February 18, 2019

Preventing Chronic Disease

#41 – Jake Kushner, M.D.: How to thrive with type 1 diabetes and how everyone can benefit from the valuable insights

“You have this unique population of [type 1 diabetics] where you can see the insulin that goes into them, and you can see it's direct impact on weight gain. . . and they’re at risk for cardiovascular illness. And to me that just says that there's something about the Standard American Diet that's making us sick. And ultimately we will all be at risk for cardiovascular disease.” —Jake Kushner

Read Time 28 minutes

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


We discuss:

  • How Jake became interested in type 1 diabetes [5:30];
  • The pathophysiology of type 1 diabetes, the increase in prevalence, and the role of beta cells [17:00];
  • The role of body weight and BMI in the risk of developing T1D [27:00];
  • Genetics of T1D and the risk of inheritance [32:00];
  • Hemoglobin A1c [36:15];
  • Insulin: the amazing story of its discovery, its effect on cellular metabolism and IGF-1, and why the hell it’s so expensive [39:15];
  • Diabetes Control and Complication Trial: blood glucose and the complications associated with diabetes [54:45];
  • Cognitive impairment, epigenetic changes, and other dangers associated with high, peak blood glucose, and big swings in blood glucose levels [1:09:15];
  • Depression, anxiety, and other challenges of living with T1D [1:15:30];
  • Jake’s realization that the current standard of care of T1D is inadequate [1:26:15];
  • Managing diabetes with exercise [1:30:15];
  • The Bernstein method, and protein’s impact on glucose and insulin [1:36:15];
  • Jake radically changes his approach to treating patients [1:45:00];
  • What other tools are there for controlling T1D? [1:49:45];
  • Is the ketogenic diet appropriate for those with T1D? [1:52:45];
  • The most important lessons that can be applied by the non-diabetic population [1:59:00];
  • The two dream measurements Peter wishes were available [2:04:00]; and
  • More.


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

  • Peter and Jake had dinner one night in Houston, Texas
  • Jake was the first person to introduce Peter to the CGM

Advisor for Sanofi

  • Working on the exciting drug sotagliflozin ⇒ a new class of drugs that will hopefully benefit people with type 1 diabetes (T1D)
  • Peter says, “Super interesting, not just for type 1 diabetes, but potentially Type 2. And frankly if you subscribe to the idea that lower levels of glucose and insulin are just better overall, there may even be other applications.”

Jake’s path to becoming a pediatric endocrinologist

  • Trying to decide in between being a pediatrician and being a molecular biologist
  • “I thought I would do that and the classical path as an endocrinologist is to go and find a rare disorder and discover the molecular basis for it and find some unique product that you could then replace and provide it”
  • Was also interested in pediatrics
  • undergraduate at Berkeley working continuously in basic science research labs
  • Several years afterwards as a research technician, first at UCSF and then Oregon.
  • Medical school at Albany Medical College in New York
  • Pediatric resident at Brown University
  • Enamored by endocrinology in general, so he applied and got fellowship at Children’s Hospital Boston
  • Also served as a research fellow at the Joslin Diabetes Center at Harvard Medical School

How Jake became so interested in type 1 diabetes

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

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

Onset of T1D in adults

  • The presentation of DKA is less frequent in older people, who generally become diabetic at a slower pace which is known as cryptic type 1 diabetes
  • In these people… they probably have autoimmune antibodies, and they have some degree of loss of beta cells ⇒ “and this phenomenon explains some of the adult onset diabetes that you just don’t quite understand”

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

  • So Type 1 is approximately one in 300 people
  • The typical age of onset is around nine years old
  • And they live into adulthood, and many can survive into their 80s
  • “It’s the most common life threatening, medication requiring, illness of childhood.”

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

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Jake Kushner, M.D.

Dr. Jake Kushner, a nationally renowned expert in type 1 diabetes research, served as Chief for Texas Children’s Diabetes and Endocrinology and the Section of Pediatric Diabetes and Endocrinology at Baylor College of Medicine from 2011 to 2017. Dr. Kushner is a University of California at Berkeley graduate. He earned his medical degree from Albany Medical College in New York and completed his residency in pediatrics at Brown University and clinical fellowship at Children’s Hospital Boston as well as a research fellowship at the Joslin Diabetes Center at Harvard Medical School. Dr. Kushner was previously with the University of Pennsylvania School of Medicine and the Children’s Hospital of Philadelphia (CHOP) as an assistant professor in the division of endocrinology and diabetes. His research is focused on the insulin-secreting beta cells of the pancreas. His clinical interests include the care of children with type 1 diabetes, cystic fibrosis related diabetes, and the treatment of children with hypoglycemia. [bcm.edu]

Jake currently serves as medical director of McNair Interests, a private equity group with investments in type 1 diabetes and other chronic illnesses. His primary focus is to leverage existing and future medical-related investments and resources for McNair Interests to help individuals with chronic illnesses.

Twitter: @JakeKushnerMD

Disclaimer: This blog is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this blog or materials linked from this blog is at the user's own risk. The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard, or delay in obtaining, medical advice for any medical condition they may have, and should seek the assistance of their health care professionals for any such conditions.
  1. Hi Peter,
    When referring to :
    “People who are in hardcore ketosis who have circulating beta-hydroxybutyrate may become completely immune to low blood glucoses
    In other words, there can be cases where someone has dangerously low blood glucose (say 25) and yet they feel fine due to the presence of ketones
    The problem, however, is that they may go from feeling fine to fatally low blood glucose without warning. ”

    Would low blood ketone like 0.1-0.2 mmol/l be enough to compensate for an average of 2 mmol/l of blood glucose? In that scenario, this person would have low blood glucose baseline and even post-prandial, blood glucose would not spike much. How would this person know if this is a safe situation to be in?

    Thank you !

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