Type 1 diabetes. Well, it doesn't always travel solo. In fact, if you have type 1 diabetes, you're at higher risk for some other autoimmune conditions like celiac disease, thyroid problems. We're going to get into it, uh, with my good friend Steve on this edition of the taking control of your diabetes podcast. I am one of your hosts, Dr. Jeremy Pettis, joined as always by my good friend and colleague, Dr. Steve Edelman.

And if you're just tuning in, we're both endocrinologists. We both have type 1 diabetes since we were 15 years old. We do research, and we work here at Taking Control of Your Diabetes, which is now celebrating its 30 years of existence. So, Steve, on this episode, um, we're talking about something that comes up a lot, that people with type 1 diabetes, they have, um, other autoimmune conditions. So, when should you get screened for these? How can you treat them? What kind of like, you know, care should you get if you have them? All those kinds of things. And before we dive into the specifics, I wanted to tell you that I was reminded when, you know, we were kind of preparing for this. A video you did a long time ago in the old office, it must have been 15 years ago. We were saying diabetes was like a raindrop, you know, and like through life you get hit with these different raindrops. Like you might get hit with one and you get married, or one you have kids, and one you have type 1 diabetes. And you... you're making the point it doesn't seem fair that if you get hit with a type 1 diabetes raindrop that you can... you can get these other things, and not only can you, but you're at higher risk. It seems like if we get type 1, we should be just null from having any other medical problems. Like, we already have our thing. Leave us alone.

I'm really impressed you remember that. Uh, yeah, diabetes is just another raindrop. And, uh, you know what? There are certain things that aren't fair in life. And, um, even the fact that we don't even know why we develop type 1 diabetes. We just have no clue at all. Lots of theories. And it's just one of those things that happens to people and, thank goodness, we have ways to treat it and live successfully until a cure comes along.

Yeah. And the other thing that, you know, Steve and I kind of have an inside joke is that all the time we get these emails, like, you know, medical updates. It's like, "Type 1 diabetes associated with poor sleep," or, "you know, knee pain," and we just forward it to each other and say, "Add it to the list." Like, here's another thing. So, we do have to deal with these things. There's lots of positives of having type one we, you know, we talk about all the time. But we're going to talk specifically about these other autoimmune conditions because they are more common... but less wrinkles.

Less wrinkles. We have less wrinkles. If you look at Steve and I, especially Steve, he looks amazing. Um, that's one positive thing about having type one and having good friends like Steve and I. Um, okay. So, what are the most common things? Thyroid and celiac disease. So, thyroid is the most common kind of problems that people might have when they have type 1 diabetes. And, um, you know, the numbers vary, but they say up to like 30% or so of people with type 1 diabetes will have thyroid conditions. And the tricky thing about thyroid disease in type one is that it can cause an overactive thyroid disease, where you produce too much thyroid hormone, and an underactive, uh, thyroid, where you get too little. So, hyper or hypo. And it gets further confusing because hyperthyroid is usually Graves' disease. That's actually a guy's name, like Johnny Graves. Um, I used to think, you know, it was like a... like a graveyard. No, it's, um, like Graves' disease. But, um, and, um, hypothyroidism we usually call Hashimoto's thyroiditis. So, people sometimes use those terms also. So, um, let's start with maybe just kind of generally, people are saying, "Okay, how do I know if I have a thyroid problem? How often should I be screened? Is it easy to do?" What do you tell people there, Steve?

