin on board and they bottom out in a workout. They have a bad feeling or maybe they have some anxiety around hypos.

[00:07:36] Mike Riddell: Yes, yes.

[00:07:37] Rob Howe: Anything that can kind of limit that or make you feel more confident would be a big impact.

[00:07:42] Mike Riddell: It would be. And we are learning from data that's presented here that exercise at certain times of day are more risky for hypoglycemia. If you exercise later in the afternoon, maybe a few, one or two hours after you've had a bolus of insulin, that's a high risk time of day for a hypo in exercise and then another hypo overnight. modifying, learning how to modify behaviors so that they're less risky and more attuned to glycemic stability. We're learning from studies presented here. In the morning, before Ebola is a pretty safe time to do a bit of exercise.

[00:08:12] Rob Howe: You mentioned Diabetes Wise and Dessi are mutual and amazing athlete and researcher. You guys, as a group, there was like a global cohort of diabetes researchers, like released a position statement around AID and exercise. And I really liked the visualizations in that. Because exactly what you're talking about with the time of day and the different systems and like what to think about. So the three types of exercise, whether it's aerobic resistance or high intensity interval training, what was that like putting that together and those different

[00:08:40] Mike Riddell: learnings with that group? It was a lot of fun. And I really, my hat's off to Desi and Othmar Moser, who were the two first co-first authors for that. I played a supporting leadership role, but we were able to get almost 20 international experts who'd worked with athletes, who'd worked with AID systems, who'd work with average patients who were new to exercise, and putting our heads together about what's the best approach to minimize both hypo and hyperglycemia, which can happen too, as you know. And what was unique about this is that we created a position, a paper that follows the type of AID system you're on. Because as you know, there's quite a few now. We've got Omnipod 5 out in Canada now, which is great. You've had it here for a while. We've got Tandem Control IQ, We've got MiniMed 780G. They're all a little bit different in their technology and their language. And we wanted to create a position statement that walked healthcare providers and patients, we hope, what to do with their particular device. And I think that's the first of its kind.

[00:09:41] Rob Howe: I found it really enlightening. And I got to see because of the animations and the illustrations are really easy to say, OK, well, this is what I do. And for me, I was like, OK, well, intuitively through trial and error, I've learned when I play golf, I have a different approach than when I play basketball or when I'm doing a strength exercise. And so to be able to see that labeled out in those illustrations was really helpful.

[00:10:04] Mike Riddell: Thanks. It might seem a complex. It is. And it might seem that we have all the answers and we don't. There is still so much we need to learn. And these are just starting point recommendations. But people, as you know, have to find what works for them. What diet approach, how to set their technology systems into an activity mode or when to take it in and out. This is an individualized experience living with type 1, as you know.

[00:10:30] Rob Howe: Well, I think that's what often gives so many people, myself included, a headache, right? It's because one day to another, one week to another, one year to another, one person to another. Managing diabetes is complicated.

[00:10:41] Mike Riddell: It makes it hard to give advice that's so personalized. But people like you, you're inspiration to people that are diagnosed because you show that you can problem solve. You show that you've got some basic knowledge that over time with the duration of your diabetes, you're going to learn more and more and more and share those stories. And what might work for you playing basketball might not be what I need for when I go for a bike ride. But as long as we share our experiences and share our knowledge, I think we're going to help our community.

[00:11:06] Rob Howe: And I think that pushes things forward, right? It helps people get started earlier. And I'm grateful for that as well. Like I often say on the podcast, like I'm just the end of one of myself. I run with myself and I get to learn from your own end of one and then also the research that you and your lab do.

[00:11:23] Mike Riddell: And the tech companies, at least the ones in academia, are realizing that our ends of ones add up over time. And our systems in the future could be using our own data to better optimize the settings for stress and exercise and different meals. And I think that is something that we can both look forward to in coming iterations of these so-called closed-loop systems that are more personalized to our physiology and our behaviors.

[00:11:49] Rob Howe: Well, and that's what was interesting. I was in a session this morning on the role of artificial intelligence in a clinical standpoint. And the idea of a personalized diabetes regimen through a closed-loop system for a person or even an archetype of a person is particularly exciting and seemingly not so far away.

[00:12:05] Mike Riddell: No, I've had the pleasure of working with both of those presenters, Rayhan Lal. I think it was, and I think Pete Jacobs from OHSU, these are bioengineers or clinicians who really are visionary about what could happen with AI technology and precision medicine for our ends of ones.

[00:12:22] Rob Howe: When you think of like AID systems, like where we are today and where we're going, does it make it easier or simpler rather, I think, to exercise or with T1D, like planned or unplanned? So from my end of my experience, I find that maybe it's more predictable than if I was just on either manual injections or a pump with no closed loop or hybrid closed loop. But I still have to learn what my body's going to do in those workouts. And maybe the first time isn't always this smooth.

[00:12:50] Mike Riddell: There's always pros and cons to any new technology. You and I were diagnosed at a time where we didn't have continuous glucose monitors. So we would have taken our needles and we would have not thought about our sugars all that much. unless we felt we weren't playing well or feeling well. But now we're seeing our data change minute by minute. That extra information, it's good, but it can also kind of hamper us because it's like data overload and my numbers are starting to go up a little bit or down a little bit, whereas you and I probably just would have finished playing our game unless we had a severe low or a severe high. So it always comes with the realization that we have to expect the unexpected and know how to adapt and manipulate our behaviors, our food intake, The settings on our pump. It's not a hands-off disease. No matter how great the technology is, it's still not a hands-off. And we have to carry that burden of always thinking and looking at it, which you know can be tough.

[00:13:44] Rob Howe: I heard a quote recently from an Olympic sprinting coach. And they were asking about like force plates and, you know, exercise science and technology has come a long way in recent years. And he was saying that his perspective on his team was to make sure that they had the latest and greatest technology and rely on it as little as possible.

[00:14:05] Mike Riddell: Wouldn't that be great if we could do that with our clothes looks? Wouldn't that be great? But we are not there yet.

[00:14:10] Rob Howe: Not quite. It is exciting, though, to see some of the papers that are being published, some of the posters that are out and some of the studies on at least early phase of what could potentially be therapies that would make it a little bit easier to live on these things.

[00:14:23] Mike Riddell: That's a great point. I'm sure you're talking to people who are talking about other drugs and medications that are changing our health and physiology. I can tell you about one that you may not know of. Yeah, I would love to. There is some research that's presented here and talked about here. It's a drug that is normalizing our glucagon response to hypoglycemia or exercise. Glucagon is a hormone that can help raise your blood sugars. And we need glucagon if we have a severe hypoglycemic ratio, we might get an injection of it. But people with diabetes can make a glucagon, but we tend not to release it normally. And this company has got a new medication that will allow the glucagon to come out of the pancreas and get into the bloodstream and keep our blood sugars up. So that's exciting. Other medications are working on glucose stability. The incretin therapy is interesting. Not a lot of incretin therapy in type 1, but lots of GLP-1 and receptor agonists in type 2. And I think that might have applications in type 1 for glucose stability and weight control and all these other things.

[00:15:22] Rob Howe: There's a few studies coming out here that are talking about, I know, a study, the ADJUST T1D, semaglutide and T1D. That's right. You know, being released here at the scientific science.

[00:15:31] Mike Riddell: And sotagliflozin, which is a type of an SGLT antagonist. There's data presented this afternoon about the importance of that agent for kidney health in type 1. We have to remember that we've got to keep our kidneys functioning. And it's a drug that could have some benefits for us.

[00:15:46] Rob Howe: It's exciting. I think, you know, we're continuing to learn so much about the system. We had a guest on the podcast talk about the beta cells are less than one gram of cells. And they're less than 1% of the pancreas size. And they manage your diabetes, they manage your blood glucose and glucagon perfectly forever until they don't. And so these such small little things making really big impacts.