Well, typically, on... on, really, the simplest level, we try to get a test of the thyroid level once a year. We typically get a test called the TSH, thyroid stimulating hormone. And that's a hormone that comes from the brain and goes opposite to the actual thyroid level. So, for example, if you have Hashimoto's, a form of low thyroid, um, what happens is your brain says, "Hey, we need more thyroid, let's secrete this hormone." And so, it's a good screening test. And so, you're saying, yeah, it's... it's opposite. So, if you have low thyroid, high TSH. Yeah, but you didn't like really nail the point down. That's why I'm here to kind of complete the thought. Um, so yes, and, and you know this TSH, the nice thing about it is it's pretty rare, um, in medicine that it costs a couple dollars. It's a very simple blood test that literally every lab can do. And everybody with type 1 diabetes should be doing this probably every year. Yeah. Um, and just add it to kind of your usual, um, things, your A1C, your cholesterol, that kind of stuff. Yeah. On the other end of the spectrum, if it's suppressed, if it's really low, that could give the doctor an indication that there's too much thyroid coming from the thyroid gland. But I should say that, you know, there are PE endocrinologists, that's all they do is thyroid conditions. There's lots of different ones, but these are the two that are associated with autoantibodies towards the thyroid. So, I would say to you, do we know what causes autoimmune thyroid dysfunction? No, I mean, I think it's... it's worth talking about autoimmunity in general real quick. So, what is it? Yeah. Well, um, it's basically when your own body, your own immune system, misrecognizes something in your body as foreign and attacks and destroys it. And usually it's, uh, these T-cells, and I like to think of the T-cells or these little guardians that are going around your body kind of monitoring for, um, viruses and bacteria. And usually they are very, very, very, very good at identifying something foreign, like a virus or bacteria, um, compared to something from yourself. You know, they might scan around, say, "Oh, that's part of a pancreas. I don't need to attack that," or, "That's part of my liver. I shouldn't attack that. But this is part of a virus. Let me call my buddies here and declare war," on, you know, whatever this is. So, the immune system, like I said, is usually very, very good at this. But every once in a while, it kind of gets it wrong. And in the case of type 1 diabetes, it misrecognizes the beta cell as something foreign, a virus, a bacteria, and it just goes after it until they're all dead. And in the... in the case of, um, like low thyroid, it's that it misrecognizes the thyroid gland as something, uh, foreign and starts attacking and destroying it. So, let's talk about low thyroid. So, yes, you should get screened every year. What are some symptoms? What does the thyroid do? The thyroid has lots of functions, metabolic functions, but I think the best thing is to talk about the symptoms, which you can think about what it does, and basically, uh, you lose energy. Yeah.

And you just are tired all the time, and then people gain weight with that, and they have mental fog with it as well when it gets too low. We should say that there's a natural history to these thyroid conditions. It doesn't all happen at once, and things change over time.

So, I mean, I think that's... those are the two major symptoms. You also get cold intolerance. So, for example, sometimes a good question you would ask, you know, "Do you have to turn on the heat at night a lot?" And they say, "Yeah, my husband or my wife is hot as heck, and, you know, and I'm asking them to turn up the heat." So, and when we talk about hyperthyroid, it's typically the opposite of these symptoms as well. Yeah. So, I would say the thyroid gland, first of all, sits right here, kind of on your neck, um, if you're watching on YouTube. If you're not, kind of right on top of your... your trachea, um, is this kind of U-shaped gland, and it secretes thyroid hormone, which, um, affects metabolism of basically every organ. Yeah. And when you don't have enough of it, everything slows down. Your heart rate slows down, your, um, your motility of your intestines slows down. So, people can get constipated. You don't use as much energy, so you gain weight, you... you get cold, all these kinds of things. Now, the problem with this is when you ask somebody, a patient, "Are you tired?" "Yes." "Are you gaining weight?" "Yes." You know, these are common things that everybody has. And I find actually, and maybe you do also, sometimes people are kind of hoping that their thyroid is off. Yeah. You know, they come in because you want an answer. Yeah. Um, you know, "Gosh, I hope my thyroid is a little low so I can take a pill and kind of like, you know, magically cure things." Um, but you know, if it's normal, you should actually be happy about that. So, it's probably the most common thing that people say when they're gaining weight: "Check my thyroid."