[00:16:10] Mike Riddell: Isn't it amazing that they presented last night the Vertex data to show that the islet transplants, I think there was almost all of the participants who got the transplants were still off insulin. Maybe the couple were taking a bit of insulin.

[00:16:23] Rob Howe: Yeah, I believe it was like nine of...

[00:16:25] Mike Riddell: How did that make you feel to hear that they might be on the verge of a cure? Maybe.

[00:16:29] Rob Howe: I saw the charts and some of the patients in the study had really difficult glucose control, like not very well managed. And then to see like the three-month slices of the data and then the first three months, they're like much tighter control and then to be completely in range for

[00:16:45] Mike Riddell: that next one. And no hypoglycemia and then no need for these AID systems or insulin bullets.

[00:16:50] Rob Howe: Like that's pretty encouraging. It is. And I think, you know, you're talking about, We've had other researchers from TixiMed, Tix100, we're talking about a drug that would eliminate hypoglycemia. You take that as well as managing with a hybrid closed-loop system. Now you're slowly chipping away.

[00:17:08] Mike Riddell: We are chipping away. There's still work to be done, but it does look good. What exciting to be here and see what's going on.

[00:17:15] Rob Howe: What did you think of the Vertex Day? You've lived with diabetes a little longer than I have, but to see those nine people. I was inspired, absolutely inspired, yeah.

[00:17:23] Mike Riddell: My son has type 1. I wish that when he was diagnosed, there was that opportunity. But I know friends who are at this meeting whose children have positive antibodies and there might be something for these kids. It's incredible.

[00:17:37] Rob Howe: I had lunch with the family. One of the kids has type 1 and the other is in phase 1. And thankfully, they're still not diagnosed with type 1 yet. But, you know, as these things are coming out, they're in a study to be ready to take the Tzield.

[00:17:51] Mike Riddell: Yeah, that's right. Is there teplizumab? to modify the immune reaction and hopefully slow it down yeah and so you know to think

[00:17:59] Rob Howe: having lunch with them today thinking about 20 years ago uh and a bit of thought to have an idea that that could be possible is pretty encouraging it is very encouraging so uh what do you anything else that you're excited about from an exercise and diabetes standpoint i think i've told you

[00:18:13] Mike Riddell: everything i could think about right now we've got education initiatives we've got new hormones new drugs. We've got AID systems that could be integrated with wearables to kind of quantify when we do activity. I think there's other stuff going on, but those are the big ones that I saw.

[00:18:28] Rob Howe: Yeah, I think it's interesting, like the shift between like Oura Ring and Dexcom, for example, like a consumer electronics and exercise brand integrating, adding the glucose

[00:18:37] Mike Riddell: piece of it. Yeah, I can't see the harm of getting more sensors in more people's hands. Well, I'll tell you one interesting story. We put sensors on an elite soccer club in Europe. Like one of the top soccer clubs in the world. They have one player with diabetes. He was not on our study. So everybody on the team did not have diabetes. They wore these sensors and their glucoses were going up because of the intense competition. So we're learning so much by putting sensors on people who have pre-diabetes, early type 2, healthy, elite athletes. So we're learning a lot. And it doesn't hurt to know this, I don't think.

[00:19:11] Rob Howe: Yeah, I agree. Let's talk about that for a second, because I, you know, I think the access to CGM for people with diabetes is a no brainer. Like we have to have that. And Canada does it better than the U.S. as well. But one thing that's really interesting to me, and I got this from learning a little bit about like lack of sleep and its impact on your blood glucose and how really, as you'll know, as somebody went through medical school, there's those times where you're not sleeping very well at all.

[00:19:35] Mike Riddell: Like last night for me, exactly.

[00:19:37] Rob Howe: Exactly, at 88, right? And so even a week or two of suboptimal sleep can really affect your insulin sensitivity. I think so, yeah. And I think for us, people with diabetes, we think that maybe that's the diabetes that's doing that. And it's really these other factors.