Yeah. And once again, it's important. That's why the screening is so important, because if you do a TSH once a year, you could pick it up long before you get to the extreme symptoms. Now, okay, let's say you have some of these symptoms. Maybe you don't, and you... you just go in, you get screened, they say you have low thyroid. What's the treatment, Steve?

Well, it's... it's pretty darn easy. Uh, typically we just start with a low dose of thyroid medication. Now, when we type ones, we can't take insulin by mouth. Gets destroyed in the stomach by, you know, digestive enzymes. But it's great news. You can get thyroid hormone in a pill. And you start off with a low dose. You wait three or four or five weeks. You check it again. And once you get into the mid-range of the normal, you're pretty much done. And your thyroid requirements hardly change over your lifetime. It may during certain periods, but it's probably one of the easiest things to treat. And it... it is pretty wild how easy it is compared to type 1 diabetes. It's mostly by the nature of how we have to give it. You know, we have to give insulin through injections. And there's problems if it's too high or too low. And that's what makes people go nuts about type 1 diabetes. Thyroid is generally: take a pill once a day. The pills are finicky. You generally have to take them on an empty stomach, no food for like 30 minutes, no other pills, because, um, it can be difficult to absorb. And if people are taking it with food or whatever, or with other like supplements, sometimes the absorption gets off. I never tell them that.

Yeah. You know, the other thing about thyroid medication, it takes 3 to 4 weeks to reach equilibration. So, you know, if you miss one, if you miss a couple days, it's not a big deal. If you take extra by accident, it's not a big deal. I haven't had too many problems with it. In the olden days with... with generic forms, they weren't very good, but nowadays, generics, thyroid. I mean, some people, like, do have issue like that, you know, like getting their numbers in range and things like that. But you're right, usually once you're there, you're there. Um, I was going to say something else about that, but yes, it's very easy to take. Um, once you get screened, you're on that kind of lifelong. The only reason you might have to change your dose is generally if your weight changes kind of dramatically up or down. So, thankfully, that's a relatively easy one. Get screened, be aware of the symptoms, and if you need to get treated, get treated. Um, anything else to say about hypothyroidism?

I would just say that it... it does occur more commonly in females. Uh, and the, I think the key is to diagnose it early and, uh, a yearly screen, as you said, the test is super cheap, and it's probably the most common autoimmune condition associated with type 1 diabetes. All right. So, now on the hyper side, this is a little bit different. This is, you know, what we call Graves' disease. So, um, here you're not destroying the thyroid. Your body is actually making auto- antibodies that actually activate the thyroid gland. So, it just becomes completely dysregulated and starts secreting thyroid hormone like, you know, all the time. So, every symptom we just said about low thyroid, take the opposite of that, and that's what you have with hyperthyroidism. Your heart rate is, uh, sped up. You get kind of agitated, kind of jittery. You can lose weight. You now are, uh, intolerant to heat instead of cold. Um, feeling anxious. You can get, you know, uh... Steve's making a palpitation kind of, um, hand gesture. You feel like your... your heart's beating out of your chest. And then your eyes can, yeah, actually get enlarged. That's an... an interesting one, where you can get a deposition of this kind of fibrous material behind your eyes, and it kind of makes your eyes bulge out. So, we always say if you can see the entirety of somebody's, like, iris essentially, um, the whites, that, you know, that they might have thyroid eye disease. And there's... there's medicine specifically for that now. So, people, um, might actually see that specifically on... on TV. But all right. So, maybe you have some of these symptoms. Maybe you get your, um, your labs checked, and they say, "Gosh, you have high thyroid disease." There's some other tests they would do to make sure it's actually Graves'. There's antibodies they can test. There's scans they can do. But once you get diagnosed, what's the treatment here, Steve? Well, there's anti-thyroid medications, and there's a whole slew of them, and they've gotten better and better throughout the years. And typically, you... you prescribe one, and you also prescribe a beta blocker if the heart rate is too fast, and that may be only temporary until things calm down. And if your thyroid gland is so big and they're not responding to medications, they can do surgery and take out a major part of your thyroid gland, and then maybe give you radioactive iodine, which is another therapy. So, what's your go-to therapy for someone?

Yeah, they... I mean, so they say with the pills, you have about a 50% success rate at a year of kind of reversing Graves' disease. And some people say, "Okay, I'll try the pills and we'll see what happens." Other people say, "I want to get this dealt with immediately." And we don't really do surgery anymore, um, unless it's like kind of like super severe cases. So, we do this radioactive iodine a lot. And that sounds scary, right? Like, you know, "What am I going to be glowing?" And like, you know, like radioactivity, what's that about? It's almost October 31st. Yeah, so you can be radioactive iodine man. Um, so the thyroid, uh, is unique that thyroid hormone is actually very heavy in... in iodine, and it's one of the very few places in our body that uses iodine for kind of anything. So, we give people a pill to swallow, literally, that has a little bit of like radioactive iodine in it. So, when they swallow it, all that radioactive iodine goes to the thyroid, and it essentially, like, slowly kind of, like, burns the thyroid, but it's very, very local, very, very safe. This doesn't cause radiation to the body, anything like that. And so, over the next, you know, 6 weeks or so, you essentially kind of kill the thyroid gland. And then you've created a low thyroid situation. So, people actually have to take thyroid hormone, if that makes sense. Yeah. And that's actually the goal. Uh, you know, the radiologist, they'll do an uptake scan, they'll do a calculation, and then they'll give you the certain amount of radioactive iodine. And they've studied this for decades, and it doesn't cause cancer in your neck and other areas of the body. For some people, they hear radioactive, as you mentioned, uh, but it's really one of the best ways to treat it, because you don't... you can get recurrence of Graves' disease, as you know quite well. You know, you could be quiescent for years, and if you have enough of this thyroid tissue, it could act up again. Uh, and so I, if I had Graves', I would like to get the whole thing destroyed by radioactive iodine and then just take, uh, a thyroid medication that keeps me in the normal range. Yeah. So, neither of these condition... like, no medical disease is great, but as far as medical conditions go, these are very treatable, and they're actually relatively easy to diagnose. Um, so just again, when you get your yearly labs, everybody should get their labs done at least yearly. You should have kind of like your "diabetes warranty program" you always talk about. That's right. Every year I get my eyes checked. Every year, you know, I get my, uh, my feet examined. Every year I get my kidney test, my... my cholesterol test. And you should get your thyroid test done every year and... and ask about it. Or, um, if you get it done and you see that that TSH is flagged as abnormal, that's actually one that's helpful. So, there's a lot of labs they flagged as abnormal. We're like, "Don't worry about it. That test doesn't mean anything." Yeah, this is one that's pretty clear if it's... if it's off. Yeah, that... that's great advice. I... I want to say one more thing about Graves, um, is that this Graves' eye disease that you mentioned, you know, it... that could be pretty severe. It could be a sight- limiting because it gets so big. And the thing is, it runs a separate course than the thyroid levels. So, you could be fully treated with, you know, for Graves' disease, your thyroid levels are normal, and then your eyes start to bulge again. Mhm. Uh, and some people go to ophthalmologists that specialize in thyroid eye disease.

So, it... it sounds scary, but I don't think... and there's... there's specialists that spend time on this. So, it's just important to know that the eye condition just doesn't correlate with your thyroid levels. It could come up at any time. So, a level of awareness is all you need. You won't have any serious problems. Um, okay. So, let's move on to celiac.