[00:19:51] Mike Riddell: Yeah, it's like the physiology that is taxed because of lack of sleep or poor diet or stress at work or maybe an intense competitive professional sporting event. That's as stressful as you know. It's stressful and it has its impacts on the body and you can see it in things like heart rate and blood pressure and you can see it in glucose. That's kind of cool.

[00:20:14] Rob Howe: And a healthy body without diabetes is going to release insulin to bring down that. And so that's something I think I had to, you know, that was the first real diabetes challenge I had in my life and in my athletic career was so much stress on my mind for performance. I wanted to play. I wanted to do well. I was nervous. I wanted us to win. And all of that adrenaline and cortisol drove my fasting blood sugar from, you know, 80 milligrams per deciliter to up in the three, four hundred. with no food. And that was like, I mean, you really had to... It looks like you ate cake, but you just... Yeah. And so I think now, like, if I had had a graph and I've been able to see that, that would have been great information. Like you said, could have been overwhelming at the time. But learning about the stress and adrenaline...

[00:21:01] Mike Riddell: You know, and seeing that the athletes who don't have diabetes have this little bump in their glucose, but because their body can secrete insulin, it brings it back down. What we're doing right now with a study that is funded through the Helmsley Trust is you've done discussions about the inhaled technosphere insulin. We're looking at active athletes with type 1 who get this rise in their glucose. They may even be on a closed-loop system. We give them a little bit of that inhaled insulin, and it brings their glucose down much more quickly, and we're not seeing hypoglycemia. So these little strategies might have helped us. Absolutely. They might have helped us.

[00:21:37] Rob Howe: And I think while we're talking about the inhaled insulin, or Afrezza for those listening the fast in fast out is really bad you know i think even overnight uh hyperglycemia i feel more comfortable treating it sometimes i have yeah i i like using it for you know especially on a time i'm maybe on an airplane and so i'm sedentary

[00:21:57] Mike Riddell: they don't kick you off the airplane for bringing out the inhaler they don't they don't kick me off

[00:22:01] Rob Howe: for doing the inhaler but they might if i did lunges up and down yes the hallway it allows me to get my sugar down without having to rage bolus, so to speak, or on the pump. And I think now, like, with the auto-correction boluses and things, like, it's easier to manage those and you're starting to behave more like a pancreas would, which is exciting. But when you really want that, because you know how it is, especially when you're an athlete and you've taken yourself out of competition and you're trying to get your glucose back in range, like, you want to do it as

[00:22:29] Mike Riddell: fast as you can. Yeah, isn't it funny that carbs can bring our sugars up pretty quickly, but insulin, it's not that quick to bring it down, at least when you infuse it or inject it. This could offer a bit of a solution. We're doing a study where if you have Afrezza or inhaled insulin at noon, what happens at 2 p.m. with exercise? Maybe it's a bit safer because, as you said, it's a faster on and off. So we're comparing those scenarios, high blood sugars. So maybe we'll learn more for next year's shot.

[00:23:01] Rob Howe: Man, I'm ready to nerd out. I need to visit the lab. It's long overdue. But when you're thinking about like diabetes and high performance, like it's just minuscule decisions. And they always say it's a game of inches, right? It's a game of... You got to really like try to figure out the details.

[00:23:15] Mike Riddell: Yeah, we say millimeters.

[00:23:16] Rob Howe: Yeah, you guys. Yeah, yeah, for sure. That's great. Great. Well, I'm going to call you Dr. Riddell. Mike, thank you so much for...

[00:23:23] Mike Riddell: Rob, it's always a pleasure to sit and just chat, brainstorm and celebrate what you're doing and what our research and clinical community is doing for all of us who live with diabetes,

[00:23:33] Rob Howe: whatever type, form or stage. Yeah, absolutely. It really is. And thank you so much for your time and generosity and kind words as well. I really appreciate it. You're welcome. Thank you.