And Steve and I were talking about this before this podcast, that we would like to come back and do a whole podcast on celiac because it... it... it is, uh, certainly deserving of a lot of time to be spent on this. So, um, some of the stats first. So, if you look at kind of the general population, maybe like 1% of folks will have celiac. In type 1, that goes up to about 6 to 10%, depending on who you ask. So, again, we're at higher risk of... of getting this with type 1 diabetes. And here, it's where, um, the body has a specific reaction to gluten, um, and it causes, uh, kind of, uh, pronounced inflammation in... in the gut. And this can be very severe, very damaging, and cause a lot of... a lot of gastrointestinal problems. Um, this is actually very different than people that have gluten sensitivity. So, everybody's heard about gluten, you know, uh, today because every restaurant, or there's all these gluten-free options, and... and God bless people that are gluten-free because, you know, it makes them feel better. That's totally fine. This is a confirmed medical diagnosis that if people are exposed to gluten, they get an actual physiologic kind of inflammation, um, that can be very, very severe.

So, the gluten sensitivity people, they're all drama queens. Is that what you're trying to say? I knew you were going to say that. So, no, it's just, um, if you ask people with celiac disease, they, um, it's kind of a love-hate relationship. They're glad there's gluten awareness. Um, but people with true celiac, I mean, you can't use the... the same dish that gluten has been used in, or the same toaster, or things like that. That's cross-contamination. That sounds like people who are kosher. Yeah. You got to have a separate set of dishes.

So, um, you know, and this one's interesting. So, why do people get it? You know, I was thinking about this because, you know, you say, "Okay, gluten. Gluten's in, uh, wheat. It's in bread." These very kind of common things. Yeah. Why do humans have this? It seems like if we were allergic to gluten, like, that should have kind of died out years ago. And I was reading about this, that apparently the... the kind of T-cells... the... the certain T-cell receptor that's... that's associated with celiac and type 1 diabetes, um, presumably had some, like, protective effects in terms of helping people fight off viruses and bacteria. But then when we had the, uh, the... the, like, kind of cultural revolution, where we started farming more and people were exposed to gluten, that's when this, like, this, uh, kind of appeared. But it's persisted because it had some advantages in terms of fighting off, you know, viruses. So, it's kind of an interesting... that is, you know, evolution of the human race, I suppose, as to why celiac disease kind of exists. Um, well, that reminds me of in type 2 diabetes, we talk about insulin resistance, that in the olden days, you know, when there was a famine, if you had a little bit of insulin resistance, you'd be the last one standing. Uh, and then with the current changes in our society, it's one of the causes of the big increase in type 2. So, that's interesting. Survival of the fittest. But the other thing, Jeremy, well, I was going to say, that's... I mean, that is interesting. We call that the thrifty hypothesis. The thrifty gene hypothesis. People that were able to store fat. Um, that was an advantage that you could, you know, persist through a famine. And now we're dealing with the repercussions of that, that we're not, you know, in modern society, it's not a famine. There's that excess of calories. And these people that have this protective gene to store fat, well, guess what? That's on overdrive now. And people are dealing with obesity, type 2 diabetes, etc. Yeah. And you mentioned the T-cell, and that reminded me to... to tell our listeners and viewers that that when we're screening for early type 1 diabetes in family members and the general society, we know that if these folks do not have type 1, but they have, you know, either Graves' or Hashimoto's thyroiditis or celiac, they are at a much higher risk of getting type 1 diabetes down the line. So, you know, it... they're all sort of related. We don't know the exact details, but it's interesting that you mentioned the T-cell.

Yeah. And, and that's a good point because a lot of times when I have somebody, especially they're newly diagnosed with type 1, I say, "Does anybody else in your family have type 1 diabetes?" And they usually say no, because most type ones are the only one in their family, but "Grandma had lupus," or "Uncle Charlie had, you know, thyroid disease." So, they kind of cluster in... in autoimmunity and kind of rear their heads in different ways in different family members. Yeah. And I was involved in a study where they took a huge database of millions of people who had health insurance in the United States, and they identified people with just the auto... those three autoimmune conditions, no type 1. And they followed them over time, and there was an eightfold greater risk of them developing type 1 diabetes in the next two or three years if they had celiac or... or thyroid.

High or low thyroid. Yeah. All right. So, back to... to celiac. Okay. So, we said it's up to 10% of people. It's related to gluten. Um, symptoms are mostly gastrointestinal in nature. Diarrhea, abdominal pain, bloating, weight loss, fatigue. You can get some anemia, growth issues in children. So, who should be screened? Well, everybody at diagnosis should get screened. And there's some simple antibody tests you can do as kind of the first line, um, uh, thing to kind of diagnose it. And they're... they're much more aggressive about repeat screening in children, that they usually test annually in kids because it can affect growth, um, bone health, those kinds of things. In adults, it's a little less clear how often to check. We usually say at diagnosis and maybe yearly for the first couple years because I was reading that it's... it's interesting that, um, if you have type 1 diabetes and you're going to get celiac, it tends to be within the first couple years that you have type one. So, maybe you and I are out of the woods on this one. Yeah. But something like 50% of people that have celiac, they had it within their first year of type 1 diabetes. I mean, what a shitty year, right? You get type 1 diabetes, and then guess what? You also have celiac, because that's... that's affects your quality of daily living, especially everything you eat. But the thing is, many times the diagnosis is missed, and I have missed it myself, because not everyone gets all these symptoms. They don't get them at the same intensity, and I've been... or completely asymptomatic. So, that's another thing that comes up, that people will screen, they have zero symptoms, but you can kind of have this silent celiac where you're still having the inflammation, um, but you don't know it. But you're right, I mean, again, a lot of people have stomach issues, right? They... they have diarrhea, constipation. Well, you have a lot of gas, so I thought you had celiac for a while. Um, so it can be missed. So, if you haven't ever been screened, you probably should, but again, um, at diagnosis, every year in kids, and adults, you know, at least the first few years after diagnosis, and then certainly if you have any kind of symptoms. And to just... to kind of round out the diagnosis, usually we start with these autoantibody tests. If they're positive, the way that you actually have to kind of like, um, lock down the diagnosis is they do an endoscopy, an upper endoscopy. That's where they stick a tube down your throat, and they actually can go all the way through your stomach into the first part of your small intestine and take a biopsy there, because celiac affects primarily the first part of your intestines. And they do a biopsy, and they can look under a microscope and see kind of the characteristic inflammation that... that confirms the diagnosis of celiac. So, they... everyone gets that biopsy of their small intestine if they have a positive antibody screen or maybe if even the antibody's negative, but something's really looking like celiac, it's just kind of the way to, um, to diagnose it. Now, there's all kinds of caveats, because sometimes people will, um, worry that they have celiac and go gluten-free, and then the inflammation can heal, and then you get the biopsy, and and it's negative. So, kind of the best way to do it, they'll say, is when you're on a gluten diet, if that makes sense, that you're promoting the inflammation so you can see it. I see.

Yeah. Um, now treatment, I got to say, I think it's just archaic. I mean, what's the treatment for celiac, Steve? Gluten-free diet.

Yeah. Don't eat gluten. I mean, like, um, I guess it's kind of like a no-brainer, but also, it's hard to do. I mean, there's gluten in so many things. Um, and, you know, people probably have gone their life eating certain things that they've enjoyed. I mean, thankfully, like we talked about, there's gluten-free options and gluten substitutes and all these kinds of things. But, um... You and I were in San Diego, and there's... almost all the nice restaurants have gluten-free options, but I don't think that's true everywhere in this country. Then you can go to "Whole Paycheck," and they have a whole aisle on gluten-free, uh, things. And I think... so I think it's better, but it's also a pain to eat with someone that's gluten-free. Yeah. You know, you have... you have to, like, they have to figure out what they eat. They're talking to the waiter, like, 10 minutes. Oh, stop. I mean, I think the people that are most embarrassed by that is them. You know, they don't want to put them out. Whatever. You know, I'm kidding.

Um, now I do want to go back to this gluten sensitivity thing, because they're not drama queens. You know, this is like a real thing, and there's... everybody knows somebody who said, "Hey, I, you know, I just took gluten out of my diet, and I feel so much better." I mean, it's real. Um, do people with type 1 diabetes have more gluten sensitivity? That I don't know, but I would probably assume so if we're more, uh, prone to, um, celiac, but something I don't know. It's one of the rare things I don't know, Steve, but I'll... I'll look it up and get back to you. Yeah, you know, Jeremy, I mean, there... I can understand this whole gluten sensitivity issue, 'cause it's kind of a fad, and you know, there could be a placebo effect of switching the type of foods you eat. But nonetheless, I do agree with you that, um, you know, gluten... there are people who cut it out, and they feel a ton better. But... but you know, it's not autoimmune induced, because theoretically, they would get the test. So, it's, um, you know, it's... it's like many conditions, it's overlap.

Yeah. Now, I would say the key to, um, treatment is... is obviously it's gluten-free, but meet with, like, a good dietitian. Um, you need kind of a good team, ideally, because, you know, with type 1 diabetes, you're already trying to limit your carbs, and when you're eating gluten, it might shift, you know, other things you're trying to eat. Um, in general, people that are gluten-free tend to have just as good as blood sugars, if not better, than people that are not. I mean, if you're eating less grains, these kinds of things. Um, but it's just something else that you need to consider when diet is such a big part of type 1 diabetes treatment. And here's kind of another component to it that you got to add on top of it. Yeah, that's hard.

Um, anything else for gluten-free? No, I think that's it. You know, I will say I went into ChatGPT and said something about, you know, the basics of gluten-free diet, and it... and it said, "Would you like me to create a grocery list for, you know, like somebody who's new to, um, being gluten-free?" I said, "Yeah." And it came up with all this stuff that's, um, again, kind of like this paleo diet before we were farmers and things like that. Meats and, and you know... Thrifty gene hypothesis. There you go. Um, okay. So, sorry. Anything else about celiac? No, that was good. I think... I think you need to do a whole podcast. We need to do a podcast on Celiac because now that you've read about it, asked ChatGPT, we have a lot of information. Exactly. Thank you. Um, so in the last couple minutes, um, you know, we can kind of rattle through other ones. I mean, like literally every other autoimmune disease is... is going to be more common in type 1 diabetes. So, lupus, rheumatoid arthritis, Addison's disease, certain types of pituitary issues, um, I think psoriasis even, like, you know, all these things that are kind of in the autoimmune category. But Addison's, or adrenal failure, is probably the other one that I would call out. So, what do you want to say about that? What is it?

Yeah, Addison's disease is a condition where you... you're... you have antibodies that destroy the ability of your body to produce cortisol and other steroids. And we... we know that too much cortisol and steroids over the long period of time is not good. But everyone needs steroids. Uh, it is basic bodily function. And I'll just tell a quick story about my patient, and I think we didn't mention this, but uh, she had polyglandular autoimmune failure. So, she had type 1 diab... she has type 1 diabetes, hypothyroidism. She also has celiac and vitiligo. Uh, and we haven't talked about that. But then listen to this, Jeremy. She... she comes in to see me, and she's coming in with a helper because she's so weak. Okay. She had just been to Scripps Hospital. I don't mind naming them. They did this huge million-dollar workup with a zillion tests and scans and scopes. And I looked at her, and I thought she had adrenal insufficiency, Addison's disease, something that John F. Kennedy had, but hid it from the news media, 'cause that's what you do when you're president and you have a condition. And she was weak, lost weight, her blood pressure was low, she had nausea, vomiting, abdominal pain. And I ordered a test called the ACTH in a similar fashion. It's the TSH of Addison's disease. And it was sky high, meaning that her brain was saying, "I need steroids." This hormone is supposed to stimulate the adrenal glands to produce cortisol. And she just wasn't able to due to autoimmune destruction. So, it was a shocking that... it either... Well, you know, you say John F. Kennedy because it's interesting. So, yes, you have... Addison's. So, you have low cortisol, and the way the brain kind of reacts is by increasing this ACTH level, and ACTH, when it gets really high, the other component of it can be cut in half to melanocyte-stimulating hormone, which is... kind of darkens the skin. Yeah. So that's why John F. Kennedy kind of had this characteristic kind of orange, you know, color to him, um, that everybody would kind of recognize. So, it's a... it's kind of a one of those fun things of medicine that, you know, you see somebody with a certain color skin, you think kind of Addison's. But anyway, so it's also common in type 1 diabetes. It has all these symptoms that are a little bit nebulous, particularly like pronounced, uh, fatigue, uh, muscle atrophy of the, like, what we call the proximal muscles, the legs, the... the upper arms. Um, testing, you can get a, a cortisol level, you can do something called a stimulation test. You don't need to know all the details. Um, but this is one of those things that it's harder to pinpoint because we don't routinely screen for it, right? And there's no like slam dunk symptom other than somebody coming in saying, "I don't, you know, quite feel right." You know, those kinds of things. You might just have to ask your doctor, "Hey, I heard, you know, about adrenal insufficiency and type 1 diabetes, and I... I Googled it. I Googled it. I think I might have some of the symptoms. Can you please screen me for it?"

Yeah. And that's pretty easy. And the therapy is quite straightforward. You give steroids back, you know, in the form of hydrocortisone. And, uh, Barbara, I won't mention her last name, uh, but she felt tremendous in about 3 or 4 days. She didn't feel back to normal for several weeks because she had been so low in her, uh, thyroid... her cortisol levels for so long. And, um, you... there are other things people need to worry about when you have Addison's, like, you know, when you... when you're having surgery or have some other stressful situation, you have to increase your dose, but we don't want to get into the weeds right now. But it's easily treatable.

Yeah, it's a once-a-day pill usually. And steroids is a funny term, because here we're talking about what we call corticosteroids, which is cortisone. So, think about, you know, your shoulder hurts, you get a cortisone injection, that kind of thing. Very different than anabolic steroids, which is testosterone and people using, you know, for weightlifting, that kind of thing. So, this is a different kind of steroid. But anyway, so I'd say those are kind of like the main things. And if people leave here with nothing else, it's a kind of awareness. Um, on the flip side, what I will say is that doctors love to kind of blame things on type 1 diabetes. You know, you come in, your shoulder hurts, "Oh, you have type 1 diabetes." So, don't let them get away with that either. There are things that are associated with type 1, and those should be kind of considered, but it isn't always type 1 diabetes. You know, we're allowed to have kind of other things, too. So, I hate that when my patients come and see me and they're like, "Yeah, you know, my... I cut my finger. Can you look at it 'cause my doctor said I have diabetes?" Or whatever it is. People are lazy. Bleep those guys, man. You know, they they do it for type 2 as well. Everything's due to your diabetes. So, I think your... your point about being aware is the key.

Yeah. Knowing what these conditions can do, and just a little red light goes off in your head. "Hey, I listened to that great podcast, Edelman, you know, showing the younger guy how to do a podcast, plus one Pettis and others." Um, yeah. So, get... be aware, and again, most ofS this is just routine blood tests on your annual kind of exam to have that done. Thyroid, celiac, maybe Addison's. Um, so hope, uh, you guys learned something from this. I actually did, you know, going back and reading a lot of the stuff that we've learned, but it's always good to learn it over again and kind of, uh, chat with people about it. So, please be sure to, uh, like us, subscribe, follow, give us comments, give us stars. We literally read every single comment. Um, every, uh, rating matters in terms of helping, uh, uh, keep this going. So, please, uh, please, uh... uh, give us your feedback. And Steve, as always, complete pleasure. Complete pleasure. Yes. Thank you. Thank you, sir. All right. Bye-bye.